Mood Disorders

SIG EM CAPS (5/9, including 2 or/and 4 must be present) during the same 2 wk period most of the day, nearly everyday, and represent change from previous functioning.

S: Sleep (insomnia or hypersomnia)

I: interest loss (anhedonia)

G: guilt or hopelessness (may be delusional)

E: no energy or fatigue

M: mood (sad or depressed, appears tearful)

C: concentration lack or indecisiveness

A: appetite increase or decrease; wt. loss or gain (5% x 1 mo)

P: psychomotor agitation or retardation (observable by others, not merely subjective feelings)

S: Suicidal ideation (recurrent thougts of death, suidical ideation with or without a plan, previous attempt, or specific plan for committing suicide.

Sx do not meet criteria for mixed episode (manic-depression).

Sx must result in significant disruption in social, occupational, or other important areas of functioning.

Sx are not due to meds, drug abuse, or gen. med. condition like hypothyroidism.

Sx are not accounted for by bereavement, sx persists more than 2 mo.

Diff. Dx of major depressive disorder:

Dysthymia, depression due to gen. med. condition, adjustment disorder due to depressed mood, substance-induced mood disorder, manic episodes with irritable mood, mixed episodes (depression/hypomania). Hypothyroidism, Parkinson's disease, Vitamin B12 deficiency, corticosteroids, BB, antipsychotics, reserpine.

Tx:

• Admit patient if there is SI/HI or paranoia.

• Begin antidepressant medications, SSRIs

• Benzodiazepines if agitated.

• ECT is best choice if the patient is acutely suicidal (works quicker than antidepressants) or for patients worried about SE from medications.

Subclassifications of major depressive disorder:

• Unipolar vs bipolar

• Melancholic vs nonmelancholic

• Psychotic vs nonpsychotic

• Atypical depression

• Masked depression

Seasonal Affective Disorder (SAD). A subtype of of MDD, involves depressive episodes mostly in winter, with improvement in spring and summer. Abnormal melatonin secretion may be responsible. Phototherapy and sleep deprivation are useful in treatment.

Dysthymic disorder. Characterized by a persistent feeling of low-level depression symptoms that does not meet the criteria for major depressive disorder but lasts more than 2 years. Each year, ~10% of dysthymic patients go on to develop MDD. Many Pts have evidence of personality d/o. Men and women are equally likely to develop dysthymic d/o. Never without depressed mood for more than 2 months

at a time,

Patients are often “depressed all my life,” sarcastic, complaining, brooding, resistant to therapy—leads to

negative countertransference by physician toward patient.

Dx: Depressed mood, change in appetite, sleep, decreased energy, inability to concentrate, hopelessness and low self-esteem. Vegetative symptoms are less prevalent than in MDD. Pt must have depressed mood on most days than not for 2 years, and at least two of the associated sx.

Tx: Combination psychotherapy and cognitive therapy. Medications can be used for persistent sx. SSRIs is the next step in management.

DSM-5 Diagnostic Criteria for Manic Episode

A. A distinct period of abnormally and persistently elevated, expansive, or irritable mood and abnormally and persistently increased goal-directed activity or energy, lasting at least 1 week and present most of the day, nearly every day (or any duration if hospitalization is necessary)

B. During the period of mood disturbance and increased energy or activity, three (or more) of the following symptoms (four if the mood is only irritable) are present to a significant degree and represent a noticeable change from usual behavior:

• 1. Inflated self-esteem or grandiosity

  2. Decreased need for sleep (eg, feels rested after only 3 hours of sleep)

  3. More talkative than usual or pressure to keep talking

  4. Flight of ideas or subjective experience that thoughts are racing

  5. Distractibility (ie, attention too easily drawn to unimportant or irrelevant external stimuli), as reported or observed

  6. Increase in goal-directed activity (either socially, at work or school, or sexually) or psychomotor agitation (ie, purposeless non-goal-directed activity)

  7. Excessive involvement in activities that have a high potential for painful consequences (eg, engaging in unrestrained buying sprees, sexual indiscretions, or foolish business investments)

C. The mood disturbance is sufficiently severe to cause marked impairment in social or occupational functioning or to necessitate hospitalization to prevent harm to self or others, or there are psychotic features D. The episode is not attributable to the physiologic effects of a substance (eg, a drug of abuse, a medication, other treatment) or another medical condition

DIGFAST needs 3 criteria.

Distractibility, insomnia, delusions of grandeur, flight of ideas, increased activity, speech is pressured, thoughtlessness seeks pleasure without considering consequences. Sx lasting at least 1 week.

Management of acute Mania:

• Hospitalize

• Mood stablizers. Lithium is drug of choice, takes 1 week to have effect.

  • Lithium has stabilizing properties on concentration of intracellular calcium, which has been linked to the mood disorder in mania, where intracellular calcium has been found to be elevated.

• Antipsychotics are used until mania is controlled. Drug of choice is risperidone.

• Give IM depot phenothiazine in noncompliant, severely manic patients.

