MOOD DISORDERS

Classification of mood disordes:

1.      Major depressive disorder

2.      Bipolar disorder (type I; type II)

3.      Dysthymic disorder

4.      Cyclothmyc disorder

Symptoms describe major depressive disorders:

Sadness

Hopelessness

Emptiness

Low self esteem

Decreased interest

Decreased pleasure

Decreased activity

ANHEDONIA

Feeling of worthlessness

Feeling of guilt

Feeling of confusion

Diurnal variation (more depressed in the morning, better in the evening)

Change in appetite

Insomnia/hypersomnia

Early morning awakening

Psychomotor retardation/agitation

Loss of energy

Daily fatigue

Decreased desire

Difficulty in concentrating

Decreased attention

Recurrent thought of death

Recurrent thought of suicide

MOOD CONGRUENT DELUSIONS

The atypical (masked; underground) depression may show PREVAILING SOMATIC SYMPTOMS

Seasonal Affective Disorder (SAD)

Etiology

Biological:

Heredity

Neurotransmitter activity

Limbic-hypothalamic-pituitary-adrenal axis

Psychosocial:

Loss of primary attachment figure

Negative interpretation of ordinary life events

Learned helplessness

Lifetime prevalence: 5-12% for men                                                                   DOUBLE for women

Bipolar Disorder: Phasic periodic alterations of mood into depression or to elation with elevated mood and multiplicity of symptoms listed below. The recovery often complete, which differentiate MDP from schizophrenia, where the progression is continuous deterioration,  and in schizophrenia there is no complete recovery to perfect social functioning which is the case in MDP. However, without treatment the recovery in MDP might take a year or more, but with treatment it is possible to reach complete functional recovery within weeks or months. The elation and mood elevation often described as positive phases of the disorder, and depression as negative phase of the disorder. In major depression, only the depressive phases is present, therefore it is also called unipolar depression. In MDP both polarities are presented, in rare circumstances on the same time, which is a differential diagnostic challenge.

Symptoms of manic episode:

Inflated self-esteem

Increased energy

Increased sexual interest

Lack of modesty

Lak of social judgement

Inappropriate behavior e.g. wasting money, gambling

Disinhibited behavior

Grandiosity

Mood congruent delusions

Decreased need for sleep

Talkativeness

Pressured speech

Flight of ideas

Expansive grandiose delusions

Egodiastole: overconfidence, expansivity

Distractibility

Increased activity

Agitation

Loss of insight

Los of critical sense

Activities with negative consequences: social impairment; legal

Hypomania is a mild presentation of the above symptomatolgy. Frequently it does not get medical attention, in addition, because of increased energy, self confidence, expansivity it is associated with increased creativity, and success in many aspects of life.

Bipolar I type MDP: severe depressive disorder present multiple times during the life sometimes alternating with severe episodes of mania. Between the episodes the person can functioning properly

Bipoar II type MDP: severe depressive disorders presented multiple times during the life, and hypomania may alternate with depression.

Treatment:

Only 25% receive of MDP cases treatment

Without treatment: 6-12 month episode duration

Without treatment it can turn into Chronic depression

Pharmacotherapy: Antidepressants

Heterocyclic antidepressants

Selective serotonin reuptake inhibitors (SSRI)

Monoamino oxidase inhibitors (MAOI)

For most antidepressant it takes 3 weeks to start to work (down regulation)

First line recommended group of drugs: SSRI

Electroconvulsive (ECT) therapy efficient first of all in severe depression

Psychotherapy in conjunction with biological therapy ore efficient than each of tem separately

 ‘Switch’ in MDP: antidepressant drugs can provoke sudden switch to mania

Lithium can effectively prevent mood swings to mania or depression, therefore also called mood stabilizer. It is very efficient, but about 30% of patients are non-respondents. In this case other type off mood stabilizers, like some of antiepileptic drugs are recommended. Lihium has many adverse effects. Other requirement of the therapy is the regular control of serum lithium level, because below the therapeutic serum level lithium therapy is not efficient, and above the therapeutic level lithium is toxic, and can cause life threatening complications. 

Lithium therapy complications:

1.      Renal

2.      Thyroid

3.      Weight gain

4.      Tremor

5.      Intoxication

Intoxication: lithium therapeutic level is between 0,5 – 1,5 maeq/L. Without lithium therapy the normal serum lithium leel is 0. Above the therapeutic range, tremor, diarrhea, epileptic fits, confusion, coma and death can be resulted. The therapy is to stop lithium treatment, parenteral fluid therapy with sodium (compete with lithium, so lithium will excreted by the kidney much easier) and symptomatic therapy.

