The lecture has been given on Nov. 23rd & 30th, 2010 by Dr. Nazar M. Mohammad Amin.

1. Mood Disorders
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2. Mood Disorders
History
Depression was described in most of the Holy
Books.
It was thought to be due to evil spirits or as a
punishment for angering the gods.
Hippocrates (460–377 bc) described melancholia
whom he thought as a brain disorder caused by
excess of black bile.
The concept of melancholia remained for many
centuries with different explanations ranging
from supernatural powers to changes in the
blood.
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3. Mood Disorders
History
Email kreaplin differentiated manic depressive
illness from dementia praecox. His approach was
mostly Biological while Sigmund Freud and
Adolph Meyer in the middle of the 20th Century
adopted a psychological approach to depression
as introjection of anger towards loved objects.
Deperssion was later classified into endogenous
and neurotic depression, with the endogenous
type thought to be responding to ECT.
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4. Mood Disorders
History
Hippocrates described Mania too.
Physicians throughout the centuries associated
Melancholy with Mania.
The term Bipolar disorder entered DSM III for
the first time in 1980.
British literature use the term affective disorders.
Psychiatry Volume 8, Issue 4, Pages 107-144
(April 2009)
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5. Mood Disorders
Epidimiology
The prevalence of mood disorders depend on
the definition applied.
An American study ( National Comorbidity
Survey) found a life prevalence of 20.8% and an
age of onset of 30 years.
Lifetime prevalence of major depression is 4-
19% of the population. It is twice in females as in
males.
Major age of onset is 25-30 years.
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6. Mood Disorders
Epidimiology
Bipolar I disorder life time prevalence is 1-5%, for
dysthymia is 3-7% and 0.5% for cyclothymia.
The prevalence depends on the classification used .
Major depressive disorder.
Dysthymia
Bipolar disorders.
cyclothymia.
Recurrent brief depressive disorder.
Recurrent brief hypomania.
Schizoaffective disorder.
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7. Mood Disorders
Epidimiology
Onset is usually insidious for depression and
more acute in mania.
Mood disorders in general are recurrent and
bipolar disorders usually have more episodes
than unipolar disorders.
Long term prognosis of mood disorders in
general is better than that of schizophrenia and
schizoafffective disorder.
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8. Mood Disorders
Epidimiology
Patients with mood disorders have higher risk of
suicide (15-30)% compared with the general
population.
Mortality from mood disorders especially
depression is greater than in the general
population.
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9. Mood Disorders
psychological models
Cognitive behavioural models:
Is based on five areas: social, cognitive,
behaviour, physiololgical and mood.
This model is based on the clinical features that
maintain the patient’s current state and interfere
with his improvement.
Social include interpersonal, family, and marital
problems.
Cognitive include negative automatic thoughts
and images, assumptions and schemas.
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10. Mood Disorders
psychological models
Social model for depressive disorder
In childhood sexual and physical abuse, parental
indifference, loss of a parent. In adults social
isolation, physical illness, unemployment,
women with fulltime work and having three
preschool childern.(Brown and Harris 1980).
Psychodynamic model for depression
Low actual self representation, insecure adult
attachment and primitive superego.
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11. Cognitive symptoms in mood
disorders
Coginitive disorders are important symptoms in
mood disorders and some of the symptoms may
remain even after remission. Impairments in
memory, decision making are examples.
Cognitive impairments indicate ventromedial
prefrontal area involvement.
The resilience of some pateints who do not
develop mood disorders despite exposure to
adverse environmental events is being studied
to find ways of prevention of mood disorders.
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12. Mood disorders
clinical features
Depression
There are three groups of symptoms:
emotional symptoms, psychomotor symptoms,
and negative beliefs.
Negative belief such as low self esteem and
inappropriate guilt, feeling of hopelessness,
helplessness and worthlessness.
psychomotor symptoms include reduced
movements, activity, facial expression, decreased
verbal activity and withdrawal, increased activity
such as agitation in the form of hand wringing to
pacing. 12

13. Mood disorders
clinical features
Depression
Affect is a relatively transient state of feeling
depressed, sad or blue.
Chronic depression is diagnosed when it lasts for
more than two years.
Double depression occurs when the patient has
both major depression and dysthymia.
