Author: Michael Jibson, M.D., Ph.D., 2009License: Unless otherwise noted, this material is made available under the terms ...
Citation Key                              for more information see: http://open.umich.edu/wiki/CitationPolicyUse + Share +...
Mood Disorders           M2 Psychiatry SequenceMichael JibsonFall 2008
IntroductionDefinition•  “Mood” (or “affect”) is a pervasive   emotional state that influences one’s view of   self, other...
IntroductionHistory•  “Melancholy” (Gr: “black bile”) has been   recognized throughout history, and has been   attributed ...
IntroductionSignificance•  Depression is #1 and bipolar disorder #6 on   the WHO Global Burden of Disease for ages   15-45
Neurobiology of Mood DisordersBiogenic amines•  Low norepinephrine and serotonin levels are   associated with depression• ...
Neurobiology of Mood DisordersNeuroendocrine dysfunction in depression•  Hypothalamic-pituitary-adrenal (HPA) axis  •  Hyp...
Neurobiology of Mood DisordersNeuroendocrine dysfunction in depression•  Hypothalamic-pituitary-thyroid axis  •  10% of se...
Neurobiology of Mood DisordersNeurophysiological dysfunction in depression•  Sleep architecture is disrupted  •  Decreased...
Neurobiology of Mood DisordersNeuroimaging in depression•  Decreased volume of frontal lobes,   amygdala, and hippocampus•...
Psychosocial FactorsStress•  Early life losses (e.g., death of a parent) are   associated with greater risk of depression ...
Psychosocial FactorsCognitive factors•  Negative self-image, interpretation of   events, and expectation for the future ar...
Psychosocial FactorsPsychoanalytic theory•  Depression arises from ambivalence toward   a lost love object
Episodic Mood Symptoms (DSM-IV Criteria)Major Depressive Episode•  Two weeks of depressed mood or anhedonia   (diminished ...
Episodic Mood Symptoms (DSM-IV Criteria)Major Depressive Episode•  Accompanied by 3-4 “vegetative”   symptoms (cont.):  • ...
Episodic Mood Symptoms (DSM-IV Criteria)Major Depressive Episode•  Symptoms cause significant distress or   impairment in ...
Episodic Mood Symptoms (DSM-IV Criteria)Major Depressive Episode•  Subtypes of Depression  •  Atypical – reversed vegetati...
Episodic Mood Symptoms (DSM-IV Criteria)Major Depressive Episode•  Subtypes of Depression  •  Melancholia    •  Prominent ...
Episodic Mood Symptoms (DSM-IV Criteria)Major Depressive Episode•  Subtypes of Depression  •  Postpartum – within 4 weeks ...
Episodic Mood Symptoms (DSM-IV Criteria)Major Depressive Episode•  Subtypes of Depression  •  Seasonal pattern – depressio...
Episodic Mood Symptoms (DSM-IV Criteria)                             Criteria for Major Depressive Episode (DSM-IV)A.     ...
Episodic Mood Symptoms (DSM-IV Criteria)                             Criteria for Major Depressive Episode (DSM-IV)       ...
Episodic Mood Symptoms (DSM-IV Criteria)Manic Episode•  A distinct period of at least one week during   which there is an ...
Episodic Mood Symptoms (DSM-IV Criteria)Manic Episode•  The symptoms must cause substantial   impairment in ability to fun...
Episodic Mood Symptoms (DSM-IV Criteria)Manic Episode•  Accompanied by 3-4 diagnostic symptoms:  •  Inflated self-esteem o...
Episodic Mood Symptoms (DSM-IV Criteria)Manic Episode•  Accompanied by 3-4 diagnostic symptoms:  •  Flight of ideas or rac...
Episodic Mood Symptoms (DSM-IV Criteria)                            Criteria for Manic Episode (DSM-IV)A.  A distinct peri...
Episodic Mood Symptoms (DSM-IV Criteria)                             Criteria for Manic Episode (DSM-IV)                  ...
Manic Episode  Image of        Image ofmanic episode   manic episode  example         example  removed         removed
Episodic Mood Symptoms (DSM-IV Criteria)Manic Episode•  Subtypes  •  Mixed – meets criteria for both depressive and     ma...
Episodic Mood Symptoms (DSM-IV Criteria)Manic Episode•  Subtypes  •  Psychotic features    •  Psychosis occurs in ~80% of ...
