Mood Disorders (Affective disorders) 3Hours

Mood Disorders (Affective disorders) 3Hours
A group of psychiatric disorders in which pathological moods and related vegetative and psychomotor disturbances dominate the clinical picture.
It refers to sustained emotional states, not merely to the external (affective) expression of the present emotional state, sustained over a period of weeks to months, often in periodic or cyclical fashion.

Depressive disorders afflict at least 20 percent of women and 12 percent of men at some time during their lives. Despite the availability of effective treatments, many persons with mood disorders are disabled, and rates of suicide (which occurs in about 15 percent of depressive disorders) are high in both young and (especially) elderly men. Although depressive disorders are more common in women, more men than women die of suicide.

Major Depressive Disorder and Bipolar Disorder:
Major depressive disorder (unipolar depression) is reported to be the most common mood disorder. It may manifest as a single episode or as recurrent episodes. The course may be up to 2 years or longer—in those with the single-episode form. Whereas the prognosis for recovery from an acute episode is good for most patients with major depressive disorder, three out of four patients experience recurrences throughout life.

Bipolar disorders (previously called manic-depressive psychosis) consist of at least one hypomanic, manic, or mixed episode. Mixed episodes represent a simultaneous mixture of depressive and manic or hypomanic manifestations. Although a minority of patients experience only manic episodes, most bipolar disorder patients experience episodes of both polarity. Manias predominate in men, depression and mixed states in women.
Recent clinical studies have shown the existence of a spectrum of ambulatory depressive states that alternate with milder, short-lived periods of hypomania rather than full-blown mania (bipolar II disorder).


Mood Disorders
• Major depressive disorder: characterized by one or more major depressive episodes (at least 2 weeks of depressed mood or loss of interest accompanied by at least four additional symptoms of depression, see later).

• Dysthymic disorder: characterized by at least 2 years of depressed mood for more days than not, accompanied by additional depressive symptoms that do not meet criteria for major depressive episode.
• Bipolar I disorder: characterized by one or more manic or mixed episodes, usually accompanied by major depressive episodes.
• Bipolar II disorder: characterized by one or more major depressive episodes accompanied by at least one hypomanic episode.
• Cyclothymic disorder: characterized by at least 2 years of numerous periods of hypomanic symptoms that do not meet criteria for a manic episode, and numerous periods of depressive symptoms that do not meet criteria for a major depressive episode.
• Mood disorder due to general medical condition: characterized by a prominent and persistent disturbance in mood that is judged to be a direct physiological consequence of a general medical condition.
• Substance-induced mood disorder: characterized by prominent and persistent disturbance in mood that is judged to be a direct physiological consequence of a drug of abuse, toxin exposure, or a medication.

MAJOR DEPRESSIVE DISORDERS
- Clinical features vary in nature and severity from patient to patient.
- The following list of features is not necessarily to be present in all patients.
A. Mood (Affective) Changes:
• Feeling low (more severe than ordinary sadness).
• Lack of enjoyment and inability to experience pleasure (anhedonia).
• Irritability.
• Frustration.
• Tension.

B. Appearance & Behaviour:
• Neglected dress and grooming.
• Facial appearance of sadness:
- turning downwards of corners of mouth.
- down cast gaze.
- tearful eyes.
- reduced rate of blinking.
- head is inclined forwards.

• Psychomotor retardation (sometimes agitation).
- lack of motivation and irritation.
- slow movements.
- slow interactions.
• Social isolation and withdrawal.
• Delay of tasks and decisions.
• Loss of interest in work and pleasure activities.

C. Biological Features (Neurovegetative Signs):
• Change in appetite (usually reduced but in some patients increased).
• Change in sleep (usually reduced but in some patients increased).
Early morning (terminal) insomnia; waking 2 - 3 hours before the usual time, this is usually associated with severe depression.
• Change in weight (usually reduce but may be increased).
• Fatigability, low energy level, (simple task is an effort)
• Low libido and /or impotence.
• Change in bowel habit (usually constipation).
• Change in menstrual cycle (amenorrhoea).
• Diurnal variation of mood (usually worse in the morning).

D. Cognitive Functions & Thinking:
• Poor attention and concentration.
• Poor memory (subjective).
• Pessimistic thoughts; depressive cognitions as suggested by Beck:
- Present: patient sees the unhappy side of every event (discounts any success in life, no longer feels confident, sees himself as failure).
- Past: unjustifiable guilt feeling and self-blame.
-Future: gloomy preoccupations; hopelessness, helplessness, death wishes ( may progress to suicidal ideation and attempt ).


