Mood Disorders 1-23-09 1 Dr Gluzman

8/11/2019 Mood Disorders 1-23-09 1 Dr Gluzman

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MOOD DISORDERS

Ellen Gluzman, MD


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DEPRESSIVE SPECTRUM

DISORDERS


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MAJOR DEPRESSIVE DISORDER


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Major Depressive Episode DSM-IV TR

CriteriaA. Five (or more) of the following symptoms have been present

during the same 2-week period and represent a change fromprevious functioning; at least one of the symptoms is either (1)depressed mood or (2) loss of interest or pleasure. Note: Do notinclude symptoms that are clearly due to a general medicalcondItion, or mood-incongruent delusions or hallucinations.1. depressed mood most of the day, near!y every day, as

indicated by either subjective report (e.g., feels sad orempty) or observation made by others (e.g., appearstearful). Note: In children and adolescents, can be irritablemood.

2. markedly diminished interest or pleasure in all, or almost all,activities most of the day, nearly every day (as indicated byeither subjective account or observation made by others)

3. significant weight loss when not dieting or weight gain (e.g.,a change of more than 5% of body weight in a month), ordecrease or increase in appetite nearly every day. Note: Inchildren, consider failure to make expected weight gains.

4. insomnia or hypersomnia nearly every day


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Major Depressive Episode DSM-IV

TR Criteria5. psychomotor agitation or retardation nearly every day

(observable by others, not merely subjective feelings ofrestlessness or being slowed down)

6. fatigue or loss of energy nearly every day

7. feelings of worthlessness or excessive or inappropriate guilt(which may be delusional) nearly every day (not merelyself-reproach or guilt about being sick)

8. diminished ability to think or concentrate, or indecisiveness,nearly every day (either by subjective account or asobserved by others)

9. recurrent thoughts of death (not just fear of dying),recurrent suicidal ideation. without a specific plan, or asuicide attempt or a specific plan for committing suicide


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Clinical Features

Children

School Phobia and excessive clinging

Somatic Complaints

Adolescents

Irritable mood

Poor academic performance Substance abuse, antisocial behavior, sexual promiscuity, truancy, running away

Elderly

Prevalence 25-50%

Can be correlated with low socioeconomic status, loss of a spouse, concurrent physicalillness, social isolation

Characterized more by somatic complaints


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Characteristic Findings

Mood and Affect

Speech latency and lowered intensity

Social withdrawal or isolation

Sexual Dysfunction

Reduced libido, erectile dysfunction, and delayed or impaired ability toachieve orgasm

Ruminations

Anxiety (90% of all depressed patients)


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Risk factors for recurrent MDD

Severe index episode

Longer duration of a prior episode of MDD

Incomplete recovery from a prior episode ofMDD

Increasing age


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Specifiers

With Atypical FeaturesA. Mood reactivity (i.e., mood brightens in responseto actual or potential positive events)

B. Two (or more) of the following features: significant weight gain or increase in appetite

hypersomnia

leaden paralysis (i.e., heavy, leaden feelings in arms or legs)

long-standing pattern of interpersonal rejection sensitivity (notlimited to episodes of mood disturbance) that results in significantsocial or occupational impairment

C. Criteria are not met for With MelancholicFeatures or With Catatonic Features during thesame episode.


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Specifiers

Characteristics associated with atypical features

Early age onset

Chronic course

Higher frequency in females

Higher frequency in borderline personality disorder Good response to SSRIs, bupropion, MAOIs but not to TCAs

Possible improvement of carbohydrate cravings and improveddepression with chromium picolinate 600 micrograms/day


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Specifiers

With Seasonal PatternA. There has been a regular temporal relationship between the onset of Major

Depressive Episodes in Bipolar I or Bipolar II Disorder or Major DepressiveDisorder, Recurrent, and a particular time of the year

B. Full remissions (or a change from depression to mania or hypomania) also

occur at a characteristic time of the yearC. In the last 2 years, two Major Depressive Episodes have occurred that

demonstrate the temporal seasonal relationships defined in Criteria A and B,and no nonseasonal Major Depressive Episodes have occurred during thatsame period.

