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Mood Disorders: A Biopsychosocial Approach
Katharine Gillis FRCPCAssociate ProfessorDepartment of PsychiatryUniversity of Ottawa
MOOD DISORDERS
Major Depressive Disorder Dysthymic Disorder Bipolar Disorders: I with Mania II with hypomania Cyclothymia
LIFETIMES PREVALENCES Major Depressive Disorder
women 10-25 %men 5-12%
Dysthymia 6 %
Bipolar Disorders type I 0.4-1.6 % type II 0.5%
In the Family Practice Setting 25% of all patients who visit their family
physicians will have a diagnosable mental disorder
The incidence of major depression is 10% in primary care patients
Effective treatment can reduce morbidity and decrease utilization of other health services
Medical patients with major depression have a worse prognosis for their medical recovery
Key Concepts in Mood Disorders
Mood Disorders are usually EPISODIC Need to inquire about current episode, but
also past episodes Past history of episodes that are high or low
are the often the key to sorting out the diagnosis
Genetics are very important in mood disorders especially Bipolar: ALWAYS ask about family history of mood symptoms or suicide
Key Concepts in Mood Disorders
Is there a history of inter episode wellness- better prognosis
Are the symptoms chronic Treatment goal is to treat current
symptoms but also to try and prevent future episodes of mood symptoms
Treatment usually medication based for moderate to severe symptoms plus or minus a specific type of psychotherapy.
How is Major Depression different from just feeling down?
Just feeling down should not have “physical symptoms” associated with it
Just feeling down should not impair function Just feeling down should not last daily for at
least two consecutive weeks or more Untreated an episode of major depression
on average lasts 6-12 months
Key Concept for Major Depression
For Major Depression must have persistent symptoms of depression or LOSS of INTEREST for at least 2 consecutive weeks
Many people with depression do NOT report feeling depressed, but have loss of interest
Elderly patients often have new onset of somatic complaints but may deny feeling depressed
Need a cluster of four other symptoms besides loss of interest or depression to make the diagnosis
Key Concept for Major Depression
Physical symptoms of depression include changes FROM BASELINE in sleep, appetite, energy and physical movements
Physical symptoms are often referred to as “vegetative symptoms”
The presence of new onset of vegetative symptoms can be a good predictor of response to antidepressant treatment
Physical Symptoms of Major Depression
Sleep- change from baseline. Usually too little.
All sleep phases can be effected but the classic symptom is early morning awakening.
Excessive sleep from baseline is an atypical feature and occurs more in teenagers
Physical Symptoms of Major Depression
Appetite-change from baseline usually a decrease
Loss of taste for food* Loss of weight Increase in appetite from baseline,
especially with carbohydrate craving is an atypical feature and occurs more in teenagers
Physical Symptoms of Major Depression
Fatigue- change from baseline Diminished spontaneous movements
may be observed and is called psychomotor slowing
Physical restlessness may be observed and is called psychomotor agitation
Other Important Symptoms of Major Depression
Guilt Impaired concentration Social withdrawal Suicidal thoughts: Safety assessment Panic attacks* Obsessive compulsive symptoms*
*Not in DSM-4 criteria
Specifiers for Mood Disorders
Specifiers describe the most recent mood episode such as:
With Postpartum Onset (within 4 weeks of delivery
With Catatonic features With Atypical Features With Rapid Cycling
Specifier- With Seasonal Pattern Only applies to Major Depressive Episode (not manic
or hypomanic) Regular temporal relationship between onset of major
depressive episode and a particular time of year usually fall or winter
Full remission also occurs at regular time of year usually spring (or switch to mania)
In the last 2 years two major depressive episodes have occurred as above with no nonseasonal episode of MDE occurring in the two years
Seasonal episodes of MDE outweigh nonseasonal episodes in their lifetime
Specifier-With Psychotic Features
Psychosis may be present in 10-15% of patients with a Major Depressive Episode
Associated with worse prognosis Increase risk of suicide and homicide Important to always screen for psychotic
symptoms Has treatment implications- antipsychotic
needs to be added to antidepressant. May be an indication to consider ECT.
Epidemiology of Major Depression. Who is at risk?