• Psychotic Features Associated with Severe Depression
A. Delusions (mood-congruent)
1. Delusion of guilt (patient believes he deserves severe punishment).
2. Nihilistic delusion (patient believes that some part of his body ceased to exist or function, e.g. bowel, brain…).
3. Delusion of poverty and impoverishment.
4. Persecutory delusion (patient accepts the supposed persecution as something he deserves, in contrast to schizophrenic patient).



B. Hallucinations (mood-congruent)
1. Usually second person auditory hallucinations (addressing derogatory repetitive phrases).
2. Visual hallucinations (scenes of death and destruction) may be experienced by a few patients.
? Epidemiology of Major Depression
• It is more prevalent than bipolar mood disorder (more in women).
• Lifetime prevalence is in the range of 15 - 25 %.
• The mean age of onset is about 40 years (25 - 50 years).
• It may occur in childhood or in the elderly.
• In adolescents may be precipitated by substance abuse.
• More common in those who lack confiding relationship (e.g. divorced, separated, single…).
• No correlation has been found between socio - economic status and major depressive disorder.
Etiology of Major Depression:
The causative factors are multifactorial (interacting together)
A-GENETIC FACTORS :as supported by family and twin studies.
B-- BIOLOGICAL FACTORS
Reduced levels of:
• Noradrenaline
• Serotonin
• Dopamine

C-PSYCHOLOGICAL FACTORS
• Stressful events
• Premorbid personality factors
• Cognitive faults (distortions)

? Differential Diagnosis of Major Depression :

• Depression secondary to medical diseases: - Thyroid dysfunction. - Diabetes mellitus. - Cushing’s disease. - Parkinson’s disease. - Stroke. - Carcinoma (especially of the pancreas and lung). - Multiple sclerosis.
• Depression secondary to medications:
- Antihypertensives (resepine, beta-blockers). - Corticosteroids.
- Antineoplastic drugs.
- Bromocriptine.
- Indomethacin.
- L - dopa.

• Psychiatric disorders:
? Dysthymic disorder (less severe, and chronic).
? Adjustment disorder with depressed mood.
? Substance - induced mood disorder.
? Schizophrenia, schizoaffective disorder.
? Somatization disorder

DSM-V Criteria for Major Depressive Episode
A. Five (or more) of the following symptoms have been present during the same 2- week period and represent a change from previous functioning; at least one of the symptoms is either (1) depressed mood or (2) loss of interest or pleasure.
Note: Do not include symptoms that are clearly attributable to another medical condition.
1. Depressed mood most of the day, nearly every day, as indicated by either subjective report (e.g., feels sad, empty, hopeless) or observation made by others (e.g., appears tearful). (Note: In children and adolescents, can be irritable mood.)
2. Markedly diminished interest or pleasure in all, or almost all, activities most of the day, nearly every day (as indicated by either subjective account or observation).
3. Significant weight loss when not dieting or weight gain (e.g., a change of more than 5% of body weight in a month), or decrease or increase in appetite nearly every day. (Note: In children, consider failure to make expected weight gain.)
4. Insomnia or hypersomnia nearly every day.
5. Psychomotor agitation or retardation nearly every day (observable by others, not merely subjective feelings of restlessness or being slowed down).
6. Fatigue or loss of energy nearly every day.
7. Feelings of worthlessness or excessive or inappropriate guilt (which may be delusional) nearly every day (not merely self-reproach or guilt about being sick).
8. Diminished ability to think or concentrate, or indecisiveness, nearly every day (either by subjective account or as observed by others).
9. Recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation without a specific plan, or a suicide attempt or a specific plan for committing suicide.
B. The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.
C. The episode is not attributable to the physiological effects of a substance or to another medical condition.
Note: Criteria A–C represent a major depressive episode.
D. The occurrence of the major depressive episode is not better explained by schizoaffective disorder, schizophrenia, schizophreniform disorder, delusional disorder, or other specified and unspecified schizophrenia spectrum and other psychotic disorders.
E. There has never been a manic episode or a hypomanic episode.
Note: This exclusion does not apply if all of the manic-like or hypomanic-like episodes are substance-induced or are attributable to the physiological effects of another medical condition.
PSYCHOMOTOR RETARDATION
(1) Paucity of spontaneous movements
(2) Slumped posture with downcast gaze
(3 )fatigue
(4) Reduced flow and amplitude of speech
(5) Poor concentration and forgetfulness.
(6) Inability to make simple decisions.

