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Robert Kelly, MD
Assistant Professor of Psychiatry
Weill Cornell Medical College
White Plains, New York
Depressive, Bipolar
and Related
Disorders
Lecture available at www.robertkelly.us
Financial Conflicts of Interest
As faculty of Weill Cornell Medical College we are
committed to providing transparency for any and all
external relationships prior to giving an academic
presentation.
I do not have an interest in any commercial products
or services—Robert Kelly, MD
Mood Disorder Criteria
Distress or Impairment
Clinically Significant
“Abnormal”
Involves Mood
Elevated
Expansive
Irritable
Depressed
Mood Disorders, DSM-5Depressive Disorders
Major Depressive Disorder
Persistent Depressive Disorder
Bipolar and Related DisordersBipolar I Disorder
Bipolar II Disorder
Cyclothymic Disorder
Schizoaffective DisorderDepressive Type
Bipolar Type
Adjustment Disorders
… Disorder Due to Another Medical Condition
Substance-Induced … Disorder
Other Specified …
Unspecified …
Case I
22-year-old, CC: SI + depressed mood
College student
Good social relationships
No mood disorder history
No substance abuse history
No general medical condition history
Only lasted 1-2 days
Significant suicidal impulses
Intense dysphoria
Substance/Medication-Induced Depressive Disorder
Prominent and Persistent
Depressed Mood or Anhedonia
Elated, Expansive, or Irritable
Evidence
Temporal--intoxication or withdrawal
Etiologically Related
Not Due to Other Mental Disorder
Not During Delirium
Clinically Significant Distress or Impairment
Case II
62-year-old man, depressed after MI
Depressed mood
Anxiety about death
Poor sleep
Feelings of guilt about health
Tired
Poor concentration
Poor appetite
Thoughts that life is not worth living
Depressive Disorder Due to Another Medical Condition
Prominent and Persistent
Depressed Mood or Anhedonia
Elated, Expansive, or Irritable
Evidence
Direct Physiological Consequence
Not Due to Other Mental Disorder
Not During Delirium
Clinically Significant Distress or Impairment
Case III
80-year-old grief-stricken female
Husband passed away one month ago
Tearful
Poor sleep
Feels husband’s death is her fault
Tired
Poor concentration
Poor appetite
Thoughts of wanting to jump in front of traffic
Auditory hallucinations: husband’s voice while awake
Major Depressive Episode
Depressed Mood or Anhedonia
Mood + SIGECAPS (most sx)
Two Weeks
Not Substance/Medication-Induced
Not Due to Another Medical Condition
Not Bereavement
Clinically Significant Distress or Impairment
Major Depressive Disorder
Major Depressive Episode
Not Schizoaffective Disorder
Not Superimposed on Psychotic Disorder
Not Bipolar Disorder
Case IV
32-year-old woman, “always” depressed
Low mood
Low self-esteem
Pessimistic
Chronic fatigue
Periodic insomnia
During childhood very anxious rather than depressed
Suicide attempt age 19
Some “brighter” periods, never more than 1 month
Persistent Depressive Disorder (Dysthymia)
Depressed Mood
Children and Adolescents: Irritability
Two Years
Children and Adolescents: One Year
Two or more Symptoms
SiGECAps
Hopelessness
Major Depressive Episode Can be Comorbid
Never Manic or Hypomanic Episode
Not Superimposed on Psychotic Disorder
Not Substance/Medication-Induced
Not Due to Another Medical Condition
Clinically Significant Distress or Impairment
Case V
55-year-old male with bizarre delusions
BIB police after threatening to stab others
Claims he was defending himself
No prior psychiatric history
Increasingly irritable past month
Says he is from another planet
Says he has three heads
Incoherent at times
Oriented to time and place
Manic Episode
Elevated, Expansive, or Irritable
DIGFASTDistractibility
Involvement in pleasurable, risky activities
Grandiosity
Flight of Ideas
Activity Increase
Sleep not needed
Talkative (pressured speech)
One Week
Not Substance/Medication-Induced
Not Due to Another Medical Condition
Marked Impairment
Bipolar I Disorder
Manic Episode
(Major Depressive Episode)
Not Schizoaffective Disorder
Not Superimposed on Psychotic Disorder
