Mood DisordersMood Disorders

““Iceberg” Iceberg” PhenomenonPhenomenon

Depressed PatientsSeen By Psychiatrists

Watts, 1966 WPA/PTD Educational Program on Depressive Disorders

Depressed PatientsDepressed Patients

DEPRESSION

The Unmet Needs in DepressionThe Unmet Needs in Depression

Major cause of disability worldwide (WHO):Major cause of disability worldwide (WHO):11

1. Murray, CJ, Lopez AD. The Global Burden of Disease: A Comprehensive Assessment of Mortality and Disability from Diseases, Injuries, & Risk Factors in 1990 Projected to 2020. Cambridge, MA: 1996.

Rank 2000 2020 (Estimated)

1 Lower respiratory infections Ischemic heart disease

2 Perinatal conditions Unipolar major depression

3 HIV/AIDS Road traffic accidents

4 Unipolar major depression Cerebrovascular disease

5 Diarrheal diseases COPD

Mood DisordersMood DisordersDepressive Disorders:Depressive Disorders:– Major Depressive Disorder.Major Depressive Disorder.

– Dysthymic Disorder.Dysthymic Disorder.

Bipolar Disorders:Bipolar Disorders:– Bipolar I Disorder.Bipolar I Disorder.

– Bipolar II Disorder.Bipolar II Disorder.

– Cyclothymic Disorder.Cyclothymic Disorder.

Major Depressive DisorderMajor Depressive Disorder

Lifetime prevalence unipolar Lifetime prevalence unipolar depression:depression:– Up to 21% in women.Up to 21% in women.

– 13% in men.13% in men.

Typical age of onset:Typical age of onset:– 20s, but can occur at any time.20s, but can occur at any time.

Symptoms of Symptoms of DepressionDepression

A loss of interest for at least two weeks or more, A loss of interest for at least two weeks or more, accompanied by five or more psychological, somatic or accompanied by five or more psychological, somatic or behavioral symptoms:behavioral symptoms:• • Sadness.Sadness.• • Lack of energy.Lack of energy.• • Sleep/appetite disturbances.Sleep/appetite disturbances.• • Guilt.Guilt.• • Thoughts of suicide/death.Thoughts of suicide/death.• • Psychomotor retardation.Psychomotor retardation.• • Loss of concentration.Loss of concentration.

Mood SymptomsMood Symptoms Persistent sad, depressed mood.Persistent sad, depressed mood.

Loss of interest or pleasure in Loss of interest or pleasure in previously enjoyable activities.previously enjoyable activities.

DSM-IV criteria specify that DSM-IV criteria specify that person must have 1 of above plus person must have 1 of above plus 4 additional sx for at least 2 4 additional sx for at least 2 weeksweeks

Physical SymptomsPhysical Symptoms Sleep disturbance:Sleep disturbance:– Too much or too little.Too much or too little.

Loss of energy or fatigue.Loss of energy or fatigue.

Appetite disturbance/weight change:Appetite disturbance/weight change:– Loss of appetite or increase in appetite.Loss of appetite or increase in appetite.

Changes in activity level:Changes in activity level:– Psychomotor retardation or agitation.Psychomotor retardation or agitation.

Cognitive SymptomsCognitive Symptoms

Difficulty concentrating, Difficulty concentrating, thinking, and making decisions.thinking, and making decisions.

Feelings of worthlessness, guilt, Feelings of worthlessness, guilt, or hopelessness.or hopelessness.

Recurrent thoughts of death or Recurrent thoughts of death or suicide.suicide.

Suicide Risk FactorsSuicide Risk Factors

Prior history of suicide.Prior history of suicide.Pre-existing psychiatric disorder.Pre-existing psychiatric disorder.Depression and hopelessness.Depression and hopelessness.Delirium.Delirium.Advanced disease with poor prognosis.Advanced disease with poor prognosis.Loss of control and helplessness.Loss of control and helplessness.Exhaustion and fatigue.Exhaustion and fatigue.Chronic pain.Chronic pain.

SpecificersSpecificersMild.Mild.

Moderate.Moderate.

Severe without psychotic features.Severe without psychotic features.

Severe with psychotic features.Severe with psychotic features.

Partial remission.Partial remission.

Full remission.Full remission.

Chronic.Chronic.

Additional SpecifiersAdditional Specifiers

With catatonic features.With catatonic features.

With melancholic features.With melancholic features.

With atypical features.With atypical features.

With postpartum onset.With postpartum onset.

With seasonal pattern.With seasonal pattern.

Melancholic FeaturesMelancholic FeaturesAnhedonia.Anhedonia.

Doesn’t feel better even when pleasant or Doesn’t feel better even when pleasant or good things happen.good things happen.

Depression worse in the morning.Depression worse in the morning.

Early morning awakenings.Early morning awakenings.

