The document provides an overview of mood disorders, focusing on major depressive disorder and bipolar disorder, including their symptoms, diagnostic criteria, and treatment options. It details types of depression, including atypical and agitated depression, as well as pharmacotherapy approaches such as SSRIs, SNRIs, and mood stabilizers like lithium. The content also addresses suicide risk factors associated with mood disorders, emphasizing the significance of early diagnosis and treatment.

1. MOOD DISORDERS
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2. Mood disorders
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3. Mood disorders
• Major depressive disorder
• Bipolar disorder disorder
• Either have both mania & depression /may present with mania
• Hypomania
• Less severe than mania
• Cyclothymia
• Less severe form of bipolar disorder
• Dysthymia
• Less severe & c/c form of major DepressionTONY SCARIA 2010
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4. Rapid cycling
• Picture of mania & depression alternates rapidly with each other with
out a normal intervening period
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5. Mood disorders
Unipolar mood disorders Bipolar disorders
Depression (single episodes or recurrent episodes of
depression alone)
• Mania (recurrent episodes of mania alone)
• Episodes of mania & depression  manic
depressive illness
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6. Depression
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7. depression
• Mc psychiatric disorder after anxiety disorder
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8. depression
• F>>M
• Around middle age
• Divorced and separated persons
• Mc cause of suicide
• Maximum DALY among psychiatric ds
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9. Symptoms of depression (should be present
> 2weeks )
• Sleep
• Insomnia or hypersomnia
• Early morning awakening
• Reduced latency of REM sleep
• Lack of appetite & weight loss
• Decreased energy levels & easy fatigability
• Negative cognitions & poor concentration
• Anhedonia
• Guilt feeling  himself or trivial matters
• Suicidal thoughts
• Depressed mood
• Psychomotor activity retardationTONY SCARIA 2010
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10. • Social withdrawal
• Delusion of nilhilsm
•
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11. Becks cognitive triad of depression
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12. Diagnostic criteria of depression
5 or more symptoms should last for > 2 weeks
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13. Omega sign
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14. Otto veraguth fold
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15. Other features of depression
• Psychotic features
• In severe depression
• Delusions & hallucinations
• Mood congruent / incongruent
• With atypical features
• Hypersomnia /over eating/ weight gain
• With melancholic features  involutional melancholia
• Old age
• Severe anhedonia
• Guilt feelings
• Early morning awakening
• Weight loss
• With catatonic features
• Stupor TONY SCARIA 2010
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16. Symptoms of depression
Mood Thought Cognition Psychomotor activity
• Low & sad
• Social withdrawal
• Anhedonia
• Social withdrawal
• Delusion of nilhilism
• Suicidal ideas
• Hypochondriacal
delusions
• Guilt feeling
• Loss of self esteem
• Poor concentration
• Pseudodementia in
elderly
• Psychomotor
retardation
• Lack of initiative &
energy
Somatic symptoms & biological
disturbances
Psychotic symptoms
• Decrease in appetite
• Terminal insominia Early morning
awakening
• Reduced latency of REM sleep
• Diurnal variation (depression is worse
in the morning )
• May be mood congruent or mood
incongruent 2nd person auditory
hallucination / delusionTONY SCARIA 2010
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17. Types of depression
• Mild
• Moderate
• Severe
• Severe depression + psychotic
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18. Causes of depression
• Hypo / hyperthyroidism
• Hypo / hyper parathyroidism
• cushings ds
• Addisons ds
• Withdrawal of steroids
• Post partum psychosis
• Post MI
• AIDS cancer
• OCD TONY SCARIA 2010
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19. Etiology
• NT disturbances
• Serotonin & NE
• Hormonal disturbances
• Elevated HPA activity
• Hypothyroidism  depression
• Neuroanatomical considerations
• ↓↓ in dorsolateral of prefrontal cortex
• ↑↑in amygdala
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20. TONY SCARIA 2010
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21. Aaron beck cognitive triad of depression
• Negative view of self (idea of worthlessness
• Ideas of helplessness
• Ideas of hopelessness
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22. Diagnostic criteria of depression
Major depressive disorder
5 or more of above symptoms
Minor depressive disorder
Atleast 2 of the above symptoms
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23. Rx
• Pharmacotherapy
• Psychotherapy
• Other somatic rx
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24. Pharmacotherapy
• PTx given in case of
• In c/ depression (>2 years)
• >3 depressive episodes
• Antidepressants exert 3-4 weeks for therapeutic action
• Choice of antidepressant  by s/e profile of drug
• For a period (which ever is longest)
• Of 6 months
• Drn of previous period
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25. Atypical depression
• Hypersomnia
• Increased carbohydrate
craving
• Obesity
• Interpersonal sensitivity
• Leaden paralysis
• Always lying down on bed
• Feeling heaviness of legs
• Rx
• MAOi
(moclobemide/phenelzine
)
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26. Involutional melancholia
• severe depression in which melancholia (Somatic symptoms) occur in
involutional period of life (40-65 years).