D. Seasonal Major Depressive Episodes substantially outnumber the

nonseasonal Major Depressive Episodes that may have occurred over theindividual's lifetime.


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Specifiers

Common reported symptoms

increased appetite with carbohydrate craving,

increased weight, increased sleep, daytime drowsiness

Higher in females (4:1)

Higher in Northern regions

Related to decreased availability of sunlight in winter

Dysregulation of melatonin

Light therapy is an effective treatment


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Specifiers

With psychotic features

Related to severe disease and poor prognosis

More common with bipolar disorder family history

Often require antipsychotics in addition toantidepressants, and may need ECT

Can be applied to depressive or bipolar episodes

With melancholic features

Severe anhedonia, early morning awakening, weight loss,feelings of guilt

Endogenous depressionchanges in autonomic system

Can be applied to depressive or bipolar episodes


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Specifiers

Postpartum onset

Within 4 weeks postpartum

Often associated with psychotifc features

Can be applied to both depressive and bipolar

episodes

Chronic

Depressive disorder criteria met for 2 years

Can be applied to all depressive episodes


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Clinical features of MDD

Produces more impairment of physical functioning, role

functioning, social functioning, and perceived current health

Associated with more bodily pain

Causes patients to spend more days in bed because of poor

health than do hypertension, diabetes, arthritis, and chronic

pulmonary disease


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Clinical features: Suicide

45 to 77% of people who complete suicide

had a mood disorder.

10-15% of patients with mood disorder will go

on to commit suicide.

3% of the treated population will attempt over

10 years


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Clinical features

Factors that increase risk of suicide

Demographic factors

Male sex

Recent loss

Never married

Older age

Symptoms

Severe depression

Anxiety

Hopelessness

Psychosis, especially with command hallucinations


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Clinical features

Factors that increase risk of suicide

History of suicide attempts, especially if multiple or severeattempts

Family history of suicide

Active substance abuse

Suicidal thinking

Presence of a specific plan

Means available to carry out the plan

Absence of factors that would keep the patient fromcompleting the plan

Rehearsal of the plan


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Cost of Depression

The total cost in the United States is generallyestimated at $44 billion.

The direct costs of treating depression are about $12billion, only $890 million of which is accounted for by the

price of antidepressants The morbidity cost is around $24 billion

The mortality costs are $8 billion

Due to increased accident rates, substance abuse,

development of somatic illness such as coronary heartdisease, and increased use of medical hospitalizationand outpatient treatment


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Course of illness

Onset

50% of patients had significant depressive symptoms before diagnosis

Before age 40 (mid-20s DSM) in about 50% of patients

Later onset associated with family history of mood disorders, antisocialpersonality disorder, and alcohol abuse.

Duration

Untreated episodes last 6 to 13 months; most treated episodes last about 3months

Withdrawal from antidepressants 3 months before completion results inrecurrence of symptoms

As the course progresses symptoms last longer.

DSM statistics

60% of patients will have a 2ndepisode 70% chance of 3rd

90% chance of a 4th


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Course of Illness

Development of Manic Episodes:

5 to 10 percent develop a manic episode 6 to 10 years after their 1stepisode.

Mean age of switch is 32 years after 2 to 4 depressive episodes

Prognosis Chronic condition, and patients symptoms recur

Patients who have been hospitalized for a 1stepisode have 50% chanceof recovering in the 1styear

25% experience a recurrence in the 1st6 months after release from a

hospital, 30 to 50% in the 1

st

2 years, and about 50 to 75% in 5 years. Generally the more episodes, the time in between episodes lessens

and severity worsens.


