Mood Disorders
Study guide:
Definition:
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Mood disorders: emotional disturbance involving episodes of depression, mania, or both.
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Depressive disorders: Sadness severe enough or prolonged enough to impair function.
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Bipolar disorders: Episodes of mania and depression, which may alternate, although many patients have a predominance of one or the other.
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Mania is abnormal periods (≥1 week) of great excitement, euphoria, delusions, and overactivity .
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Hypomania a mild form of mania thar does not cause functional impairment.
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Mixed episode is having both a manic episode and a major depressive episode nearly every day for ≥ 1 week.
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Dysthymia: mild depressive symptoms lasting for ≥ 2 years without remission.
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Cyclothymic disorder: hypomania and dysthymia (≥ than half the days of ≥ 2 years)
Etiology:
Depressive Disorders
Bipolar disorders
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Genetics (40–50%, gene–environment interactions).
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Early life experience: Parental separation, neglect, physical or sexual abuse, and maternal postpartum depression.
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Personality traits and disorders: e.g. borderline and OCD.
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Acute stress: Loss or humiliation events.
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Chronic stress: Chronic pain and any other chronic illness ( in heart disease and stroke).
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Neurobiology: Abnormal regulation of cholinergic, noradrenergic, dopaminergic & serotonergic (5-HT) neurotransmission + Neuroendocrine dysregulation.
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Genetics (Gene–environment interactions).
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Environment: High risk of mania post partum in those with untreated bipolar affective disorder.
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Neurobiology: Structural & functional abnormalities (in hippocampus and amygdala). Neurotransmitters: levels of monoamines → mania.
Types:
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Depressive disorders:
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Bipolar disorder:
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Bipolar I: manic or mixed episodes.
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Bipolar II: depressive episode with at least one episode of hypomania.
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Bipolar III*: depressive episodes with hypomania only when on antidepressant.
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Diagnosis:
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Major depressive disorder (Clinical criteria (DSM-V):
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Symptoms (≥ 2 weeks):
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At least one of: depressed mood and/or anhedonia.
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And some of these to total 5 symptoms or more:
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Changes in appetite/weight.
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Altered sleep pattern
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(increase or decrease).
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Lack of energy.
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Difficulty concentrating.
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Agitation.
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Reduced self-esteem.
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Suicidal thoughts.
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Impairment in social, occupational or other important areas of functioning.
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Exclusion of medical conditions, medication, or drug abuse.
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CBC, electrolytes, and TSH, vitamin B12, and folate levels to rule out physical disorders.
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Bipolar disorders (Clinical criteria (DSM-V):
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Bipolar-I:
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Current or recent major depressive episode.
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At least one previous manic episode or mixed episode.
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Exclusion of psychotic disorder.
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Bipolar-II
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Current or recent major depressive episode.
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At least one previous hypomanic episode.
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No history of manic or mixed episode.
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Exclusion of psychotic disorder.
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Impairment in social, occupational or other important areas of functioning.
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Current episode meets criteria for hypomania or depression.
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CBC, electrolytes, and TSH, vitamin B12, and folate levels to rule out physical disorders.
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Exclusion of stimulant drug abuse clinically or by urine testing.
Management:
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Assess the risk of suicide, homicide, and drug and alcohol abuse.
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Depressive disorder:
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Psychological treatment:
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Cognitive-behavioral therapy (CBT).
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Interpersonal therapy (IPT).
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Plus Antidepressants if the depression is moderate or severe.
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Electroconvulsive therapy considered in pregnant women, refractory to other
medications, catatonic patients, strong suicidal ideations, psychotic features or
stupor.-
Produce painless seizure in anesthetized patients.
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SE: headache, partial amnesia (resolves in 6 months).
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Bipolar disorder:
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Treatment of acute mania or hypomania:
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Discontinuation of antidepressants.
- Benzodiazepines for short term.
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MOA: binds to a regulatory site on the GABAA receptor to augment the inhibitory effect of GABA → reducing anxiety, sedation, and muscle relaxation.
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SE: dependence & prolonged alcohol hangover.
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Antipsychotic medication (2nd generation). *Please refer to Schizophrenia file.
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Treatment of acute depression (moderate-severe):
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SSRIs are first line.
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Benzodiazepines for short term.
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Maintenance treatment (for prevention of relapse):
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Mood stabilizers (Lithium, Valproate, Carbamazepine, and lamotrigine)
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In-patient admission is advised when:
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Highly distressing psychosis.
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Active suicidal ideation or planning, especially with history of previous attempts.
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The patient is catatonic (leading to extreme selfneglecting).
Serotonin syndrome (with any drug that increase serotonin levels): hyperthermia, confusion, myoclonus, cardiovascular collapse, flushing diarrhea, and seizure.
Other medications: bupropion, trazodone, and mirtazapine.
Prognosis:
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Depression is self-limiting disease, 1st episode remits without treatment typically in 6-12 months, and 80% will have a further episode, with the risk of future episodes.
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Average length of untreated manic episode is 4 months (16 weeks).
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5% and 15% of patients will have rapid cycling (four or more mood episodes (depressive, manic or mixed) within 1 year); rapid cycling is associated with a poor prognosis.
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Completed suicide occurs in 10–15% of patients.
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Elderly are more successful to commit suicide, however, adults and adolescence have more attempts.
References:
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MARWICK K, BIRRELL S, BOURKE J. PSYCHIATRY. EDINBURGH: ELSEVIER; 2013.
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KUMAR P, CLARK M. KUMAR & CLARK'S CLINICAL MEDICINE. 8TH ED. EDINBURGH: SAUNDERS ELSEVIER; 2012.
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COLLEDGE N, WALKER B, RALSTON S. DAVIDSON'S PRINCIPLES AND PRACTICE OF MEDICINE. 21ST ED. LONDON: ELSEVIER; 2010.
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RANG H, DALE M. RANG AND DALE'S PHARMACOLOGY. 7TH ED. LONDON: ELSEVIER CHURCHILL LIVINGSTONE; 2012.
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MERCKMANUALS.COM. BIPOLAR DISORDERS: MOOD DISORDERS: MERCK MANUAL PROFESSIONAL [INTERNET]. 2014 [CITED 14 NOVEMBER 2014]. AVAILABLE FROM: HTTP://WWW.MERCKMANUALS.COM/PROFESSIONAL/PSYCHIATRIC_DISORDERS/MOOD_DISORDERS/BIPOLAR_DISORDERS.HTML
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MERCKMANUALS.COM. DEPRESSIVE DISORDERS: MOOD DISORDERS: MERCK MANUAL PROFESSIONAL [INTERNET]. 2014 [CITED 14 NOVEMBER 2014]. AVAILABLE FROM: HTTP://WWW.MERCKMANUALS.COM/PROFESSIONAL/PSYCHIATRIC_DISORDERS/MOOD_DISORDERS/DEPRESSIVE_DISORDERS.HTML
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LE T, BHUSHAN V, SOCHAT M, SYLVESTER P, MEHLMAN M, KALLIANOS K. FIRST AID FOR THE® USMLE.
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LE T. FIRST AID FOR THE USMLE STEP 2 CS. NEW YORK, NY: MCGRAW-HILL; 2010.
First Author: Lama AlLuhaidan.
Second Author: Abdullah AlAsaad
Reviewed by: Roaa Amer
Haifa Al Issa
Format Editor: Adel Yasky
Audio recording:
- Read by: Bothainal Al Aqeel
- Directed by: Rana Al Zaharani
- Audio production: Bayan Alzomaili