Prevalence for men 5-12%, women 10-25%
Mean age of onset is around 40 50% of all patients have onset between
the ages of 20 and 50 10% of post partum women are at risk of
Major Depressive Episode. Etiology remains unclear, stress vs. hormone
Epidemiology of Major Depression. Who is at risk?
No correlation between socioeconomic status and MDE but unemployed are at 3X more risk
MDE more common in rural than urban areas
Prevalence of mood disorder does not vary among races
Loss of a parent before age 11 is a risk Loss of a spouse is a risk
Recurrence Rates in Major Depression
After 1 episode 50 % After 2 episodes 75 % After 3 episodes 90 % +
DYSTHYMIA
Depressed mood most days for 2 years Depressed symptoms include: appetite disturbance sleep disorder fatigue low self-esteem poor concentration hopelessness indecision
DYSTHYMIA (cont.)
Never symptom-free for over 2 months
Symptoms cause impaired functioning Antidepressant may or may not be
helpful. Psychotherapy may help particularly if many negative cognitions.
Bipolar Disorder Bipolar disorder is characterized by the
occurrence of mood episodes, usually with inter-episode wellness.
A mood episode can be a major depressive, manic, hypomanic, or mixed episode
An episode is demarcated by either switch to an opposite state ( manic to depressive) or 2 months or more of partial or full remission after an episode
Bipolar Type I Prevalence 1% of population men=women Must have at least one Manic Episode Does not require a depressive episode but
most patients have depression in their lifetime
Most have more depressive than manic episodes
Manic episodes are not subtle and usually require hospitalization
Manic Episode Criteria Elevated mood (may be irritable, expansive)
persisting for at least one week Need 3 (or 4 if irritable) of the following:
Grandiosity Delusions Reduced sleep Talkative Racing thoughts (flight of ideas) Distractibility Psychomotor agitation Poor impulse control, excessive involvement in
pleasurable activities
Manic Episode Criteria
Severe, marked impairment in function at work or socially, or need for hospitalization or presence of psychotic features
Symptoms present at least one week
Condition not caused by general medical condition or substances
Mixed Episode Criteria Criteria are met for both a manic episode
and a major depressive episode (except for duration) nearly every day for 1 week
Severe, marked impairment in function at work or socially, or need for hospitalization or presence of psychotic features
Condition not caused by general medical condition or substances
Bipolar I Average onset for first manic episode is age
32 Most have had 2-3 episodes of depression
by history prior to first manic episode Symptoms of acute mania develop over
hours to days Untreated manic episode lasts 3 months Untreated depressive episode lasts 6-13
months
Bipolar II Must have hypomanic episode(s) not manic Prevalence 0.5 % population May have major depressive episodes Less functional impairment than Type 1 Often does not require hospitalization If patient looks hypomanic but delusions
present then diagnose as manic Did an antidepressant cause the hypomanic
symptoms? If so may be Bipolar III.
Hypomanic Episode Elevated, expansive or irritable mood
lasting at least 4 days Need 3 (or 4 if irritable) of the following:
Grandiosity Delusions Reduced sleep Talkative Racing thoughts (flight of ideas) Distractibility Psychomotor agitation Poor impulse control, excessive involvement in
pleasurable activities
Hypomanic Episode Unequivocal change in functioning from
baseline The disturbance in mood and the change in
functioning is observable by others The episode is NOT severe enough to cause
marked impairment in work or social functioning, or to need hospitalization, no psychotic features
Symptoms are not caused by a general medical condition or substances
Rapid Cycling Bipolar Disorder Can be applied to Bipolar I and II At least four mood episodes in previous 12
months- depression, mania, hypomania, mixed state
Episode demarcated by either switch to opposite state or 2 months of partial or full remission between episodes
Rapid cycling diagnosis has treatment implications
CYCLOTHYMIA
Numerous periods of depressive symptoms AND hypomania symptoms over 2 years
Never symptom free for 2 months No time of Major Depression or Mania Symptoms cause impaired functioning
Common Medical Conditions Associated with Mood Disorders
Hypo/hyper thyroidism Cardiovascular disease especially MI CNS- infection, tumour, stroke, head injury,
hypoxia Parkinson's, Huntington's, Multiple Sclerosis B12, folate deficiency Chronic pain Sleep Apnea