? Management of Major Depression:
Treatment of Depression
A Strategic map for managing mood disorders,
(1) Symptom remission (acute phase) and restoration of psychosocial functioning (acute and continuation phases).
(2) Prevention of a relapse (continuation phase).
(3) Prevention of recurrences, or new episodes in patients with recurrent depressions (maintenance phase).

• Hospitalization is indicated for: ? Suicidal or homicidal patient.
- ? Patient with severe psychomotor retardation who is not eating or ? drinking (for ECT).
- ? Diagnostic purpose (observation, investigation…).
- ? Drug resistant cases (possible ECT).
- ? Severe depression with psychotic features (possible ECT).
• Medications have proven to be very useful in the treatment of severe depression. They shorten the duration in most cases. ?
-Antidepressants.
-Tricyclics / Tetracyclics .
- Monoamino oxidase inhibitors (MAOI) .
-Selective serotonin reuptake inhibitors (SSRIs) .
-Others (new agents)
- Desirable therapeutic antidepressant effect requires a period of time, usually 3-6 weeks. (Side effects may appear within the first few days.)

- After a first episode of a unipolar major depression, treatment should be continued for six months after clinical recovery, to reduce the rate of relapse.
- If the patient has had two or more episodes, treatment should be prolonged for at least a year after clinical recovery to reduce the risk of relapse.
- Lithium Carbonate can be used as prophylaxis.
• Electroconvulsive therapy ( ECT ):
• Psychosocial:



Treatment of Depression

A- Psychotherapy:
- Supportive therapy.
- Family therapy.
- Cognitive-behavior therapy (for less severe cases or after improvement with medication).

B- ELECTROCONVULSIVE THERAPY(ECT):
The effect of ECT is best in severe depression especially with marked biological (neurovegetative) and psychotic features. . It is mainly the speed of action that distinguishes ECT from antidepressant drug treatment. Despite many of the largely societal criticisms of the modern use of ECT, this modality should be given a higher priority when treating patients with extreme suicidality, associated medical illnesses, difficult adverse reactions to routine psychopharmacological agents, or other medical emergency situations (such as catatonia) that demand the most rapid treatment response available.
ECT is effective, even in patients who have failed to respond to one or more medications or combined treatment. It is effective in both psychotic and nonpsychotic forms of depression. Usually, 8 to 12 treatments are needed.

C- Light therapy has been most clearly evaluated in mood disorder with seasonal pattern, either as monotherapy or in combination with medication. Patients who respond do so within 2 to 4 weeks.

D-Antidepressant Medications;
1-Tricyclic anti depressant:
a-Amitriptyline (Tryptizol) 75–250mg/day side effect: Sedative ,increase appetite ,Drowsiness, Orthostatic hypotension, Cardiac arrhythmia, weight gain, anticholinergic effect (Dry mouth, blurred vision, urinary hesitancy, constipation.), Overdose may be fatal.
b- Clomipramine (Anafranil): dose 75–250 mg Drowsiness, weight gain.
c- Imipramine (Tofranil) 75–250 mg, Sedative ,increase appetite Drowsiness, Orthostatic hypotension, Cardiac arrhythmia, weight gain, anticholinergic effect (Dry mouth, blurred vision, urinary hesitancy, constipation.), Overdose may be fatal.

2-Tetracyclic anti depressant:
Maprotiline (Ludiomil):75–225mg; Drowsiness, weight gain, lower than tricyclics anticholinergic effect (Dry mouth, blurred vision, urinary hesitancy, constipation.), Overdose may be fatal.

3-Mono Amine Oxidize Inhibitor (MAOI):
??Irreversible
• Phenelzine ( Nardil )
• Tranylcypramine ( Parnate )
• Isocarboxazid ( Marplan )

- Reversible
• Moclobemide ( Aurorix )

MAOI have serious side effect with High Tyramine Content Diet and when combined with other anti depressant (Hypertensive crises).

4-SelectivSerotinine Reuptake Inhibitor(SSRI):
a- Fluoxetine (Prozac) 20–80mg
b- Paroxetine (Paxil ,Seroxat) 10–60mg
c- Sertraline (Zoloft) 50–200 mg
d- Fluvoxamine ( Faverin ) 50-300mg

