Mood Disorders

1. Mood Disorders Dr Joanna Bennett

2. Mood Disorders Pervasive alterations in emotions that are manifested by depression, mania, or both, and interfere with the person’s ability to function normally

3. Mood Disorders • Major depression: 2 or more weeks of sad mood, lack of interest in life activities, and other symptoms • Bipolar disorder (formerly called “manic-depressive illness”): mood cycles of mania and/or depression and normalcy and other symptoms

4. Some related disorders • Seasonal affective disorder (SAD) • Postpartum depression • Postpartum psychosis

5. Prevalence • International studies • Major depression - 3-16% • Bipolar disorder 0.3-1.5% • Caribbean • 4.9% (PAHO 2005) • Community prevalence and risk factors for mood disorders are generally unknown

6. DSM Diagnostic criteria – Major depressive disorder • At least one of the following three abnormal moods • significantly interferes with the person's life: • Depressed mood • Loss of interest & pleasure • Irritable mood (under 18 yrs) Occurring most of the day, nearly every day, for at least 2 weeks

7. Diagnostic criteria: Depression • At least five of the following symptoms should have been present during the same 2 week depressed period: • Depressed or irritable mood • Loss of interest & pleasure • Appetite/weight disturbance (gain/loss) • Sleep disturbances • Fatigue/loss of energy • Guilt • Poor concentration • Morbid thoughts of death

8. Diagnostic criteria: Depression • The symptoms are not due to • Physical illness, alcohol, medication, or street drug use. • Normal bereavement. • Bipolar Disorder • Delusional or Psychotic Disorders

9. Mania: Signs and symptoms • Grandiose delusions, inflated sense of self-importance • Racing speech, racing thoughts, flight of ideas • Impulsiveness, poor judgment, distractibility • Reckless behavior • In the most severe cases, delusions and hallucinations

10. Mania: Signs and symptoms • Increased physical and mental activity and energy • Heightened mood, exaggerated optimism and self-confidence • Excessive irritability, aggressive behavior • Decreased need for sleep without experiencing fatigue

11. Types of Bipolar disorder

12. Diagnostic criteria: Mania • Persistently elevated, expansive or irritable mood, lasting at least 1 week (or any duration if hospitalization is necessary) • 3 (or more) of the symptoms have persisted (4 if the mood is only irritable) and have been present to a significant degree:

13. Diagnostic criteria: Mania • inflated self-esteem or grandiosity • decreased need for sleep • more talkative than usual or pressure to keep talking • flight of ideas or subjective experience that thoughts are racing • distractibility • excessive involvement in pleasurable activities

14. Nursing diagnosis • Psychiatrists have formulated clear guidelines for categorizing mental disorders (DSM-1V, ICD-10) – determines interventions • Nursing diagnosis provides basis for nursing intervention • Systematic collection & integration of data to formulate Nursing Diagnosis • The Nurse combines nursing diagnoses and DSM/ICD classifications to develop the treatment plan

15. Nursing Diagnosis • Assessment/psychiatric interview/MSE • Example nursing diagnosis • Risk for Suicide • Ineffective Coping • Hopelessness • Self-Care Deficit

16. Aetiology • Depression often triggered by stressful life events • Contributing factors: • Intensity and duration of these events • individual’s genetic endowment • coping skills • social support network - depression and many other mental disorders are broadly described as the product of a complex interaction between biological and psychosocial factors

17. Biological factors • Focus on alterations in brain function • Abnormal concentrations of many neurotransmitters and their metabolites in urine, plasma, and cerebrospinal fluid • Overactivity of the HPA (hypothalamus-pituitary-adrenal) axis - stress • dysfunction in serotonin (5-HT(1A) receptor activity could be due to a hypersecretion of cortisol

18. Monoamine Hypothesis • Prevailing hypothesis - depression is caused by an absolute or relative deficiency of monoamine transmitters in the brain • Evidence that reserpine, a medication for hypertension, caused depression by depleting the brain of both serotonin and the three principal catecholamines (dopamine, norepinephrine, and epinephrine).

19. Monoamine Hypothesis • monoamine hypothesis remains important for treatment purposes. • Many currently available pharmacotherapies that relieve depression or mania, or both, enhance monoamine activity. • One of the foremost classes of drugs for depression, SSRIs, increase the level of serotonin in the brain.

20. Psychosocial and Genetic Factors in Depression • Social, psychological, and genetic factors act together to predispose to, or protect against, depression. • many episodes of depression are associated with some sort of acute or chronic adversity • past parental neglect, physical and sexual abuse, and other forms of maltreatment impact on both adult emotional well-being and brain function

21. Psychosocial and Genetic Factors in Depression • early disruption of attachment bonds can lead to enduring problems in developing and maintaining interpersonal relationships and problems with depression and anxiety.

22. Cognitive factors • how individuals view and interpret stressful events contributes to whether or not they become depressed. • the impact of a stressor is moderated by the personal meaning of the event or situation • Increased vulnerability to depression is linked to cognitive patterns that predispose to distorted interpretations of a stressful event

23. Genetic factors in depression & Bipolar • Susceptibility to a depressive disorder 2-4 times greater among the first-degree relatives of patients with mood disorder • The risk among first-degree relatives of people with bipolar disorder 6-8 times greater.

24. Genetic factors in depression & Bipolar • Does not prove a genetic connection. • First-degree relatives typically live in the same environment, share similar values and beliefs, and are subject to similar stressors, the vulnerability to depression could be due to nurture rather than nature

25. Treatment • 50 to 70 % of depressed patients who complete treatment respond to either antidepressants or psychotherapies • Surveys consistently show that a majority of individuals with depression receive no treatment

26. Treatment • The acute phase - 6 to 8 weeks medication • patients should be seen weekly or biweekly for monitoring of symptoms, side effects, dosage adjustments, and support • Psychotherapies during the acute phase for depression typically consist of 6 to 20 weekly sessions

27. Treatment - ECT • 60 to 70 % response rate seen with ECT • Proposed to be useful with poor response to medication • depression is accompanied by potentially uncontrollable suicidal ideas and actions • The most common adverse effects are confusion and memory loss for events surrounding the period of ECT treatment.

28. Management- Maintenance • Medication • acute phase treatment and at least 6 months of continued treatment • TCA’s, SSRI’s, NARIs, MAOIs, • St John Wort (Herbal) as effective as antidepressants

29. Psychosocial interventions : depression • NICE Guidelines (2009) • Mild depression – psychological • Moderate depression – Medication or Psychological • Severe depression – CBT & medication

30. Drug Treatment - Bipolar • Lithium – Long-term • Anticonvulsants – carbamazipine (not shown to be effective in acute treatment) • Antidepressants – SSRIs (inaequate evidence of effectiveness) • Antipsychotics – olanzapine, rispiridone (effective short-term)

31. Psychosocial interventions - Bipolar • CBT - group /individual • 12-14 sessions < depressive episodes • Family therapy • psychoeducation, communication skills training, and problem-solving skills training.