Mood stabilizer Anticonvulsants

Divalproex (Depakote)

Carbamazepine (Tegretol)

Tranquillants: Usually used in acute mania, or sometimes in deep depression, when the patient is very agitated. Tranquillants dnt have mood stabilizer effext

Haloperidol (Halodol)

Olanzapine (Zyprexa)

Risperidone (Risperdal)

Benzodiazepines: are useful to sedate and calm the patient. They have positive anxiolytic effect, but they don’t have specific antidepressant or antimaniac effect.

Lorazepam  (Ativan)

Clonazepam (Klonopin)

Dysthymic Disorder: very mild form of the listed symptomatolgy of major depressive disorder. Dysthymia is not psychosis. Frequently escorted with dysphoria. Main symptoms are:

Dysthymia

Low self esteem

Decreased productivity

No symptoms of MDD, anhedonia, suicidality

6 % of the population

2x as frequent in women

Cyclothymic Disorder: Mild presentation similar to MDD, but usually patient don’t need hospitalization

Mood swings between Dysthymia//hypomania

Nonepisodic

Not associated with psychosis

1% of the population

Differential Diagnosis of mood disorders

Organic Medical conditions (organic psycho-syndrome)

Cancer (pancreas, GIT)

Viral (pneumonia, influenza, AIDS)

Endocrine (Cushing; Hypothyroidism)

Neurologic (Parkinson, Multiple sclerosis, Huntington, Stroke, Dementia)

Nutritional

Renal

Cardiopulmonary

Differential diagnosis of Maniform symptomatology

Hyperthyroidism

Steroid treatment

Lues

Orbitofrontal cortex

Stroke

Tumor

Infection

Substance induced mood disorders

Other Psychiatric conditions

Schizophrenia

Somatoform disorders

Eating disorders

Anxiety disorders

Adjustment disorders

Normal bereavement

Substance abuse & withdrawal

Underdiagnosed are mood disorders and overdiagnosed are schizophrenia in low socioeconomic groups

Case Studies

v  A34-year-old man complains of feeling blue at his first visit to you. An MSE reveals a disheveled appearance, a depressed mood, psychomotor retardation, and suicidal thoughts. Thought processes are significant for thought blocking and some slowing. Deficits with remote and short-term memory are noted. Judgment and insight are also impaired. Your diagnosis is a major depressive episode.

1. The type of sleep disturbance you would most expect to see in this patient is which of the following?

(A) sleeping too deeply (difficulty being awakened)

(B) early morning awakening

(C) increased rapid eye movement (REM) stage latency

(D) decreased response to sedative drugs

(E) sleeping too lightly (awakened too easily)

2.  You would expect the biochemical/hormonal profile of this patient to be significant for which of the following?

(A) increased catecholamine activity

(B) increased cortisol secretion

(C) increased sex hormones

(D) increased immune functions

(E) decreased monoamine oxidase (MAO) activity

Answers

1. (B) Although many sleep disturbances have been described in depression, early morning awakening has been most consistently linked with major depression.

2. (B) Increased cortisol in depression is one of the earliest observations in biological psychiatry, and is well borne out in subsequent studies. Catecholamines are decreased in depression as are sex hormones and immune function. Levels of MAOs are unknown.

v  A52-year-old man with a history of major depression is treated with paroxetine (Paxil). He has been your patient for 2 years and has recently missed his last two appointments reporting to you that “I’ve been spectacular!” You have documented two calls from his wife since his last visit. She initially reported that her husband has been “very different.” You learn that he has spent more money on frivolous items than he ever has. In addition, when she went to the bank to withdraw money for groceries, she was told that the account was overdrawn. Recently, his wife called again to make an appointment for her husband. She reports that one moment her husband is giddy and without notice he quickly becomes agitated and angry. During the interview, the patient questions your credentials and accuses you of being more loyal to his wife than to him. Most of the interview is spent interrupting the patient as you try to decipher his rapid speech.

1. Which of the following statements is true?

(A) Patients with bipolar disorder usually have a more favorable course than depressive patients.

(B) A lower percentage of patients with bipolar disorder eventually get treatment as compared to patients with unipolar depression.