Episodic Mood Symptoms (DSM-IV Criteria)Manic Episode•  Subtypes  •  Rapid cycling – 4 or more episodes per year
Episodic Mood Symptoms (DSM-IV Criteria)Hypomanic Episode•  Same diagnostic features as a manic episode,   but:  •  Shorte...
Mood Disorders (DSM-IV Criteria)Major Depressive Disorder•  One or more major depressive episodes   without a manic or hyp...
Mood Disorders (DSM-IV Criteria)Major Depressive Disorder•  Onset and course  •  Peak age of onset is late 20s  •  Age ran...
Mood Disorders (DSM-IV Criteria)Major Depressive Disorder•  Onset and course  •  Onset may be sudden or gradual    •  Grad...
Mood Disorders (DSM-IV Criteria)Major Depressive Disorder•  Onset and course  •  50% of patients will experience a subsequ...
Mood Disorders (DSM-IV Criteria)Major Depressive Disorder•  Onset and course  •  50% recover within 6 months
Mood Disorders (DSM-IV Criteria)Major Depressive Disorder•  Complications and co-morbidity  •  15% lifetime suicide risk
Mood Disorders (DSM-IV Criteria)Major Depressive Disorder•  Complications and co-morbidity  •  Depressive pseudodementia  ...
Mood Disorders (DSM-IV Criteria)Major Depressive Disorder•  Complications and co-morbidity  •  Substance abuse  •  Anxiety...
Mood Disorders (DSM-IV Criteria)Major Depressive Disorder•  Epidemiology  •  Lifetime risk is 10-25% for women, 5-12% for ...
Mood Disorders (DSM-IV Criteria)Major Depressive Disorder•  Epidemiology  •  Monozygotic twins show 50-75% concurrence  • ...
Mood Disorders (DSM-IV Criteria)Major Depressive Disorder•  Treatment  •  Antidepressant medications    •  Selective Serot...
Mood Disorders (DSM-IV Criteria)Major Depressive Disorder•  Treatment  •  Antidepressant medications    •  Tricyclic antid...
Mood Disorders (DSM-IV Criteria)Major Depressive Disorder•  Treatment  •  Antidepressant medications    •  All medications...
Mood Disorders (DSM-IV Criteria)Major Depressive Disorder•  Treatment  •  Psychotherapy    •  Cognitive behavioral therapy...
Mood Disorders (DSM-IV Criteria)Major Depressive Disorder•  Treatment  •  Psychotherapy    •  65-70% effectiveness in mild...
Mood Disorders (DSM-IV Criteria)Major Depressive Disorder•  Treatment  •  Electroconvulsive therapy (ECT)    •  Indicated ...
Mood Disorders (DSM-IV Criteria)Major Depressive Disorder•  Treatment  •  Electroconvulsive therapy (ECT)    •  Relative c...
Mood Disorders (DSM-IV Criteria)Major Depressive Disorder•  Treatment  •  Electroconvulsive therapy (ECT)    •  Effective ...
Mood Disorders (DSM-IV Criteria)Major Depressive Disorder withPsychotic Features•  10% of depressed patients develop psych...
Mood Disorders (DSM-IV Criteria)Major Depressive Disorder withPsychotic Features•  Treatment  •  Combination of antidepres...
Mood Disorders (DSM-IV Criteria)Major Depressive Disorder withPsychotic Features•  Treatment  •  ECT    •  May be appropri...
Mood Disorders (DSM-IV Criteria)Dysthymic Disorder•  At least 2 years of depressed mood•  2 or more vegetative symptoms•  ...
Mood Disorders (DSM-IV Criteria)Dysthymic Disorder•  Lifetime risk is 6%; point prevalence is 3%•  Often co-morbid with ep...
Mood Disorders (DSM-IV Criteria)Dysthymic Disorder•  Treatment  •  Antidepressant medications  •  Psychotherapy (CBT, IPT)
Mood Disorders (DSM-IV Criteria)Bipolar I Disorder (formerly “manic-depression”)•  At least one manic episode with or with...
Mood Disorders (DSM-IV Criteria)Bipolar I Disorder (formerly “manic-depression”)•  Onset and course  •  Peak age of onset ...