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27. Agitated depression
• This is a type of severe depression with marked motor restlessness or
agitation. It is either seen alone or along with involutional
melancholia. It is more common after the age of 40 years.
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28. TCA and tetracyclic depressants
• Block SERT (transporters of 5HT & NE)
• Increase levels of 5HT & NE in synapse
• Block H1
• Sedation
• a1 & a2
• Postural hypotension
• Sodium and cardiac sodium channels
• Arrhthmias & seizures
• Anticholinergic symptoms
• Constipation
• Urinary retention  C/I in BPH
• Blurred vision  C/I in glaucoma
• Dry mouth/ delirium /decreased sweatingTONY SCARIA 2010
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29. TONY SCARIA 2010
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30. TCA and tetracyclic depressants
• Amoxapine
• D2 blocking action  EPS
• Impipramine
• For nocturnal enuresis
• Clomipramine
• Fist line in OCD
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31. TCA
• Amitryptilline
• Desipramine
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32. Selective serotonin reuptake inhibitors (SSRI)
• Fist line drug for depression /OCD/Post traumatic stress
disorder/panic disorder/phobias/generalised aniety disorders
• Fluoxetine
• Citalopram
• Escitalopram
• Sertraline
• Paroxetine
• Vilazodone
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33. TONY SCARIA 2010
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34. TONY SCARIA 2010
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35. Down regulation of 5HT1A
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36. S/E of SSRI
• Delayed ejaculation
• Rx of premature ejaculation
• Decreased libido
• Anorgasmia
• Sedation
• Sweating
• Weight gain
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37. Serotonin syndrome
• Concurrent administration of SSRI + MAO inhibitor /L-tryptophan /
Lithium
• ↑↑ plasma serotonin
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39. • Diarrhea
• Restlessness
• Hyperreflexia
• Myoclonus
• Seizures
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40. TONY SCARIA 2010
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41. Rx of serotonin syndrome
• Cyproheptadine
• Supportive care
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42. Serotonin norepinephrine reuptake inhibitor
(SNRI)
• Dual reuptake of inhibitors
• SNRI  HTn in higher dose
• Venlafaxine
• Desvenlafaxine
• Duloxetine
• milnacipran
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43. Monoamine oxidase inhibitor
• MAO A
• Metabolism of serotonin NE & dopamine
• MAO B
• Metabolism of dopamine
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44. Nonspecific MAO inhibitors
• Tranylcypromine
• Phenelzine
• Isocarboxazid
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45. TONY SCARIA 2010
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46. Substances that can cause cheese reaction
contains tyramine  usually destroyed in GIT by
MAO
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47. Nonspecific inhibition of MAO  elevation of
tyramine in blood hypertension= Cheese
reaction
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48. TONY SCARIA 2010
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49. • Rx of cheese reaction
• Phentolamine
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50. Atypical antidepressants
• Trazodone & nefazodone
• SARI (serotonin antagonist & reuptake inhibitors)
• Weak inhibition of serotonin reuptake & strong antagonism @ 5HT2A & 5HT2c
• Trazadone  priapism
• Mirtazapine
• Bupropion
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51. Mirtazapine 
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52. TONY SCARIA 2010
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53. TONY SCARIA 2010
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54. Activates 5HT2 & 5HT3 sedation
no sexual S/E
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55. Bupropion
• Norepinephrine dopamine reuptake inhibitors
• Less sexual S/E or weight gain or sedation
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56. Antidepressant used for smoking cessation 
bupropion
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57. Bupropion  can cause seizures
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58. Tianeptine & amineptine
• Enhance reuptake of serotonin
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59. Psychotherapy for depression
• Cognitive behaviour therapy
• Interpersonal therapy
• Behaviour therapy family therapyTONY SCARIA 2010
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60. • Cognitive behaviour therapy
• Most effective psychotherapeutic technique
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61. • ECT
• Severe depression with suicidal risk
• With stupor
• With psychotic symptoms/refractoriness
• Transcranial magnetic stimulation
• No anaesthesia /nonconvulsive /safe s/e profile
• Vagal N stimulation with an electrode
• Deep brain stimulation
• c/c & intractable
• Sleep deprivation