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14. Mood disorders
clinical features
Mania
The three cardinal symptoms of mania include:
emotions, psychomotor symptoms, and expansiveness
or increased self-esteem.
The symptoms in hypomania are less sever than mania.
There is elevated spirit mixed with irritability and hostility.
There is decreased need for sleep and excessive motor
activity.
There is decreased concern about money with
overspending and running into debts.
There is inflated self esteem and overestimating one’s
abilities.
There is pressure of speech and loud speech.
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15. Mood disorders
clinical features
Mania
The patient might have psychotic symptoms as
flights of ideas, excessive distractability and
grandiose delusions. Unlike schizophrenia the
psychotic symptoms are mood congruent.
To diagnose hypomanic episode 4 days of
symptoms are necessary and for a manic episode
one week of symptoms is required.
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16. Mood disorders
Diagnosis and Classification
There was a lot of confusion regarding
classification of Mood Disorders.
The DSM and ICD used different classifications.
Nevertheless in the newer versions they got
closer.
Depression is both a mood or symptom and a
syndrome.
It is calssified into mild, moderate and sever. It
could be a single episode or recurrent.
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17. Mood disorders
Diagnosis and Classification
The symptoms must last for at least 14 days.
They include loss of interest, lack of energy,
impairment of sleep, appetite or concentration
and suicidal thoughts.
Dysthymia: a constant or recurrent mild
depression lasting for at least two years.
Manic states: in a manic episode the patient has
elevated, expansive or irritable mood and other
symptoms that could last for at least one week.
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18. Mood disorders
Diagnosis and Classification
Bipolar I disorder is diagnosed when the patient
has at least one manic episode. In the manic
episode the patient Has elevated, expansive or
irritable mood for at least one week. The
condition is sever and requires hospitalization.
Hypomania is less sever and does not require
hospitalization and lasts for at least four days.
Mania indicates bipolar I disorder and
hypomania alternating with major depression
indicates bipolar II disorder.
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19. Mood disorders
Diagnosis and Classification
Both psychotic depression and melancholia
were not adequately described in the
classificaton systems available. Both ICD and
DSM failed to specify the close association of
depressive disorder and anxiety.
Presence of anxiety could confuse the
diagnosis.
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20. Mood disorders
Diagnosis and Classification
Manic patients usually do not complaint of their
symptoms and they are observed by realtives
and their doctors.
There is decreased need for sleep, disinhibition
and increased energy.
Robert Kendell Psychiatry 8:2
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21. Mood disorders
Diagnosis and Classification
To diagnose any of the mood disorders the
symptoms need to interfere with the life of the
patient, must not be due to substance abuse,
not secondary to another medical disorder and
due to another mental disorder such as
schizophrenia.
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22. Brain structural changes in
mood disorders
Hippocampal volume is reduced in patients
with major depressive disorder.
Studies on both disorders bipolar disorder and
major depressive disorder revealed changes in
the amygdala too.
Lithium and antidepressants produced changes
in the gray matter size in some studies
compared to preclinical data.
Sophia frangou Psychiatry 8:4
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23. Depression and diabetes mellitus
Clinically significant depression is associated with a
65% increased risk of diabetes mellitus.
Characteristics of depression frequently found in the
community, namely nonsevere depression,
persistent depression, and untreated depression,
may play a role in the development of diabetes in a
predominantly elderly adult population.
Antonio Campayo, Peter de Jonge, Juan F Roy, Pedro Saz, Concepción de la Cámara,
Miguel A. Quintanilla, Guillermo Marcos, Javier Santabárbara, and Antonio Lobo
Am J Psychiatry 2010 167: 580-588.
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24. Depression in the elderly
A study in Pakistan revealed an increase in the
prevalence of depression in the elderly and they
atributed that to the change in the family system
from extended to nuclear system.
Depression in the elderly: "Does family system
play a role?" A cross-sectional
study
BMC Psychiatry 2007, 7:57
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25. Management of mood disorders
It is necessary that every patient, whom we
suspect to have mood disorders, should be
thoruoghly assessed by careful and full history
and mental state examination. The notes of the
social worker and clinical psychologists should be
studied too. The necessary investigations to
exclude other possible causes should be done
including full blood count, drug screening ,
hormonal essays including thyroid function tests,
EEG, CT scan and if necessary other
neuroimaging techniques.
