mood disorders.ppt

8/11/2019 Mood disorders.ppt

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Mood (Affective) DisordersDepartment of Psychiatry

1stFaculty of Medicine

Charles University, PragueHead: Prof. MUDr. Ji Raboch, DrSc.


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Mood (Affective) Disorders

Mood disordersare very common, their life

prevalence is up to 20 %, and they have a highlevel of morbidity and mortality as well as animmense impact on disabilities worldwide.

The fundamental disturbance is a change in moodor affect, usually to depression (with or without

associated anxiety) or to elation. The mood changeis usually accompanied by a change in the overalllevel of activity.

Most of these disorders tend to be recurrent, andthe onset of individual episodes is often related tostressful events or situations.

The mood disorders may be subdivided intounipolarand bipolartypes:

1. those that are characterized by depressiononly

2. those that are characterized by manicepisode eitheralone or in combination with depression


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Classification of Mood Disorders

International Classification of Diseases (ICD-10) came into use in WHO Member States asfrom 1994

F30 Manic episodeF31 Bipolar affective disorder

F32 Depressive episode

F33 Recurrent depressive disorder

F34 Persistent mood (affective) disordersF38 Other mood (affective) disorders

F39 Unspecified mood (affective) disorder


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Test Methods

Self-reported scales: Young Mania Rating Scale (YMRS) Beck scale (depression)

Zung scale (depression)

Interview with physician:

Hamilton scale (HAMD)

Montgomery and Asberg scale (MADRS)


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F32 Depressive Episode

The lowered mood varies little from day to day, isunresponsive to circumstances and may beaccompanied by so-calledsomaticsymptoms:

loss of interest or pleasure in activities that are normallyenjoyable (anhedonia)

lack of emotional reactivity to normally pleasurablesurroundings and events

waking in the morning 2 hours or more before the usual time

depression worse in the morning

objective evidence of definite psychomotor retardation oragitation

loss of appetite

weight loss

loss of libido


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F32 Depressive Episode

F32 Depressive episodeF32.0 Mild depressive episode

F32.1 Moderate depressive episode

F32.2 Severe depressive episode withoutpsychotic symptoms

F32.3 Severe depressive episode withpsychotic symptoms

F32.8 Other depressive episodesF32.9 Depressive episode, unspecified


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F32.0 Mild Depressive Episode

Two or three of the above symptoms areusually present.

For mild depressive episodeare typicaldepressed mood, anhedonia and increased

fatigability. The afflicted person is usuallydistressed by the symptoms and has somedifficulty in continuing with ordinary workand social activities, but will probably not

cease to function completely.


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F32.1 Moderate DepressiveEpisode

An individual with moderate depressiveepisodesuffers from more symptoms(four or more of the above symptoms areusually present) of greater severity andwill usually have considerable difficulty incontinuing with social, work or domesticactivities.


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F32.2 Severe Depressive Episodewithout Psychotic Symptoms

In a severe depressive episode, thesufferer usually shows considerable distressor agitation. Loss of self-esteem or feelingsof uselessness or guilt are likely to beprominent, and suicide is a distinct dangerin particularly severe cases. ; a number of"somatic" symptoms are usually present.

Agitated depression Major depression

Vital depression


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F32.3 Severe Depressive Episodewith Psychotic Symptoms

Psychotic symptoms may be present, such as delusions (ideas of sin, poverty or imminent disasters) hallucinations (defamatory or accusatory voices or of

rotting filth or decomposing flesh) depressive stupor

Severe ordinary social activities are impossible When the psychotic symptoms are consistent

with the patients mood, they are referred to asmood congruent, when they are inconsistent,they are referred as mood incongruent.

Single episodes of: major depression with psychotic symptoms psychogenic depressive psychosis psychotic depression reactive depressive psychosis


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F33 Recurrent Depressive Disorder

Recurrent depressive disorderis characterized by

repeated episodes of depression without any historyof independent episodes of mood elevation andoveractivity.

