MOOD DISORDERS

INTRODUCTION
 A mood disorder is the term given for a group of
diagnoses a disturbance in the person's mood is
hypothesized to be the main underlying feature. The
classification is known as mood (affective) disorders.
Two groups of mood disorders are broadly recognized;
the division is based on whether the person has ever
had a depressive, manic or hypomanic episode.
• Thus, are:
 Depressive disorders, of which the best known
and most researched is major depressive disorder
(MDD) (Clinical depression) or major depression,
and
 Bipolar disorder (BD), formerly known as "manic
depression" and described by intermittent
periods of manic and depressed episodes.
 Categorization of Mood Disorders

I. Mood episodes
– are comprised off periods when the patient
exhibits symptoms of a predominant mood
state.
– are not diagnostic entities.
Mood episodes are classified as follows:
a. Major Depressive Episode.
b. Manic Episode.
c. Mixed Episode.
d. Hypomanic Episode.
 Major Depressive Episodes

DSM-IV Diagnostic Criteria

A. At least five of the following symptoms for at least
two weeks duration.
B. Must be a change from previous functioning.
C. At least one symptom is depressed mood or loss of
interest or pleasure.
1. Pervasive depressed mood.
2. Pervasive anhedonia.
3. Significant change in weight.
4. Sleep disturbance.
5. Psychomotor agitation or retardation.
 Major Depressive Episodes cont…
6. Pervasive fatigue or loss of energy.
7. Excessive guilt or feelings of worthlessness.
8. Difficulty concentrating.
9. Recurrent thoughts of death or thoughts of
suicide.
D. Symptoms must cause significant social or
occupational dysfunction or significant subjective
distress.
E. Cannot be caused by a medical condition, medication
or drugs.
F. Symptoms cannot be caused by bereavement.
 Manic Episodes
DSM-IV Diagnostic Criteria
A. At least one week of abnormally and persistently
elevated, expansive or irritable mood (may be less than
one week if hospitalization is required).
B. During the period of mood disturbance, at least three
of the following have persisted in a significant manner
(four if mood is irritable):
1. Inflated self-esteem or grandiosity.
2. Decreased need for sleep.
3. The patient has been more talkative than usual or
feels pressure to keep talking.
4. Flight of ideas (jumping from topic to topic) or a
subjective sense of racing thoughts.
5. Distractibility.
 Manic episodes cont…
6. Increased goal-directed activity or psychomotor
agitation.
7. Excessive involvement in pleasurable activities
with a high potential for painful consequences
(i.e. sexual indiscretion).
C. Does not meet criteria for a mixed episode.
D. Symptoms must have cause marked impairment in
social or occupational functioning, or have required
hospitalization to prevent harm to self or others, or
psychotic features are present.
E. The symptoms cannot be caused by a medical
condition, medication or drugs.
 Hypo manic episodes
DSM-IV Diagnostic Criteria
A. At least 4 days of abnormally and persistently
elevated, expansive or irritable mood.
B. During the period of mood disturbance at least
three of the following have persisted in a
significant manner (four if mood is irritable):
1. Inflated self-esteem or grandiosity.
2. Decreased need for sleep.
3. The patient is more talkative than usual and
feels pressure to keep talking.
4. Flight of ideas (jumping from topic to topic) or
a subjective sense of racing thoughts.
 Hypo manic episodes cont…
5. Distractibility.
6. Increased goal-directed activity or psychomotor
agitation.
7. Excessive involvement in pleasurable activities that
have a high potential for painful consequences.
C. The mood disturbance and change in functioning is
noticeable to others.
D. The change in functioning is uncharacteristic of the
patient’s baseline but does not cause marked social
or occupational dysfunction.
E. Symptoms cannot be due to a medical condition,
medication or drugs.
 Mixed mood episodes
DSM-IV Diagnostic Criteria

A. Patient meets criteria for both for at least one week.

B. Symptoms are severe enough to cause marked

impairment in occupational or social functioning,
require hospitalization, or psychotic features are
present.

C. Organic factors have been excluded (medical

conditions, medications, drugs).
 Classifications of mood disorders
II. Mood Disorders
• The mood disorders are clinical diagnoses
defined by the presence of characteristic mood
episodes.

