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Mood Disorders. Bruce Shapiro, M.D. April 6, 2001. Do psychiatrists have mood swings?. What Determines Mood?. Harlow and Spitz. Gross Anatomy. Neuroimaging. Regionalization questions. Synapse. Intracellular activities. Brain mediated environment. History. Mood Disorders.

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Mood Disorders

Bruce Shapiro, M.D.

April 6, 2001


Do psychiatrists have mood swings?


What Determines Mood?


Harlow and Spitz


Gross Anatomy


Neuroimaging


Regionalization questions


Synapse


Intracellular activities


Brain mediated environment


History...

Mood Disorders


History

  • The Bible (King Saul, Job)

  • Hippocrates - Humoral theory

  • Arateus - Psychological theory

  • 1800’s - Physical diagnosis

  • 1900’s - Psychological diagnosis

  • 1930’s - Somatic interventions

  • 1940’s - Psychoanalysis

  • 1950’s - Psychopharmacology

  • 1980’s - Biological markers

  • 1990’s - Neuroimaging

  • 2000’s - Herbals and magnetism ...


Hippocrates


Mood Disorders

Famous Sufferers ...


Abraham Lincoln


Winston Churchill


Churchill'sBlack Dog

  • "Black Dog”: Churchill's name for his depression

  • Lord Moran: inborn melancholia

  • Periods of solitude

  • Periods of high energy

  • Highly functional


Ernest Hemingway


Suicide - Familial Aspects


A Quote

“In my last severe depression, I took coca again and a small dose lifted me to the heights in a wonderful fashion”


Sigmund Freud


Freud and Mom or Mom and Freud?


Famous Living Bipolars

  • Robert Boorstin, writer, special assistant to President Clinton

  • Rosemary Clooney, singer

  • Dick Cavett, writer, media personality

  • Kitty Dukakis, former First Lady of Massachusetts

  • Patty Duke (Anna Pearce), actor, writer

  • Connie Francis, actor, musician

  • Shecky Greene, comedian

  • Kristy McNichols, actress

  • Kate Millett, writer

  • Charley Pride, musician

  • Axl Rose, musician

  • Ted Turner, entrepreneur, media giant

  • Jonathon Winters, comedian, actor, writer, artist


Famous Living Unipolars

  • Buzz Aldrin, astronaut

  • Rona Barrett, entertainment reporter, author

  • Art Buchwald, writer

  • Barbara Bush, former U.S. First Lady

  • Ray Charles, musician

  • Eric Clapton, musician

  • Dick Clark, television personality

  • Leonard Cohen, musician, writer

  • Francis Ford Coppola, director

  • Michael Crichton, writer

  • Kathy Conkrite, writer

  • Sheryl Crow, musician

  • Mike Douglas, media personality

  • Tony Dow, actor, director

    >>


Famous Living Unipolars

  • James Farmer, civil rights activist

  • John Kenneth Galbraith, economist, educator, author

  • Mariette Hartley, actor

  • Anthony Hopkins, actor

  • Robert McFarlane, former US National Security Advisor

  • Joan Rivers, comedienne, talk show host

  • Roseanne, actor, writer, comedienne

  • Rod Steiger, actor

  • William Styron, writer

  • James Taylor, musician

  • Livingston Taylor, musician

  • Mike Wallace, news anchor

  • Marie Osmond, entertainer


Mood Disorders

Classification and

Demographics ...


Mood Disorders (DSM-IV)

  • Depressive Disorders

    • Major Depressive Disorder (single/recurrent)

    • Dythymic Disorder

    • Depressive Disorder, NOS

  • Bipolar Disorders

    • Bipolar I

    • Bipolar II

    • Cyclothymic Disorder

    • Bipolar Disorder, NOS

  • Mood Disorder due to:

    • Medical condition

    • Substance induced


Mood Disorders - DSM IV


Unipolar vs Bipolar

UnipolarBipolar

Prev5%1%

GenderF>MF=M

Onset30’s20’s

Suicide15%20%

Sleepinsomhyper

Rxunipolarbipolar III

Geneticslowerhigher


Epidemiology

  • Lifetime risks:

    • Major Depression: 6 %

    • All mood disorders: 8 %

  • Prevalence

    • Major Depression: (point prevalence approx 5 -6 %)

      • Males: 2.6 - 5.5%

      • Females: 6.0 - 11.8 %

    • Dysthymia: 3 - 4 %

    • In primary care practice:

      • Major Depression: 4.8 - 9.2 %

      • All depressive disorders: 9 - 20 %

  • Bipolar Disorder: 1.0 - 2.5 %

  • 5 - 15 % of adult depressions are bipolar


Prevalence of Mood Disorders

  • 20% of the U.S. population reports at least one depressive symptom in a given month

