MOOD DISORDERS

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Dr. Ravi Paul

MOOD EPISODES

Major Depressive Episode Manic Episode Mixed Episode Hypomanic Episode

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Major Depressive Disorder

Major Depressive Disorder, Single Episode Major Depressive Disorder, Recurrent Bipolar I Disorder, Single Manic Episode Bipolar I Disorder, Most Recent Episode Manic Bipolar I Disorder, Most Recent Episode Depressed Bipolar I Disorder, Most Recent Episode Mixed

Bipolar I Disorder

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DSM-IV-TR Diagnostic Criteria for Depression

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.

Note: Do not include symptoms that

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DSM-IV-TR Diagnostic Criteria for Depression

1.

Depressed mood most of the day, nearly every day, as indicated by 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

Markedly diminished interest or pleasure in all, or almost all, activities most of the day, nearly 5/13/12 every day Ravi Paul Dr. (as indicated by either
2.

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. insomnia or hypersomnia nearly every day

4.

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5. psychomotor agitation or retardation nearly every day (observable by others, not merely subjective feelings of restlessness 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 merely self-reproach or guilt about being sick)
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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

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B. The symptoms do not meet criteria for a mixed episode. C. The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning. D. The symptoms are not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition (e.g., hypothyroidism).
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E. The symptoms are not better accounted for by bereavement, i.e., after the loss of a loved one, the symptoms persist for longer than 2 months or are characterized by marked functional impairment, morbid preoccupation with worthlessness, suicidal ideation, psychotic symptoms, or psychomotor retardation.

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Mental Status Examination Depressive Episodes

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General Description

Generalized psychomotor retardation is the most common symptom of depression, although psychomotor agitation is also seen, especially in older patients. Hand-wringing and hair-pulling are the most common symptoms of agitation. Classically, a depressed patient has a 5/13/12 Dr. Ravi Paul stooped posture, no spontaneous

Mood, Affect, and Feelings

Depression is the key symptom, although about 50 percent of patients deny depressive feelings and do not appear to be particularly depressed. Family members or employers often bring or send these patients for treatment because of social withdrawal and generally decreased activity. 5/13/12 Dr. Ravi Paul

Speech

Decreased speech;

rate

and

volume

of

Respond to questions with single words and exhibit delayed responses to questions. The examiner may literally have to wait 2 or 3 minutes for a response to a question.
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Perceptual Disturbances

Depressed patients with delusions or hallucinations are said to have a major depressive episode with psychotic features. Even in the absence of delusions or hallucinations, some clinicians use the term psychotic depression for grossly regressed depressed patients: mute, not bathing, soiling.

Delusions and hallucinations that are consistent with a depressed mood 5/13/12 Dr. are said to beRavi Paul congruent. mood

Thought

Depressed patients customarily have negative views of the world and of themselves. Their thought content often includes non-delusional ruminations about loss, guilt, suicide, and death. About 10 percent of all depressed patients have marked symptoms of a thought disorder, usually thought blocking and profound poverty of content.
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Sensorium and Cognition Orientation

Most depressed patients are oriented to person, place, and time, although some may not have sufficient energy or interest to answer questions about these subjects during an interview.

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Memory

About 50 to 75 percent of all depressed patients have a cognitive impairment, sometimes referred to as depressive pseudodementia. Such patients commonly complain of impaired concentration and forgetfulness.

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Impulse Control

About 10 to 15 percent of all depressed patients commit suicide, and about two thirds have suicidal ideation. Patients with depressive disorders are at increased risk of suicide as they begin to improve and regain the energy needed to plan and carry out a suicide (paradoxical suicide). It is usually clinically unwise to give a 5/13/12 Dr. Ravi Paul depressed patient a large

One out of seven with recurrent depressive illness commits suicide 70% of suicides have depressive illness 70% of suicides see their primary care physician within 6 weeks of attempted suicide Suicide is the seventh leading cause of death in the United States
Dr. Ravi Paul

Suicide and Major Depression: the rule of sevens

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Judgment and Insight

Judgment is best assessed by reviewing patients' actions in the recent past and their behavior during the interview. Depressed patients' description of their disorder is often hyperbolic; they overemphasize their symptoms, their disorder, and their life problems. It is difficult to convince such patients that improvement is 5/13/12 Dr. Ravi Paul

Reliability

In interviews and conversations, depressed patients overemphasize the bad and minimize the good. A common clinical mistake is to unquestioningly believe a depressed patient who states that a previous trial of antidepressant medications did not work. Such statements may be false, and they require confirmation from another source. Paul 5/13/12 Dr. Ravi

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 (four if the mood is only irritable) and have been present to a significant degree: 5/13/12 Dr. Ravi Paul

DSM-IV-TR Criteria for Manic Episode

1.

inflated self-esteem or grandiosity decreased need for sleep (e.g., feels rested after only 3 hours of sleep) more talkative than usual or pressure to keep talking flight of ideas or subjective experience that thoughts are racing
Dr. Ravi Paul

2.