Mood disorders are classified as follows:

a. Depressive Disorders.
b. Bipolar Disorders.
c. Other Mood Disorders.
 Mood Disorder
Depressive disorder
MDD

Dysthymia

DD-NOS

Bipolar disorder
Bipolar disorder I

Bipolar disorder II

Cyclothymia

BD-NOS
 Unipolar Depression

• Major Depressive
disorder (MDD),
commonly called major
depression, unipolar
depression or clinical
depression. It is also
called Depression with
out periods of mania
 Risk factors/epidemiology
• Major depression is seen more frequently (2:1) in
women due to several factors, such as hormonal
differences, great stress, or simply a bias in the diagnosis.
• The life time prevalence of MDD is 15-17%.
• The typical age of onset is 40 years.
• There is also a higher incidence in those who have no
close interpersonal relationships or are divorced or
separated.
• Many studies have reported abnormalities in serotonin,
norepinephrine, and dopamine.
• Other risk factors include family history, exposure to
stressors, and behavioral reasons, such as learned
helplessness.
 Sign and symptoms of MDD
1. Depressed mood 7. Feelings of

2. Anhedonia worthlessness and

excessive or
3. Change in appetite
inappropriate guilt
4. Change in sleep
8. Indecisiveness or
5. Change in body activity
decreased concentration
6. Loss of energy
9. Suicidal ideation
 Differential diagnosis

• Dysthymia
• Other mood disorders – Bipolar disorder
• Personality disorder
• Schizophrenia
• General medical condition
• Substance abuse and dependence
 DSM-IV-TR Criteria for MDD
A. At least five symptoms for at least two weeks duration.
B. Must be a change from a previous functioning.
C. At least one is depressed mood/loss of interest.
1. Pervasive depressed mood
2. Pervasive anhedonia
3. Significant change in weight
4. Sleep disturbance
5. Psychomotor agitation or retardation
6. Pervasive fatigue or loss of energy
7. Excessive guilt or feelings of worthlessness
8. Difficulty concentrating
9. Recurrent thought of death or thoughts of suicide
D. Symptoms must cause significant social or
occupational dysfunction or significant subjective
distress.
E. Cannot be caused by a medical condition,
medication or drugs.
DSM-IV-TR Criteria for severity/psychotic/remission
specifies for current/most recent) MDD

Severity
• Mild
In partial In full
• Moderat remission remission
Unspecified
e
• Severe
• Diagnostician recognizes several subtypes or cause
specifies.
1. MDD with psychotic features: depression is
accompanied by hallucination or delusions, which may
be mood congruent or incongruent.
2. MDD, chronic
3. MDD, with catatonic features accompanied by at least
two of the following:
Motor immobility or stupor
Excessive purposeless motor activity
Extreme negativism or mutism.
Bizarre or inappropriate posturing, stereotyped
movement, or facial grimacing and echolalia or
echopraxia
4. MDD, with melancholic features: depression is accompanied by severe
anhedonia or lack of reactivity to usually pleasurable stimuli and at least three
of the following.
- Quality of mood distinctly depressed
- Mood is worse in the morning
- Early morning awakening
- Marked psychomotor slowing
- Significant weight loss
- Excessive guilt
5. MDD with Atypical features: depression is accompanied
by mood reactivity and two of the following:
- Significant weight gain
- Hypersomnia
- “Heavy” feeling in extremities (leaden paralysis
- Chronic patern of rejection sensitivity resulting in significant social or
occupational dysfunction
- Does not meet criteria MDD with melancholic or catatonic features.
 Management
Treatment must first secure the safety of the patient given that
suicide in such high risk.
• Pharmacotherapy
Pharmacotherapy includes medication such as TCAs, SSRI, MOIs, and
atypical agents
Selecting antidepressant agent:
1. All antidepressant drugs have shown equal efficacy. But the
various agents have different S/E profiles
2. Agent selection is also based on the expected tolerance to S/Es,
the patients age, suicide potential and any coexisting disease or
medications
a. SSRIs are much safer in patients with a hx of cardiac sx
b. SSRIs are safer than TCAs making them preferable for suicidal
patients.
 Antidepressants

Tricyclic
antidepressan
t (TCAs)
• Amitriptylin SSRIs Atypical MOIs
e • Fluoxetine Agents - Phenelzine
• Bupropion
• Imipramine • Sertaline -
• Venlafaxine
• Clomiprami • Paroxetine Tranylcypromi
• Nefazodon
ne • Fluvoxamin ne
• Protriptylin e e -
• Mirtazapin
e • Citalopram Isocarboxazid
• Noriptyline e
• Desipramin
e
• Electroconvulsive therapy for depression
- ECT is a safe and very effective treatment for
depression, especially if there is a high risk for
suicide or insufficient time for a trial of medication.