  • 12% report two or more depressive symptoms in a year

  • Major Depression: 5% in the previous 30 days,

  • Bipolar Disorder - approximately 1 % of the population

  • Increase in cohort post 1940

  • Younger age of onset


Genetics

  • Unipolar

    • Dizygotic: 30%

    • Monozygotic: 50%

    • Family history: 25%

  • Bipolar

    • Dizygotic: 30%

    • Monozygotic: 80%

    • Family history: 50%


Gender differences

  • Bipolar - no difference

  • Unipolar - Female > Male

    • ?genetic

    • sociocultural

    • alcoholism/substance abuse


Mood Disorders: Across the Lifespan

  • Infancy - Spitz and Harlow

  • Childhood - depressive equivalents

  • Adolescence - major onset; substance abuse

  • Adulthood - major onset

  • Geriatric - multiple symptoms; pseudodementia; differential medical diagnoses


Predisposing factors

  • Prior mood disorder or moodswings

  • Positive family history

  • Female gender

  • Severe prolonged stress

  • Recent loss

  • Postpartum period

  • Medical co-morbidity

  • Current alcohol/substance abuse


Prognosis

  • Major Depression recurrence rates:

    1 episode: 50 - 60%

    2 episodes: 70%

    3 episodes: 90%

  • Untreated episode: 6-12 months

  • 20-30 % chronicity

  • Episode length and frequency: shorter episodes with increasing frequency

  • Treatment yields good results


Mood Disorders

Clinical Syndromes ...


Hypomania:What does it feel like?

“At first when I'm high, it's tremendous...ideas are fast...like shooting stars you follow until brighter ones appear...all shyness disappears, the right words and gestures are suddenly there...uninteresting people, things, become intensely interesting. Sensuality is pervasive, the desire to seduce and be seduced is irresistible. Your marrow is infused with unbelievable feelings of ease, power, well-being, omnipotence, euphoria...you can do anything...but, somewhere this changes”.


Mania:What does it feel like?

“The fast ideas become too fast and there are far too many...overwhelming confusion replaces clarity...you stop keeping up with it--memory goes. Infectious humor ceases to amuse. Your friends become frightened...everything is now against the grain...you are irritable, angry, frightened, uncontrollable, and trapped”.


Clinical Mania

  • A sustained period of behavior that is different from usual

  • Increased energy, activity, restlessness,

  • Racing thoughts and rapid talking

  • Excessive "high" or euphoric feelings

  • Extreme irritability and distractibility

  • Decreased need for sleep

  • Unrealistic beliefs in one's abilities and powers

  • Uncharacteristically poor judgment

    >>


Clinical Mania

  • Reckless behavior

  • Increased suspiciousness/paranoid ideation

  • Increased sexual drive

  • Abuse of drugs, particularly cocaine, alcohol, and sleeping medications

  • Flight of ideas

  • Provocative, intrusive, or aggressive behavior

  • Possibly delusions (paranoid/grandiose/religious)

  • Possibly hallucinations

  • Denial that anything is wrong


Cycle Length


Bipolar: Frequency of Recurrence


Hypomania

  • Inflated self-esteem

  • Decreased need for sleep

  • More talkative than usual

  • Excessive involvement in pleasurable activities that have a high potential for painful consequences (e.g., the person engages in unrestrained buying sprees, sexual indiscretions, or foolish business investments)

  • Increased activity

  • No major life disruption

  • No need for hospitalization

  • No psychotic symptoms


Cyclothymia

  • Alternating hypomania and

    non-major depression

  • At least 2 years in duration


Depression:What does it feel like?

“I doubt completely my ability to do anything well. It seems as though my mind has slowed down and burned out to the point of being virtually useless....[I am] haunt[ed]...with the total, the desperate hopelessness of it all... Others say, "It's only temporary, it will pass, you will get over it," but of course they haven't any idea of how I feel, although they are certain they do. If I can't feel, move, think, or care, then what on earth is the point?”


