Major Depression and Other Mood Disorders

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Major Depression and Other Mood Disorders

• Lloyda B. Williamson, M.D.,
• Assist. Professor
• Dept. of Psychiatry
• Behavioral Medicine
• University of Alabama, School of
  Medicine,Tuscaloosa Campus
• November 7, 2006

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Mood Disorders

• Depressive Disorders
• -Major Depression
• -Dysthymic Disorder
• -Depressive Disorder, Not otherwise specified
• Bipolar Disorder
• -Bipolar I Disorder
• -Bipolar II Disorder
• -cyclothymic Disorder

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Depressive Disorders

• Major Depression - 1 or more episodes of
  depressed mood or loss of interest or pleasure
  for at least 2 weeks with at least 4 more
  symptoms
• -Dysthymic Disorder - depressed mood, more days
  than not, over a 2 year period with 2 more
  symptoms of depression

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Depressive Disorders

• Depressive Disorder, NOS- pts who do not meet
  criteria for Major Depressive Disorder,
  -Dysthymic Disorder or Adjustment Disorder with
  Depressed mood or Adjustment Disorder with mixed
  Anxiety and Depressed mood

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Major Depressive Disorder - Epidemiology

• Lifetime prevalence
• -women10 - 25
• -men 5 - 12
• -pre-pubertal children boysgtgirls
• -puberty to 50 yrs women 2x men
• -after 50 yrs womenmen

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Major Depression - Course

• Onset sudden or gradual
• Recurrent illness
• -risk of relapse after 1 episode 50
• -risk of relapse after 3 episodes 80
• -average lifetime of episodes 4
• Full recovery from an episode after
• 6 months 50

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Major Depression Course (cont.)

• Factors that contribute to relapse
• -high number of previous episodes
• -inadequate antidepressant treatment
• -partial response to treatment
• -discontinuation of effective treatment
• -rapid discontinuation of antidepressants
• -highly emotional environment
• -co-morbid medical or non-affective psychiatric
  disorders

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Major Depression Course (cont.)

• 5-10 of individuals with a single episode of
  major depression will eventually develop bipolar
  disorder

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Major Depression - Etiology

• Family studies 2 - 3 x more frequent in 1st
  degree biological relatives
• Twin studies concordance rate- 50 monozygotic
  twins 20 dizygotic twins

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Major Depression- Diagnosis

• Must have 5 of the following during the same 2
  week period (with 1 symptom either depressed mood
  or loss of pleasure)

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Major Depression-SIG E CAPS

• Sleep (insomnia or hypersomnia)
• Interest (diminished)
• Guilt (feelings of worthlessness)
• Energy (loss of or fatigue)
• Concentration (diminished ability to think)
• Appetite (decreased or increased unintentional
  weight loss)
• Psychomotor agitation or retardation
• Suicidal ideation

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Major Depression - Specifiers

• With psychotic features
• With atypical features
• Post-Partum onset
• Seasonal Affective Disorder
• With Catatonic features

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Major Depression -Differential Diagnosis

• Mood disorder due to a general medical condition
• Substance-induced mood disorder
• Dysthymic Disorder
• Dementia
• Manic episodes with irritable/ mixed states
• Attention-Deficit Hyperactivity Disorder
• Adjustment disorder with depressed mood

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Organic Illnesses Associated with Depression

• Rheumatologic - systemic lupus erythematosus,
  rheumatoid arthritis
• Cardiac - mitral valve prolapse, myocardial
  infarction, hypertension
• Endocrine - hyperthyroidism, hypothyroidism,
  diabetes mellitus, hypercalcemia, Cushings
  syndrome, postpartum state

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Organic Illnesses Associated with Depression
(cont.)

• Gastrointestinal - cirrhosis, inflammmatory bowel
  disease, pancreatitis, intestinal bypass,
• Hematologic - sickle cell anemia
• Nutritional deficiencies - B12, Folate, iron,
  thiamine, niacin
• Infectious - encephalitis, hepatitis, influenza,
  infectious mononucleosis, pneumonia, tuberculosis

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Organic Illnesses Associated with Depression
(cont.)

• Renal - renal transplant, uremia
• Neoplastic - intracranial. Leukemia, pancreatic
  lymphoma
• Neurologic - subdural hematoma, multiple
  sclerosis, CVA, Parkinsons, uncontrolled
  epilepsy
• Miscellaneous - psoriasis, sarcoidosis

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Drugs Commonly Associated with Depression

• Amphetamines, other CNS stimulants
• Barbituates
• Benzodiazepines
• Cimetidine
• Clonidine
• Beta-blockers
• Corticosteriods

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Drugs Commonly associated with Depression (cont.)