• Psychotherapy for major depressive disorder

- A wide variety of psychotherapies are effective in
the treatment of major depressive disorder
especially cognitive, behavioral psychotherapy and
insight oriented psychotherapy.
- Combined pharmacotherapy and psychotherapy is
the most effective treatment for MDD, after ETC
 Course and prognosis
Course and Prognosis of MDD

Major depressive disorder

Age at onset 36–45 years
Duration of 18- 24% develop episodes lasting more
episode than 1 year
Recovery 5–10% do not recover from index episode
Long term More benign in one third of patients,
outcome length of cycle shortens with more
frequent episodes
Mortality and Up to 15% commit suicide
suicide
 Dysthymia
• Dysthymia, which is a chronic, milder mood
disturbance where a person reports a low mood
almost daily over a span of at least two years.

• The symptoms are not as severe as those for

major depression, although people with
dysthymia are vulnerable to secondary episodes
of major depression (sometimes referred to as
double depression).
 Epidemiology
A. Lifetime prevalence is 6%, with a female-to-
male ratio of 3:1.

B. Onset usually occurs in childhood or

adolescence.

C. Dysthymia that occurs prior to the onset of

major depression has a worse prognosis than
major depression without dysthymia.
 DSM-IV Diagnostic Criteria
A. Depressed mood is present for most of the day, for more
days than it is not present, and depression has been
present for at least two years.
B. Presence of at least two 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. Hopelessness.
C. Over the two-year period, the patient has never been
without symptoms for more than two months
consecutively.
 Cont…
D. No major depressive episode has occurred
during the first two years of the disturbance.
E. No manic, hypo manic or mixed episode, or
evidence of cyclothymiacs is present.
F. Symptoms do not occur with a chronic psychotic
disorder.
G. Symptoms are not due to substance use or a
general medical condition.
H. Symptoms cause significant social or
occupational dysfunction or marked subjective
distress
 Differential Diagnosis of Dysthymic Disorder
A. MajorDepressiveDisorder.

B. Substance-Induced Mood Disorder.

C. Mood Disorder Due to a General Medical

Condition.

D. Psychotic Disorders.
E. Personality Disorders.
 Treatment
Antidepressants.
• Many patients respond well to
antidepressants.
• SSRIs are most often used.
• If these or other antidepressants, such as
venlafaxine, nefazodone or bupropion, have
failed, then a tricyclic antidepressant, such as
desipramine, 150 to 200 mg per day, is often
effective.
Psychotherapy:
 Differences of Dysthymia and MDD

Dysthymia MDD

– Two years in duration • Two weeks in duration

– Depressed mood • Depressed mood

– Two additional • Four additional

symptom symptom
– More cognitive • More vegetative
symptom symptom
– Onset mild – Onset may be severe
 Bipolar I disorder
• It is a mood disturbance in which the patient
typically experience manic symptoms for at
least one week that cause significant distress
or impairment in his/her level of functioning.
 Epidemiology of Bipolar I Disorder
• The lifetime prevalence of bipolar disorder is
approximately 0.5-1.5%.
• The male-to-female ratio is 1:1
• The first episode in males tends to be a manic
episode, while the first episode in females
tends to be a depressive episode.
• First-degree relatives have higher rates of
mood disorder. Bipolar disorder has a 70%
concordance rate among monozygotic twins.
 Clinical Features of Bipolar I Disorder
• Ninety percent of patients who have a single
manic episode will have a recurrence.
• Mixed episodes are more likely in younger
patients.
• Episodes occur more frequently with age.
• Manic episodes can result in violence, child abuse,
excessive debt, job loss, or divorce.
• The suicide rate of bipolar patients is 10-15%.
• Bipolar I disorder with a rapid cycling pattern
carries a poor prognosis and may affect up to 20%
of bipolar patients.
 DSM-IV Criteria for Bipolar I Disorder
A. One or more manic or mixed episodes.
B. The disorder is commonly accompanied by a history
of one or more major depressive episodes, but a
major depressive episode is not required for the
diagnosis.
C. Manic or mixed episodes cannot be due to a medical
condition, medication, drugs of abuse, toxins, or
treatment for depression.
D. Symptoms cannot be caused by a psychotic disorder.
Differential Diagnosis of Bipolar I Disorder
• Cyclothymiacs Disorder.

• Psychotic Disorders

• Substance-Induced Mood Disorder.