Mood Disorders (DSM-IV Criteria)Bipolar I Disorder (formerly “manic-depression”)•  Onset and course  •  Episodes are often...
Mood Disorders (DSM-IV Criteria)Bipolar I Disorder (formerly “manic-depression”)•  Onset and course  •  70-80% of patients...
Mood Disorders (DSM-IV Criteria)Bipolar I Disorder (formerly “manic-depression”)•  Complications  •  10-15% lifetime suici...
Mood Disorders (DSM-IV Criteria)Bipolar I Disorder (formerly “manic-depression”)•  Epidemiology  •  Lifetime prevalence is...
Mood Disorders (DSM-IV Criteria)Bipolar I Disorder (formerly “manic-depression”)•  Acute treatment  •  Antipsychotic medic...
Mood Disorders (DSM-IV Criteria)Bipolar I Disorder (formerly “manic-depression”)•  Maintenance treatment  •  Mood stabiliz...
Mood Disorders (DSM-IV Criteria)Bipolar II Disorder•  At least one hypomanic episode (no manic   episode) with at least on...
Mood Disorders (DSM-IV Criteria)Bipolar II Disorder•  Lifetime prevalence is 2-3%•  Treatment is the same as major depress...
Mood Disorders (DSM-IV Criteria)Cyclothymic Disorder•  Chronic fluctuating mood not meeting criteria   for manic or major ...
Mood Disorders (DSM-IV Criteria)Cyclothymic Disorder•  50% risk of eventual development of bipolar I   or bipolar II disor...
Mood Disorders (DSM-IV Criteria)Substance Induced Mood Disorder•  Prominent and persistent mood disturbance   (depressed o...
Mood Disorders (DSM-IV Criteria)Substance Induced Mood Disorder•  Alcohol is most common substance causing   depressed moo...
Mood Disorders (DSM-IV Criteria)Substance Induced Mood Disorder•  May improve spontaneously with   detoxification•  Some c...
Mood Disorders (DSM-IV Criteria)Mood Disorder Due to a General Medical Condition•  Prominent and persistent mood disturban...
Mood Disorders (DSM-IV Criteria)Mood Disorder Due to a General Medical ConditionNeurologic•  Cerebrovascular disease   •  ...
Mood Disorders (DSM-IV Criteria)Mood Disorder Due to a General Medical ConditionEndocrine                  Other•  Addison...
Mood Disorders (DSM-IV Criteria)Mood Disorder Due to a General Medical ConditionInfectious and Inflammatory•  AIDS        ...
Mood Disorders (DSM-IV Criteria)Adjustment Disorder with Depressed Mood•  Development of depressed mood within 3   months ...
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10.28.08(a): Mood Disorders

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10.28.08(a): Mood Disorders

  1. 1. Author: Michael Jibson, M.D., Ph.D., 2009License: Unless otherwise noted, this material is made available under the terms of theCreative Commons Attribution–Share Alike 3.0 License:http://creativecommons.org/licenses/by-sa/3.0/We have reviewed this material in accordance with U.S. Copyright Law and have tried to maximize your ability to use, share, and adaptit. The citation key on the following slide provides information about how you may share and adapt this material.Copyright holders of content included in this material should contact open.michigan@umich.edu with any questions, corrections, orclarification regarding the use of content.For more information about how to cite these materials visit http://open.umich.edu/education/about/terms-of-use.Any medical information in this material is intended to inform and educate and is not a tool for self-diagnosis or a replacement for medicalevaluation, advice, diagnosis or treatment by a healthcare professional. Please speak to your physician if you have questions about yourmedical condition.Viewer discretion is advised: Some medical content is graphic and may not be suitable for all viewers.