* All SSRIs may cause agitation, sedation, GI distress, sexual dysfunction
5- ?Other antidepressants:
• Trazodone ( Trazolan )
• Venlafaxine ( Effexor )
•?Mirtazapine ( Remeron )
• Nefazodone ( Serzone )
Prognosis of Unipolar Depressive Disorders
- About 25 % of patients have a recurrence within a year.
- Ten percent will eventually develop a manic episode.
- A group of patients have chronic course with residual symptoms and significant social handicap.
DSM-V Diagnostic Criteria for Dysthymic Disorder
A. Depressed mood for most of the day, for more days than not, as indicated by either subjective account or observation by others, for at least 2 years.
Note: In children and adolescents, mood can be irritable and duration must be at least 1 year.
B. Presence, while depressed, of two (or more) of the following:
1. Poor appetite or overeating.
2. Insomnia or hypersomnia.
3. Low energy or fatigue.
4. Low self-esteem.
5. Poor concentration or difficulty making decisions.
6. Feelings of hopelessness.
C. During the 2-year period (1 year for children or adolescents) of the disturbance, the individual has never been without the symptoms in Criteria A and B for more than 2 months at a time.
D. Criteria for a major depressive disorder may be continuously present for 2 years.
E. There has never been a manic episode or a hypomanic episode, and criteria have never been met for cyclothymic disorder.
F. The disturbance is not better explained by a persistent schizoaffective disorder, schizophrenia, delusional disorder, or other specified or unspecified schizophrenia spectrum and other psychotic disorder.
G. The symptoms are not attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication) or another medical condition (e.g., hypothyroidism).
H. The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.
Note: Because the criteria for a major depressive episode include four symptoms that are absent from the symptom list for persistent depressive disorder (dysthymia), a very limited number of individuals will have depressive symptoms that have persisted longer than 2 years but will not meet criteria for persistent depressive disorder. If full criteria for a major depressive episode have been met at some point during the current episode of illness, they should be given a diagnosis of major depressive disorder. Otherwise, a diagnosis of other specified depressive disorder or unspecified depressive disorder is warranted.


DSM-V Criteria for Manic Episode
For a diagnosis of bipolar I disorder, it is necessary to meet the following criteria for a manic episode. The manic episode may have been preceded by and may be followed by hypomanic or major depressive episodes.
A. A distinct period of abnormally and persistently elevated, expansive, or irritable mood and abnormally and persistently increased activity or energy, lasting at least 1 week and present most of the day, nearly every day (or any duration if hospitalization is necessary).
B. During the period of mood disturbance and increased energy or activity, three (or more) of the following symptoms (four if the mood is only irritable) are present to a significant degree and represent a noticeable change from usual behavior:
1. Inflated self-esteem or grandiosity.
2. Decreased need for sleep (e.g., feels rested after only 3 hours of sleep).
3. More talkative than usual or pressure to keep talking.
4. Flight of ideas or subjective experience that thoughts are racing.
5. Distractibility (i.e., attention too easily drawn to unimportant or irrelevant external stimuli), as reported or observed.
6. Increase in goal-directed activity (either socially, at work or school, or sexually) or psychomotor agitation (i.e., purposeless non-goal-directed activity).
7. Excessive involvement in activities that have a high potential for painful consequences (e.g., engaging in unrestrained buying sprees, sexual indiscretions, or foolish business investments).
C. The mood disturbance is sufficiently severe to cause marked impairment in social or occupational functioning or to necessitate hospitalization to prevent harm to self or others, or there are psychotic features.
D. The episode is not attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication, other treatment) or to another medical condition.
Note: A full manic episode that emerges during antidepressant treatment (e.g., medication, electroconvulsive therapy) but persists at a fully syndromal level beyond the physiological effect of that treatment is sufficient evidence for a manic episode and, therefore, a bipolar I diagnosis.
Note: Criteria A–D constitutes a manic episode. At least one lifetime manic episode is required for the diagnosis of bipolar I disorder.
Hypomanic Episode
The criteria for hypomanic episode describe a mild form of mania that may be seen either in the course of bipolar I disorder or as a regular part of bipolar II disorder.
Diagnostic Criteria for Hypomanic Episode
A. A distinct period of abnormally and persistently elevated, expansive, or irritable mood and abnormally and persistently increased activity or energy, lasting at least 4 consecutive days and present most of the day, nearly every day.
B. During the period of mood disturbance and increased energy and activity, three (or more) of the following symptoms (four if the mood is only irritable) have persisted, represent a noticeable change from usual behavior, and have been present to a significant degree:
1. Inflated self-esteem or grandiosity.
2. Decreased need for sleep (e.g., feels rested after only 3 hours of sleep).
3. More talkative than usual or pressure to keep talking.
4. Flight of ideas or subjective experience that thoughts are racing.
5. Distractibility (i.e., attention too easily drawn to unimportant or irrelevant external stimuli), as reported or observed.
6. Increase in goal-directed activity (either socially, at work or school, or sexually) or psychomotor agitation.
7. Excessive involvement in activities that have a high potential for painful consequences (e.g., engaging in unrestrained buying sprees, sexual indiscretions, or foolish business investments).
C. The episode is associated with an unequivocal change in functioning that is uncharacteristic of the individual when not symptomatic.
D. The disturbance in mood and the change in functioning are observable by others.
E. The episode is not severe enough to cause marked impairment in social or occupational functioning or to necessitate hospitalization. If there are psychotic features, the episode is, by definition, manic.
F. The episode is not attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication, other treatment).
Note: A full hypomanic episode that emerges during antidepressant treatment (e.g., medication, electroconvulsive therapy) but persists at a fully syndromal level beyond the physiological effect of that treatment is sufficient evidence for a hypomanic episode diagnosis. However, caution is indicated so that one or two symptoms (particularly increased irritability, edginess, or agitation following antidepressant use) are
not taken as sufficient for diagnosis of a hypomanic episode, nor necessarily indicative of a bipolar diathesis.
Note: Criteria A–F constitute a hypomanic episode. Hypomanic episodes are common in bipolar I disorder but are not required for the diagnosis of bipolar I disorder.
DSM-V Diagnostic Criteria for Cyclothymic Disorder
A. For at least 2 years (at least 1 year in children and adolescents) there have been numerous periods with hypomanic symptoms that do not meet criteria for a hypomanic episode and numerous periods with depressive symptoms that do not meet criteria for a major depressive episode.
B. During the above 2-year period (1 year in children and adolescents), the hypomanic and depressive periods have been present for at least half the time and the individual has not been without the symptoms for more than 2 months at a time.
C. Criteria for a major depressive, manic, or hypomanic episode have never been met.
D. The symptoms in Criterion A are not better explained by schizoaffective disorder, schizophrenia, schizophreniform disorder, delusional disorder, or other specified or unspecified schizophrenia spectrum and other psychotic disorder.
E. The symptoms are not attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication) or another medical condition (e.g., hyperthyroidism).
F. The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.
Differentiation of Mood disorders
Diagnoses
MDE
Milder depression
Manic or Mixed episode
Hypomania