Sadness vs Clinical Depression

  • Intensity

  • Duration

  • Neurovegetative changes

  • Self esteem changes

  • Normal Grief vs. Depressive Illness


Depressive Disorders - DSM - IV

  • Major Depressive Disorder (296.xx)

  • Dysthymic Disorder (300.4)

  • Depressive Disorder NOS (311)

  • Mood Disorder due to general medical condition (293.83)

  • Substance-Induced mood disorder (293.83)


Clinical Depression

  • Loss of the ability to experience pleasure

  • Unexplained or prolonged sadness or crying spells

  • Significant changes in appetite and sleep patterns

  • Diurnal variation of mood

  • Irritability, anger, worry, agitation, anxiety

  • Pessimism, indifference

  • A sense of hoplessness/helplessness


Clinical Depression

  • Loss of energy, persistent lethargy, pathological fatigue

  • Feelings of guilt, worthlessness

  • Inability to concentrate, indecisiveness

  • Social withdrawal

  • Difficulty with personal hygiene

  • Unexplained aches and pains

  • May have delusions or hallucinations

  • Recurring thoughts of death or suicide


Other Specifiers

Catatonic Features

With Melancholic Features

With Atypical Features

With Postpartum Onset


Physical Symptom Indicators

  • Fatigue

  • Pain

  • Sleep disturbances

  • GI disorders (IBS)

    • unexplained by medical testing


Atypical Presentations

  • Anxiety/panic symptoms

  • Irritability

  • Hysterical symptoms

  • Hypochondriacal symptoms

  • Unexplained pain syndromes

  • Substance abuse presentations

  • “Personality disorder”


Dysthymia

  • This disorder is characterized by a chronic state of depression, exhibited by a depressed mood on most days for at least 2 years. (1 year in children and adolescents).

  • There are no psychotic symptoms

  • .


Dysthymia: symptoms and duration

  • poor appetite or overeating

  • insomnia or hypersomnia

  • low energy or fatigue

  • low self-esteem

  • poor concentration or difficulty making decisions

  • feelings of hopelessness

    Dysthymic individuals must not have gone for more than 2 months without experiencing two or more of these symptoms


Mood Disorders

Suicide ...


Suicide Rates in Mood Disorders

  • Unipolar: 15 %

  • Bipolar: 20 %


Suicide Risk Factors

  • Clinical depression

  • Suicidal ideation

  • Self oriented (non-manipulative)

  • Available lethal method

  • Male>Female

  • White>black

  • Elderly

  • Loss with alcohol/substance abuse


Suicide Rates


Suicide - Clusters


Mood Disorders

Causes

and

Treatments ...


Psychological Models

  • Psychoanalytic

  • Interpersonal

  • Cognitive

  • Behavioral/learned helplessness


Treatment: Psychological

  • Individual Psychotherapy

    • Psychodynamic/Psychoanalytic

    • Cognitive

    • Interpersonal

    • Supportive

  • Group Therapy

  • Couples Therapy

  • Family Therapy


Biological Models

  • Genetic

  • Neurotransmitter dysfunction

  • Neuroendocrine dysfunction

  • Chronobiological

  • Sensitization/Kindling


Serotonergic pathways


Neurotransmission


Neurons


Basic Synapse


Serotonin Synapse


Reuptake pump


Synaptic Interactions


Synaptic Transmission


Biological Markers in Major Depression

  • DST

  • TRH/TSH

  • Shortened REM latency


Treatment: Biological

  • Antidepressants

  • Antipsychotics (typical, atypical)

  • Mood stabilizers (thymoleptics)

  • Augmentation strategies

  • Herbal

  • Phototherapy

  • ECT

  • rTMS


Mood Stabilizing Medications

  • Lithium carbonate/citrate

  • Tegretol (carbamazepine)

  • Depakote (valproic acid)

  • Neurontin (gabapentin)

  • Lamictal (lamotrigine)

  • Klonopin (clonazepam)

  • Zyprexa (olanzapine)


Antidepressant Medication

  • Antidepressant medications are non-addictive.

  • Another antidepressant can be tried should the first have unacceptable side-effects.

  • Antidepressants take time to work

  • Physical symptoms are more likely to respond before psychological symptoms

  • Undulating improvement


Antidepressant medications

  • TCA’s (imipramine, nortriptyline, desopramine)

  • MAOI’s (phenelzine, tranylcypromine, meclobemide)

  • SSRI’s (fluoxetine, sertraline, paroxetine, fluvoxamine, citalopram)

  • SNRI’s (venlafaxine)

  • CRI’s (buprorion)

  • Alpha2 adrenergic antagonists (mirtazapine)

  • Serotonin2A antagonists and serotonin reuptake inhibitors (trazodone, nefazodone)

  • Modified amino acids (SAMe)

  • Psychostimulants

  • Augmentation strategies (Li, T3, buspirone, anxiolytics)


Electroconvulsive Therapy (ECT)

  • History

  • Indications

  • Efficacy

  • Adverse effects

  • Safety


rTMS


Integrative Treatments

  • Nature AND Nurture

  • In major syndromes: combinations of medication and psychotherapy

  • Treat the individual

  • Never give up


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