• Mood Disorder Due to a General Medical

Condition.
 Treatment of Bipolar I Disorder
• Hospitalization may be necessary
• Assessment of suicidality is essential;
• Pharmacotherapy
1. Mood stabilizers, such as lithium and the
anticonvulsants,
2. ECT is very effective for bipolar disorder
(depressed or manic episodes),
3. Antidepressants may be used for treatment of
major depressive episodes, but they should only
be used in conjunction with a mood stabilizer to
prevent precipitation of a manic episode.
Guidelines for Pretreatment Laboratory Evaluation and Monitoring of Patients Receiving Lithium

Price L and Heninger G. N Engl J Med 1994;331:591-598

 Some cautions and interaction
Caution in giving lithium to:
• the elderly (because of an increased sensitivity
to adverse effects, decreased renal clearance,
and multiple drug regimens)
• pregnant women (because of physiologic
changes and possible teratogenicity)
• surgical patients (because of physiologic
changes)
• patients with concurrent medical illnesses.
Drugs and Physiologic States Having Clinically Important Interactions with Lithium

Price L and Heninger G. N Engl J Med 1994;331:591-598

 Side effect

• Most patients receiving lithium have side

effects, reflecting the drug's narrow
therapeutic index. Many symptoms and
signs of toxicity are closely correlated with
plasma lithium concentrations, and
patients with evidence of severe toxicity
may require hemodialysis.
 Side effect
Symptoms and Signs of Toxic Effects of Lithium

Price L and Heninger G. N Engl J Med 1994;331:591-598

 Treatment cont…
4. Adjunctive use of antipsychotics (if psychosis is

present) or sedating benzodiazepines, such as

clonazepam and lorazepam (for severe agitation),

maybe necessary.

Psychotherapy

• 1. Therapy aimed at increasing insight and dealing with

the consequences of the manic episodes may be very

helpful.
 Bipolar II disorder

• The clinical features of bipolar II disorder are

those of major depressive disorder combined
with those of a hypomanic episode.
 Epidemiology

• The lifetime prevalence of bipolar II is 0.5%.

• It is more common in women than in men.
 Clinical Features of Bipolar II Disorder
• Hypomanic episodes tend to occur in close
proximity to depressive episodes, and episodes
tend to occur more frequently with age.

• Social and occupational consequences of

bipolar II can include job loss and divorce.
• These patients have a suicide rate of 10-15%.

• The rapid cycling pattern carries a poor

prognosis.
 DSM-IV Diagnostic Criteria of Bipolar II Disorder

• One or more major depressive episodes and at

least one hypomanic episode.
• Mood episodes cannot be caused by a medical
condition, medication, drugs of abuse, toxins, or
treatment for depression.
• Symptoms cannot be caused by a psychotic
disorder.
 Differential Diagnosis of Bipolar II Disorder

• Cyclothymic Disorder.

• Substance-Induced Mood Disorder.

• Mood Disorder Due to a General Medical

Condition.
 Treatment of Bipolar II Disorder
• The treatment of Bipolar II disorder includes
a mood stabilizer and an antidepressant if
depression is present.

• Treatment is similar to that of Bipolar I

disorder,
 Cyclothymia
• Cyclothymia is a milder form of bipolar
disorder, consisting of recurrent hypomanic
and dysthymic episodes, but no full manic
episodes or full major depressive episodes.

• Cyclothymic disorder consists of chronic

cyclical episodes of mild depression and
symptoms of mild mania.
 Epidemiology of Cyclothymic Disorder

• The prevalence is 1%, but cyclothymic disorder

constitutes 5-10% of psychiatric outpatients.

• The onset occurs between age 15 and 25, and

women are affected more than men by a ratio
of 3:2.

• Thirty percent of patients have a family history

of bipolar disorder.
 Differential diagnosis of Cyclothymic disorder
• Bipolar II Disorder. Patients with bipolar type II
disorder exhibit hypomania and episodes of major
depression.

• Substance-Induced Mood Disorder/Mood Disorder

Due to a General Medical Condition.

• Personality Disorders (antisocial, borderline,

histrionic, narcissistic) can be associated with
marked shifts in mood. Personality disorders may
coexist with cyclothymic disorder
 Diagnosis
DSM-IV Diagnostic Criteria
A. Many periods of depression and hypomania, occurring for at
least two years. Depressive episodes do not reach the severity
of major depression.
B. During the two-year period, the patient has not been
symptom-free for more than two months at a time.
C. During the two-year period, no episodes of major depression,
mania or mixed states were present.
D. Symptoms are not accounted for by schizoaffective disorder
and do not coexist with schizophrenia, schizophreniform
disorder, delusional disorder, or any other psychotic disorder.
E. Symptoms are not caused by substance use or a general
medical condition.
F. Symptoms cause significant distress or functional impairment.
 Treatment of Cyclothymic disorder
• Mood stabilizers are the treatment of choice, and lithium is
effective in 60% of patients. The clinical use of mood stabilizers
is similar to that of bipolar disorder.

• Depressive episodes must be treated cautiously because of the

risk of precipitating manic symptoms with antidepressants
(occursin50% of patients).

• Antidepressants can also increase the rate of cycling. Patients are

often treated concurrently with antimanics and antidepressants.

• Patients often require supportive therapy to improve awareness

of their illness and to deal with the functional consequences of
their behavior.
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