3.

4.

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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

excessive involvement in pleasurable activities that have a high potential for painful consequences (e.g., engaging in unrestrained buying sprees, 5/13/12 sexual indiscretions, or foolish Dr. Ravi Paul

7.

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,
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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 5/13/12 Dr. Ravi Paul therapy, and light therapy) should

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Mental State Examination

General Description

Manic patients are excited, talkative, sometimes amusing, and frequently hyperactive.

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q q q

Manic patients classically are:

Mood, Affect, and Feelings

Euphoric, but they can also be Irritable, especially when mania has been present for some time. They also have a low frustration tolerance, which can lead to feelings of anger and hostility.

Manic patients may be emotionally labile, switching from laughter to 5/13/12 Dr. Ravi Paul irritability to depression in minutes or

Speech
q

Manic patients cannot be interrupted while they are speaking, and they are often intrusive nuisances to those around them. As the mania gets more intense, speech becomes louder, more rapid, and difficult to interpret.

As the activated state increases, their speech is filled with puns, jokes, rhymes, plays on words, and irrelevancies. Ravi Paul 5/13/12 Dr.

Thought
q

Delusions occur in 75 percent of all manic patients. Mood-congruent manic delusions are often concerned with great wealth, extraordinary abilities, or power. (Power, Wealth, Identity)

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Perception
q

Auditory Hallucinations: Hearing voices telling him that you have great wealth, power etc. Hearing voices that have persecutory content

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Sensorium and Cognition

q

Grossly, orientation and memory are intact, although some manic patients may be so euphoric that they answer questions testing orientation incorrectly (Delirious Mania-Emil Kraeplin)

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Impulse Control
q

About 75 percent of all manic patients are assaultive or threatening. Manic patients do attempt suicide and homicide, but the incidence of these behaviors is unknown.

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Dr. Ravi Paul

Judgment and Insight

q

Impaired judgment is a hallmark of manic patients. They may break laws about credit cards, sexual activities, and finances and sometimes involve their families in financial ruin. Manic patients also have little insight into their disorder.
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Reliability
q

Manic patients are notoriously unreliable in their information. Because lying and deceit are common in mania, inexperienced clinicians may treat manic patients with inappropriate disdain.

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A 22-year-old man was brought to the GP by his girlfriend, who complained that over the previous few weeks he had become increasingly moody and withdrawn, and had been drinking too much. The GP, who had known him for years, was struck by his gaunt and miserable appearance, but was nevertheless surprised when, after his partner Dr. Ravi Paul consulting room, left the 5/13/12

Mental State Examination

Depression is a Syndrome
Clusters of symptoms in depression:

Vegetative Cognitive Impulse control Behavioral Physical (somatic)

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vegetative features: sleep, appetite, weight, and sex drive; cognitive features:

attention span, frustration tolerance, memory, negative distortions;

Impulse control: suicide and homicide; behavioral features: motivation, pleasure, interests, fatigability; and physical {or somatic) features: 5/13/12 headaches, Dr. Ravi Paul aches, and stomach

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MEDICATION

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PLACEBO

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MANAGEMENT

Safety Complete diagnostic evaluation Treatment: pharmacotherapy psychotherapy and

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SAFETY

Hospitalization Clear indications for hospitalization are: The risk of suicide or homicide, Patient's grossly reduced ability to get food and shelter Need for diagnostic procedures. A history of rapidly progressing 5/13/12 symptoms Dr. Ravi Paul and the rupture of a

TRICYCLICANTIDEPRESSANTS
Anticholiner gic Effects Sedation Conduction Orthostatic Abnormalities Hypotensio n Seizures

Amitriptylin ++++ e Clomiprami ++++ ne Doxepin +++ Imipramine +++ Trimipramin++++ e

