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Ex.Professor and Head Psychiatry Department Govt. Medical College AMRITSAR

Dr.Paramjit Singh

MD., CCS

AFFECTIVE DIORDERS

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Depression-An under-recognized condition Non- attendance

(A) The Epidemiological Catchment Area Study carried out in the USA suggests that approximately one third of people suffering from depression do not seek help or treatment

(B) A European survey of 80,000 people also revealed third of people with major depression had not consulted a health-care specialist.

Men were less likely to consult a medical specialist than women. Many believed --------They would get better by themselves Some--------------------Too embarrassed to seek help

Other reasons why patients don’t consult doctors include:• They may not recognise they have an illness

• They may regard their symptoms as appropriate in their circumstances

• Many people do not know depression can be treated easily

• Misconceptions over treatment

Poor recognition

• GPs manage about 80 per cent of all mental illness, but evidence suggests that depression is frequently missed in general practice.

1. Half of patients severe depression -----------not recognised at the first consultation.

2. A further 10%------------- Recognised in subsequent consultations.

3. 20%--------------------------Remit during this time.

4. The remaining 20%-------- may remain unrecognised even after six months

5. Recognising difficulty -----------presentations with somatic symptoms - 70% cases - and of depression related to physical disorders

6. Other factors include an aversion on the part of both GPs and patients to talk about psychological problems and inadequate time for consultations

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MAJOR DEPRESSIVE DISORDER ORAFFECTIVE DISORDER( DEPRESSIVE EPISODE)

INCIDENCE

Male 5-12%

Female 10-25%

More in females, the ratio 2:1

Age 20-50 years

Average 40 years

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Lifetime Prevalence of Various Mood Disorders

Mood Disorder Lifetime

Prevalence

Depressive disorders

Major depressive disorder (MDD) 10–25% for women

5–12% for men

Recurrent, without full 25–30% of persons with MDD

interepisode recovery,

superimposed on dysthymic disorder (double depression)

• Dysthymic disorder 3–6%

Bipolar disorders

• Bipolar I disorder 0.4–1.6%

• Bipolar II disorder <1%

• Bipolar I disorder or bipolar II 5–15% of persons with

disorder, with rapid cycling bipolar disorder

Cyclothymic disorder 0.4–

1.0%

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ICD-10 Criteria for Depressive Episode

A. Five (or more) of the following symptoms have been present during the same 2-week period and represent a change from previous functioning;

At least one of the symptoms is either (1) depressed

mood or (2) loss of interest or pleasure.. (1)Depressed mood most of the day, nearly every day, Either subjective report (e.g., feels sad or empty) or

Observation made by others (e.g., appears tearful). Note: in children and adolescents, can be irritable mood.

(2) Markedly diminished interest or pleasure in all, or almost all, activities most of the day, nearly every day

(as indicated either by 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), or Decrease or increase in appetite nearly every day. Note: in children, consider failure to make expected

weight gains.

(4) Insomnia or hypersomnia nearly every day

(5) Psychomotor agitation or retardation nearly every day

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(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

(8) Diminished ability to think or concentrate, or

indecisiveness, nearly every day

(either by subjective account or as observed by others)

(9) Recurrent thoughts of death (not just fear of dying),

recurrent suicidal ideation without a specific plan, or

A suicide attempt or a specific plan for committing

suicide

B. The symptoms do not meet criteria for a mixed episode.

C. Significant distress or impairment in social,

occupational, or other important areas of functioning.

D. Not due to the direct physiological effects of a

Substance

General medical condition (e.g., hypothyroidism).

E. Not better accounted for by bereavement,

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Somatic syndrome

Some depressive symptoms are widely regarded as having special

clinical significance and are here called "somatic." (Terms such as

biological, vital, melancholic, or endogenomorphic are used for this

syndrome in other classifications.)

