a basic description about mood disorders mainly MDD and bipolar disorder. Can be made useful in presentations and theory exams. Subject was imbibed from different presentations and DSM IV manual. Thanks for viewing.

1. MOOD DISORDERS
-NANDU KRISHNA J

2. • Pervasive and sustained feeling tone
• That is experienced internally
• That influences a person’s behavior and
perception of the world.
• Distinguished from affect – the external
expression of mood.

3. • Mood disorders - are a group of clinical conditions
characterized by
• Loss of that sense of control
• A subjective experience of great distress.
• Importance : virtually always impair interpersonal, social and
occupational functioning
Elevated mood Depressed mood Others
expansiveness Lack of energy / interest Change in activity level
Flight of ideas Feeling of guilt Change in cognitive
abilities
Decreased sleep Difficulty of concentration Change in speech
Grandiose ideas Loss of appetite Change in biological
functions
Thoughts of death/ suicide

4. • Unipolar disorders or Major Depressive disorder
(with only major depressive episodes)
• Bipolar disorders(with both manic and
depressive episodes/ with manic episodes alone)
Three additional categories of mood disorders
• Cyclothymia(less severe form of BPD)
• Dysthymia (less severe form of UPD)
• Hypomania (episode of manic
symptoms that does not meet the
DSM-IV-TR criteria for manic episode)

5. • occurs without a H/O manic, mixed, hypomanic
episode.
• must last at least 2 weeks
• experiences two major symptoms
-depressed mood
-loss of interest or pleasure

6. • And also experiences at least four symptoms that
includes:
-changes in appetite and weight,
-changes in sleep and activity,
-psychomotor agitation or retardation,
-lack of energy,
-feelings of worthlessness or inappropriate guilt,
-problems thinking and making decisions,
-recurring thoughts of death or suicide.

7. Incidence and Prevalence
• prevalance 5-17%
• 10-20% of chronically ill medical outpatients
Sex
• Women : Men = 2:1
Age
• Mean age of MDD: 40 years but recently, the
incidence of MDD is increasing in <20 years of
age –(alcohol and drug abuse)

8. Marital status
• Poor interpersonal relationships
• Divorced or separated
Socioeconomic and cultural factor
• No correlation for MDD
Comorbidity
• Increased risk of having one or
more additional comorbid Axis I
disorders like alcohol abuse or
dependence, panic disorder,
obsessive compulsive disorder,
social anxiety disorder.
• Worsen the progress and increase the risk of
suicide

9. BIOLOGIC THEORIES
• Neurochemical factors
• Norepinephrine and Serotonin
• sensitivity of β-adrenergic receptors and
clinical antidepressant responses direct role
• Depletion of serotonin depression
• SSRIs are effective in the treatment of
depression.
• Dopamine ; Acetylcholine (Ach) ; Gamma-
Aminobutyric acid (GABA)

10. • Genetic factors
To identify specific susceptibility genes using
the molecular genetic methods.
• Endocrine-HPA axis
» HPA activity; hallmark of stress responses
» Hypercortisolemia suggests central disturbances
• Alteration in the sleep neurophysiology
» premature loss of deep (slow wave) sleep
» nocturnal arousal
» REM latency, which
persist after recovery
of a depressive episode.

11. • Immunological disturbance
lymphocyte proliferation; which
produce CRF and IL-1.
• Structural functional brain imaging
abnormal hyper densities
• Neuroanatomical considerations
mood disorders involve
pathology of brain mainly in
regions like prefrontal cortex,
anterior cingulate,hippocampus
and the amygdala.