(C) Bipolar disorder has a stronger genetic link than depression.

(D) More women are diagnosed with bipolar disorder than with major depression.

(E) Bipolar disorder is more common than major depression

The patient returns for a follow-up visit 4 weeks after you initiate treatment with divalproex sodium. He presents looking irritable and demonstrates pressured speech and grandiose delusions. He reports that he is the lost son of a famed millionaire. He exhibits symptoms of depression characterized by decreased sleep, poor appetite and concentration, and thoughts of suicide. He admits to drinking alcohol every day since his last visit. His wife reports that his moods seem to change with the seasons.

2.  In addition to starting valproic acid, the other pharmacologic management change indicated at the prior visit would have been to which of the following?

(A) Check the patient’s serum paroxetine level.

(B) Select a more effective antidepressant.

(C) Stop the antidepressant.

(D) Select a medication as needed for insomnia.

(E) Start lithium.

Answers

1  (C) Bipolar I disorder clearly has a stronger genetic link than major depression and probably has the strongest genetic link of all the major psychiatric illnesses. Bipolar II disorder has a strong genetic link but not as strong as bipolar I disorder. Bipolar illness usually carries a poorer prognosis than unipolar depression. A higher percentage of patients with bipolar disease are eventually treated compared with patients with unipolar depression. Bipolar disorder has no gender predilection and has not been shown to be any more common in broad geographic areas.

2. (C) Antidepressants can precipitate or exacerbate mania in patients with bipolar disorder who are not infrequently first diagnosed as suffering from unipolar depression. SSRI levels have not been shown to correlate with efficacy.

Because the paroxetine appears to have precipitated a mania, the drug should have been stopped. Insomnia would have likely resolved itself with the discontinuation of the SSRI and resolution of the manic episode. Starting two mood stabilizers at once is not supported by clinical trial evidence.

v  1. A patient places a call after hours to the practice you are covering. You do not have access to the patient’s chart but learn that the history suggests the patient experiences dysthymia followed by episodes of hypomania. In making a decision about the patient’s medication, you quickly recognize the diagnosis. Which of the following choices best categorizes the patient’s diagnosis?

(A) bipolar II disorder

(B) bipolar I disorder

(C) cyclothymia

(D) bipolar III disorder

(E) double depression

v  2. On a subsequent visit, the patient brings his brother to your office. His brother asks what his risk of developing a mood disorder is. What do you answer?

(A) the same as anyone in the general population

(B) 25%

 (C) 10%

(D) 1%

(E) the answer is unknown

Answers

1. (C) Cyclothymia is cycling between hypomania and dysthymia. Treatment is the same as in bipolar disorder. Bipolar III disorder does not exist. Double depression occurs when a major depressive episode is superimposed on dysthymic disorder.

2. (B) First-degree relatives of patients with bipolar disorder have a 25% risk of any mood disorder.

v  A 42-year-old business executive presents for his first contact with a mental health provider. He reports that for the last 4 months he has been feeling depressed. His low energy level and poor motivation are affecting his job performance and the CEO of his company advised him to “take a couple of weeks off.” The patient reports that he started feeling down when his wife discovered that he was involved in his third extramarital affair. Since then he has moved into a small apartment by himself. He is sleeping almost 12 hours every night, has a poor appetite, and is experiencing financial difficulty due to indiscriminate purchases. He laments the loss of his former self. He reports that he used to need only 4–5 hours of sleep and once was able to “party all night and work all day.” This case best illustrates an Axis I diagnosis of which of the following?

(A) bipolar I disorder

(B) bipolar II disorder

(C) MDD

(D) narcissistic personality disorder

(E) impulse control disorder not otherwise specified

Answer

 (B) This patient’s history is most consistent with a mood pattern defined by prolonged periods of hypomania (symptoms of mania not severe enough to cause occupational dysfunction or psychiatric treatment) and now a major depressive episode. Hypomania with major depression defines bipolar II disorder. In bipolar I disorder, the mania is more severe causing notable occupational dysfunction and usually contact with psychiatrists. This patient is in the midst of a major depressive episode but his history of mania indicates a bipolar diagnosis. This is an important distinction to make in diagnosis because improper treatment with antidepressants can precipitate a manic episode. Narcissistic personality disorder is an Axis II diagnosis. This patient does display impulsivity but impulse control disorder, not otherwise specified, can be diagnosed only after the exclusion of major mental illness such as bipolar disorder, which may have impulsive features.

v  A52-year-old woman who has been treated with medication for 3 years for a chronic mood disorder reports that although she feels well, she wonders if her medication is causing side effects. She complains of dry mouth, trouble urinating, and occasional dizziness when she gets out of bed. Which of the following medications is she most likely being prescribed?