Psychomotor retardation or agitation.Psychomotor retardation or agitation.

Anorexia.Anorexia.

Inappropriate guilt.Inappropriate guilt.

Catatonic FeaturesCatatonic Features Motoric immobility.Motoric immobility.

Purposeless movement.Purposeless movement.

Mutism.Mutism.

Physical rigidity.Physical rigidity.

Echolalia.Echolalia.

Posturing.Posturing.

Dysthymic DisorderDysthymic DisorderLess severe but more chronic Less severe but more chronic

(Chronic “low grade” depression)(Chronic “low grade” depression)..

Depressed mood, plus 2 additional sx:Depressed mood, plus 2 additional sx:– Poor appetite or overeating.Poor appetite or overeating.– Insomnia or hypersomnia.Insomnia or hypersomnia.– Low energy or fatigue.Low energy or fatigue.– Low self-esteem.Low self-esteem.– Poor concentration or difficulty making decisions.Poor concentration or difficulty making decisions.– Feelings of hopelessness.Feelings of hopelessness.

Symptoms must have lasted for at least 2 yrs.Symptoms must have lasted for at least 2 yrs.

Never without symptoms for longer than 2 months.Never without symptoms for longer than 2 months.

Bipolar I DisorderBipolar I Disorder Often called manic depression.Often called manic depression.

Typically involves episodes of Typically involves episodes of major depression and mania.major depression and mania.

Lifetime prevalence is 1% for both Lifetime prevalence is 1% for both men and women.men and women.

Typical age of onset is late teens-Typical age of onset is late teens-early 20s.early 20s.

Symptoms of Manic EpisodesSymptoms of Manic Episodes

Elevated, expansive or irritable mood for at Elevated, expansive or irritable mood for at least 1 week, plus 3 additional symptoms.least 1 week, plus 3 additional symptoms.Inflated self-esteem/grandiosity.Inflated self-esteem/grandiosity.Decreased need for sleep (3 hrs.).Decreased need for sleep (3 hrs.).Unusual talkativeness or pressured speech.Unusual talkativeness or pressured speech.Flight of ideas/racing thoughts.Flight of ideas/racing thoughts.Marked distractibility.Marked distractibility.Increased activity (Hyperactivity).Increased activity (Hyperactivity).Excessive involvement in pleasurable activities.Excessive involvement in pleasurable activities.

Course of Bipolar I DisorderCourse of Bipolar I Disorder

There is great variability in cycle time.There is great variability in cycle time.

35% of individuals go through only 1 35% of individuals go through only 1 cycle in 5 years.cycle in 5 years.

1% of individuals go through 1 cycle 1% of individuals go through 1 cycle every 3 months.every 3 months.

Rapid cycling: 4 or more cycles/ year.Rapid cycling: 4 or more cycles/ year.

Other Bipolar DisordersOther Bipolar Disorders

Bipolar II:Bipolar II:– Alternate between hypomanic and major Alternate between hypomanic and major

depressive episodes.depressive episodes.

Cyclothymic Disorder:Cyclothymic Disorder:– Alternate between depressive (not MDE) Alternate between depressive (not MDE)

and hypomanic episodes for at least 2 yrs.and hypomanic episodes for at least 2 yrs.

– Never without symptoms for longer than 2 Never without symptoms for longer than 2 months.months.

Hypomanic EpisodeHypomanic Episode

Elevated, expansive or irritable mood Elevated, expansive or irritable mood for at least 4 days.for at least 4 days.

Symptoms similar to manic episode, Symptoms similar to manic episode, except no marked impairment/ except no marked impairment/ hospitalization.hospitalization.

The Manic-Depressive Spectrum:The Manic-Depressive Spectrum:Cycling Patterns…Cycling Patterns…

Manic

Hypomanic

Dysthymic

Depressed

COMORBID DISORDERSCOMORBID DISORDERSSubstance Abuse – At least 60%. Substance Abuse – At least 60%. Alcohol, Cocaine, THC.Alcohol, Cocaine, THC.Effect – More mixed and rapid cycling, Effect – More mixed and rapid cycling, poorer response to Lithium, slower time poorer response to Lithium, slower time to recovery and more lifetime to recovery and more lifetime hospitalizations.hospitalizations.Narcissistic PD.Narcissistic PD.Borderline PD.Borderline PD.20-30% OCD or Panic Disorder.20-30% OCD or Panic Disorder.

Differential DiagnosisDifferential DiagnosisGMC: Hypothyroidism, Syphlis & GMC: Hypothyroidism, Syphlis & Hyperparathyroidism.Hyperparathyroidism.

Substance (Amphetamine , Steroids ,…).Substance (Amphetamine , Steroids ,…).

Schizophrenia & Schizoaffective.Schizophrenia & Schizoaffective.