• Give antidepressants only when there's history of recurrent episodes of depression and only together with mood stabilizers (to prevent inducing manic episode).

DSM-5 Diagnostic Criteria for Hypomanic Episode

A. A distinct period of abnormally and persistently elevated, expansive, or irritable mood and abnormally and persistently increased activity or energy, lasting at least 4 consecutive days and present most of the day, nearly every day.

B. During the period of mood disturbance and increased energy and activity, three (or more) of the following symptoms (four if the mood is only irritable) have persisted, represent a noticeable change from usual behavior, and have been present to a significant degree:

• 1. Inflated self-esteem or grandiosity.

  2. Decreased need for sleep (eg, feels rested after only 3 hours of sleep).

  3. More talkative than usual or pressure to keep talking

  4. Flight of ideas or subjective experience that thoughts are racing

  5. Distractibility (ie, attention too easily drawn to unimportant or irrelevant external stimuli), as reported or observed.

  6. Increase in goal-directed activity (either socially, at work or school, or sexually) or psychomotor agitation.

  7. Excessive involvement in activities that have a high potential for painful consequences (eg, engaging in unrestrained buying sprees, sexual indiscretions, or foolish business investments)

C. The episode is associated with an unequivocal change in functioning that is uncharacteristic of the individual when not symptomatic.

D. The disturbance in mood and the change in functioning are observable by others.

E. The episode is not severe enough to cause marked impairment in social or occupational functioning or to necessitate hospitalization. If there are psychotic features, the episode is, by definition, manic.

F. The episode is not attributable to the physiologic effects of a substance (eg, a drug of abuse, a medication, other treatment).

Bipolar disorder I and II

• • Bipolar I disorder is a diagnosis reserved for those who have had manic episodes, while bipolar II disorder is used for those who have never had a manic episode but have had hypomanic episodes and at least one major depressive episode.

  • Bipolar 1 disorder has a mean age of onset of 18.2 years and for bipolar II disorder, it is 20.3 years. Depressive episodes have a median duration of 15 weeks, while the median duration is 7 weeks for manic episodes and 3 weeks for hypomania. Over the course of their illness, patients will spend more time depressed than in elevated mood states. Among patients who have recovered from their first manic episode, 40% will have a recurrence into depression or mania within the subsequent 2 years. In contrast to major depressive disorder, in bipolar I disorder, women are just as likely to be affected as men, whereas in bipolar II disorder, women are twice as likely to be affected.

  • Bipolar disorder is considered to be highly genetic, with a heritability of 89%. Among first-degree relatives of a bipolar proband, the risk of having bipolar disorder is 8.7%. Twin studies reveal monozygotic concordance rates of 40% compared to dizygotic concordance rates of 5.4%. This suggests that while genetics play a large role in determining illness onset, environmental factors exist as well. Unlike major depressive disorder, bipolar disorder episodes, in particular mania and hypomania, can be triggered by events that impact circadian rhythms (eg, sleep deprivation, seasonal change, time zone travel) and exposure to rewarding stimuli (eg, falling in love, starting a creative project, a period of personal growth).

  • Comorbidity: Nearly 75% of people with a lifetime history of major depressive disorder will have another psychiatric illness at some point in their lives. Anxiety disorders are most prevalent, with nearly 60% of patients with depression meeting criteria for one of these conditions, while substance-use disorders are seen in as many 24% of patients with major depressive disorder. Major depressive disorder is also highly comorbid with other medical conditions, including obesity, hypertension, diabetes mellitus, rheumatologic disorders, immune-mediated dermatologic disorders, and cardiovascular disease. Depression is frequently observed in patients with neurologic disorders. The prevalence rates of comorbid depression are 30% to 50% for patients with Alzheimer disease, 20% to 72% for patients with stroke, 40% to 50% for patients with Parkinson disease, 19% to 54% for patients with multiple sclerosis (MS), and 7% to 63% for patients with obstructive sleep apnea. Comorbidity is also very common in bipolar disorder. Approximately 75% of patients with bipolar disorder are diagnosed with an anxiety disorder at one time in their life; 42.3% are diagnosed with a substance use disorder and 62.8% with an impulse control disorder, while approximately 60% are diagnosed with a personality disorder. Medical illnesses, including asthma, type 2 diabetes mellitus, hypercholesterolemia, epilepsy, kidney disease, and thyroid disease, are up to 6 times more common among those with bipolar disorder than among healthy controls and those with major depressive disorder.

  • In bipolar disorder, 25% to 50% will attempt suicide, while 15% to 20% of patients die by suicide.

Mood disorder due to Medical Conditions and Medications

A mood d/o can be caused by a medical illness. Examples: MS, stroke, Cushing's disease, cancer, RA. Medications used to treat nonpsychiatric disorders can also cause mood d/o that begin within 1 month of the initiation of the medication. BB, steroids, steroids, OCP, and barbiturates. Alcohol may also cause depression.

Patient Health Questionnaire-9

Mood Disorders Questionnaire