  2. 2. Citation Key for more information see: http://open.umich.edu/wiki/CitationPolicyUse + Share + Adapt { Content the copyright holder, author, or law permits you to use, share and adapt. } Public Domain – Government: Works that are produced by the U.S. Government. (17 USC § 105) Public Domain – Expired: Works that are no longer protected due to an expired copyright term. Public Domain – Self Dedicated: Works that a copyright holder has dedicated to the public domain. Creative Commons – Zero Waiver Creative Commons – Attribution License Creative Commons – Attribution Share Alike License Creative Commons – Attribution Noncommercial License Creative Commons – Attribution Noncommercial Share Alike License GNU – Free Documentation LicenseMake Your Own Assessment { Content Open.Michigan believes can be used, shared, and adapted because it is ineligible for copyright. } Public Domain – Ineligible: Works that are ineligible for copyright protection in the U.S. (17 USC § 102(b)) *laws in your jurisdiction may differ { Content Open.Michigan has used under a Fair Use determination. } Fair Use: Use of works that is determined to be Fair consistent with the U.S. Copyright Act. (17 USC § 107) *laws in your jurisdiction may differ Our determination DOES NOT mean that all uses of this 3rd-party content are Fair Uses and we DO NOT guarantee that your use of the content is Fair. To use this content you should do your own independent analysis to determine whether or not your use will be Fair.
  3. 3. Mood Disorders M2 Psychiatry SequenceMichael JibsonFall 2008
  4. 4. IntroductionDefinition•  “Mood” (or “affect”) is a pervasive emotional state that influences one’s view of self, others, and the environment.
  5. 5. IntroductionHistory•  “Melancholy” (Gr: “black bile”) has been recognized throughout history, and has been attributed to psychological, biological, and psychosocial factors at least since Hippocrates.
  6. 6. IntroductionSignificance•  Depression is #1 and bipolar disorder #6 on the WHO Global Burden of Disease for ages 15-45
  7. 7. Neurobiology of Mood DisordersBiogenic amines•  Low norepinephrine and serotonin levels are associated with depression•  Elevated norepinephrine and serotonin levels are associated with mania•  Most antidepressants increase synaptic transmission of norepinephrine, serotonin, or both
  8. 8. Neurobiology of Mood DisordersNeuroendocrine dysfunction in depression•  Hypothalamic-pituitary-adrenal (HPA) axis •  Hyperactivation leads to excess cortisol secretion •  Dexamethasone suppression test (DST) shows nonsuppression of cortisol in 50% of cases •  Immune functions may be suppressed with depressed mood
  9. 9. Neurobiology of Mood DisordersNeuroendocrine dysfunction in depression•  Hypothalamic-pituitary-thyroid axis •  10% of severely depressed patients have hypothyroidism
  10. 10. Neurobiology of Mood DisordersNeurophysiological dysfunction in depression•  Sleep architecture is disrupted •  Decreased total sleep time •  Decreased REM latency •  Increased total REM sleep
  11. 11. Neurobiology of Mood DisordersNeuroimaging in depression•  Decreased volume of frontal lobes, amygdala, and hippocampus•  Decreased metabolic activity in the frontal lobes, hippocampus, and amygdala
  12. 12. Psychosocial FactorsStress•  Early life losses (e.g., death of a parent) are associated with greater risk of depression in adulthood•  Acute life stress is highly associated with onset of depression
  13. 13. Psychosocial FactorsCognitive factors•  Negative self-image, interpretation of events, and expectation for the future are associated with depression•  “Learned helplessness” refers to passivity and despair associated with lack of control over life events
  14. 14. Psychosocial FactorsPsychoanalytic theory•  Depression arises from ambivalence toward a lost love object
  15. 15. Episodic Mood Symptoms (DSM-IV Criteria)Major Depressive Episode•  Two weeks of depressed mood or anhedonia (diminished interest or pleasure)•  Accompanied by 3-4 “vegetative” symptoms: •  Decreased appetite or weight loss (>5% of body weight in one month) or increased appetite •  Insomnia (usually early waking) or increased sleep •  Psychomotor retardation or agitation (cont.)
