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Mood Disorders

Mood Disorders. Mood Disorders. Refer to a number of disorders where the patient displays an “extreme” mood state Positive: Excitement, elation Negative: Sadness, emptiness Complex etiology: Most patients are believed to have genetic predisposition

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Mood Disorders

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  1. Mood Disorders Depression, Bipolar Disorder

  2. Mood Disorders • Refer to a number of disorders where the patient displays an “extreme” mood state • Positive: Excitement, elation • Negative: Sadness, emptiness • Complex etiology: Most patients are believed to have genetic predisposition • Not necessarily triggered by a stressful event • Extremely common, considered a major world health issue (WHO, 2006) • Among the most treatable mental health disorders Depression, Bipolar Disorder

  3. Prevalence of Mood Disorders • Many people who suffer clinical depression do not seek treatment • Cultural, gender differences • CAMH (Toronto) rates range from 10-25% of the population seeking treatment • Bipolar disorder is equally common in males and females • Major depression twice common in females • Women also more likely to seek treatment. Depression, Bipolar Disorder

  4. Depression: Case Study • A very capable professional woman in her mid-30s became depressed as a consequence of difficulties in conceiving a child. The couple had delayed trying to have children, and desperately desired to become parents. The difficulty in conceiving, and consequent involvement in an IVF program, also led to significant marital stress. • The patient had started to cry frequently and had some suicidal thoughts (although she had no intent to act upon them). She had little energy and was easily fatigued -- in contrast to her usual active and productive self. Depression, Bipolar Disorder

  5. Depression: Case Study • She developed insomnia, her concentration was impaired, and she lost her appetite. At times she would shop and spend more than usual in order to cheer herself up.She was referred to a counsellor for both individual and marital therapy. • The individual counseling focused upon the issues of her grief over not being able to bear children, her guilt about not attempting to conceive earlier, and the tension within the marriage. However, despite skilled therapy for an adequate time, her symptoms persisted. Depression, Bipolar Disorder

  6. Major Depressive Episode • Five or more of the following symptoms that: • present during the same 2-week period • change from previous functioning • at least one of the symptoms is either (1) depressed mood or (2) loss of pleasure. • depressed mood most of the day, nearly every day, as indicated by either subjective report (e.g. feels sad or empty) or observation made by others (e.g. appears tearful). • Children or adolescents – irritability Depression, Bipolar Disorder

  7. Major Depressive Episode (2) markedly diminished interest or pleasure in all, or almost all, activities most of the day, nearly every day (self-report or anecdote) (3) significant weight loss when not dieting or weight gain, or decrease or increase in appetite nearly every day • children – failure to meet weight milestones Depression, Bipolar Disorder

  8. Major Depressive Episode (4) insomnia or hypersomnia nearly every day (5) psychomotor agitation or retardation nearly every day (observable by others, not only through self-report) (6) fatigue or loss of energy nearly every day Depression, Bipolar Disorder

  9. Major Depressive Episode (7) Feelings of worthlessness or excessive or inappropriate guilt (which may be delusional) nearly every day (8) Diminished ability to think or concentrate, or indecisiveness, nearly every day (self-report or anecdote) (9) Recurrent thoughts of death, recurrent suicidal ideation (without a specific plan), or a suicide attempt or a specific plan for committing suicide B. The symptoms do not meet criteria for a mixed episode (I.e. in one day, rapid alternation between mania and depression) Depression, Bipolar Disorder

  10. Major Depressive Episode C. Symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning. D. The symptoms are not due to the direct physiological effects of a substance, or a general medical condition. E. The symptoms are not better accounted for by bereavement, i.e., after the loss of a loved one, the symptoms persist for longer than 2 months or are characterized by marked functional impairment. Depression, Bipolar Disorder

  11. Depressive Disorder Major Depressive Disorder • Presence of a single MDE that is chronic (2 months) • Recurring MDE episodes Dysthymia • not meeting full criteria • relatively intact functional capacity (need 2 months duration) • Specifiers: Postpartum onset, With seasonal pattern (Seasonal Affective Disorder) • Some features may be unusual (agitation, delusions, catatonia) Depression, Bipolar Disorder

  12. Bipolar Disorder • Much lower prevalence: 1-2% • Atypical prior to age 12 • Initially may characterize as cyclothymia: alternations between elevated and depressed mood, without extreme effects on daily functioning. • May or may not progress to bipolar disorder • Characterized by clinical depression (MDE) with alternating manic or hypomanic episodes (elevated mood, either extreme behaviour or not, respectively) Depression, Bipolar Disorder

  13. Case Study • “Kevin”, a 28 year-old accountant, recently separated from his wife of 6 years and was apparently devastated by the breakup. His friends at work described him as “extremely moody” after his wife left him. • According to other people present, at the company Christmas party a few weeks later, Kevin was having a casual yet involved discussion with some of his colleagues regarding dating and sexual prowess. Depression, Bipolar Disorder

  14. Case Study • With little warning, Kevin began bragging about how he had slept with hundreds of women, and about the size of his penis. He then began ridiculing the other males in the crowd at how small their penises must be for not having slept with as many women as him. • After some minutes of this screaming and taunting behaviour, Kevin challenged the other males in the group to pull their pants down to “see what they were made of”. He then took off his own clothes, jumped onto a nearby table and started masturbating, screaming unintelligibly. • Kevin was restrained by security shortly thereafter. A brief hospitalization and eventual psychiatric assessment confirmed that Kevin had experienced a Manic Episode. Depression, Bipolar Disorder