Recovery is usually complete between episodes, buta substantial part of patients will have a recurrence

and about 30% may develop a persistentdepression. The lifetime prevalence - about 1020 %;

women:men 2:1. The risk of suicide (approximately 1015%.

Seasonal affective disorder- onset of moodsymptoms is connected with changes of seasons,with depression typically occurring during the wintermonths and remissions or changes from depressionto mania occurring during the spring.


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Kupfer 1991

severit

yofdepression

time

6-12weeks

4-9months

1 or moreyears

no depression

symptoms

syndrome

treatment stage

response

relapse

remission

relapse recurrence

recovery


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F33 Recurrent depressive disorderF33.0 Recurrent depressive disorder, current episode

mild

F33.1 Recurrent depressive disorder, current episode

moderateF33.2 Recurrent depressive disorder, current episode

severe without psychotic symptoms

F33.3 Recurrent depressive disorder, current episode

severe with psychotic symptomsF33.4 Recurrent depressive disorder, currently in

remission

F33.8 Other recurrent depressive disorders

F33.9 Recurrent depressive disorder, unspecified


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F30 Manic Episode

F30 Manic episodeF30.0 Hypomania

F30.1 Mania without psychotic symptoms

F30.2 Mania with psychotic symptomsF30.8 Other manic episodes

F30.9 Manic episode, unspecified


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F30.0 Hypomania

Hypomaniais characterized by persistent mild elevation of mood for at least

several days

increased energy and activity

usually marked feelings of well-being and bothphysical and mental efficiency

Increased sociability, talkativeness,overfamiliarity, increased sexual energy,

and a decreased need for sleep are oftenpresent but not to the extent that theylead to severe disruption of work or resultin social rejection. There are no

hallucinations or delusions

F30 1 M i ith t P h ti


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F30.1 Mania without PsychoticSymptoms

Mania without psychotic symptoms: last for at least 1 weak

mood is elevated out of keeping with individualscircumstances and may vary from carefree joviality toalmost uncontrollable excitement

elation is accompanied by increased energy, resulting inoveractivity, pressure of speech, and a decreased need forsleep

normal social inhibition are lost, attention cannot besustained, and there is often marked distractibility

self-esteem is inflated, and grandiose or over-optimisticideas are freely expressed

perceptual disorders may occur

the individual may embark on extravagant and impracticalschemes, spend money recklessly, or become aggressive,amorous, or factious in inappropriate circumstances.

F30 2 M i ith P h ti


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F30.2 Mania with PsychoticSymptoms

Mania with psychotic symptomsrepresents amore severe form of mania: inflated self-esteem and grandiose ideas may develop into

delusions, and irritability and suspiciousness into delusionsof persecution

in severe cases, grandiose or religious delusions of identity

or role may be prominent, and flight of ideas and pressure ofspeech may result in the individual becomingincomprehensible

sustained physical activity and excitement may result inaggression or violence, and neglect of eating, drinking, andpersonal hygiene may result in dangerous states of

dehydration and self neglect

Mania with: mood-congruent psychotic symptoms mood-incongruent psychotic symptoms

Manic stupor


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F31 Bipolar Affective Disorder Bipolar affective disorderis characterized by

repeated, at least two episodes in which the patientsmood and activity levels are significantly disturbed(manic or depressive syndromes, patients who sufferonly from repeated episodes of mania arecomparatively rare).

The first episode may occur at any age from childhoodto old age. The frequency of episodes and the pattern of

remissions and relapses are both very variable. The lifetime prevalence is between 0,5 an 1 %.

Suicidalityabout 19%. Comorbiditywith alcohol anddrug abuse

The rapid-cycling specifieridentifies those patientswho have had at least four episodes of a majordepressive, manic, or mixed episode during the past

12 months.