(1) Marked loss of interest or pleasure in activities that are normally

pleasurable;

(2) Lack of emotional reactions to events or activities that normally

produce an emotional response;

(3) Waking in the morning 2 hours or more before the usual time;

(4) Depression worse in the morning;

(5) Objective evidence of marked psychomotor retardation or agitation

(remarked on or

reported by other people);

(6) Marked loss of appetite;

(7) Weight loss (5% or more of body weight in the past month);

(8) Marked loss of libido.

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Criteria for Seasonal Pattern

With seasonal pattern

can be applied to:-

Major depressive episodes in bipolar I disorder, bipolar II disorder, or Major depressive disorder, recurrent)

A. There has been a regular temporal relationship between the

onset of and a particular time of the year (e.g., regular appearance

of the major depressive episode in the fall or winter)

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

hypomania) also occur at a characteristic time of the year (e.g.,

depression disappears in the spring).

C. 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 non seasonal major depressive

episodes have occurred during that same period.

D. Seasonal major depressive episodes (as described above)

substantially outnumber any non seasonal major depressive

episodes that may have occurred over the individual's lifetime.

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• Recurrent depressive disorder, current episode mild

Without somatic syndrome With somatic syndrome

• Recurrent depressive disorder, current episode moderate

Without somatic syndrome With somatic syndrome

• Recurrent depressive disorder, current episode without psychotic symptoms

• Recurrent depressive disorder, current episode severe with psychotic symptoms

With mood-congruent psychotic symptoms With mood-incongruent psychotic symptoms

• Recurrent depressive disorder, currently in remission

• Other recurrent depressive disorders

• Recurrent depressive disorder, unspecified

• Persistent mood [affective] disorders

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Diagnostic Criteria for Dysthymic Disorder

A Depressed mood for most of the day, for more days than not, for at least 2 years. B. Presence, while depressed, of two (or more) of the following:

(1) Poor appetite or overeating

(2) Insomnia or hypersomnia

(3) Low energy or fatigue

(4) Low self-esteem

(5) Poor concentration or difficulty making decisions

(6) Feelings of hopelessness

C. Never without symptoms for more than two months during the last 2-year period

D. No major depressive episode has been present during the first 2 years of the disturbance (1 year for children and adolescent

Early onset------------Before 21 years of age

Late onset-------------21 years or older

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ICD-10 Diagnostic Criteria for Adjustment DisordersA. Onset of symptoms must occur within 1 month of exposure to an identifiable psychosocial stressor, not of an unusual or catastrophic type.. Symptoms may be variable in both form and severity.The predominant feature of the symptoms may be further specified as:-

Brief depressive reactionA transient mild depressive state of a duration not exceeding 1 month.

Prolonged depressive reactionA mild depressive state occurring in response to a prolonged exposure to a stressful situation but of a duration not exceeding 2 years.

Mixed anxiety and depressive reactionBoth anxiety and depressive symptoms are prominent, but at levels no greater than those specified for mixed anxiety and depressive disorder or other mixed anxiety disorders.

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Bipolar affective disorder Episodes are demarcated by a switch to an episode of opposite or mixed

polarity

Bipolar affective disorder, current episode hypomanicA. The current episode meets the criteria for hypomania.B. There has been at least one other affective episode in the past, meeting the

criteria for hypomanic or manic episode, depressive episode, or mixed affective episode.

Bipolar affective disorder, current episode manic without psychotic symptoms

The current episode meets the criteria for mania without psychotic symptoms..Bipolar affective disorder, current episode manic with psychotic symptoms The current episode meets the criteria for mania without psychotic symptoms.• . With mood-congruent psychotic symptoms• With mood-incongruent psychotic symptomsBipolar affective disorder, current episode moderate or mild depressionA. The current episode meets the criteria for a depressive episode of either mild

or moderate severity.1. Without somatic syndrome2. With somatic syndrome

Bipolar affective disorder, current episode severe depression without psychotic symptoms

Bipolar affective disorder, current episode severe depression with psychotic symptoms

3. With mood-incongruent psychotic symptoms4. With mood-congruent psychotic symptoms

Bipolar affective disorder, current episode mixed

. Both manic and depressive symptoms must be prominent most of the time during a period of at least 2 weeks.

