Mood Disorders
Introduction
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Mood – pervasive emotional state of patient
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Depression - #1 burden of disease for ages 15-45
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Bipolar - #6 burden of disease ages 15-45
Mood Disorder Neurobiology
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Depression – associated with low levels of NE & serotonin in body
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Mania – associated with high levels of NE & serotonin in body
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Antidepressants – aim to increase the synaptic transmission of NE/serotonin, or both
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Hypothalamic-Pituitary-Adrenal (HPA) axis – depression causes hyperactivation
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Excess cortisol secretion – as a result of whole HPA axis screwed up
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Dexamethasone Suppression Test (DST) – in depression, cortisol unsuppressed in DST
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Hypothalamic-pituitary-thyroid axis – depression associated w/ hypoactivation hypothyroidism
Depression
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Sleep cycle – altered for the worse decreased sleep time, more frequent REM, less slow wave sleep
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Neuroimaging – decreased volume/metabolism in frontal lobes, amygdala, hippocampus
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“Learned Helplessness” – fatalist mentality of chronically depressed, believe life events out of control
The Major Depressive Episode
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Major Depressive Episode – defined as 2 weeks of consistently depressed mood with some symptoms:
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Decreased appetite/weight loss – in most cases; but can be increased in atypical
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Insomnia – usually early waking; but can be increased in atypical
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Psychomotor – retardation & slow movement; but can be increased in atypical
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Fatigue – loss of energy
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“Learned Helplessness” – fatalist mentality of chronically depressed; often inappropriate guilt
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Death/Suicide Ideation – recurrent thoughts of death/suicide
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Impaired Function – to qualify as major depressive, must impair function or cause significant distress
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Substance Abuse/Medical Illness – don’t qualify as major depressive episodes
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Bereavement – normal in many circumstances, also doesn’t qualify
Depressive Episode Subtypes
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Atypical – can have increased appetite, hypersomnia, preserved affect; sensitive to rejection
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Melancholia – prominent anhedonia (no pleasure or interest in anything), along w/ depressive symptoms
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Postpartum – depressive episodes within 4 weeks of delivery of child
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Catatonic – depressive episode with characteristic motor signs (similar to Schizophrenia)
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Psychotic Features – accompany 10% of depressive episodes 1% population psychotic!
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Seasonal – depressive episodes occur most commonly in fall/winter
The Manic Episode
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QUIZ: Manic Episode – defined as 1 week of continuous elevated/expansive/irritable mood with some symptoms:
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Inflated self-esteem – takes on grandiose ideas, increased involvement in goal-directed activity
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Decreased sleep need – manic episode requires little to no sleep each day
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Loud, rapid, intrusive speech – can talk for hours without breaking/prompting
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Flight of ideas – constantly racing thoughts, very distractible
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High-risk behavior – fast driving, indiscriminate sex, spending sprees, bad investments, etc.
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Impaired Function - to qualify as manic episode, must impair function or have active psychosis
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Subtypes – include mixed, psychotic features, rapid cycling:
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Mixed – episode meets criteria for both depressive episode and manic episode “crash and burn”
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Psychotic Features – present in 80% manic episodes, has grandiose delusions and poor insight
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Rapid Cycling – episodes occur 4 or more times per year
The Hypomanic Episode
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Hypomanic Episode – defined as 4-7 days of symptoms same as manic episode
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QUIZ: Unimpaired Function – unlike a manic episode, patient stays unimpaired and can be very productive
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No Psychosis/Hospital Admission – patient stays away from threshold of manic episode
Major Depressive Disorder
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Major Depressive Disorder – having one or more depressive episodes, without manic/hypomanic episode
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QUIZ: Prevalence – twice as common in women as men:
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Lifetime risk – 10-25% for women; men half
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Point Prevalence – 5-10% of women; men half
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Onset – very wide age range, can be sudden or gradual, strong genetic component
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Recurrence – 50% of patients experience recurrence
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Recovery – 50% recover after 6 months
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Treatment – include medications, psychotherapy, and electroconvulsive therapy (ECT)
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Antidepressant Rx – SSRIs, tricyclic antidepressants = 1st line; MAOIs = 2nd line; 6-month Tx
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Psychotherapy – cognitive behavioral therapy (stopping spirals), good for mild Tx, good with Rx
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Electroconvulsive Therapy – used w/ severe depression, 80% effective, great Tx but $$$
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Indications – non-response to other therapies, psychotic features, high sucide risk, starvation/dehydration, pt. request, prior response
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CI: intracranial mass, dementia, severe personality disorder, anesthesia risk
Major Depressive Disorder + Pyschotic Features
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Prevalence – about 10% of depressed patients 1% population!
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Mood – psychotic symptoms usually congruent with mood
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Treatment – can give combination drugs or ECT:
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Combination drugs – unlike other depressive disorders, need antidepressant and antipsychotic
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ECT – electroconvulsive therapy also highly effective treatment (80%)
Dysthymic Disorder
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Dysthymic Disorder – at least 2 years of mildly depressed mood, with a couple depressive symptoms
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Prevalence – lifetime risk 6%, point prevalence 3%
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“Double Depression” – can be co-morbid w/ major dep. slightly depressed always + depressive bursts
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Treatment – antidepressants, psychotherapy (cognitive behavioral Tx CBT, interpersonal Tx IPT)
Bipolar I Disorder
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Bipolar I Disorder – have one or more manic episodes, regardless of depressive
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Prevalence – 1% lifetime prevalence, 1:1 M:F, strong genetic component
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Onset – range teens-60s, peaks 20s, rapid onset: elevated mood euphoria irritability pyschosis
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Triggers – often triggered by stress, lack of sleep; can be followed/proceeded by depressive episode
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QUIZ: Recurrence – 90% of patients have recurrent episodes, prophylaxis essential
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Recovery – 70-80% recover to full function between episodes, rest are persistently unstable
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Complications – high suicide risk; can also ruin life (relationships, reputation, etc)
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Treatment – involves antipsychotics & mood stabilizers:
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Antipsychotics – 1st line treatment
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Mood Stabilizers – lithium, Valproic acid, anticonvulsants – 1st line Tx and prophylaxis!
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No Antidepressants – bad idea, can help trigger manic episodes
Bipolar II Disorder
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Bipolar II Disorder – have one or more hypomanic episodes (no manic), at least one depressive
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Prevalence, Onset, Course, Complications, Treatment – same as Bipolar I
Cyclothymic Disorder
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Cyclothymic Disorder – chronic fluctuating mood not qualifying for manic/major depressive episodes
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Onset – very gradual, unlike Bipolar I & II disorders
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Prevalence, Treatment – same as Bipolar I & II 1%, give antipsychotics & mood stabilizers
Substance Induced Mood Disorder
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Substance-Induced Mood Disorder – persistent mood disturbance related to intoxication/withdrawal
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Common Drugs – alcohol = depressant, amphetamine, cocaine, steroids = mood elevators
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Treatment – can resolve spontaneously after de-tox, or may need antidepressants
Mood Disorder Due to General Medical Condition
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Definition - persistent mood disturbance related to direct physiological effects of illness
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Illnesses – huge range, can be neurologic, endocrine, infectious…
Adjustment Disorder with Depressed Mood
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Definition – depressed mood within 3 months of stressor, symptoms resolve by 6 months after removal
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Depression Criteria – not met during adjustment disorder, although obvious stressor exists
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