  16. 16. Episodic Mood Symptoms (DSM-IV Criteria)Major Depressive Episode•  Accompanied by 3-4 “vegetative” symptoms (cont.): •  Fatigue or loss of energy •  Feelings of worthlessness or inappropriate guilt •  Impaired concentration or indecisiveness •  Recurrent thoughts of death or suicide
  17. 17. Episodic Mood Symptoms (DSM-IV Criteria)Major Depressive Episode•  Symptoms cause significant distress or impairment in function•  Not attributable to substance abuse or medical illness•  Not in the context of normal bereavement
  18. 18. Episodic Mood Symptoms (DSM-IV Criteria)Major Depressive Episode•  Subtypes of Depression •  Atypical – reversed vegetative symptoms •  Hypersomnia •  Increased appetite or weight gain •  Rejection sensitivity
  19. 19. Episodic Mood Symptoms (DSM-IV Criteria)Major Depressive Episode•  Subtypes of Depression •  Melancholia •  Prominent anhedonia •  Intense vegetative symptoms
  20. 20. Episodic Mood Symptoms (DSM-IV Criteria)Major Depressive Episode•  Subtypes of Depression •  Postpartum – within 4 weeks of delivery of a child •  Catatonic – characteristic motor signs (see Schizophrenia notes) •  Psychotic features – psychosis is present only during depressive episodes
  21. 21. Episodic Mood Symptoms (DSM-IV Criteria)Major Depressive Episode•  Subtypes of Depression •  Seasonal pattern – depression occurs at specific times of the year •  Depression most common in fall and winter
  22. 22. Episodic Mood Symptoms (DSM-IV Criteria) Criteria for Major Depressive Episode (DSM-IV)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. (1) depressed mood most of the day, nearly every day, as indicated by either subjective report (e.g., feels sad or empty) 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 made by others) (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 gains. (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) (cont.) American Psychiatric Association: Diagnostic and Manual of Mental Disorders, 4th ed, Text Revision (DSM-IV-TR)
  23. 23. Episodic Mood Symptoms (DSM-IV Criteria) Criteria for Major Depressive Episode (DSM-IV) (cont.) (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 suicideB.  The symptoms do not meet criteria for a Mixed Episode.D.  The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.F.  The symptoms are not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition (e.g., hypothyroidism).E. The symptoms are not better accounted for by Bereavement, i.e., after the loss of a loved one, the symptoms persist for longer than 2 months or are characterized by marked functional impairment, morbid preoccupation with worthlessness, suicidal ideation, psychotic symptoms, or psychomotor retardation. American Psychiatric Association: Diagnostic and Manual of Mental Disorders, 4th ed, Text Revision (DSM-IV-TR)
  24. 24. Episodic Mood Symptoms (DSM-IV Criteria)Manic Episode•  A distinct period of at least one week during which there is an abnormally and persistently elevated, expansive, or irritable mood
  25. 25. Episodic Mood Symptoms (DSM-IV Criteria)Manic Episode•  The symptoms must cause substantial impairment in ability to function, or be accompanied by active psychotic symptoms
  26. 26. Episodic Mood Symptoms (DSM-IV Criteria)Manic Episode•  Accompanied by 3-4 diagnostic symptoms: •  Inflated self-esteem or grandiosity •  Decreased need for sleep •  Loud, rapid, and intrusive speech (cont.)
  27. 27. Episodic Mood Symptoms (DSM-IV Criteria)Manic Episode•  Accompanied by 3-4 diagnostic symptoms: •  Flight of ideas or racing thoughts, distractibility •  Increased involvement in goal-directed activities •  High-risk behavior – fast driving, indiscriminate sex, spending sprees, ill-considered financial investments, etc.
  28. 28. Episodic Mood Symptoms (DSM-IV Criteria) Criteria for Manic Episode (DSM-IV)A.  A distinct period of abnormally and persistently elevated, expansive, or irritable mood, lasting at least 1 week (or any duration if hospitalization is necessary).B. During the period of mood disturbance, three (or more) of the following symptoms have persisted (four if the mood is only irritable) 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) (6) increase in goal-directed activity (either socially, at work or school, or sexually) or psychomotor agitation (cont.) DSM-IV-TR, pp. 362