• Phototherapy  seasonal affective disordersTONY SCARIA 2010
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62. Resistant depression
• 10-20 %
• Depression a/w Personality ds /substance abuse /anemia /TB/DM
• May have white matter intensities
• Augmentation strategy is used
• Combination of antidepressants
• Small dose Li+ antidepressant
• Thyroxine+ Anti depressant
• ECT + antidepressant
• Antipsychotic + antidepressant
• Light therapy
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63. Mania
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64. Mania
• Triad of mania
• Elated mood
• Pressure of speech
• Increased psychomotor activity
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65. TONY SCARIA 2010
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66. CF of mania
Mood Thought & speech Psychomotor activity Psychotic features
• Elated mood
• Irritability
• Pressure of speech
• Flight of ideas
• Delusion of grandeur
• Distractability
• High self esteem
• Increased 
restlessness
• Goal directed activity
• Religious & spiritual
contents
Mania
• Increased sexual drive
• Decreased need for sleep
• Spending excessive money
• Absent insight TONY SCARIA 2010
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67. Bipolar disorder
• Recurrent episodes of mania and depression
• Mania alone
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68. Bipolar disorder type I Bipolar disorder type II
• Episodes of mania & major depression with
euthymia in between
• Mania alone
• Mania + hypomania
• Mania + hypomania + depression
• Hypomania + major depression
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72. Type III bipolar disorder
• Antidepressant induced bipolar
• Patient with depression on intake of antidepressant develops mania
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73. Symptoms should last atleast 7 days
• Elevated mood
• Increased self esteem or grandiosity
• Decreased need for sleep
• Over talkativeness
• Flight of ideas
• Inability to concentrate  distractility
• Increase involvement in activities that have painful consequences
• Increase involvement in gola directed activitiesTONY SCARIA 2010
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74. Etiology
• Neuro transmitters
• Increased levels of dopamine
• Genetic
• 18 q
• 22q
• 21q
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75. Rx of BPD
• Mood stabilsers
• Li
• Valproate
• Carbamazepine
• Oxcarbazepine
• Lamotrigene
• BZD
• Lorazepam & clonazepam in ac mania
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76. Rx of BPD
• Manic phase
• Li is the DOC
• Depressive phase
• Lamotrigene + Li
• Prophylaxis
• Li
• Valproate
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77. TONY SCARIA 2010
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78. Persistent mood disorder
• Symptoms for more than 2 years in adults
• In children & young adolescent 1 yr
Dysthymia Cyclothymia c/c major depression
Depressed mood for > 2
years
Episodes of hypomania &
depression not enough to
meet the criteria of BPD
Depression for > 2 years
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79. Dysthymia diagnostic criteria
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80. Double depression
• Patient with cyclothymia
develops major depression
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81. Rx of BPD
Rx of acute mania Rx of bipolar depression
• Lithium
• valproate
• Carbamazepine
• Atypical & typical antipsychotics
• Benzodiazepines
Maintenance treatment /prophylactic Rx of BPD
• Li
• Carbamazepine
• Valproate
• Other drugs  topiramate /lamotrigine /atypical antipsychotics (aripiprazole olanzapine)
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82. • Somatic therpaies
• Used in Rx resistant depression
Ablative limbic Sx Vagal Nerve
stimulation
Transcranial
magnetic
stimulation
Deep brain
stimulation
• Anterior
cingulotomy
• Anterior
capsulotomy
• Subcaudate
tractotomy
• Limbic
leucotomy
• Left vagus is
used
• Right vagus is
not used as it
supplies heart
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83. Hypomania
• Symptoms slr to mania
• Duration is 4 days only
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84. Rapid cycling
• 4 or more episodes of depression and or mania or hypomania occur
per year
• With either less than 2 weeks of normal mood b/w episodes or switch directly
from one pole to another with out intervening normal period
RF for rapid cycling  prone for rapid cycling
• Female gender
• Hypothyroidism
• Alcoholism
• Antidepressants with out mood stabilisers
• Bipolar type II
• Cyclothymia TONY SCARIA 2010
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85. Rapid cyclers
• DOC  valproate
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86. Li
• Prototypical mood stabiliser
• Act in 1- 2 weeks
• Not metabolised  get excreted unchanged through kidney
• Indications
• Cluster head ache
• neutropenia
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87. Li
• treatment of
• a/c manic episode in patient of BPD
• MDP (manic depressive psychosis)bipolar depression.
