MOOD DISORDERS
DISORDERS OF EMOTIONS
Winston churchill
Lord Byron
Harrison ford
DEFINITIONS
• Emotion – feeling states associated with
experiences
• Affect – an external expression of transitory
emotional state
• Mood- sustained emotional states
• Bipolar- condition where patients
experience both depressive and manic
attacks
INTRODUCTION AND HISTORY
• Records of depression from antiquity, in Bible, Indian
scriptures etc.
• Hippocrates used the term melancholia for any severe
mental disturbance and Celsus described melancholia as
a depression caused by black bile.
• In 1854 French physician described folie circulaire
patients suffer alternating attacks of depression and
mania.
• Kahlbaum used the term cyclothymia
• In 1899 Emil Kraepelin MDP which is now called as
Bipolar Disorder
CLASSIFICATION
• Depression
• Bipolar mood disorder
• Recurrent depression
• Persistent mood disorders
• Cyclothymia
• Dysthymia
EPIDEMIOLOGY
• Depression a common condition
• Lifetime prevalence 5-12% in men. In
women 25%
• 15% of all medical inpatients have
depression
• BP mood disorder is less common-lifetime
prevalence 1%
Contd.
• Depression two time more common in
women in all cultures
• Bipolar illness equal in men and women
• Manic episodes more common in men and
depression in women
• Women more likely to develop rapid
cycling
Contd.
• Age:
• BPAD – 5 -50 year. Mean age 30 years
• Depression – mean age 40 years
• Recent epidemiological data suggests that
depression may be increasing in people less than
20 yrs. old, possibly due to increasing use of
alcohol and drugs.
Contd.
• Marital status:
• Depression more common in people without close
interpersonal relationships, divorced or separated
• BPAD more in divorced and single
• Socioeconomic and cultural factors:
• BPAD more common in higher social classes
• Depression more common in rural areas
Etiology
• Biological factors:
• Genetic factors
• Biogenic amines and other neurotransmitters
• Neuroendocrine factors
• Sleep abnormalities
• Circadian rhythms
• Kindling
• Neuroimmune factors
• Brain imaging
• Neuroanatomy
Contd.
• Genetic factors
• Family studies
• Adoption studies
• Twin studies
• Linkage studies
• Ch 11 and BPAD 1 disorder
• X ch and BPAD 1
Contd.
• Psychological factors:
• Cognitive theory
• Learned helplessness
• Personality
• Social factors:
• Life events and stress
Genetic factors
• Relatives of a patient with mood disorder
have a higher risk of developing the disease
compared to gen. population. The risk increases
with relationship becoming closer. The risk in first
degree relatives is about 20-25%. If one parent
has the disease, the risk in children is 27% and if
both parents have the illness, the risk increases to
75%.
• Concordance rate in MZ twins is about 70%
vs 20% for DZ twins.
Contd.
• Adoption studies: 28% of biological
parents of adoptees of with the illness had
the illness themselves compared with 12%
of adoptive parents.
• Linkage studies: no consistent results.
Association reported for chromosomes 5,
11,18 and X. the D2 receptor gene located
on chromosome 5, the gene for tyrosine
hydroxylase on 11.
Contd.
• X chromosome: linkage suggested with a
region that contains genes for color
blindness and glucose 6-phosphate
dehydrogenase deficiency.
Biogenic amines
• Based on the finding that antidepressants
increase the levels of these amines at the
synapses and drugs that reduce their
levels at synapses induce depression.
Phospholipids
• There is some evidence that depression is
associated with abnormal neuronal
membrane metabolism.
• Some studies have shown that EPA, highly
unsaturated fatty acids, is beneficial in
patients with depression.
Neuroendocrines
• Dexamethasone suppression test-non
suppression of cortisone
• CRH stimulation test- reduced corticotrophin
response.
• TRH stimulation test-25% of depressed
patients show blunted response.
• GH- depressed have reduced secretion during
sleep.
Sleep
• Initial, terminal and intermittent insomnia
and hypersomnia in depression
• Decreased need for sleep in manics
• EEG abnormal in depression- delayed
onset, reduced REM latency, a longer first
REM period.
Kindling
• It is the electrophysiological process in
which repeated sub threshold stimulation of
neurons eventually generates an action
potential. Repeated sub threshold
stimulation of brain produces a seizure. The
observation that anti epileptics are useful in
treating mood disorders suggests that they
may due to kindling in temporal lobes.
Neuroimmunity
• Immunological abnormalities in
depression.
• May be due to hypercortisolemia.
Brain imaging
• Inconclusive findings.