Bipolar affective disorder, currently in remission

The current state does not meet the criteria for depressive or manic episode of any severity or for any other mood [affective] disorder (possibly because of treatment to reduce the risk of future episodes).

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MANIA

DEPRESSION

Normal State

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BIPOLAR AFFECTIVE DISORDERS

MANIA

DEPRESSION

NORMALSTATE

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ICD-10 Diagnostic Criteria for Mood [Affective] Disorders

Manic episode

.Mania without psychotic symptomsA. Mood must be predominantly elevated, expansive, or irritable, Change must be prominent and sustained for at least 1 week (unless it is

severe enough to require hospital admission).

B. At least three of the following signs must be present (four if the mood is

merely irritable), leading to severe interference with personal functioning in daily living:

(1) increased activity or physical restlessness;

(2) increased talkativeness ("pressure of speech");

(3) flight of ideas or the subjective experience of thoughts racing;

(4) loss of normal social inhibitions, resulting in behavior that is inappropriate to the circumstances;

(5) decreased need for sleep;

(6) inflated self-esteem or grandiosity;

(7) distractibility or constant changes in activity or plans;(8) behavior that is foolhardy or reckless e.g., spending sprees, foolish enterprises, reckless driving;(9) Marked sexual energy or sexual indiscretions.

C. There are no hallucinations or delusions, although perceptual disorders may occur

D.The episode is not attributable to psychoactive substance use or to any organic mental disorder.

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Mania with psychotic symptoms

.

Delusions or hallucinations are present,

The commonest examples are those with grandiose, self-

referential, erotic, or persecutory content.

.

Congruent with the mood:

With mood-congruent psychotic symptoms

Example: - Grandiose delusions or voices telling the

individual that he or she has superhuman powers)

With mood-incongruent psychotic symptoms

Example: -voices speaking to the individual about affectively

neutral topics, or delusions of reference or persecution)

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Hypomania

A. The mood is elevated or irritable to a degree that is definitely abnormal for

The individual concerned and Sustained for at least 4 consecutive days.

B. At least three of the following signs must be present, leading to

some interference with personal functioning in daily living:

(1) Increased activity or physical restlessness;

(2) Increased talkativeness;

(3) Distractibility or difficulty in concentration;

(4) Decreased need for sleep;

(5) Increased sexual energy;

(6) Mild overspending, or other types of reckless or irresponsible behavior;

(7) Increased sociability or overfamiliarity.

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Table 14.6-7. DSM-IV Criteria for Manic Episode

A. A distinct period of abnormally and persistently elevated, expansive, or irritable mood,

lasting at least 1 week (or any duration if hospitalization is necessary).

B. During the period of mood disturbance, three (or more) of the following symptoms

have persisted

(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 a high potential for painful

consequences (e.g., engaging in unrestrained buying sprees, sexual indiscretions, or

foolish business investments)

C. The symptoms do not meet criteria for a mixed episode.

D. The mood disturbance is sufficiently severe to cause marked impairment in

occupational functioning or in usual social activities or relationships with others, or to

necessitate hospitalization to prevent harm to self or others, or there are psychotic

features.

E. The symptoms are not due to the direct physiological effects of a substance (e.g., a drug

of abuse, a medication, or other treatment) or a general medical condition (e.g.,

hyperthyroidism).

Note: Manic-like episodes that are clearly caused by somatic antidepressant treatment

(e.g., medication, electroconvulsive therapy, light therapy) should not count toward a

diagnosis of bipolar I disorder.