• Prohylaxis of MDP 0.8 mEq
• Cyclothymia
• It has a low toxic : therapeutic ratio.
• therapeutic level of Lithium = 0.8 - 1.2 mEq/L.
• Lithium toxicity
• when serum lithium levels exceed 1.5 to 2 mEq/L. Hence frequent bood tests are
done to monitor the drug levels.
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88. TONY SCARIA 2010
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89. • S/E
• Teratogenic  EBSTEINS ANOMALY
• Tremors  postural  Rx propranolol
• Polyuria diabetes insipidus
• Renal failure
• Hypothyroidism
• Exacerbation of psoriasis
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90. Lithium toxicity
• >1.5mEq
• Excreted changed through kidney
• R/F
• Low sodium diet / dehydration/renal impairement
• Symptoms
• GI symptoms
• Abdominal pain/vomiting
• Neurological
• Coarse tremors/ataxia /dysarthria
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91. • Late signs of Li toxicity
• Impairement of consciousness
• Muscular fasciculations
• Increased deep tendon reflexes
• Convulsions
• Rx
• Stop Li
• Polyethyelene glycol
• Hemodialysis
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92. TONY SCARIA 2010
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93. • Lithium carbonate, sodium valproate and olanzapine are equally
effective in acute mania.
• Lamotrigine is effective in the depressed phase of Bipolar Disorder.
• The response rate to lithium carbonate is 70–80% in acute mania.
Lithium also has a prophylactic effect in prevention of recurrent
mania and, to a lesser extent, in the prevention of recurrent
depression.
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94. Suicide
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95. Suicide
• Depressive disorder /schizophrenia/alcohol dependence /personality
disorders
• Low CSF levels of 5-hydroxyindoleacetic acid (5-HIAA) high risk
• A metabolite of serotonin ( markedly low serotonin)
• Male
• >45 yrs
• Divorced
• Widowed
• Unemployed
• F h/o
• c/c illness TONY SCARIA 2010
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96. TONY SCARIA 2010
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97. Causes of suicide
Psychiatric ds Physical illness Psychosocial factors Biological factors Other risk factors
• Depression 
MC psychiatric
cause
• Alcoholism (2nd
MC)
• Drug / substance
abuse
dependence
• Schizophrenia
10-12 %
commit suicide
• Anorexia
nervosa 10%
• Borderline
personality
disorder 10%
• Cancer
• AIDS
• Multiple sclerosis
• Head trauma
• Love failure
• Marital
difficulties
• Family dispute
• Markedly low
serotonin
• Decreased 5HIAA
in urine &
plasma
• Male sex
• Age > 40
• Single
• Past attempt of
suicide  most
important risk
factor
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98. Family problems  Mc cause
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99. Methods of suicide
• Hanging MC
• Followed by poisoning
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100. Becks cognitive triad of depression
• Hopelessness  MC predisposition for suicide
• Helplessness
• Wortlessness
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101. • Anabolic steroids initially produce mania & their withdrawal produces
depression
• Glucocorticoids & ACTH  depression
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102. Psychiatric disorders in
postpartum period
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103. Post partum psychiatric disorders
Postpartum blues Postpartum depression Postpartum psychosis
40-85 % incidence 8-15 % incidence 0.1-0.2 %
• Depressed affect
• Tearfulness
• Fatigue
• Depressed affect
• Anxiety
• poor concentration
• Mood congruent delusions
• Hallucination
• Thoughts of harming self/ baby
• Supportive
• Followup to assess for
postpartum depression
• CBT & SSRI • Hospitalisation
• Atypical antipsychotics
• ECT
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104. Postpartum blues
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105. Post partum psychosis
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106. TONY SCARIA 2010
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