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26. Management of mood disorders
It is important to find out if the case in unipolar
or part of a bipolar disorder.
Risk assessment is a must to find out if the
patient is a risk to himself in the form of suicide
or self harm. The risk to others including
homicidal risk is necessary too.
The targets of our management should include
the patient and the caregivers too.
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27. Management of mood disorders
The line of management depends on whether
the disorder is acute or chronic, bipolar unipolar,
recurrent or a single episode.
The choice of the treatment method should be
made by discussion with the patient, his relatives
and individual physician.
The treatment methods include:
Psychological
Pharmacological
Physical
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28. Management of mood disorders
Psychological treatments
According to the National Institute for Health and
Clinical
Excellence guideline for depression, psychological
treatments are the treatments of choice for mild
depressive episodes.
In moderate depressive episodes they are an
alternative to antidepressant medication, and for
severe depressive episodes cognitive therapy
in combination with antidepressants is the
treatment of choice.
Only cognitive therapy is established as effective in
preventing the recurrence of depressive episodes. 28

29. Management of mood disorders
Psychological treatments
From an evidence-based perspective, cognitive
therapy for depression is the best established
psychological treatment for mood disorders.
In contrast, psychological treatments can be
effective in preventing recurrence of bipolar
episodes, although there is little evidence for
their effectiveness in acute bipolar episodes
(depression, mania, hypomania, or mixed
affective episodes).
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30. Management of mood disorders
Psychological treatments
Psychological treatments for depression include:
Cognitive therapy, behaviour therapy, cognitive
behaviour therapy, problem solving, interpersonal
therapy and psychodynamic therapy.
Psychological treatment for bipolar disorder needs
to be longer and includes psychoeducation,
prevention of relapse and encouraging the patient
to comply with the medication.
Richard Morriss and Jan Scott
Psychiatry 8:4
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31. Pharmacological
management of unipolar
affective disorder
In mild depression psychotherapy is the first line
treatment and pharmacological therapy is not
recommended routinely as first line therapy.
In moderate to sever depression when other
treatments for two weeks fail antidepressants
should be first line treatment.
In dysthymia antidepressants could be used as
first line treatment.
R Hamish McAllister-Williams
I Nicol Ferrier PSYCHIATR Y 8:4 113 © 2009
Elsevier Ltd. 31

32. Pharmacological
management of unipolar
affective disorder
Tricyclic antidepressants:
These drugs have many side effects including
anticholinergic effects, hypotension and
tachycardia and cardiac toxicity which makes
them dangerous in toxicity and overdoses.
Tricyclic antidepressants should not be used as
first line treatment in mild to moderate
depression.
They are recommended for severely ill
inpatients. 32

33. Pharmacological
management of unipolar
affective disorder
Specific serotonin reuptake inhibitors:
Including fluoxetene, paroxetene, fluvoxamine,
citalopram, sertraline, escitalopram.
They are recommended by NICE as first line
pharmacological treatment of depression
because they have less side effects compared to
tricyclic antidepressants. They are relatively safer
in overdoses. However they might lead to gastric
irritation, nausia, vomitting, headache, increased
anxiety and sexual dysfunction.
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34. Pharmacological
management of unipolar
affective disorder
Specific serotonin reuptake inhibitors:
They cause decreased arousal, drive and
difficulty reaching orgasm. These side effects
might lead to noncompliance.
The initial increased anxiety might lead to
suicide.
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35. Pharmacological
management of unipolar
affective disorder
Monoamine oxidase inhibitors MAOIs :
They are used for atypical depression with
reversed biological symptoms as increased
appetite and weight. It is recommended by NICE
for those who do not respond to SSRIs. The
ireversible MAOIs have serious interaction with
drugs and food containing tyramine.
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36. Pharmacological
management of unipolar
affective disorder
Monoamine oxidase inhibitors MAOIs :
The reversible MAOIs as Meclobemide has less
risk of interaction but therapeutically less
effective.
Those drugs lead to postural hypotension ,
overstimulation, sexual dysfunction, weight gain
and possibly addiction.
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37. Pharmacological
management of unipolar
affective disorder
Serotonin and noradrenaline reuptake
inhibitors SNRIs:
Venlafaxine and duloxetene.