12. PSYCHOSOCIAL THEORIES
• Psychoanalytic theory:
loss of loved object
• Behavioral theory:
experience of uncontrollable
events
• Cognitive theory:
negative expectations
SOCIOLOGICAL THEORY
• Stressful life events

13. Depression with specific features ie; specifiers are:
• Mild, moderate and severe
• Single episode or recurrent
• Chronic
• With melancholic features
• With psychotic features
• With catatonic features
• With atypical features
• With postpartum onset
• With seasonal pattern

14. • Severity: Mild, Moderate, or Severe level of
functional impairment
• Single episode: single episode of major depression
• Recurrent: 2 or more episodes of major depression
• Chronic: full criteria for a major depressive
episode have been met continually for at least the
past 2 years
• With melancholic features – severe depression
with lack to do something that used to bring
pleasure and associated with early morning
awakening, worsened mood in the morning, major
changes in appetite, and feelings of guilt, agitation.

15. • With psychotic features – accompanied by
delusions or hallucination.
• With catatonic features – includes motor activity
that involve either uncontrollable and purposeless
movement or fixed and inflexible posture.
• With atypical features – includes the ability to be
cheered by happy events, increased appetite,
excessive need for sleep, sensitivity to rejection,
and a heavy feeling in arms or legs.
• With peripartum onset
• With seasonal pattern – related to changes in
seasons and reduced exposure to sunlight

16. • Psychological tests
• Dexamethasone suppression test
• Toxicology screening test
• ICD 10 criteria

17. Treatment directed towards several goals
• First, the patient’s safety must be guaranteed
• Second, a complete diagnostic evaluation of the
patient is necessary
• Third, a treatment plan
that addresses not only
immediate symptoms
but also the patients
prospective well-being
should be initiated.

18. Hospitalization: first and critical decision
» risk of suicide or homicide
» grossly reduced ability to get food and shelter
» the need for diagnostic procedures
» history of rapidly progressing symptoms
» rupture of patient’s usual support system

19. • Psychotherapy
• Pharmacotherapy
• Physical therapy

20. TRICYCLIC ANTIDEPRESSANTS
Amitriptyline(75-150 mg daily), Imipramine(75-
150 mg daily), Clomipramine (75-150 mg daily)
• MOA: They inhibit the re-uptake of the amines
norepinephrine and serotonin at synaptic clefts.
• SIDE EFFECTS mainly sedation, anticholinergic
effects, postural hypotension, lowering of the
seizure threshold and cardiotoxicity.
• TCAs may be dangerous in overdose and in
people who have coexisting heart disease,
glaucoma and prostatism.
Pharmacotherapy

21. SELECTIVE SEROTONIN REUPTAKE INHIBITORS
citalopram (20-40 mg daily), fluoxetine (20-60
mg daily), sertaline (50-100 mg daily)
• These are less cardiotoxic and sedative than
TCAs, and fewer anticholinergic effects.
• They are safer in overdose, but can still cause
headache, nausea, anorexia and sexual
dysfunction.
• Interact with other drugs increasing serotonin
to produce serotonin syndrome.

23. MONOAMINE OXIDASE INHIBITORS (MOAIs)
phenelzine (45-90 mg daily), tranylcypromine
(20-40 mg daily), moclobemide (300-600 mg
daily)
• MOA: These drugs increase the availability of NTs
at synaptic clefts by inhibiting metabolism of NE
and serotonin.
• They can cause potentially dangerous
interactions with drugs such as amphetamines,
and foods rich in tyramine such as cheese and red
wine called cheese reaction.
• This is due to accumulation of amines on the
systemic circulation, causing a potentially fatal
hypertensive crisis.

24. OTHER ANTIDEPRESSANTS
• Venlafaxine (75-375 mg daily)
• SNRIs(<150 mg)and SSRIs(>150 mg)
• Contraindicated in children and adolescents
• S/E include hypertension above 150 mg dose,
glaucoma,
• Mirtazapine (15-45 mg daily)
• Noradrenergic and specific serotonergic
antidepressant (NaSSA)
• Superior to SSRIs and SNRIs
• S/E include weight gain, somnolence, excess
sedation, dry mouth.