Grief.Grief.

Personality Disorder: Borderline, Personality Disorder: Borderline, Narcissistic & Histrionic.Narcissistic & Histrionic.

Adjustment Disorder. Adjustment Disorder.

Causes of Mood DisordersCauses of Mood Disorders1. Genetics.1. Genetics.

2. Neurotransmitters.2. Neurotransmitters.

3. Endocrine System.3. Endocrine System.

4. Circadian Rhythms.4. Circadian Rhythms.

5. Drugs.5. Drugs.

6. Stress.6. Stress.

7. Learned Helplessness.7. Learned Helplessness.

8. Negative Cognitive Style.8. Negative Cognitive Style.

9. Cognitive Vulnerability for Depression.9. Cognitive Vulnerability for Depression.

1. Genetics1. GeneticsTwin & Adoption Studies: Twin & Adoption Studies:

StudiesStudies show genetic link for mood disorders (Link is show genetic link for mood disorders (Link is stronger for bipolar disorder than unipolar depression).stronger for bipolar disorder than unipolar depression).

Concordance Rates: Concordance Rates: Likelihood that if one member of pair has disease, other Likelihood that if one member of pair has disease, other

member will also have diseasemember will also have disease

Unipolar depression:Unipolar depression:

- MZ twins = 36% & DZ twins = 17%.- MZ twins = 36% & DZ twins = 17%.

Bipolar disorder:Bipolar disorder:

- MZ twins = 80% & DZ twins = 16%.- MZ twins = 80% & DZ twins = 16%.

2. Neurotransmitters2. NeurotransmittersDepression is associated with low levels of serotonin in Depression is associated with low levels of serotonin in relation to norepinephrine and dopamine:relation to norepinephrine and dopamine:

– Primary function of serotonin is to regulate our Primary function of serotonin is to regulate our emotional reactions.emotional reactions.

– When levels of serotonin are low, we become more When levels of serotonin are low, we become more impulsive & our moods swing more wildly.impulsive & our moods swing more wildly.

Medications that treat depression increase serotonin Medications that treat depression increase serotonin and/or norepinephrine in the synapse within a few and/or norepinephrine in the synapse within a few weeks.weeks.

3. Endocrine System3. Endocrine SystemDepression can be a symptom of some Depression can be a symptom of some endocrine disorders: endocrine disorders: HHypothyroidism & ypothyroidism & Cushing’s syndromeCushing’s syndrome..

HPA axis: HPA axis: HHypothalamus-Pituitary-Adrenalypothalamus-Pituitary-Adrenal..

Hypothalamus sends signals to pituitary Hypothalamus sends signals to pituitary gland which sends signals to adrenal gland which sends signals to adrenal gland to secrete hormones related to gland to secrete hormones related to stress response:stress response:– 50% of depressed individuals show elevated 50% of depressed individuals show elevated

levels of cortisol.levels of cortisol.

4. Circadian Rhythms4. Circadian RhythmsMood disorders are caused by disturbance in circadian Mood disorders are caused by disturbance in circadian rhythms:rhythms:– Circadian rhythms (sleep-wake, temperature, Circadian rhythms (sleep-wake, temperature,

hunger) are regulated by hypothalamus.hunger) are regulated by hypothalamus.– Exposure to light affects circadian rhythms Exposure to light affects circadian rhythms

(suppresses melatonin).(suppresses melatonin).– Prevalence of seasonal affective disorder is higher in Prevalence of seasonal affective disorder is higher in

extreme northern & southern latitudes.extreme northern & southern latitudes.– Depriving depressed patients of sleep can Depriving depressed patients of sleep can

temporarily reduce their depression.temporarily reduce their depression.– Extended bouts of insomnia triggers manic episodes.Extended bouts of insomnia triggers manic episodes.

5. DRUGS5. DRUGSReserpine.Reserpine.

Methyldopa.Methyldopa.

Corticosteroids.Corticosteroids.

Benzodiazepines.Benzodiazepines.

Alcohol.Alcohol.

Opiate analgesics.Opiate analgesics.

Inderal (rare).Inderal (rare).

6. Stress6. StressStressful life events are strongly related to the onset Stressful life events are strongly related to the onset of mood disorders:of mood disorders:– 20-50% of individuals who experience stressful life events 20-50% of individuals who experience stressful life events

become depressed.become depressed.

– Same stressors that are associated with depression are Same stressors that are associated with depression are associated with other disorders.associated with other disorders.

– Approximately 1/3 of the association between stressful life Approximately 1/3 of the association between stressful life events and depression is due to the tendency of people who events and depression is due to the tendency of people who are vulnerable to depression to place themselves in high-are vulnerable to depression to place themselves in high-risk stressful environments.risk stressful environments.

– Social support seems to reduce risk for developing Social support seems to reduce risk for developing depression when exposed to stress.depression when exposed to stress.