• Enlarged ventricles
• Smaller caudate nuclei
• Hyper dense areas
• Decreased blood flow in frontal and
increased flow in basal ganglia and medial
thalamus
Psychological factors
• Learned helplessness
• Cognitive theories
• Cognitive triad
• Cognitive distortions:
• Arbitrary inference
• Specific abstraction-focusing on a single detail while ignoring
other more imp. Details.
• Overgeneralization
• Magnification and minimization
• Personalization
• Absolutist and dichotomous thinking.
Social factors
• Life events: stressful life events precede
first episode of mood disorder.
• Most important life event associated with
subsequent depression is loss of a
parent before age 11.
• Unemployment
• Expressed emotions associated with
relapses
Clinical features
• Depression:
• Depressed mood
• Loss of interest or pleasure
• Low self esteem
• Tiredness
• Poor concentration
• Disturbed sleep
• Disturbed appetite
• Constipation
• Loss of libido
• Menstrual irregularities in women
• Suicidal thoughts or attempts
• Delusions and hallucinations
Depression
Contd.
• Mania:
• Elevated or expansive or irritable mood
• Over activity
• Over talkativeness
• Loss of inhibitions
• Reduced need for sleep
• Increased self esteem
• Delusions and hallucinations
Contd.
• Bipolar Mood Disorder 1
• BPAD 2
• Co existing disorders in mood disorders:
• Anxiety
• Alcohol use
• Other drugs
• Medical conditions
Differential diagnosis
• Depression:
• Drugs_antihypertensives, steroids, benzodiazepines,
oral contraceptives, NSAIDS, antibiotics, anti
neoplastics etc.
• Endocrine disorders-hypothyroidism, Cushing’s
syndrome, Addison’s disease,
• Tumors_ bronchogenic, pancreatic
• Infections-neurosyphilis
• C.C.F., stroke
• Nutritional- B 12, folate
• Neurological_ Parkinson’s, MS
Contd.
• Mania:
• Drugs-amphetamines, hallucinogens
• Medication- corticosteroids
• Endocrine disorders
• Other systemic causes- sle
• Intracranial causes- tumors, head injury,
neurosyphilis
Other mood syndromes
• Masked depression
• Seasonal affective disorder
• Agitated depression
• Cotard’s syndrome
• Schizoaffective disorder
• Depressive stupor
• Manic stupor
Bipolar disorder
• BPAD 1
• BPAD 2
BPAD
Management of Depression
• Hospitalization
• Pharmacotherapy
• ECT
• Psychotherapy- cognitive therapy
• Phototherapy
• Psychosurgery
Pharmacotherapy
• Antidepressants
• Tricyclics- Dibenzocycloheptanes- Amitriptyline
• Iminodibenzyls- imipramine, clomipramine
• Others- dothiepin, doxepin
• Tricyclic related- trazadone
• Tetracyclic- mianserin, maprotiline
• SSRIs- fluoxetine, citalopram, escitalopram, sertraline, paroxetine,
fluvoxamine
• SNRI’s- venlafaxine, duloxetine
• RIMAs-moclobamide
• MAOI’s- phenelzine, tranylcypromine
• NASSA- mirtazapine
Tricyclics
• Side effects: anticholinergic, postural
hypotension, cardiac effects, sedation,
seizures
• Dosage: 50 150 mg/day
• Other indications:
• Enuresis
• ADHD
• Pain
• OCD- clomipramine
• Anxiety, Panic disorder, Social phobia
SSRI’s
• Side effects:
• Nausea, vomiting, diarrhoea, loss appetite
• Sexual side effects
• Other indications:
• Anxiety
• OCD
• Social Phobia
• Panic disorder
• Bulimea nervosa
MAOI’s
• Foods that may interact:
• Cheese
• Meat and yeast extracts
• Alcohol
• Avocado
• Bananas skins
• Other drugs to be avoided:
• Sympathomimetics
• L-dopa
• Pethidine
• TCAs
Management of mania
• Hospitalization
• Pharmacotherapy- antimanics
• ECT
Antimanics
• Lithium
• Anticonvulsants: CBZ, Valproate,
Topiramate, Lamotrigene
• Benzodiazepines
• Antipsychotics
Lithium
• Not metabolized. Excreted by kidney
• Before starting:
• ECG
• Renal function tests
• Thyroid profile
• Narrow therapeutic index
• Serum levels
Contd.
• Side effects:
• Fatigue
• Drowsiness
• Dry mouth and metallic taste
• Polydipsia and polyuria
• Nausea and vomiting
• Weight gain
• Fine tremors
• Edema
Prophylaxis for BPAD
• Lithium
• Anticonvulsants