25. Physical therapies
• Electroconvulsive; Vagal nerve stimulation
• Photo therapy
• Repetitive transcranial magnetic stimulation
Three short term psychotherapies
• Cognitive psychotherapy
• Interpersonal psychotherapy
• Behavior therapy
Other therapies include
• Psychoanalytic therapy
• Marital and family therapy
Psychosocial therapies

26. TCA OR SSRI
Depending on physician preference
Failed trial due to response or
rate-limiting adverse effect
Partial
response
Cross to alternative
agent (TCA or SSRI)
Either switch to alternative
agent or attempt augmentation
Failed trial
Trial of second line agent with evidence
of activity in TCA nonresponders.
Alternatively treat with ECT.
Full remission
Maintain as
described above
Maintain treatment
for at least 4-6
months in case of first
time episode; longer
in case of recurrent
disease
Full remission
Algorithm
for treating
patient
with MDD
Uncomplicated, physically healthy outpatient without
any contraindication to a specific class of antidepressant

27. Good prognostic factors
• Abrupt or acute onset
• Severe depression
• Typical clinical features
• Well adjusted pre-
morbid personality
• Good response to
treatment
Poor prognostic factors
• Double depression
• Co-morbid physical
disease, personality
disorders or alcohol
dependence
• Chronic ongoing stress
• Poor drug compliance
• Marked mood
incongruent features

28. • A hypomanic episode:
lasts at least 4 days similar to a manic episode
except that it is not sufficiently severe to cause
impairment in social or occupational functioning,
and no psychotic features are present.
• A manic episode:
is a distinct period of an
abnormally and persistently
elevated, expansive, or
irritable mood lasting for at
least 1 week(or less if the
patient is hospitalized)

29. • Bipolar I disorder
-clinical course of one or manic episodes and,
sometimes, major depressive episode.
• Mixed episode
-a period of at least 1 week in
which both a manic episode
and a major depressive
episode occur almost daily.
• Bipolar II disorder
-a variant of bipolar disorder characterised by
episodes of major depression and hypomania
rather than mania

30. Incidence and Prevalence
a lifetime prevalence of 1-2%
Sex
Women : Men ratio 1:1 (BPD1)
Age
Mean age of BPD is 20 years
ie; late adolescent or early adulthood
(18 for BPD 1 and 22 for BPD 2)
Socioeconomic and cultural factors
BPD 1: upper socioeconomic group

31. • Neurotransmitters and structural hypothesis
excessive levels of norepinephrine and
dopamine, decreased serotonin
• Genetic considerations
• Psychodynamic theories:
faulty family dynamics

32. • Core features
- elevated/irritable mood includes
euphoria(grade 1), elation(grade 2),
exaltation(grade 3), ecstasy(grade 4).
- increased speech associated with volubility,
acceleration, pressured speech-difficult to
interrupt
- decreased need for sleep
- increased psychomotor activity like over
activity / restlessness, excitement, stupor.

33. • Psychotic features
-delusions
-hallucinations
• Other symptoms
-over religiosity
-over spending/expansive ideas
-over familiarity/ disinhibition
-appearance

34. Somatic treatment
• Antidepressants enhanced
by a mood stabilizer
• Lithium carbonate (serum level 0.5-1.0 mmol/L)
• Antipsychotics like olanzapine, haloperidol,
quetiapine and risperidone
• Other drugs like sodium valproate,
carbamazepine, benzodiazepine

35. Psychosocial treatment
• Cognitive therapy
• Interpersonal therapy
• Psychoanalytic psychotherapy
• Behavior therapy
• Group therapy
• Family and marital therapy

36. Other mood disorders include:
• Cyclothymia
• Dysthymia
• Depressive disorder not otherwise specified
Minor depressive disorder
Recurrent brief depressive disorder
Postpsychotic DD of schizophrenia
Premenstrual dysphoric disorder
• Bipolar disorder not otherwise specified
Mixed anxiety-depressive disorder
Atypical depression