PSYCHOSOCIAL FACTORS PSYCHOSOCIAL FACTORS OF DEPRESSIONOF DEPRESSION

Death and dying.Death and dying.

Disability.Disability.

Chronic pain.Chronic pain.

Loss of role.Loss of role.

Family conflict.Family conflict.

Lifelong issues.Lifelong issues.

7. Learned Helplessness7. Learned HelplessnessPeople become anxious & depressed when they People become anxious & depressed when they make an attribution that they have no control make an attribution that they have no control over the stress in their lives.over the stress in their lives.

Depressive Attributional Style:Depressive Attributional Style:

* Attribution: The way in which people * Attribution: The way in which people

assign causes to events in their lives.assign causes to events in their lives.

* People who are depressed tend to make * People who are depressed tend to make

attributions that are: attributions that are: (Internal, Stable & Global).(Internal, Stable & Global).

* Sense of hopelessness is important.* Sense of hopelessness is important.

8. Negative Cognitive Style8. Negative Cognitive StyleTendency to interpret everyday events in a negative Tendency to interpret everyday events in a negative way.way.Reflects cognitive errors:Reflects cognitive errors:– All or nothing.All or nothing.– Overgeneralization.Overgeneralization.– Arbitrary inference: Selective attention to negative aspects.Arbitrary inference: Selective attention to negative aspects.

Make negative interpretations about:Make negative interpretations about:

(Self – World – Future).(Self – World – Future).

Depressive cognitions emerge from distorted & Depressive cognitions emerge from distorted & probably automatic methods of processing probably automatic methods of processing information.information.

9. Cognitive Vulnerability9. Cognitive Vulnerability5-year longitudinal study of college students using:5-year longitudinal study of college students using:– Questionnaires: measured dysfunctional attitudes Questionnaires: measured dysfunctional attitudes

and hopelessness attributionsand hopelessness attributions– Subjects were assessed every several months for Subjects were assessed every several months for

next 5 years for symptoms of depressionnext 5 years for symptoms of depression

ResultsResults– Negative cognitive styles do indicate a vulnerability Negative cognitive styles do indicate a vulnerability

to later depressionto later depression– Subjects who scored high on measures of cognitive Subjects who scored high on measures of cognitive

vulnerability were more likely to experience later vulnerability were more likely to experience later depression (17% vs. 1%)depression (17% vs. 1%)

ManagementManagementHospitalization for mania, severe Hospitalization for mania, severe depression & suicide.depression & suicide.Mood stabilizers, antipsychotics and Mood stabilizers, antipsychotics and antidepressants. antidepressants. ECT – most effective treatment. ECT – most effective treatment. Supportive psychotherapy and CBT.Supportive psychotherapy and CBT.Lifestyle change.Lifestyle change.Substance abuse treatment.Substance abuse treatment.

PrognosisPrognosis50% attempt Suicide.50% attempt Suicide.

Untreated depression get 10 ms or more to recover.Untreated depression get 10 ms or more to recover.

75% have recurrence.75% have recurrence.

50% full recovery.50% full recovery.

30% partial remission.30% partial remission.

20% tend to be Chronic.20% tend to be Chronic.

20-30% of Dysthymic Disorder go to MDD or BD.20-30% of Dysthymic Disorder go to MDD or BD.

Serious consequences:Serious consequences:– Impaired social and occupational functioning.Impaired social and occupational functioning.

– Increased co-morbidity of psychiatric & medical conditions. Increased co-morbidity of psychiatric & medical conditions.

– Increased risk of mortality among depressed individuals.Increased risk of mortality among depressed individuals.

ConclusionsConclusionsMood disorders are chronic & recurrent disorders.Mood disorders are chronic & recurrent disorders.

Mood disorders are common.Mood disorders are common.

Many peoples suffer needlessly because their mood Many peoples suffer needlessly because their mood disorder is not diagnosed and treated.disorder is not diagnosed and treated.

Diagnosing mood disorders is straightforward.Diagnosing mood disorders is straightforward.

Drugs are effective and practical.Drugs are effective and practical.

Doctors should take the lead in recognizing and Doctors should take the lead in recognizing and treating mood disorders.treating mood disorders.

““AFTER ALL, AFTER ALL, THERE IS THERE IS

NOTHING AS NOTHING AS INTERESTING AS INTERESTING AS

PEOPLE, AND ONE PEOPLE, AND ONE CAN NEVER STUDY CAN NEVER STUDY THEM ENOUGH” THEM ENOUGH”

VINCENT VINCENT VAN GOGHVAN GOGH

Vincent van Gogh, who himself suffered from depression and committed suicide, painted this picture in 1890 of a man that can symbolize the desperation and hopelessness felt in depression.

Prof: Ashraf Tantawy