++++ ++++ ++++ +++ ++++

+++ +++ ++ ++++ +++

+++ +++ +++ +++ +++

++++ ++++ ++ ++++ +++++

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Dr. Ravi Paul

Overdose attempts with TCAs are serious and can often be fatal. Prescriptions for these drugs should be nonrefillable and for no longer than a week at a time for patients at risk for suicide. Symptoms of overdose include agitation, delirium, convulsions, hyperactive deep tendon reflexes, bowel and bladder paralysis, dysregulation of BP and temperature, and mydriasis. The patient then progresses to coma and perhaps respiratory depression. Cardiac arrhythmias may not respond to treatment. Because of the long half-lives of TCAs, the patients are at risk of cardiac arrhythmias for 3 5/13/12 Dr. Ravi Paul to 4 days after the overdose, so they should be

Overdose Attempts

FLUOXETINE 40-60mg

SELECTIVE SEROTONIN REUPTAKE INHIBITORS (SSRIS)

SERTRALINE 50-200mg PAROXETINE 20-60mg FLUVOXAMINE 50-200mg CITALOPRAM 10-40mg

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Patients with severe mania are best treated in the hospital where aggressive dosing is possible and an adequate response can be achieved within days or weeks. Adherence to treatment, however, is often a problem, because patients with mania frequently lack insight into their illness, and refuse to take medication.
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Treatment of Acute Mania

Because

Dr. Ravi Paul

impaired

judgment,

Lithium Carbonate

Lithium carbonate is considered the prototypical mood stabilizer. Onset of antimanic action with lithium can be slow, it usually is supplemented in the early phases of treatment by atypical antipsychotics, mood-stabilizing anticonvulsants, or high-potency benzodiazepines. Therapeutic lithium levels between 0.6 and 1.2 mEq/L. are

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The acute Dr. Ravi Paul lithium has been use of

Valproate

Valproate has surpassed lithium in use for acute mania. Typical dose levels of valproic acid are 750 to 2,500 mg per day, achieving blood levels between 50 and 120 g/mL. Rapid oral loading with 15 to 20 mg/kg of Divalproex sodium from day 1 of treatment has been well tolerated and associated with a rapid onset of response. 5/13/12 Dr. Ravi Paul

Carbamazepine has been used worldwide for decades as a first-line treatment for acute mania, but has only gained approval in the United States in 2004. Typical doses of carbamazepine to treat acute mania range between 600 and 1,800 mg per day associated with blood levels of between 4 and 12 g/mL.
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Carbamazepine and Oxcarbazepine

The

keto Paul congener Dr. Ravi

of

Clonazepam and Lorazepam

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The high-potency benzodiazepine anticonvulsants used in acute mania include Clonazepam and Lorazepam. Both may be effective and are widely used for adjunctive treatment of acute manic agitation, insomnia, aggression, and dysphoria, as well as panic. The safety and the benign side effect profile of these agents render them ideal adjuncts to lithium, carbamazepine, or valproate.
Dr. Ravi Paul

All of the atypical antipsychotics olanzapine, risperidone, quetiapine, ziprasidone, and aripiprazole have demonstrated antimanic efficacy and are FDA approved for this indication. Compared with older agents, such as haloperidol and chlorpromazine, atypical antipsychotics have a lesser liability for extra pyramidal side effects and tardive dyskinesia; many do not increase prolactin.
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Atypical and Typical Antipsychotics

Adverse Effects of Lithium Neurologic Benign, nontoxic: dysphoria, lack of spontaneity, slowed reaction time, memory difficulties Tremor: postural, occasional extrapyramidal Toxic: coarse tremor, dysarthria, ataxia, neuromuscular irritability, seizures, coma, death Miscellaneous: peripheral neuropathy, benign intracranial hypertension, myasthenia gravis-like syndrome, altered creativity, lowered seizure threshold Endocrine Thyroid: goitre, hypothyroidism, exophthalmos, hyperthyroidism (rare) Parathyroid: hyperparathyroidism, adenoma Cardiovascular Benign T-wave changes, sinus node dysfunction Renal Concentrating defect, morphologic changes, polyuria (nephrogenic 5/13/12 Dr. GFR, nephrotic syndrome, renal tubular diabetes insipidus), reduced Ravi Paul

Signs and Symptoms of Lithium Toxicity Mild to moderate intoxication (lithium level = 1.5 to 2.0 mEq/L) GI Vomiting Abdominal pain Dryness of mouth Neurologic Ataxia Dizziness Slurred speech Nystagmus Lethargy or excitement Muscle weakness Moderate to severe intoxication (lithium level = 2.0 to 2.5 mEq/L) GI Anorexia Persistent nausea and vomiting Neurologic Blurred vision Muscle fasciculations 5/13/12 Dr. Ravi Paul Clonic limb movements