Clinically Distress or Impairment
Schizoaffective Disorder
Mood Episode
Mood, not anhedonia
Bipolar or depressive types
Schizophrenia-like period
Two weeks
No prominent mood symptoms
Delusions or hallucinations
Prominent Mood Symptoms Most of the Time
Not Substance/Medication-Induced
Not Due to Another Medical Condition
Case VI
45-year-old female with increased zest for life
H/o MDE’s
Mood no longer depressed, feels very good
Good energy, sleeps 5 hours/night (7 normal)
Talks rapidly
Unprotected sex with multiple partners over 2 months
Now embarrassed about promiscuity and risks
Hypomanic Episode
Elevated, Expansive, or Irritable
DIGFASTDistractibility
Involvement in pleasurable, risky activities
Grandiosity
Flight of Ideas
Activity Increase
Sleep not needed
Talkative (pressured speech)
Four Days
Unequivocal, Observable Change
Not Substance/Medication-Induced
Not Due to Another Medical Condition
NOT Marked Impairment
Bipolar II Disorder
Hypomanic Episode
Major Depressive Episode
Never Manic Episode
Not Schizoaffective Disorder
Not Superimposed on Psychotic Disorder
Clinically Distress or Impairment
Cyclothymic Disorder
“Hypomanic” Periods
“Depressive” Periods
Two Years
Children and Adolescents: One Year
No Other Episodes Involved
Major Depressive
Manic
Mixed
Not Superimposed on Psychotic Disorder
Not Substance/Medication-Induced
Not Due to Another Medical Condition
Clinically Significant Distress or Impairment
Case VII
19-year-old male, admitted after suicide attempt
BIB police, found ready to jump from bridge
Partner left him 3 days prior to attempt
Significant suicidal impulses
Intense dysphoria
College student
Good social relationships
No mood disorder history
No substance abuse history
No general medical condition history
Adjustment Disorders
Emotional or Behavioral Symptoms
Temporal Relationship with Stressor
Onset within 3 months
Resolution within 6 months
Not Due to Other Mental Disorder
Not Bereavement
Clinically Significant Distress or Impairment
Case VIII
13-year-old female with anger issues
BIB police after threatening school principal
Irritable
No sleep disturbance
Good grades
Hears commenting voices while in bed
Hears name being called while walking on street
Disruptive Mood Dysregulation Disorder
Frequent, Severe Temper Outbursts
Persistent Irritability
Children Ages 6-18
Duration: 1 year
Onset prior to age 10
Not Due to Other Mental Disorder
Clinically Significant Distress or Impairment
Unspecified Mental Disorder
Replacement for Nonexistent Unspecified Mood Disorder
Distress or Impairment
Not Any Other Disorder
Lack of Information or
Clinician Chooses Not To Specify
Prevalence (Yearly)
Depressive DisordersMajor Depressive Disorder (7%; 1.5-3x higher for women)
Persistent Depressive Disorder (2%)
Bipolar DisordersBipolar I Disorder (0.6%)
Bipolar II Disorder (0.8%)
Adjustment Disorders (2-8%)
Disruptive Mood Dysregulation Disorder (2-5%)
Lifetime Prevalence
Depressive DisordersMajor Depressive Disorder (women 10-25%; men 5-12%)
Persistent Depressive Disorder (6%)
Bipolar DisordersBipolar I Disorder (0.4-1.6%)
Bipolar II Disorder (0.5% ??)
Cyclothymic Disorder (0.4-1%)
Schizoaffective Disorder (0.3%)
Suicide
Completed Suicide
60-70% suffering from “significant depression”
Young: mostly substance-induced
Elderly: mostly major depressive episode, but “minor depression” also poses risk
Lifetime Risk for Selected Disorders
Bipolar I or II Disorder: 15%
Mood Disorders, generally: 10-15%
Schizophrenia/Schizoaffective: 5%
Borderline Personality Disorder: 10%
Treatment
Medication
Psychotherapy
Electroconvulsive Therapy (ECT)
Transcranial Magnetic Stimulation (TMS)
Vagal Nerve Stimulation (VNS)
Deep Brain Stimulation (DBS)
Exercise
Light Therapy
Others
Placebo Effect
Treatment
MedicationSSRIs
SNRIs
TCAs
MAOIs
Food restrictions, possible fatal outcome
Other antidepressants
Mirtazapine
Bupropion
Mood stabilizers
Lithium
Valproic acid
Lamotrigine
Carbamazepine
Antipsychotics, 2nd Generation
Others
Treatment
PsychotherapySupportive
Psychodynamic
CBT
Others