Venlafaxine is more potent than SSRIs and
recommended by NICE for severely depressed
patients with monitoring the blood pressure.
Doluxetene is not as potent as Venlafaxine and it
might lead to initial nausea.
Both drugs lead to nausea, hypertension,
increased anxiety and sexual dysfunction.
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38. Pharmacological
management of unipolar
affective disorder
Other antidepressants:
reboxetene: is selective noradrenaline reuptake
inhibitor. It has anticholinergic side effects and
sexual dysfunction. Neverthelss it is well
tolerated but evidence of its effectiveness is
scarce.
mirtazepine: is α 2 adrenoceptor antagonist. It
cause sedation and weight gain. Therefore it
liked by patients with insomnia and disliked by
obese patients.
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39. Pharmacological
management of unipolar
affective disorder
Other antidepressants:
Mianserine is a tetracyclic drug and is α2
adrenoceptor antagonist. It is less popular now
because of agranulocytosis.
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40. Pharmacological
management of unipolar
affective disorder
Treatment resistant depression:
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41. Pharmacological
management of unipolar
affective disorder
Treatment resistant depression:
Augmetation therapy:
Antidep and psychtherapy
Antidep and atypical antipsychotic
Antidep and thyroid hormone
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42. Pharmacological
management of bipolar
affective disorder
The principles in treatment of bipolar disorders
include psychoeducation, proprer monitoring,
supporting carers, invlovement of carers and
effective psychotherapy.
R Hamish McAllister-Williams
I Nicol Ferrier PSYCHIATR Y 8:4 113 © 2009
Elsevier Ltd.
42

43. Pharmacological
management of bipolar
affective disorder
Mood stabilizers:
Lithium : it is an antimanic and used prophylactic
ally for bipolar disorder. It requires careful and
continuous monitoring to avoid toxicity. Side
effects include anorexia, metallic taste and
diarrhea, polyuria and nephrogenic diabetes
incipidus, tremor, weakness, cardiac toxicity,
goitre and teratogenic effect.
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44. Pharmacological
management of bipolar
affective disorder
Mood stabilizers:
Carbamazepine: it is used as an antimanic drug
and for prevention of affective psychosis.
However, its popularity has declined because its
efficacy decreases with time as it is liver enzyme
inducer and induces its own metabolism. It
reduces the effectiveness of other
anticonvulsants and contraceptives. It causes
sedation, ataxia and diplopia. The serious toxic
effects is Steven Johnson's syndrome.
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45. Pharmacological
management of bipolar
affective disorder
Mood stabilizers:
Valproate: it is antimanic and has been used
prophylatically but the evidence is not strong
for its action.
Side effects include gastric irritation, nausia,
increased appetite, weight gain, tremor and
thrombocytopenia. It could cause alopacia and
hepatic damage too therefore it should not be
used in patients with active liver disease.
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46. Pharmacological
management of bipolar
affective disorder
Mood stabilizers:
Lamotrigine:
Is an antiepileptic in complex partial and
generalized tonic clonic fits.
It is used for treatment of mania, depression,
rapid cycling bipolar II disorder.
Side effects:
Headache, sedation, ataxia, diplopia, nausia
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47. Pharmacological
management of bipolar
affective disorder
Mood stabilizers:
Lamotrigine:
Other side effects include rash and Stevens
Johnson’s syndrome.
It does not induce liver enzyme p 450 and
has no effect on psychotropic medication.
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48. Pharmacological
management of bipolar
affective disorder
Antipsychotics
Atypical antipsychotics as olanzepine,
resperidone, quetiepine and aripiprazole
are effective as antimanic drugs in acute
cases and prophylactically in bipolar
disorder. They are useful in maintenance
therapy. Olanzepine and aripiprazole are
effective as continuation therapy after
acute treatment.
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49. Pharmacological
management of bipolar
affective disorder
Antipsychotics
The possibility of producing
extrapyramidal side effects is less than
typicals but weight gain and metabolic
syndrome is a strong limiting factor for
their use.
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50. Pharmacological
management of bipolar
affective disorder
Antidepressants
Are used for depression but not
prophylactically especially when there is
risk of switching to mania. They could be
combined with a mood stabilizer to avoid
that risk.
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51. Your attention and patience is
appreciated
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