noood disorders

1. Mood Disorders

2. Archetypes
• Depression
– Major Depression
• Mania
– Bipolar Disorder (Manic-Depression)

5. Phenomenology:
The Mental Status Exam
• General Appearance
• Emotional
• Thought
• Cognition
• Judgment and Insight
• Reliability

6. General Appearance
• Depression
• Mania

7. Emotions: Depression
• Mood
– Dysphoric
– Irritable, angry
– Apathetic
• Affect
– Blunted, sad, constricted

8. Emotions: Mania
• Mood
– Euphoric
– Irritable
• Affect
– Heightened, dramatic, labile

9. Thought: Depression
• Process
– Slowed processing
• Thought blocking
• Content
• Everything’s awful
• Guilty, self-deprecating
• Delusional

10. Thought: Mania
• Process
– Rapid
– Pressured speech
– Loosening of Associations
• Content
– Grandiose
– Delusions

11. Cognition
• Depression
– Poor attention
– Registration
– Effort
– “Pseudodementia”
• Mania
– Distractible
– Concentration
– May seem brighter, more clever

12. Insight and Judgment
• Depression
– Unrealistically negative
• Mania
– Unrealistically positive
– Or just plain bad

15. Diagnosis and Criteria
• Episodes Versus Disorders

16. Episodes
• Major depressive
• Manic
• Mixed
• Hypomanic

17. Major Depressive Episode
• Time
– 2 weeks
• Change
– From previous functioning
• Symptoms
– 5 or more
– 1 has to be depressed mood or anhedonia
• Global Criteria

18. Symptoms of Major Depressive
Episode
• “Sig E Caps”
– Sleep
– Interest
– Guilt
– Energy
– Concentration
– Appetite
– Psychomotor retardation
– Suicide
• 5 or more

19. Manic Episode
• Time
– 1 week
• Symptom list
– 3 or more
• Global Criteria

20. Symptoms of Manic Episode
– Grandiosity
– Decreased need for sleep
– Pressured Speech
– Flight of Ideas
– Distractibility
– Increased Activity/Agitation
– Risky Activities
• 3 or more

21. The Disorders

22. Major Depressive Disorder
• “Classic Depression”
• Major Depressive
Episode
• Rule outs
– Some other disorder
– History of
mania/hypomania

23. Bipolar Disorder I
• Classic “Manic-Depression”
• At least one
– Manic or,
– Mixed episode

24. Epidemiology
• Depression
– 5-7%
– 2:1 ♀:♂
– $53 billion/year in US
– World: most costly
(developed)

25. Epidemiology
• Bipolar Disorders
– 1%
– ~1:1 ♀:♂

26. Etiology and Pathophysiology

27. Genetics
• Family studies
– Higher rates
– Breed true?
• Twin Studies
– Mono:Di ~4:1
• Linkage studies
– Numerous (? Consistency)
– Recent: Zubenko, Am J Genetics

28. Social/Environmental
• Response to Loss
– ex. Animal models
• Other stress
– Ex. Learned helplessness
• What is role of social stress?
– Ex. Nemeroff et al.

29. Neurotransmission
• Neurochemical hypotheses
– Catecholamine hypothesis
• Norepinephrine
– Ex. Axelrod
– Depletions models
• Serotonin
– Refinements
• Imbalances
• Receptors
• 2nd messengers

30. Neuroimaging
• Stroke data
– Dominant frontal
– Basal ganglia
• Fx Imaging

31. Other Physiological Findings
• Neurophysiology
– Circadian rhythms and sleep
• Neuroendocrine
– HPA axis
• DST

32. Differential Diagnosis
“We’re not living happily
ever after any more”

33. Differential Diagnosis
• Psychiatric Disorders
• Medical Disorders
• Substance Induced
• Reactive disorders
– Adjustment disorders
– Normal reactions

35. Comorbidity
• Anxiety disorders
• Substance abuse
• Psychotic disorders
• Personality disorders
• Depression in the
medically ill.

36. Comorbidity

37. Course and Prognosis of Mood
Disorders

38. Course and Prognosis of Mood
Disorders
• Recovery
• Relapse
• Recurrence

40. 0
10
20
30
40
50
60
70
80
90
0.5 1 2 4 5
Recovery

42. Predictors
• # Episodes
• Length of episodes
• Symptoms
– # and type
• Comorbidity

43. Risk of Suicide
• Depression
– 10-15% severe (hosp) pts

44. “It is unfortunate
that I didn’t get
your care earlier,
Mrs. Perkins.”
Treatment

45. Treatment
• Depression
– Pharmacological
– Psychotherapy
– Other somatic treatments

46. Antidepressants

47. Antidepressants
• 1st generation
– Monoamine Oxidase Inhibitors (MAOIs)
– Tricyclic Antidepressants (TCAs)
• 2nd
– Serotonin reuptake Inhibitors (SSRIs)
– Other specifics (Buproprion, Trazodone)
• 3rd
– Venlafaxine, Mirtazapine, Nefazodone

48. Mechanisms of action
• Monoamine Action
– Increase
• Norepinephrine
• Serotonin
– Various mechanisms
• Inhibition of catabolism (MAOIs)
• Reuptake inhibition (TCAs, SSRIs, Venlafaxine)
• Direct effects (agonism/antagonism) (some 3rd gen)

49. Side effects
• Predicable
– Anticholinergic
– Antihistaminic
– Serotonergic
• Idiopathic

50. Choice of antidepressant
• Best?
• Fastest?
• Predictors of response
– Past history
– Family history
• Major difference
– Side effects

51. Treatment failure
• Inadequate dose
• Inadequate time
• Nonadherence

53. Strategies for failure
• Choices
– Increase dose?
– Augment?
– New drug?
Lithium
Thyroid hormone
Stimulants
Atypical Antipsychotics
2nd Antidepressant

54. Long term treatment
• Recurrent depression (3+)
• Chronic depression (2 years)
• Double depression
• Others

55. Psychotherapy
• Cognitive behavioral
therapy
• Interpersonal therapy
• Others

56. Medications versus therapy
• Severe depression
• Moderate depression
• Combination treatment
• Prevention

57. Other treatments
• ECT
• TMH
• Vagal nerve stimulation

58. ECT
• Maybe the best.
• Medication failure
• Real serious
depression
• Time sensitive
• So why don’t we give
everybody ECT?

59. Bipolar Disorder
• Lithium
• Antipsychotics
• Anticonvulsants

60. Lithium
• First line
• Best for mania
• 2 weeks for effect
• Therapeutic index
• Side effects
• Acute and preventive

61. Anticonvulsants
• Sodium Valproate
• Carbamazapine
• Lamotrigine
• Gabapentin
• Antimanic
• Antidepressant
• Prevention
• Side effects

62. Antipsychotics
• Atypical (olanzapine)
• Classic
• May be as effective
• Early and late effect

63. Sedatives
• Acute use

64. Other Diagnoses

65. Other Episodes
• Mixed
• Hypomanic

66. Other Mood Disorders
• Dysthymic Disorder
• Cyclothymic Disorder
• Bipolar II
• Due to a generalized medical condition
• Substance Induced
• NOS