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BIO-PSYCHO-SOCIAL VIEW

BIOLOGICAL

SOCIAL PSYCHOLOGICAL

• Age• Sex• Neurotransmitters• Hormones• Genetic• Brain structure

• Family Stability• Social Support• Sex• Nurture• Place of living• Minority class• Social & religious

values

• Stress• Nurture• Cognitions• Personality• Painful childhood• Psychoanalysis

AETIOLOGY OF DEPRESSION

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. Medical Conditions Physiologically Associated With Affective Disorders

Endocrine Disorders

• Hypothyroidism

• Hyperthyroidism

• Parathyroid disorders

• Cushing's syndrome

Neurologic Disorders

• Cerebrovascular accidents

• Central nervous system (CNS) lesions

• Neurosyphilis

• Multiple sclerosis

• Neurosarcoidosis

• CNS vasculitis

• HIV-associated CNS pathology

Other Disorders

• Vitamin deficiencies (e.g, folate and vitamin B12)

• Anemia

• Hypoxia

• End-stage renal disease

• Systemic lupus erythematosus and other connective tissue

diseases

• Occult malignancy (eg, pancreatic cancer)

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Differentiating Characteristics of Bipolar and Unipolar Depressions Bipolar Unipolar

History of mania or hypomania Yes No (definitional)

Temperament/personality Cyclothymic/extroverted Dysthymic/introverted

Sex ratio Equal More women than men

Age of onset Teens, 20s, and 30s 30s, 40s, 50s

Postpartum episodes More common Less common

Onset of episode Often abrupt More insidious

Number of episodes Numerous Fewer

Duration of episode 3 to 6 months 3 to 12 months

Psychomotor activity Retardation > agitation Agitation > retardation

Sleep Hypersomnia > insomnia Insomnia > hypersomnia

Family history

Bipolar disorder Yes ±

Unipolar disorder Yes Yes

Alcoholism ± Yes

Pharmacological response

Cyclic antidepressants Induce hypomania-mania ±

Lithium carbonate Acute antidepressant effects Ineffective

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Basic principles of prescribing in depression • Discuss with the patient: - 1) Choice of drug and 2) utility/availability of other, non-pharmacological treatments

• Discuss with the patient likely outcomes. e.g. Gradual relief from depressive symptoms over several weeks • Prescribe a dose of antidepressant (after titration, if necessary) that is likely effective • Continue treatment for at least 4—6 months after resolution of symptoms

• Withdraw antidepressants gradually; Always inform patients of the risk and nature of discontinuation symptoms

Treatment of affective illness

Depression

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•Episode: A period lasting longer than 2 weeks (as defined by the DSM-IV-R) during which the patient is consistently within the fully symptomatic range of a sufficient number of symptoms to meet syndromal criteria for the disorder.

•Partial remission: A period during which an improvement of sufficient magnitude is observed that the individual is no longer fully symptomatic

•Response: The point at which a partial remission begins. A response, unlike a partial remission, does require treatment and thus implies that the cause of the change in the patient's condition is known, which may not be a valid assumption.

•Full remission: A relatively brief period during which an improvement of sufficient magnitude is observed that the individual is asymptomatic

•Recovery: A remission that lasts for a specified period of time. Relapse: A return of symptoms satisfying the full syndrome criteria for an episode that occurs during the period of partial or full remission, but before recovery as defined above. A relapse signals a need for treatment intervention or modification of ongoing treatment.

•Recurrence: The appearance of a new episode of major depressive disorder occurring during a recovery.

Definitions of terms related to the course of depression

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Panic Disorder 50%-65%

Social AnxietyDisorder 70%

OCD67%

PTSD48%

GAD8%-39%

COMORBID MOOD & ANXIETY DISORDERS

DEPRESSION

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STRATEGIES FOR TREATMENT

When initiating acute-phase treatment, practitioners decide where the patient should be treated (e.g., outpatient, day hospital, or inpatient). Treatment location is dictated by factors such as

(1) the imminent risk of suicide,

(2) the capacity of the patient to recognize and follow instructions or recommendations (adherence, psychosis),

(3) the level of psychosocial resources,

(4) the level of psychosocial stressors, and

(5) the level of functional impairment.

Next, one chooses among the four common acute-phase treatments

(A) Medication.(B) The combination of medication and psychotherapy.

(C) Electroconvulsive therapy [ECT]).

(D) For some, light therapy alone or in combination with medications may also be an option.