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Prognostic Indicators

Good indicators Mild episodes

No psychosis

Short hospital stay

Solid friendships during

adolescence Stable family functioning

Sound social functioningfor 5 years preceding theillness

No comorbid psychiatric

illnesses No more than one

inpatient

Advanced age of onset

Bad Indicators Coexisting dysthymic

disorder

D&A abuse

Anxiety disordersymptoms

More than onedepressive episode

Being a menpredisposes a longer,chronic course


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MOOD DISORDER

SECONDARY TO

GENERAL MEDICAL

CONDITION


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Mood Disorder Due to GMC DSM-IV

TR CriteriaA. A prominent and persistent disturbance in mood

predominates in the clinical picture and is characterized byeither (or both) of the following: Depressed mood or markedly diminished interest or pleasure in all, or

almost all, activities

elevated, expansive, or irritable mood

B. There is evidence from the history, physical examination, orlaboratory findings that the disturbance is the directphysiological consequence of a general medical condition.


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Mood Disorder Due to GMC

Hypothyroidism

Leads to depression in 40% of individuals

Manifest with vegetative symptoms before mood or cognitive changes

appear

Treat with thyroid hormone and if indicated use an antidepressant also

Cushings disease

Most associated with depression (60-80%)

More frequent in women


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Diabetes

Autoimmune disorders

SLE, MS, RA

Nutritional deficiencies Deficiencies of B Vitamins (folic acid, B6, B12)

Deficiencies in B6 and B12 can reduce the

effectiveness of antidepressant treatment


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Myocardial infarction and cardiovascular disease

15-22% of persons become depressed

If depression is untreated morbidity and mortalityincreases

Statins increased depression and suicide risk (?)

TCAs contraindicated 6 months after MI and poor choice

CBT effective

SSRIs better choice

Sertraline is best studied


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Neurological conditions Cerebrovascular diseases

27-40%

anterior than in the posterior

more left than right

May present with a poststroke emotional lability not coducive todepression

Parkinsons disease

50 to 75 %

Dementias

11% in Alzheimers disease

Worsens condition and deterioration


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SUBSTANCE-INDUCED MOOD

DISORDER


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Substance-Induced Mood Disorder

DSM IV-TR criteriaA. A prominent and persistent disturbance in mood predominates

in the clinical picture and is characterized by either (or both)of the following:

depressed mood or markedly diminished interest or

pleasure in all, or almost all, activities elevated, expansive, or irritable mood

B. There is evidence from the history, physical examination, orlaboratory findings of either:

the symptoms in Criterion A developed during, or within amonth of, substance Intoxication or withdrawal

medication use is etiologically related to the disturbance


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DSM IV-TR criteriaC. The disturbance is not better accounted for by a Mood

Disorder that is not substance induced. Evidence that thesymptoms are better accounted for by a Mood Disorder that

is not substance induced might include the following:

the symptoms precede the onset of the substance use the symptoms persist for a substantial period of time (e.g., about a

month) after the cessation of acute withdrawal or severe intoxication

substantially in excess of what would be expected given the type oramount of the substance used or the duration of use

there is other evidence that suggests the existence of an independentnon-substance-induced Mood Disorder (e.g., a history of recurrentMajor Depressive Episodes)


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DSM IV-TR criteria

D. The disturbance does not occur exclusively

during the course of a delirium.

E. The symptoms cause clinically significant

distress or impairment in social, occupational,

or other important areas of functioning.


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Substance induced mood disorder

Medications that may mood symptoms:

anesthetics, analgesics, anticholinergics, anticonvulsants,antihypertensives, antiparkinsonian medications, antiulcermedications, cardiac medications, oral contraceptives,

psychotropic medications (e.g., antidepressants,benzodiazepines, antipsychotics, disulfiram), musclerelaxants, steroids, and sulfonamides.

Higher likelihood of producing depressive features

high doses of reserpine, corticosteroids, anabolic steroids


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Substance induced mood disorder

Heavy metals and toxins

gasoline and paint

organophosphate insecticides

nerve gases

carbon monoxide and carbon dioxide


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BEREAVEMENT


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Depression in Bereavement

Duration and expression of "normal" bereavement variesconsiderably among different cultural groups

Diagnosis of depression not given unless the symptoms arestill present 2 months after the loss

Symptoms that are not characteristic of a "normal" grief reaction: guilt about things other than actions taken or not taken by the

survivor at the time of the death

thoughts of death other than the survivor feeling that he or she wouldbe better off dead or should have died with the deceased person