(A) fluoxetine

(B) imipramine (Tofranil)

(C) phenelzine

(D) lithium

(E) divalproex sodium

Answer

(B) Dry mouth, dizziness (associated with hypotension), and urinary hesitancy are due to anticholinergic and adrenergic blocking effects of TCAs such as imipramine. Fluoxetine, an SSRI, is most often associated with gastrointestinal upset, sexual dysfunction, and agitation. Phenelzine, an MAOI, can be associated with hypotension but is less likely to have anticholinergic effects. Lithium is most often associated with polyuria, polydipsia, tremor, and mental confusion at higher doses. Divalproex sodium may cause gastrointestinal upset but is otherwise commonly associated with sedation and tremor at higher doses.

v  1. A34-year-old woman presents for the treatment of her severe, medication-refractory, major depression. She is referred to you by her outpatient psychiatrist because of your expertise in ECT. After reviewing her past psychiatric history and interviewing the patient, you conclude that she should indeed undergo ECT. In discussing the effects of ECT with the patient, you should relate that the most likely side effect may be which of the following?

(A) amnesia

(B) anesthesia-related respiratory complications

(C) fractures from convulsions

(D) abnormal cardiac arrhythmias

(E) psychosis

2. You tell the patient to expect the best possible outcome, she is likely to require how many treatments?

(A) 2

(B) 4

(C) 10

(D) 20

(E) 40

Answers

1. (A) Amnesia is a common side effect of ECT presenting in the form of short-term memory deficits. Anesthesia-induced respiratory dysfunction, fractures, and arrhythmias are rare side effects. Psychosis can be improved rather than worsened; indeed, ECT is regarded as most indicated in psychotic depressions.

2. (C) For catatonic conditions, two or four ECT treatments may be effective. In major depression, 6–12 sessions are generally optimal for a good risk-benefit ratio of positive treatment effects versus memory impairment (which is more likely with 20 or 40 treatments). When ECT is given for psychosis or mania, 20 or more treatments may be necessary for a positive response.

v  A68-year-old man has a history of a left middle cerebral artery stroke. Which of the following psychiatric disturbances is most common following such a neurologic event?

(A) anxiety

(B) OCD

(C) depression

(D) mania

(E) panic symptoms

Answer

 (C) Classically, infarcts of the left frontal hemispheres (part of left middle cerebral artery distribution) present with depression whereas those of the right frontal hemisphere present with euphoria, inappropriate indifference, or mania. Obsessive-compulsive behaviors present occasionally after diffuse bilateral frontal injury. Panic and anxiety symptoms have not been described as having any particular association with left middle cerebral artery strokes although such comorbid cases probably exist.

v  A 29-year-old married woman is brought into the psychiatric department by her husband who reports that despite feeling depressed 1 month ago, she now has been acting bizarre for the past week. On initial interview, the patient states, “I feel superbly supreme, and you have no idea what an amazing person I am! I am a direct descendant of Queen Elizabeth!” The patient is talking so fast you cannot interrupt her. Her husband reports that the patient has not slept in over a week and that she has recently been adjusting her own medication(s) since her last appointment over a month ago. In addition, her husband reports that this past week alone she has bought a new car, a diamond tennis bracelet, and her third designer handbag.

1. The most likely diagnosis is which of the following?

(A) a mood disorder

(B) a psychotic disorder

(C) a personality disorder

(D) an anxiety disorder

(E) a factitious disorder

2. Which of the following medications was most likely to be the one adjusted by the patient?

(A) buspirone

(B) ranitidine (Zantac)

(C) divalproex sodium

(D) propranolol

(E) zolpidem (Ambien)

Answers

1. (A) The most likely diagnosis is bipolar disorder classified in the DSM-IV-TR as a mood disorder in which the individual experiences symptoms of a depressive disorder and symptoms of mania independently during the course of the illness. The current episode exemplifies a manic episode with symptoms that include inflated self-esteem and grandiosity, pressured speech, a decreased need for sleep, and an impulsive shopping excursion without considering possible consequences. A psychotic disorder like schizophrenia cannot be diagnosed because there is no indication of prominent psychotic symptoms (hallucinations, disorganized thought processes and speech) present for at least 6 months. Personality and anxiety disorder do not present with the classic signs of mania. There is no indication that she is making up her symptoms for some secondary gain.