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Treatment Plan

A treatment plan for depression consists of three distinct phases Phase 1: - Acute treatment, relieves the immediate symptoms of depression.

Phase 2, Continuation treatment, preserves the gains achieved initially and protects the patient from sliding back into depression.

Phase 3, Maintenance treatment, guards against future episodes.

Treatment Phases and Goals

Phase Length Treatment goal

Acute 6–12 weeks Achieve remission

Continuation 16–24 weeks Prevent relapse

Maintenance Varies Protect against recurrence

Remission = Return to level of symptoms and functioning that existed before illness.Relapse = Re-emergence of significant depressive symptoms.Recurrence = Another major depressive episode.

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Relation of Diagnosis to Treatment Selection

Diagnosis Treatment Recommendations

• Major depressive Episode Medication or time-limited

(mild-to-moderate severity) psychotherapies*

No maintenance-phase treatment

• Major depressive disorder, recurrent Consider maintenance-phase treatment

• Major depressive disorder Antipsychotic plus antidepressant

with psychotic features medications

Electroconvulsive therapy

• Major depressive disorder with melancholic Medications essential

or severe features

• Depression with atypical features Nontricylic drugs preferred

Monoamine oxidase inhibitors

• Depression with seasonal pattern Light therapy or medications

• Dysthymic disorder Medications; time-limited, depression-

targeted psychotherapies; or their

combination

Consider maintenance-phase therapy

• Complex  or chronic depressions Medication plus psychotherapy‡

Interpersonal psychotherapy,

cognitive therapy, or behavior therapy.

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Tricyclics and tetracyclicsStarting Dose mg/day

Usual Dose

Mg/day  

Tertiary amine tricyclics   

Amitriptyline 25-50 100-300

Clomipramine 25 100-250

Doxepin 25-50 100-300

Imipramine 25-50 100-300

Trimipramine 25-50 100-300

Secondary amine tricyclics

   

Desipramine 25-50 100-300

Nortriptyline 25 50-200

Protriptyline 10 15-60

Tetracyclics   

Amoxapine 50 100-400

Maprotiline 50 100-225

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SSRIsb    

Citalopram 20 20-60 c

Fluoxetine 20 20-60 c

Fluvoxamine 50 50-300 c

Paroxetine 20 20-60 c

Sertraline 50 50-200 c

Dopamine-nor epinephrine reuptake inhibitors    

Bupropionb 150 300

Bupropion, sustained release 150 300

Serotonin-norepinephrine reuptake

inhibitors   

Venlafaxineb 37.5 75-225

Venlafaxine, extended release 37.5 75-225

Serotonin modulators    

Nefazodone 50 150-300

Trazodone 50 75-300

Nor epinephrine-serotonin modulator    

Mirtazapine 15 15-45

MAOIs    

Irreversible, nonselective    

Phenelzine 15 15-90

Tranylcypromine 10 30-60

Reversible MAOI-A    

Moclobemide 150 300-600

Selective noradrenaline reuptake

inhibitor   

Reboxetine 4 6-8

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MAOI Drug Incompatibilities

Generally Contraindicated Hazardous Potentiation

Stimulants Weight-reducing or antiappetite drugs; amphetamine, cocaine

Decongestants Sinus, hay fever, and cold tablets; nasal sprays or drops;

asthma tablets or inhalants, cough preparations (or any

products containing ephedrine, phenylephedrine, or

phenylpropanolamine

Antihypertensives Methyldopa, guanethidine, reserpine

Tricyclics Migraine, desipramine, clomipramine

MAOIs Tranylcypromine, after other MAOIs

Sympathomimetics Dopamine, Metaraminol

Amine precursors L-dopa, L-tryptophan

Narcotics Meperidine (Demerol)

Some Potentiation Possible

Opioids Morphine, codeine

Sedatives Alcohol, barbiturates, benzodiazepines

Local anesthetics containing vasoconstrictors

Sympathomimetics Ephedrine, norepinephrine, isoproterenol

General anesthetics