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MANAGEMENT OF DEPRESSION


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Management of Depression

1. Perform a diagnostic evaluation

2. Evaluate the safety of the patient and others

3. Evaluate and address functional impairments

4. Determine the treatment setting

5. Establish and maintain a therapeutic alliance

6. Monitor psychiatric status and safety7. Provide education to the patient and, when appropriate, to his or her family

8. Enhance medication adherence

9. Address early signs of relapse


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Mild to Moderate

Can use solo treatment if patient prefers

Indications for therapy

Presence of significant psychosocial stressors Intrapsychic conflict, Interpersonal difficulties

Comorbid personality disorder

Pregnancy, lactation, or wish to become pregnant

Patient preference


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Indications for Combined Pharmacotherapy andPsychotherapy: Clinically significant psychosocial issues

Interpersonal problems

Comorbid personality disorder

History of only partial response to single treatment modalities

Poor adherence to treatments (combine medication with apsychotherapeutic approach that focuses on treatment adherence)


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Basis for Selection of Antidepressant

Depression symptoms Insomnia, anger, worry, fear, or restlessness

More focus on 5HT based

SSRI, tertiary-amine TCA, venlafaxine, duloxetine, MAOI,mirtazapine

Bupropion alone can increase anxiety

Anergia, lack of focus, difficulty with concentration or inattentiveness

More focus on NE based

TCA (tertiary or secondary), higher dose of venlafaxine, higherdose of paroxetine, duloxetine, mirtazapine, MAOI, bupropion

Anhedonia, low energy, concerns about sexual dysfunction

More a DA based

Bupropion, high dose sertaline


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APA guidelines (2000)

Depression and anxiety: SSRI, avoid bupropion

Depression and OCD: SSRI or clomipramine

Severe Depression: TCAs

Melancholic Depression: TCAs preferred to SSRIs

Atypical depression: SSRIs and MAOIs avoid TCAs


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Depression types

Atypical depression: MAOIs

Depression with seasonal features: light therapy

Depression with postpartum onset: estrogen after delivery, antidepressants,

ECT

Depression with psychosis: Antidepressant plus antipsychotic, ECT, amoxapine

Depression with melancholia responds better to 5-HT/NE based and ECT than

to SSRIs.


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Phases of Treatment

Acute Phase (0-16 weeks)

Start antidepressant

Expect a response 1-3 weeks after starting medication

Maintain therapeutic dose for 3-12 week

Continuation Phase (begins after the acute phase and last an additional 6-

9 months)

Maintenance phase (begins after recovery)

Continue same dose that got the patient well

Goal is to prevent new mood episodes in patients who are known to have

recurrent or chronic depression


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Indications for ECT Major depressive episode with a high degree of symptom severity and

functional impairment

Psychotic symptoms or catatonia

Urgent need for response (e.g., suicidality or nutritional compromise in apatient refusing food)

May be the preferred treatment when:

the presence of comorbid medical conditions precludes the use ofantidepressant medications

there is a prior history of positive response to ECT

the patient expresses a preference for ECT.


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BIPOLAR DISORDER


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What is the difference between the Bipolar Disorders?

Bipolar I disorder: Mixed or Mania No depression required for diagnosis

Bipolar disorder, single (mixed/manic) episode

If there is a history of depression, specify in diagnosis,i.e.:

Bipolar disorder, most recent episode _____

Bipolar II disorder: No Mixed or Manic episodes

Hypomania and at least one major depressive episode Causes significant distress or impairment in social,

occupational, or other areas of functioning.


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MANIC EPISODE


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Criteria for Manic Episode A. A distinct period of abnormally and persistently elevated,

expansive, or irritable mood, lasting at least 1 week (or any durationif hospitalization is necessary).