2. (C) From the choices given, the patient was most likely taking either lithium or divalproex sodium, which are both mood stabilizers and both indicated for the treatment of bipolar disorder. Buspirone, an anxiolytic, and propranolol, a beta-blocker used occasionally for GAD and panic disorder, are not likely to have been prescribed for this patient’s bipolar disorder. Ranitidine, although sometimes confused by patients for the benzodiazepine alprazolam, is an antacid. Changing the dose of zolpidem, a sleeping aid, would not account for her symptoms.

v  You are asked to see a 32-year-old man who was diagnosed with major depression 2 weeks ago and prescribed fluoxetine (Prozac). Once you enter the room and introduce yourself, you cannot get a question in as the man speaks rapidly about how terrific a doctor you are and how wonderful his life is. He tells you about the three cars he recently purchased. When you try to interrupt him, he says angrily, “You’re just like my skinflint wife.”

1. This patient’s affect is best described as which of the following?

(A) expansive and irritable

(B) guarded and suspicious

(C) labile and dysphoric

(D) euphoric and bizarre

(E) euthymic

2. His speech is best described as which of the following?

(A) uninterruptible

(B) pressured

(C) hypermotoric

(D) agitated

(E) tangential

Answers

1. (A) This is a typical presentation for mania, an episode that seems to have been at least partially induced by treatment with an antidepressant (all antidepressants can induce or exacerbate mania). This patient’s effect, like that of many patients with mania, is expansive and irritable. He is to a lesser extent guarded and suspicious but this does not capture the full picture of his mania. He is labile but hardly dysphoric, and he is euphoric but not bizarre. He is not euthymic.

2. (B) Although all of the other choices might explain part of his speech characterization, pressured is used to describe speech that is difficult to interrupt and at a fast rate.

v  A65-year-old woman with a past medical history of non-insulin-dependent diabetes mellitus and depression is admitted with increasingly depressed mood over the last month. She is unable to complete her crossword puzzles because of difficulty concentrating. She has difficulty falling asleep and also wakes up in the middle of the night. She denies suicidal ideation, but does feel guilty that she is depressed. Prior to this episode, she was doing well and was actively engaged in community volunteer groups. In the last month, she has lost 13 lb due to poor intake. When you ask why she is not eating, she tells you that she is worried that she will become infected with bacteria. She has been to her primary physician for an evaluation, but she says everything was normal. Her husband confirms that the patient has been very worried about “getting a disease” to the point where she will eat only food in sealed containers. He also confides in you that she has been worried that she might have cancer and despite reassurances from her primary care physician, she continues to voice her concerns to her husband that “my intestines are not working.”

1. The diagnosis that best describes her illness is which of the following?

(A) somatization disorder

(B) MDP without psychotic features

(C) dysthymia

(D) MDD with psychotic features

(E) OCD

2. Which of the following is the treatment of choice?

(A) sertraline

(B) sertraline and perphenazine

(C) lithium and sertraline

(D) divalproex sodium

(E) nortriptyline and lorazepam

Answers

1. (D) This patient is exhibiting signs and symptoms consistent with MDD with psychotic features. For more than 2 weeks, the patient has displayed depressed mood, loss of interest in pleasurable activities, weight loss, inability to concentrate, poor sleep, and guilt about her current depressive state. She is also suffering delusional-type concerns about bodily functioning and possible infection. If the patient were complaining of contamination fears and performing multiple compulsive tasks to rid herself of the pathogens, a diagnosis of OCD with co-morbid depression could be considered. Somatization disorder is characterized by more somatic complaints as well as at least one neurologic and pain symptom. Dysthymia presents with a chronic moderate level of depressive symptoms, but this patient is describing an episodic decompensation over the last month.

2. (B) Because of the delusional quality to her presentation, it is reasonable to treat this patient with a neuroleptics such as perphenazine for a few days prior to beginning a trial of an antidepressant. Antidepressants alone or with benzodiazepines would not help with the delusional aspects of her symptoms. Similarly, lithium and divalproex sodium are used as mood stabilizers in bipolar depression or mania but not commonly in the treatment of unipolar depression.