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F31 Bipolar Affective Disorder

F31 Bipolar affective disorder

F31.0 Bipolar affective disorder, current episode hypomanic

F31.1 Bipolar affective disorder, current episode manic withoutpsychotic symptoms

F31.2 Bipolar affective disorder, current episode manic withpsychotic symptoms

F31.3 Bipolar affective disorder, current episode mild ormoderate depression

F31.4 Bipolar affective disorder, current episode severedepression without psychotic symptoms

F31.5 Bipolar affective disorder, current episode severedepression with psychotic symptoms

F31.6 Bipolar affective disorder, current episode mixed

F31.7 Bipolar affective disorder, currently in remission

F31.8 Other bipolar affective disorders

F31.9 Bipolar affective disorder, unspecified

F34 Persistent Mood (Affective)


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F34 Persistent Mood (Affective)Disorders

Persistent mood disordersare persistent andusually fluctuating disorders of mood in whichindividual episodes are not sufficiently severe towarrant being described as hypomanic or even milddepressive episodes.

Lasting more than 2 years

F34 Persistent mood (affective) disorders

F34.0 Cyclothymia

F34.1 Dysthymia

F34.8 Other persistent mood (affective) disorders

F34.9 Persistent mood (affective) disorder, unspecified


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F34.0 Cyclothymia

For cyclothymiapersistent instability ofmood, involving periods of mild depressionand mild elation is typical.

This instability usually develops early inadult life and pursues a chronic course,although the mood may be normal andstable for months at a time.

The mood swings are usually perceived bythe individual as being unrelated to lifeevents.


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F34.1 Dysthymia

Dysthymiarepresents a chronic, milderform of depression which does not fulfillthe criteria for recurrent depressivedisorder especially in terms of severity.

Sufferers usually have periods of days orweeks when they describe themselves aswell, but most of the time they feel tiredand depressed.

It usually begins in adult life and lasts forat least several years, sometimesindefinitely.

The lifetime prevalence is approximately

3%, and it is more common in women.


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F34.1 Dysthymie

dysthymie: mrn chronick deprese

epidemiologie: celoivotn prevalencekolem 3%

etiopatogeneze: faktory genetick i vnj

lba: jako u depresivn poruchy kognitivn-bahaviorln psychoterapie,antidepresiva


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Treatment of Depression

Various antidepressantsaltering levels of central

neurotransmitters are available to treatdepression.

Their overall effectiveness: 65-70% Mild to moderate depressive episode: SSRIs.

Severe depression: antidepressants with broaderspectrum of effects, like SNRI or TCA. Patients with insomnia or anorexia may do better

with more sedating medication (mirtazapine,trazodon)

Patients with lethargy, hypersomnia, weight gainand lower levels of tension and anxiety mayprefer the less sedating medications such asbupropion, reboxetin or stimulating SSRIs.

IMAOs or RIMA should be tried in refractory

patients or patients with atypical depression.


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Drug trials should last 4 to 8 weeks.

No response within 4 weeks of treatment - thedose should be increased or the patient should beswitched to another drug.

In partial responders - augmentation strategy;

coadministration of lithium carbonate ortrijodthyronine.

Psychotic patient - adding on neuroleptics.

Anxious or agitated patients (also to improve the

sleep quality) - benzodiazepine coadministrationfor a short period of time.

Lithium prophylaxis is an option toantidepressants.

Supportive psychotherapy.


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First episode of depression - the drug should be

continued for another 16-20 weeks after the patientis thought to be well (continuation treatmenttoprevent recurrence).

The medication should be tapered gradually becausemany patients experience some mild withdrawal

effects. Patients with recurrent depression need long-term

maintenance therapyto prevent relapses. Electroconvulsive therapy (ECT)is the treatment of

choice for some patients with very severedepression, with high potential for suicide or otherselfdestroying behaviour and for pregnant women.

Other biological methods: phototherapy (seasonal affective disorder)

sleep deprivation repetitive transcranial magnetic stimulation (rTMS).


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Treatment of Mania

Mood stabilizers: lithium (0.61.2 mEq/L) carbamazepine (612 mg/L) valproate (50125 mg/L)

Anticonvulsants: gabapentine topiramate lamotrigine

Agitated or psychotic patient

coadministartion of antipsychotics of second generation

(olanzapine, risperidone) benzodiazepines (lorazepam, clonazepam)

ECT

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