B. During the period of mood disturbance, three (or more) of thefollowing symptom have persisted (four if the mood is only irritable)and have been present to a significant degree: (1) inflated self-esteem or grandiosity (2) decreased need for sleep (e.g., 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 (i.e., attention too easily drawn to unimportant

or irrelevant external stimuli) (6) increase in goal-directed activity (either socially, at work or

school, or sexually) or psychomotor agitation

(7) excessive involvement in pleasurable activities that have ahigh potential for painful consequences (e.g., engaging inunrestrained buying sprees, sexual indiscretions, or foolishbusiness investments)


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More Mania

Mood and Affect can be euphoric or expansive

but can quickly become labile

High potential for assault or violence

Caution is advised

75% have psychotic features, grandiose

delusions

Very poor insight


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More on Mania

Excessive ETOH intake

Disinhibited nature

Pathological gambling

Wearing clothing and jewelry of bright colorsin unusual or outlandish combinations andinattention to small details

Preoccupied with religious, political, financial,sexual, or persecutory ideas that can evolveinto complex delusions


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More on Mania

Mania in Adolescents

Misdiagnosed as Antisocial PD or Schizophrenia

Psychosis

Substance Abuse

Suicide Attempts

OCD

Multiple somatic complaints

Marked Irritability


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Specifiers With Rapid Cycling

At least four episodes of a mood disturbance in the previous 12 months thatmeet criteria for major depressive, mania, or hypomania.

Episodes are demarcated either by partial or full remission for at least 2months or a switch to an episode of opposite polarity.

Risk factors Bipolar II disorder

Being a woman Hypothyroidism

Right cerebral hemisphere disease

Mental retardation

Use of alcohol and stimulants

Features Found 5-15% of all Bipolars

less response to Lithium


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HYPOMANIC EPISODE


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Criteria for Hypomanic Episode

A. A distinct period of persistently elevated, expansive, or irritablemood, lasting throughout at least 4 days, that is clearly different from theusual nondepressed mood.

B. During the period of mood disturbance, three (or more) of thefollowing symptom have persisted (four if the mood is only irritable) andhave been present to a significant degree.

(1) inflated self-esteem or grandiosity (2) Decreased need for sleep (e.g., 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 (i.e., attention too easily drawn to unimportant or irrelevantexternal stimuli)

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

(7) Excessive involvement in pleasurable activities that have a high potentialfor painful consequences (e.g., the person engages in unrestrained buyingspree sexual indiscretions, or foolish business investments)


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BIPOLAR DEPRESSION

Depression


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Depression

Unipolar vs. Bipolar Later onset, fewer episodes,

More gradual onset

Female > male

More psychomotor agitation,typical symptoms, insomnia

Lower risk of suicide Less frequently accompanied by

psychotic symptoms in youngerpatients

Antidepressants more effective,

Lithium less effective Family history of depression

Normal [Ca2+]

Earlier onset, More episodes,Acute onset

Female = male

More psychomotor retardationand lethargy

Atypical symptoms

Hypersomnia

Greater risk of suicide

Greater likelihood of psychoticsymptoms in younger patients

Antidepressants less effective,

Lithium more effective Family history of mania and

depression

Increased [Ca2+]


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MIXED EPISODES


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Criteria for Mixed Episode

A. The criteria are met both for a Manic Episode and for aMajor Depressive Episode (except for duration) nearlyevery day during at least a 1-week period.

B. The mood disturbance is sufficiently severe to cause

marked impairment in occupational functioning or in usualsocial activities or relationships with others, or tonecessitate hospitalization to prevent harm to self orothers, or there are psychotic features.

C. The symptoms are not due to the direct physiological

effects of a substance or a general medical condition Note: Mixed-like episodes that are clearly caused by somatic

antidepressant treatment (e.g., medication, electroconvulsivetherapy, light therapy) should not count toward a diagnosis ofBipolar I Disorder.