  29. 29. Episodic Mood Symptoms (DSM-IV Criteria) Criteria for Manic Episode (DSM-IV) (cont.) (7) excessive involvement in pleasurable activities that have a high potential for harmful consequences (e.g., engaging in unrestrained buying sprees, sexual indiscretions, or foolish business investments)C.  The symptoms do not meet criteria for a Mixed Episode.D.  The mood disturbance is sufficiently severe to cause marked impairment in occupational functioning or in usual social activities or relationships with others, or to necessitate hospitalization to prevent harm to self or others, or there are psychotic features.E.  The symptoms are not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication, or other treatment) or a general medical condition (e.g., hyperthyroidism). DSM-IV-TR, pp. 362
  30. 30. Manic Episode Image of Image ofmanic episode manic episode example example removed removed
  31. 31. Episodic Mood Symptoms (DSM-IV Criteria)Manic Episode•  Subtypes •  Mixed – meets criteria for both depressive and manic episode •  Symptoms may rapidly alternate or be simultaneously present
  32. 32. Episodic Mood Symptoms (DSM-IV Criteria)Manic Episode•  Subtypes •  Psychotic features •  Psychosis occurs in ~80% of manic episodes •  Often mood congruent (e.g., grandiose delusions), but may be indistinguishable from psychotic symptoms of schizophrenia or other disorders •  Insight tends to be good between episodes, but very poor during the episodes
  33. 33. Episodic Mood Symptoms (DSM-IV Criteria)Manic Episode•  Subtypes •  Rapid cycling – 4 or more episodes per year
  34. 34. Episodic Mood Symptoms (DSM-IV Criteria)Hypomanic Episode•  Same diagnostic features as a manic episode, but: •  Shorter duration (at least 4 days) •  No significant impairment in function •  No psychosis •  No hospital admission
  35. 35. Mood Disorders (DSM-IV Criteria)Major Depressive Disorder•  One or more major depressive episodes without a manic or hypomanic episode
  36. 36. Mood Disorders (DSM-IV Criteria)Major Depressive Disorder•  Onset and course •  Peak age of onset is late 20s •  Age range for onset is childhood to late life
  37. 37. Mood Disorders (DSM-IV Criteria)Major Depressive Disorder•  Onset and course •  Onset may be sudden or gradual •  Gradual onset often includes weeks-months of subclinical symptoms •  Acute onset usually follows within 6 months of a significant stressor
  38. 38. Mood Disorders (DSM-IV Criteria)Major Depressive Disorder•  Onset and course •  50% of patients will experience a subsequent episode •  Risk of recurrence increases with age and number of previous episodes •  Average number of episodes is 4
  39. 39. Mood Disorders (DSM-IV Criteria)Major Depressive Disorder•  Onset and course •  50% recover within 6 months
  40. 40. Mood Disorders (DSM-IV Criteria)Major Depressive Disorder•  Complications and co-morbidity •  15% lifetime suicide risk
  41. 41. Mood Disorders (DSM-IV Criteria)Major Depressive Disorder•  Complications and co-morbidity •  Depressive pseudodementia •  Cognitive deficits related to poor concentration and energy •  Resolves with improvement in mood
  42. 42. Mood Disorders (DSM-IV Criteria)Major Depressive Disorder•  Complications and co-morbidity •  Substance abuse •  Anxiety disorders are common
  43. 43. Mood Disorders (DSM-IV Criteria)Major Depressive Disorder•  Epidemiology •  Lifetime risk is 10-25% for women, 5-12% for men •  Point prevalence is 5-10% for women, 2-3% for men •  Gender distribution is 2:1 W:M
  44. 44. Mood Disorders (DSM-IV Criteria)Major Depressive Disorder•  Epidemiology •  Monozygotic twins show 50-75% concurrence •  25% risk to first-degree relatives
  45. 45. Mood Disorders (DSM-IV Criteria)Major Depressive Disorder•  Treatment •  Antidepressant medications •  Selective Serotonin Reuptake Inhibitors (SSRIs) – usual 1st-line agents •  Atypical antidepressants – also used as 1st-line agents
  46. 46. Mood Disorders (DSM-IV Criteria)Major Depressive Disorder•  Treatment •  Antidepressant medications •  Tricyclic antidepressants – less common, older agents •  Monoamine oxidase inhibitors (MAOIs) – least common, older agents
