BEHAVIORAL SCIENCE

IzBen C. Williams, MD, MPHInstructor

Lecture - 11

MOOD DISORDERS

MOOD DISORDERS

MOOD DISORDERS

DEFINITIONS:The essential feature of mood disorders is a disturbance of one’s emotional state along the happy-sad axis causing subjective distress and problems in functioning.

MOOD DISORDERSDEFINITIONS:Subjectively, the person may feel: Somewhat worse than would be expected

(dysthymia) Very much worse than would be expected

(depression) Somewhat better than would be expected

(hypomania) Very much better than would be expected

(mania)

MOOD DISORDERSDIAGNOSIS:The diagnosis of mood disorder requires the identification of mood episodes , which are building blocks for making a diagnosis of mood disorder.Mood episodes:A. Major depressive episode (MDE)B. Manic episodeC. Mixed episodeD. Hypomanic episode

MOOD DISORDERSEPIDEMIOLOGY:There are no differences in the occurrence of mood disorders associated with ethnicity, education, marital status, or income.The lifetime prevalence of mood disorders is:A. Major depressive disorder: M 5-12% and F 10-20%B. Bipolar disorder: 1% overall, no sex differenceC. Dysthymic disorder: 6% overall; M : F = 1 : 3D. Cyclothymic disorder: < 1% overall; no sex

difference

MOOD DISORDERSMajor Depressive Disorder

Characteristics: Recurrent episodes of depression, each continuing for at least two weeks Symptoms of depression (qv)

Masked depression: being unaware of or in denial of depression; (50% of depressed patients) Usually complain to 1° care doctor of vague physical

symptoms These complaints may be mistaken for hypochondriasis

Seasonal affective disorder (light Tx)Suicide risk (see table of risk factors for suicide)

MOOD DISORDERSMajor Depressive Disorder

Associated clinical features:Psychotic features (mood congruent)Melancholia (profound anhedonia and

neurovegetative symptoms. Significant wt. loss)Mortality and morbidity (additional risk of

illness or death due to medical causes)Psychiatric comorbidity

MOOD DISORDERSDysthymic Disorder

Diagnosis: chronic depression (at least two years duration) but not severe enough to meet the criteria for MDE. Requires only 2 rather than 5 MDE symptoms.

Associated clinical features: social impairment, health problems, abuse of alcohol and other drugs, major depression (double depression)

MOOD DISORDERSBipolar I Disorder (misnomer)

Diagnosis: at least one manic or mixed episode Associated clinical features:

Psychotic features (mood congruent) Morbidity and Mortality Psychiatric comorbidity

Epidemiology: Mean age of occurrence 21 yrs; Likelihood of recurrence 90%

MOOD DISORDERSBipolar II Disorder

Diagnosis: at least one MDE and one hypomanic episode in the absence of manic or mixed episodes.

Associated clinical features: suicide risk particularly during depressive episodes

MOOD DISORDERSCyclothymic Disorder

Dysthymia with intermittent hypomanic episodes.Like dysthymia it is chronic rather than episodic

Diagnosis: experienced over at least two years at least one MDE and one hypomanic episode in the absence of manic or mixed episodes.

Associated features: substance abuse and social and occupational dysfunction are commonly seen

Epidemiology: up to 50% may ultimately develop bipolar disorder

MOOD DISORDERS

MOOD DISORDERSEtiology: The etiology is multifactorial

BiologicGenetic factors (family studies, adoption

studies) Neurochemical factors (NE, 5-HT and less

solidly Dopamine); and other neurotransmitters such as GABA and neuropeptides also implicated

Other biologic factors (neuroendocrine regulation, sleep and circadian rhythm, kindling

Bipolar disorderThe Genetics of Bipolar Disorder

GROUP % Occurrence

The general population 1%

Person with one bipolar parent or sibling (or dizygotic twin)

20%

Person with two bipolar parents 60%

Monozygotic twin of a person with bipolar disorder 75%

MOOD DISORDERSEtiology:

Psychosocial:StressLoss of a parent before age 11, linked to

depression in adulthoodAnger turned inward, intrapsychic processing

of loss ….depression and self hatredLearned helplessness, (animal model)Negative cognitions

MOOD DISORDERSTreatment: Overall treatment planning:

Mood disorders vary in symptoms and severity, but some overall guidelines exist Treatment settingDiagnostic evaluationAssessment of safety

MOOD DISORDERSTreatment: Treatment of major depressive disorder:

Hospitalization: may become necessary for safety, treatment (including ECT), or support

Outpatient treatment: combination of ψTx and medication, there are several models of ψTx for depression, support in its various forms

Somatic therapies (medication and ECT)

MOOD DISORDERSTreatment: Treatment for bipolar I and Bipolar II disorders:

Hospitalization: containment of manic behavior, initial or reinstituted treatment, compliance

Outpatient treatment: combination of ψTx and medication,

Somatic therapies: Lithium, Valproate, Carbamazepine, et al

Other drugs: antipsychotics, benzodiazepines, antidepressants

Mood Disorder Vignettes

1. Major Depressionhttps://www.youtube.com/watch?v=4YhpWZCdiZc2. Manic Depressive Disorder: commentaryhttps://www.youtube.com/watch?v=cqMcAeLWO9c3. Manic episodehttps://www.youtube.com/watch?v=zA-fqvC02oM