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Other Features of Mixed Episode

Severe, impairing, and more treatment

resistant

Psychosis and suicide are more common

40% of manic episodes present with mixed

features

Usually followed by a depressive episode


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Bipolar Disorder and Suicide

Patients with mixed bipolar states may be more

likely to involve others in a suicide attempt

As many as 4% of the people who commit suicide

murder someone else first. High levels of distress and hopelessness increase

the risk of suicide attempts in adolescents

Bipolar II are at higher risk of attempting andcompleting suicide


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Rules of 3

Will help uncover a bipolar episode

3 marriages before age 30

Failure of 3 antidepressants

3 different careers by age 30

3 first degree relatives with a mood disorder

3 consecutive generations with a mood disorder


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Course for Bipolar I

Most often starts with Depression 75 percent of women, 67 percent of the men

Experience both symptoms

Untreated mania last about 3 months

90% of patients who have had a manic episode are likely tohave another

As the disorder progresses, the time between episodesdecreases

After about 5 episodes, interepisode interval stabilizes for 6 to9 months


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Prognosis


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Prognosis

Poor vs Good Premorbid poor

occupational status

Substance Abuse

Psychotic features

Rapid cycling patternand mixed episodes

Interepisodedepressive features

Male gender

Younger age at initialonset

Increasing frequencyof bipolar episodes

Short duration ofmanic episodes

Advanced age of onset

Few suicidal thoughts

Few coexisting

psychiatric or medical

problems


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Prognosis for Bipolar I

Poorer prognosis when compared to MDD 40 to 50 percent will have a manic episode within 2 years of

the 1stepisode

Only 50 to 60 percent of patients achieve control with Lithium

7% have no recurrence of symptoms

45% have more than one episode

Patients can have 2 to 30 manic episodes, mean number is 9 More than 40 percent have more than 10 episodes

Long term follow up

15% are well


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Psychiatric Management

1. Perform a diagnostic evaluation2. Evaluate the safety of the patient and others and determine

a treatment setting

3. Establish and maintain a therapeutic alliance

4. Monitor treatment response5. Provide education to the patient and to the family

6. Enhance treatment compliance

7. Promote awareness of stressors and regular patterns of

activity and sleep8. Work with the patient to anticipate and address early signs of

relapse

9. Evaluate and manage functional impairments


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MANAGEMENT OF BIPOLAR

DISORDER


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FDA approved treatment for mania

Lithium

Depakote, Depakene, Carbamazepine

Zyprexa, Seroquel, Geodon, Abilify, Risperdal

Thorazine

Medications not approved at all for Bipolar (and actually

found in some studies to be ineffective)

Tiagabine

Topiramate

Gabapentin


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Management of Acute Episodes

Mania or mixed episodes Severe episodes: initiate of either lithium plus an antipsychotic or valproate

plus an antipsychotic

For less ill patients, monotherapy with lithium, valproate, or an antipsychoticsuch as olanzapine may be sufficient

Short-term adjunctive treatment with a benzodiazepine may also be helpful

For mixed episodes, valproate may be preferred over lithium

Atypical antipsychotics are preferred over typical antipsychotics because oftheir more benign side effect profile

Alternatives include carbamazepine or oxcarbazepine in lieu of lithium orvalproate

Antidepressants should be tapered and discontinued if possible

If psychosocial therapy approaches are used, they should be combined withpharmacotherapy


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Presence of a manic or mixed episode despite medicinecompliance

the first-line intervention should be to optimize the

medication dose

Introduction or resumption of an antipsychotic issometimes necessary

Severely ill or agitated patients may also require short-

term adjunctive treatment with a benzodiazepine


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If first-line medications at optimal doses fails to controlsymptoms

Addition of another first-line medication

Alternative treatment: carbamazepine or oxcarbazepine

Adding an antipsychotic if not already prescribed

Changing from one antipsychotic to another

Clozapine effective in refractory illness


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f d


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Treatment of Hypomanic Episodes

No drug is approved for hypomanic episodes

DSM-IV TR indicates that hypomania does not

have a dysfunctional course

Aggressive treatment only indicated if

escalating into mania or rapid cycling

Otherwise no treatment is warranted

f


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FDA approved for Bipolar Depression

Symbyax

Seroquel

Lamictal is not yet approved

f i l i


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Management of Bipolar Depression

First-line is lithium or lamotrigine Antidepressant monotherapy is not recommended

As an alternative, initiate simultaneous treatment with lithiumand an antidepressant

* Can also use Symbiax as it has FDA approval

In patients with life-threatening inanition, suicidality, orpsychosis, ECT also represents a reasonable alternative