  47. 47. Mood Disorders (DSM-IV Criteria)Major Depressive Disorder•  Treatment •  Antidepressant medications •  All medications work in 65-70% of cases (placebo response is 30%) •  At least 6 months of treatment is optimal •  Prophylactic treatment is effective for patients at high risk for relapse
  48. 48. Mood Disorders (DSM-IV Criteria)Major Depressive Disorder•  Treatment •  Psychotherapy •  Cognitive behavioral therapy (CBT) •  Interpersonal therapy (IPT)
  49. 49. Mood Disorders (DSM-IV Criteria)Major Depressive Disorder•  Treatment •  Psychotherapy •  65-70% effectiveness in mild-moderate depression •  Combination of psychotherapy and medication is more effective than either treatment alone
  50. 50. Mood Disorders (DSM-IV Criteria)Major Depressive Disorder•  Treatment •  Electroconvulsive therapy (ECT) •  Indicated for severe depression, lack of response to other treatments, psychotic features, high suicide risk, starvation or dehydration, prior good response, or patient preference
  51. 51. Mood Disorders (DSM-IV Criteria)Major Depressive Disorder•  Treatment •  Electroconvulsive therapy (ECT) •  Relative contraindications are intracranial mass, dementia, severe personality disorder, high anesthesia risk •  Primary side effect is memory loss and confusion (both self-limiting)
  52. 52. Mood Disorders (DSM-IV Criteria)Major Depressive Disorder•  Treatment •  Electroconvulsive therapy (ECT) •  Effective in 80% of patients •  Maintenance ECT is used when risk of relapse is high •  Maintenance antidepressant medication is used in all other cases
  53. 53. Mood Disorders (DSM-IV Criteria)Major Depressive Disorder withPsychotic Features•  10% of depressed patients develop psychotic features•  Psychotic symptoms are often (but not always) congruent with mood
  54. 54. Mood Disorders (DSM-IV Criteria)Major Depressive Disorder withPsychotic Features•  Treatment •  Combination of antidepressant and antipsychotic medications •  Neither medication works well alone •  50% effective when used together
  55. 55. Mood Disorders (DSM-IV Criteria)Major Depressive Disorder withPsychotic Features•  Treatment •  ECT •  May be appropriate 1st-line treatment •  80-90% effective
  56. 56. Mood Disorders (DSM-IV Criteria)Dysthymic Disorder•  At least 2 years of depressed mood•  2 or more vegetative symptoms•  Does not meet criteria for major depressive episode for at least the first 2 years
  57. 57. Mood Disorders (DSM-IV Criteria)Dysthymic Disorder•  Lifetime risk is 6%; point prevalence is 3%•  Often co-morbid with episodes of major depression (“double depression”)
  58. 58. Mood Disorders (DSM-IV Criteria)Dysthymic Disorder•  Treatment •  Antidepressant medications •  Psychotherapy (CBT, IPT)
  59. 59. Mood Disorders (DSM-IV Criteria)Bipolar I Disorder (formerly “manic-depression”)•  At least one manic episode with or without a depressive episode
  60. 60. Mood Disorders (DSM-IV Criteria)Bipolar I Disorder (formerly “manic-depression”)•  Onset and course •  Peak age of onset is in 20s •  Age range for onset is from teens to 60s •  Symptoms tend to progress rapidly (i.e., a few days) from pleasantly elevated mood at onset to euphoria to irritability to psychosis. Some cases progress to catatonia.
  61. 61. Mood Disorders (DSM-IV Criteria)Bipolar I Disorder (formerly “manic-depression”)•  Onset and course •  Episodes are often triggered by physical or psychosocial stressors •  Episodes are often (~60%) preceded or followed immediately by a depressive episode •  >90% of patients have recurrent episodes
  62. 62. Mood Disorders (DSM-IV Criteria)Bipolar I Disorder (formerly “manic-depression”)•  Onset and course •  70-80% of patients return to full function between episodes; 20-30% have persistent mood instability or functional impairment •  Episodes occur every 2-3 years for patients in their 20s, gradually increasing in frequency to 1-2 episodes per year for patients in their 50s
  63. 63. Mood Disorders (DSM-IV Criteria)Bipolar I Disorder (formerly “manic-depression”)•  Complications •  10-15% lifetime suicide risk •  Substance abuse is common
  64. 64. Mood Disorders (DSM-IV Criteria)Bipolar I Disorder (formerly “manic-depression”)•  Epidemiology •  Lifetime prevalence is 1% of the general adult population •  Gender distribution is 1:1 •  Monozygotic twins show ~80% concurrence •  25% risk to first-degree relatives
