Mood Disorders

Study guide:

Definition:

  • Mood disorders: emotional disturbance involving episodes of depression, mania, or both.

  • Depressive disorders: Sadness severe enough or prolonged enough to impair function.

  • Bipolar disorders: Episodes of mania and depression, which may alternate, although many patients have a predominance of one or the other.

    • Mania is abnormal periods (≥1 week) of great excitement, euphoria, delusions, and overactivity .

    • Hypomania a mild form of mania thar does not cause functional impairment.

    • Mixed episode is having both a manic episode and a major depressive episode nearly every day for ≥ 1 week.​​

  • Dysthymia: mild depressive symptoms lasting for ≥ 2 years without remission.

  • Cyclothymic disorder: hypomania and dysthymia (≥ than half the days of ≥ 2 years)


​ Etiology:

Depressive Disorders

Bipolar disorders

  • Genetics (40–50%, gene–environment interactions).

  • Early life experience: Parental separation, neglect, physical or sexual abuse, and maternal postpartum depression.

  • Personality traits and disorders: e.g. borderline and OCD.

  • Acute stress: Loss or humiliation events.

  • Chronic stress: Chronic pain and any other chronic illness ( in heart disease and stroke).

  • Neurobiology: Abnormal regulation of cholinergic, noradrenergic, dopaminergic & serotonergic (5-HT) neurotransmission + Neuroendocrine dysregulation.

  • Genetics (Gene–environment interactions). 

  • Environment: High risk of mania post partum in those with untreated bipolar affective disorder.

  • Neurobiology: Structural & functional abnormalities (in hippocampus and amygdala). Neurotransmitters: levels of monoamines → mania.

Types:

  • Depressive disorders:

  • Bipolar disorder:

    • Bipolar I: manic or mixed episodes.

    • Bipolar II: depressive episode with at least one episode of hypomania.

    • Bipolar III*: depressive episodes with hypomania only when on antidepressant.

Diagnosis:

  • Major depressive disorder (Clinical criteria (DSM-V):

    • Symptoms (≥ 2 weeks):

      1. At least one of: depressed mood and/or anhedonia.  

      2. And some of these to total 5 symptoms or more:

        • Changes in appetite/weight.

        •  Altered sleep pattern

        • (increase or decrease).

        • Lack of energy.

        • Difficulty concentrating.

        • Agitation.

        • Reduced self-esteem.

        • Suicidal thoughts.

    • ​​Impairment in social, occupational or other important areas of functioning.

    • Exclusion of medical conditions, medication, or drug abuse.

    • CBC, electrolytes, and TSH, vitamin B12, and folate levels to rule out physical disorders.

  • Bipolar disorders (Clinical criteria (DSM-V):

    • Bipolar-I:

      • Current or recent major depressive episode.

      • At least one previous manic episode or mixed episode.

      • Exclusion of psychotic disorder.

    • Bipolar-II

      • Current or recent major depressive episode.

      • At least one previous hypomanic episode.

      • No history of manic or mixed episode.

      • Exclusion of psychotic disorder.

      • Impairment in social, occupational or other important areas of functioning.

      • Current episode meets criteria for hypomania or depression.

  • ​​CBC, electrolytes, and TSH, vitamin B12, and folate levels to rule out physical disorders.

  • Exclusion of stimulant drug abuse clinically or by urine testing.

Management:

  • Assess the risk of suicide, homicide, and drug and alcohol abuse.

  • Depressive disorder:

    • Psychological treatment:

      1. Cognitive-behavioral therapy (CBT).

      2. Interpersonal therapy (IPT).

    • Plus Antidepressants if the depression is moderate or severe.

    • 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.

      • SE: headache, partial amnesia (resolves in 6 months).

  • Bipolar disorder: 

    • Treatment of acute mania or hypomania: 

      • Discontinuation of antidepressants.

      • Benzodiazepines for short term. 
        • MOA: binds to a regulatory site on the GABAA receptor to augment the inhibitory effect of GABA  reducing anxiety, sedation, and muscle relaxation.

        • SE: dependence & prolonged alcohol hangover.

      • Antipsychotic medication (2nd generation). *Please refer to Schizophrenia file. 

    • Treatment of acute depression (moderate-severe): 􏰁

      • SSRIs are first line.

      • Benzodiazepines for short term.

    • Maintenance treatment (for prevention of relapse): 

      • Mood stabilizers (Lithium, Valproate, Carbamazepine, and lamotrigine)

In-patient admission is advised when:

  • Highly distressing psychosis.

  • Active suicidal ideation or planning, especially with history of previous attempts.

  • 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:

  • 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.

  • Average length of untreated manic episode is 4 months (16 weeks).

  • 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.

  • Completed suicide occurs in 10–15% of patients.

  • Elderly are more successful to commit suicide, however, adults and adolescence have more attempts.

References:

  • MARWICK K, BIRRELL S, BOURKE J. PSYCHIATRY. EDINBURGH: ELSEVIER; 2013.

  • KUMAR P, CLARK M. KUMAR & CLARK'S CLINICAL MEDICINE. 8TH ED. EDINBURGH: SAUNDERS ELSEVIER; 2012.

  • COLLEDGE N, WALKER B, RALSTON S. DAVIDSON'S PRINCIPLES AND PRACTICE OF MEDICINE. 21ST ED. LONDON: ELSEVIER; 2010.

  • RANG H, DALE M. RANG AND DALE'S PHARMACOLOGY. 7TH ED. LONDON: ELSEVIER CHURCHILL LIVINGSTONE; 2012.

  • 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

  •  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

  • LE T, BHUSHAN V, SOCHAT M, SYLVESTER P, MEHLMAN M, KALLIANOS K. FIRST AID FOR THE® USMLE.

  • 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