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Affective Disorders

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Mood Disorders Major Depressive disorder Bipolar disorder Dysthymic disorder ... rate essentially unknown Cyclothymic Disorder Thought to be a less ... – PowerPoint PPT presentation

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Title: Affective Disorders


1
Affective Disorders
  • Brian E. Wood, D.O.
  • Department Chair, Psychiatry
  • Edward Via Virginia College of Osteopathic
    Medicine
  • Assistant Professor of Clinical Psychiatric
    Medicine
  • University of Virginia, School of Medicine

2
Mood Disorders
  • Major Depressive disorder
  • Bipolar disorder
  • Dysthymic disorder
  • Cyclothymic disorder
  • Mood Disorder due to secondary sources
  • General medical conditions
  • Substance use/abuse

3
Major Depressive Episode
Time
Mood
4
Manic Episode
Mood
Time
5
Epidemiology
  • Major Depressive Disorder
  • Prevalence 2-3/100 men, 5-10/100 women
  • Lifetime expectancy 10 in men, 20 in women.
  • Risk increases throughout life for men, peaks in
    40s then decreases in women
  • Bipolar Disorder
  • Prevalence 1/100 in men and women
  • Lifetime expectancy 1 in men and women
  • Usually occurs in the mid 20s and 30s perhaps
    slightly later in women

6
Epidemiology
  • Dysthymic Disorder
  • Much less studied
  • More common in females
  • Onset frequently in 20s to 30s
  • More common among first degree relatives with
    MDD.
  • Cyclothymic Disorder
  • Essentially occurs more frequently in the same
    groups and age ranges as Bipolar Disorder
  • More common among first degree relatives with MDD
    or Bipolar Disorder.

7
Etiology
  • Major Depressive Disorder
  • Heritability 10-13 in first degree relatives
  • Mz concordance rate higher than Dz rate
  • Increased risk in lower socioeconomic classes
  • Increased risk with family history of ETOH,
    depression or early parental loss.

8
Etiology
  • Bipolar Disorder
  • Heritability 20-25 in first degree relatives
  • Child with 1 Bipolar parent 25 risk
  • Child with both parents bipolar 50-75 risk
  • Slightly increased risk in higher socioeconomic
    groups
  • Mz concordance rate 40-70, Dz concordance rate
    20.

9
Etiology
  • Dysthymic Disorder
  • Occurs more frequently in first degree relatives
    with MDD but rate essentially unknown
  • Cyclothymic Disorder
  • Thought to be a less severe form of Bipolar
    Disoder

10
DSM IV TR MDD
  • One or more major depressive episodes for at
    least 2 wks. Duration
  • Five or more symptoms of depression (wt. Loss,
    insomnia or hypersomnia, psychomotor agitation or
    retardation, fatigue, feelings of worthlessness
    or innappropriate guilt, diminished
    concentration, recurrent thoughts of death or
    suicide) including either depressed mood or loss
    of interest or pleasure.
  • Rule outs for bereavement, substance induced, etc.

11
DSM IV TR Bipolar Disorder
  • One or more manic or mixed episodes usually
    accompanied by MDE
  • Manic episode characterized by at least 1 wk of
    elevated, expansive, or irritable mood with at
    least three symptoms including grandiosity,
    insomnia, talkativeness, flight of ideas or
    racing thoughts, distractibility, increased
    activity, excessive involvement in pleasurable
    activity.
  • Rule outs for substances, medical conditions,
    etc.
  • Occupational or social dysfunction

12
Differential Diagnosis
  • MDD
  • Mood disorder due to general medical condition or
    substance induced
  • Manic or mixed episodes with irritable mood
  • Adjustment Disorder
  • Simple or complicated Bereavement
  • Dementia with prominent apathy

13
Differential Diagnosis
  • Bipolar Disorder
  • Mood disorder due to general medical condition or
    substance induced
  • Hypomanic episode
  • MDE with prominent irritability
  • Attention Deficit/Hyperactivity Disorder

14
Pharmacologic Treatment MDD
  • Pharmacologic Treatment (monotherapy)
  • Antidepressants
  • TCAs
  • MAOIs
  • SSRI (generally first line treatment)- steady
    state from 6 - 15 days.
  • Other antidepressants (Venlafaxine, Mirtazapine)
  • Psychostimulants

15
Tricyclic Antidepressants
  • Primary action on NE, SE.
  • Also have alpha 1 blocking, histamine blocking
    and anticholinergic effects
  • AV nodal block
  • Lethal in overdose
  • Infrequently used today for treatment of
    depression but some resurgence in use due to tx.
    Resistance and off label uses (ex. Pain control)

16
Monoamine Oxidase Inhibitors
  • Primary action on MAO that breaks down NE
  • Significant alpha 1 and histaminergic effects but
    little antcholinergic or AV node effects.
  • Risk of hypertensive crisis with Tyramine
    containing foods or with noradrenergic agents
    (ex. Pseudoephedrine)

17
SSRIs
  • Primary action at 5HT2 receptor.
  • Most widely prescribed psychotropic medication in
    use today and generally first line treatment for
    depression.
  • Generally very well tolerated with minimal
    incidence of side effects.
  • Not lethal in overdose.
  • Do have significant drug-drug interactions due to
    CP450 metabolism.

18
Effects of SSRIs on Cytochrome P450 Enzymes
Cytochrome Polymorphism Inhibitors Potentially significant Interactions
1A2 Possible Fluvoxamine Haloperidol Phenytoin Theophylline Caffeine
2C9 Yes 2-3of whites 15-20of Asians Fluoxetine Fluvoxamine Sertraline Phenytoin Diazepam Tolbuamide
2D6 Yes 5-8 of whites lower in Asians and African Americans Fluoxetine Fluvoxamine Paroxetine Sertraline Citalpram TCAs Haloperidol Perphenazine Thioridazine Clozapine Risperidone B-Blockers Type 1C antiarrhythmics
3A Possible Fluoxetine Fluvoxamine Sertraline Citalpram TCAs Carbamazepine Alprazolam Triazolam Terfenadine Astemizole
Adapted from DeVane (1994)
19
ECT
  • Application of brief electrical pulse to induce
    controlled generalized seizure.
  • Mechanism of action unknown but correlates with
    surge of neurotransmitters in the CNS and
    changes in permeability in the blood-brain
    barrier.
  • Modern ECT applied with general anaesthesia and
    neuromuscular blockade.
  • Probably the highest efficacy of any single agent
    used to treat affective disorders.

20
Other Treatments
  • Interpersonal psychotherapy
  • Cognitive-behavioral therapy
  • Psychodynamic psychotherapy

21
Pharmacologic Treatment of Bipolar Disorder
  • Li compounds primary effect at voltage gated
    Na channel of the neuron
  • Anticonvulsants effect at the voltage gated Na
    channel and membrane stabilization effects.
  • Valproic acid
  • Carbamazepine
  • Other anticonvulsants

22
Summary
  • Affective disorders are disorders of mood
    regulation and include both hyper-excitable and
    hypo-excitable states defined by episodes.
  • They are generally recurrent diseases but
    occasionally occur in single episodes.
  • They are familial with probable genetic
    inheritance but with significant environmental
    factors affecting expression.
  • Affective disorders are treatable diseases
    requiring careful evaluation, initiation of
    appropriate treatment, and follow up in order to
    improve condition, quality of life and minimize
    risks.
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