  65. 65. Mood Disorders (DSM-IV Criteria)Bipolar I Disorder (formerly “manic-depression”)•  Acute treatment •  Antipsychotic medication – 1st-line treatment •  Mood stabilizers •  Lithium – 1st-line treatment •  Valproic acid – 1st-line treatment •  Other anticonvulsants – carbamazepine, lamotragine, topiramate •  Avoid antidepressant medications during manic phase
  66. 66. Mood Disorders (DSM-IV Criteria)Bipolar I Disorder (formerly “manic-depression”)•  Maintenance treatment •  Mood stabilizers (same as above) •  Antidepressant medications may be indicated
  67. 67. Mood Disorders (DSM-IV Criteria)Bipolar II Disorder•  At least one hypomanic episode (no manic episode) with at least one depressive episode•  Similar onset, course, and complications to bipolar I disorder
  68. 68. Mood Disorders (DSM-IV Criteria)Bipolar II Disorder•  Lifetime prevalence is 2-3%•  Treatment is the same as major depressive disorder and bipolar I disorder
  69. 69. Mood Disorders (DSM-IV Criteria)Cyclothymic Disorder•  Chronic fluctuating mood not meeting criteria for manic or major depressive episodes•  Insidious onset in adolescence or young adulthood followed by chronic course
  70. 70. Mood Disorders (DSM-IV Criteria)Cyclothymic Disorder•  50% risk of eventual development of bipolar I or bipolar II disorder•  Lifetime prevalence is 0.4-1%•  Treatment is the same as major depressive disorder and bipolar I disorder
  71. 71. Mood Disorders (DSM-IV Criteria)Substance Induced Mood Disorder•  Prominent and persistent mood disturbance (depressed or elevated) related to intoxication or withdrawal from a substance (drug of abuse, medication, toxin)
  72. 72. Mood Disorders (DSM-IV Criteria)Substance Induced Mood Disorder•  Alcohol is most common substance causing depressed mood•  Amphetamine, cocaine, and steroids (e.g., prednisone) are commonly associated with mood elevation
  73. 73. Mood Disorders (DSM-IV Criteria)Substance Induced Mood Disorder•  May improve spontaneously with detoxification•  Some cases require additional treatment with antidepressant medications•  Antidepressants are rarely effective if intoxication or withdrawal continues or recurs
  74. 74. Mood Disorders (DSM-IV Criteria)Mood Disorder Due to a General Medical Condition•  Prominent and persistent mood disturbance (depressed or elevated) related to the direct physiological effects of an illness
  75. 75. Mood Disorders (DSM-IV Criteria)Mood Disorder Due to a General Medical ConditionNeurologic•  Cerebrovascular disease •  Neoplasm•  Dementia •  Parkinson’s disease•  Huntington’s disease •  Progressive supranuclear palsy•  Hydrocephalus •  Seizure disorder•  Migraine •  Sleep apnea•  Multiple sclerosis •  Traumatic brain injury•  Narcolepsy •  Wilson’s disease M. Jibson
  76. 76. Mood Disorders (DSM-IV Criteria)Mood Disorder Due to a General Medical ConditionEndocrine Other•  Addison’s disease •  Cancer (esp. pancreatic)•  Cushing’s disease •  Cardiopulmonary disease•  PMS •  Porphyria•  Parathyroid disorders •  Uremia•  Postpartum •  Vitamin deficiencies (B12,•  Thyroid disorders folate, niacin, thiamine) M. Jibson
  77. 77. Mood Disorders (DSM-IV Criteria)Mood Disorder Due to a General Medical ConditionInfectious and Inflammatory•  AIDS •  Sjogren’s arteritis•  Encephalitis •  Systemic lupus erythematosus•  Mononucleosis •  Temporal arteritis•  Pneumonia •  Tuberculosis•  Rheumatoid arthritis M. Jibson
  78. 78. Mood Disorders (DSM-IV Criteria)Adjustment Disorder with Depressed Mood•  Development of depressed mood within 3 months of the onset of a stressor•  Symptoms resolve within 6 months of the removal of the stressor•  Symptoms do not meet criteria for another mood disorder
  79. 79. Additional Source Information for more information see: http://open.umich.edu/wiki/CitationPolicySlide 22: American Psychiatric Association: Diagnostic and Manual of Mental Disorders, 4th ed, Text Revision (DSM-IV-TR), Washington, DC, American Psychiatric Association, 2000, p. 356Slide 23: American Psychiatric Association: Diagnostic and Manual of Mental Disorders, 4th ed, Text Revision (DSM-IV-TR), Washington, DC, American Psychiatric Association, 2000, p. 356Slide 28: DSM-IV-TR, pp. 362Slide 29: DSM-IV-TR, pp. 36275: Michael Jibson76: Michael Jibson77: Michael Jibson

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