MDE +
+
-- --
--

Dysthymic disorder
--?
+ -- --
Bipolar I disorder +
-- +
-- + +
--
Bipolar II disorder +
-- +
-- -- +
Cyclothymia -- + --? +

? +most be present to make the diagnoses
? --most be absent to make the diagnoses
? ? most not occur during the first 2 years of the illness



Treatment of Bipolar disorders
Hospitalization is often indicated for the acutely suicidal or dangerous patient on self or on the others; or patient how show gross disorganized behavior and may also be considered for the patient with associated medical problems.

Treatment of mania (Mood stabilizers):
Lithium
Lithium has been the main line of treatment for acute and prophylactic treatment of mania. In comparative studies with antipsychotic agents, it yields better overall improvement in most aspects of manic symptomatology, including psychomotor activity, grandiosity, manic thought disorder, insomnia, and irritability. However, the onset of antimanic action with lithium can be rather slow (2week), even with aggressive dosing. Until recently, this was traditionally accomplished with the typical neuroleptic drugs, including the phenothiazines, or butyrophenones such as haloperidol (Haldol).
Lithium doses; should be administered to achieve concentrations in serum between 0.6 and 1.2 mEq per liter.
High serum level (1.5 mEq per liter) can lead to toxicity: seizures, confusion, coma and cardiac dysrhythmia. In sever overdose dialyses is effective.

In bipolar disorders the high likelihood of relapse (50 percent in the first 5 months following lithium discontinuation and 80 to 90 percent within the first year and a half), and this should be explained to the patient.

Valproic Acid:
200-3000 mg/day
As effective as lithium in treating bipolar illness, may be more effective in treating mixed episode while lithium is more effective in treating traditional mania.
It is also used as prophylactic agent especially in rapid cycling cases.
Carbamazepine:
200-1800 mg/day
effective in acute mania , bipolar depression and as prophylactic agent.
Because of the rapidly growing evidence for the parallel acute antimanic efficacy of the mood-stabilizing anticonvulsants carbamazepine and valproic acid, it is suggested that these alternative agents be used as initial treatment.

ECT: may be used to treat booth phase of bipolar disorder.






Treatment of Dysthymia and Cyclothymia:

1- Dysthymia:
Traditionally treated with psychotherapy (cognitive and behavioral therapy). SSRI and MAOI are more effective than the tricyclic antidepressant.
2- Cyclothymia:
Treated with mood stabilizers and supportive psychotherapy.