• Indomethacin
• Alpha-methyldopa
• Oral contraceptives, estrogens
• Reserpine, guanethidine
• Sulfonamides

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Depression in Children Adolescents

• Presenting symptoms may include
• -sad or irritable mood
• -loss of interest/pleasure in usual activities
• -school difficulties
• -school-refusal
• -somatic complaints
• -aggressive/antisocial behavior patterns
• -weight change or sleep pattern disruption

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Depression inGeriatric Population

• Often overlooked due to impaired cognition,
  sadness and confusion
• Medical and neurological complications and side
  effects of medications can obscure the diagnosis
• Higher suicide rates
• 30 of patients with dementia also have major
  depression

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Major Depression - Treatment

• Antidepressants
• Electroconvulsive therapy (ECT)
• Psychotherapy
• Vagal Nerve Stimulation

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Bipolar Disorder- Overview

• Occurs in 1 - 2 of population
• Presentation varies widely, sharing features with
  Major Depressive D/O Schizophrenia
• Thus, individuals may look very different when
  manic or depressed
• Bipolar Disorder is frequently misdiagnosed

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Bipolar Disorder - Subtypes

• Bipolar I- at least 1 manic episode, with or
  without major depression
• Bipolar II - no manic episodes but at least 1
  hypomanic episode and at least 1 major depressive
  episode
• Cyclothymia - symptoms of major depression do not
  reach threshold for diagnosis of major depression
  and mood elevation present does not reach
  threshold for diagnosis of a manic episode

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Bipolar Disorder - Subtypes

• Mania vs hypomania - mania is associated with
  significant social or occupational dysfunction or
  with hospitalization, while hypomania is not
• Rapid-cycling - an illness with a course of
  numerous mood episodes (four or more per year)

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Bipolar Disorder-Epidemiology

• Lifetime prevalence 1
• Only 27 receive treatment (worst rate of
  under-treatment of any psychiatric illness
• Incidence equivalent among males females
• Average age of onset around 19 yrs most present
  between 15 - 19 yrs

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Bipolar Disorder-Epidemiology(cont.)

• New onset bipolar disorder is rare after 5th
  decade of life when it occurs it is usually
  secondary to medical/ neurological condition,
  effects of medications, especially
  antidepressants and steroids
• Prevalence similar across ethnic groups

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Bipolar Disorder-Epidemiology(cont.)

• Associated with a lifetime rate of completed
  suicide of up to 15
• Associated with extremely high rates of divorce,
  numerous jobs, excellent academic achievement
  followed by a decline in occupational
  performance, generally chaotic life histories

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Bipolar Disorder-Epidemiology(cont.)

• Comorbidity
• -60 develop substance abuse at some point in
  their lifetimes
• -lifetime prevalence of anxiety disorders of
  approximately 50

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Bipolar Disorder - Course

• Single manic episode - indicates the near
  certainty of future manic or depressive episodes
  and the need for long-term medication management
• Untreated bipolar patients - may experience
  episodes yearly or more frequently
• Manic episodes - more often in summer
• Depressive episodes - more often in winter

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Bipolar Disorder-Differential Diagnosis

• Major Depressive Disorder never experience
  periods of mood elevation
• Schizophrenia never experience manic or mixed
  episodes
• Schizoaffective disorder persistent psychotic
  symptoms without manic, mixed or depressive
  episode

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Bipolar Disorder -Differential Diagnosis (cont.)

• Attention Deficit Hyperactivity Disorder
  distractibility or impulsivity exist in the
  absence of mood symptoms

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Bipolar Disorder - Evaluation

• Depression- screen ALL patients who meet criteria
  for major depression for the presence of lifetime
  manic or hypomanic symptoms to rule out bipolar
  disorder

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Bipolar Disorder Evaluation(cont.)

• Mania - irritable or euphoric mood, with 3 (if
  euphoric) or 4 (if irritable) of the seven
  cardinal symptoms of mania, for at least 1 week
• 7 cardinal symptoms remembered by mnemonic
  DIGFAST

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Bipolar Disorder - DIGFAST

• 1. Distractibility - most common manic symptom
• 2. Impulsivity - in activities that do not
  display usual judgment
• 3. Grandiosity - inflated self-esteem may be
  delusional increased self-confidence out of
  proportion to lifes circumstances

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Bipolar Disorder- DIGFAST

• 4. Flight of Ideas- racing thoughts
• 5. Activities - increase in goal-directed
  activities (social, sexual work, school)
• 6. Sleep - decreased need for differs from
  insomnia of depression (decreased sleep)
• 7. Talkativeness - pressured speech or tendency
  to be more talkative

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Common SecondaryCauses of Mania

• Substance abuse/intoxication/ withdrawal
  (alcohol, cocaine, caffiene)
• Medications (antidepressants, steriods, L-dopa,
  amphetamines, barbituates, ACTH)
• Neurologic conditions (multiple sclerosis,
  frontal lobe syndromes, temporal lobe epilepsy,
  stroke, head trauma, subcortical dementias,
  encephalitis, Huntintons disease, pseudobulbar
  palsy)

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Common SecondaryCauses of Mania (cont.)

• Endocrine conditions (Hyperthyriodism, Cushings
  syndrome)
• Other medical illnesses (Infections herpes
  simples encephalitis, HIV, encephalitis,
  syphillis, other viral or parasitic
  encephalitides Autoimmune disease systemic
  lupus erythematosus Metabolic states
  hypogylcemia, hypoxia)

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Mania in Children Adolescents

• Often presents as an extremely irritable or
  explosive mood with poor psychosocial functioning

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Bipolar Disorder - Treatment

• Mood stabilizers- lithium, valproic Acid,
  carbamazepine, lamotrigine, atypical
  antipsychotics
• Eliminate and avoid mood-destabilizing
  medications - antidepressants
• Patient education
• Family education