ECT is also a potential treatment for severe depression duringpregnancy

Interpersonal therapy and cognitive behavior therapy may beuseful when added to pharmacotherapy. Psychodynamic alsoeffective


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M f R id C li


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Management of Rapid Cycling

Initial intervention

Identify possible contributors such as

hypothyroidism, or drug and alcohol use

If caused by an antidepressant should be taperedif possible

Initial treatment

Lithium or valproate An alternative treatment is lamotrigine

FDA approved for maintenance


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FDA approved for maintenance

treatment

Lithium

Zyprexa

Lamictal

M i t T t t


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Maintenance Treatment

The medications with the best empirical evidence to supporttheir use in maintenance treatment include lithium and

valproate

Possible alternatives include lamotrigine, carbamazepine, or

oxcarbazepine Reassess ongoing antipsychotic treatment upon entering

maintenance treatment

Maintenance therapy with atypical antipsychotics may be

considered Concomitant psychosocial intervention


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DYSTHYMIC DISORDER

DSM-TR Criteria for Dysthymic


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y y

Disorder

A. Depressed mood for most of the day, for more days thannot, as indicated either by subjective account orobservation by others, for at least 2 years. Note: In childrenand adolescents, mood can be irritable and duration must

be at least 1 year.

B. Presence, while depressed, of two (or more) of thefollowing:

1. poor appetite or overeating

2. insomnia or hypersomnia

3. low energy or fatigue4. low self-esteem

5. poor concentration or difficulty making decisions

6. feelings of hopelessness


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D th i di d MDD


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Dysthymic disorder vs. MDD

MDD has more severe symptoms in quantity thanDD.

Cognitive symptoms and social-motivational

symptoms are more frequent in DD It is difficult to determine which one of the two

conditions impairs more functioning.

Risk of 75% that MDD will be developed within the

next 5 years

C


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Course

Early and insidious onset as a chronic course They come to treatment when they have a superimposed

major depression

Remission rate as low as 10% per year

Recovery rate 73.9%, with median

time of 52 months Estimated risk of relapse into another period of chronic

depression was 71.4%

68% and 90% of dysthymic patients experience at least onemajor depressive episode

D bl D i


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Double Depression

Major depressive episode must appear 2 years ormore (1 year in children and adolescents) after theonset of dysthymia for double depression to bediagnosed

More severe depressive symptoms, morepsychosocial impairment, a greater risk of suicidemore treatment resistance and more comorbidity,especially with avoidant and dependent personality

disorders, less likely to remit) and is more likely torecur


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CYCLOTHYMIA

DSM IV TR Criteria for Cyclothymia


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DSM IV TR Criteria for Cyclothymia

A. For at least 2 years, the presence of numerous periods withhypomanic symptoms and numerous periods with

depressive symptoms that do not meet criteria for a Major

Depressive Episode. In children and adolescents, the

duration must be at least 1 year.B. During the above 2-year period (1 year in children and

adolescents), the person has not been without the

symptoms in Criterion A for more than 2 months at a time.

Clinical features


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Clinical features

50% have depressive features as presentation Experience mood states that alternate between

depression, irritability, cheerfulness, and relativenormality that last days, weeks, or months.

Complain of unpredictable changes in energy, vaguephysical symptoms, and a seasonal pattern of moodswings (e.g., depression in the winter)

44% of the cyclothymic patients developedhypomania while taking antidepressants

Course


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Course

Insidious onset and a chronic course

15%50% risk that the person will

subsequently develop Bipolar I or II Disorder.

50% start out with depressive symptoms

Treatment of Cyclothymia


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Treatment of Cyclothymia

Mood Stabilizers are the first line of treatment Use the same plasma concentrations that you would

use for Bipolar disorder

Be cautious when using antidepressants as there is a40-50% of patients that will develop antidepressantinduced hypomania.

Psychotherapy should be geared towards helpingthem become familiar with their condition and helpthem with coping mechanisms to deal with theirmood swings.

Documents

Mood Disorders 1-23-09 1 Dr Gluzman