  15. DSM-IV: Manic Episode • A distinct period of abnormally and persistently elevated, expansive or irritable mood, lasting at least 1 week (or any duration if hospitalization is necessary) B. During the period of mood disturbance, 3 or more of the following symptoms have persisted (4 if mood is irritable) and have been present to a significant degree: 1) inflated self esteem or grandiosity 2) decreased need for sleep (e.g. feels rested after only 3 hours of sleep) 3) more talkative than usual or pressure to keep talking Depression, Bipolar Disorder

  16. DSM-IV: Manic Episode 4) flight of ideas, or subjective experience that thoughts are racing 5) distractibility 6) increase in goal-directed activity (work, school, or sexually) or psychomotor agitation 7) excessive involvement in pleasurable activities that have a high potential for painful consequences • unrestrained buying sprees, sexual indiscretions, or foolish business investments Depression, Bipolar Disorder

  17. DSM-IV: Manic Episode C. The symptoms do not meet criteria for a Mixed Episode D. The mood disturbance is sufficiently severe to cause marked impairment in occupational functioning or in usual social activities or relationships with others, or to necessitate hospitalization to prevent harm to self or others, or there are psychotic features. Depression, Bipolar Disorder

  18. DSM-IV: Manic Episode E. The symptoms are not accounted for by use of a substance or medical condition. • Hypomania: If symptoms persist for only 4 days, and episodes do not affect everyday functioning. Depression, Bipolar Disorder

  19. DSM-IV: Bipolar Disorder Bipolar I Disorder, Single Manic Episode A. Presence of only one Manic Episode and no past MDEs (could have dysthymia) B. The Manic Episode is not better accounted for by Schizoaffective disorder, and is not superimposed on other psychotic disorders. Depression, Bipolar Disorder

  20. DSM-IV: Bipolar Disorder Bipolar I Disorder, Most Recent Episode Hypomanic A. Currently or most recently in a Hypomanic Episode B. There has previously been at least one Manic Episode or Mixed Episode. C. The mood symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning. D. The mood episodes are not better accounted for by Schizoaffective disorder, and is not superimposed on other psychotic disorders. Depression, Bipolar Disorder

  21. DSM-IV: Bipolar Disorder • Other subtypes: • Bipolar I Disorder, Most Recent Episode Manic • Bipolar I Disorder, Most Recent Episode Mixed • Bipolar 1 Disorder, Most Recent Episode Depressed • Bipolar II Disorder – no Mania or Mixed episodes • In all above cases, Major Depression must be present. Depression, Bipolar Disorder

  22. Etiology of Mood Disorders • Note that most studies are done on patients with years of depression or bipolar disorder • Begs the question of which came first, the brain abnormalities or the depression. • Assumption is mood disorders are biological because they respond to treatment. Depression, Bipolar Disorder

  23. Etiology of Mood Disorders • Ignores negative thought patterns that can maintain depressive symptomatology – people with mood disorders have been shown to think differently about themselves, others, and the world (Segal, 2004) • Common nature of depression argues against biological cause • Is depression adaptive? Depression, Bipolar Disorder

  24. Neuropathology: Depression • Monoamine hypothesis: depression is caused by insufficient activity of monoamines (NE and 5-HT) • Depression does not respond to DA agonists • Lowering of NE and 5-HT metabolism in depressed patients has been shown in PET studies (Bremner et al., 1997; Smith et al., 1999). • Substance P (peptide) shown to increase DA levels • ventral tegmental area and prefrontal cortex and alleviate symptoms of depression (Kramer et al., 1998; Lejeune et al., 2002). Depression, Bipolar Disorder

  25. Neuropathology: Depression • Overactivity of the beta-adrenoreceptor • G protein-coupled receptor involved in the synthesis of second messengers or ion channels • These receptors are desensitized by 5HT and NE The effects of NE and 5HT on this receptor is likely related to the delayed mood altering response of anti-depressants Depression, Bipolar Disorder

  26. Neuropathology • Depression is associated with decreased volume of the prefrontal cortex, basal ganglia, amygdala and cerebellum (Soares and Mann, 1997; Drevets, 2001) • Bipolar disorder is associated with decreased volume of the cerebellum and temporal lobes (Soares and Mann, 1997) and increased volume of the ventricles (Strakowski et al., 2002). Depression, Bipolar Disorder

  27. Neuropathology • Seasonal pattern for depression: • Winter – cravings for carbohydrates and weight gain; oversleep (may be treated with phototherapy in early morning 4:30 a.m. to 6 a.m. seem to be peak times) • Summer – sleep less, lose appetite, and lose weight Depression, Bipolar Disorder

  28. Other Information Suicide Rate in Canada (StatsCan, 1997) • Males: 19.6/100000 • Females: 5.1/100000 • Number of suicides have quadrupled since 1960, but have remained stable over the last 20 years. • Rates are fairly steady over the lifespan (15+ years of age), but it is rising in young adolescents and children • A leading cause of death during adolescence Depression, Bipolar Disorder

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