Mood disorders

MOOD DISORDERS

BY Ahmed albehairy, md.Psychiatry consultant, moh.

Mood Disorders , Types

- Affective disorders.- Include: major depressive disorders. bipolar disorders , I, II, III. Dysthymic disorder. Cyclothymic. mood disorder due to GMC. substance induced mood disorders. NOS, depression & bipolar

Epidemiology

Life time prevalence

MDD 10-25% W, 5-12%M

Dysthymic disorders 6%

BAD 6%

BAD I 0.4 -1.6%

BAD II 0.5%

Rapid cycling 5-15% of BAD

Cyclothymic 0.4-1 %

Epidemiology

Sex :

MDD, W < M, BAD W=M

manic ---W, DEP.--- M

Age :

BAD onset 30, + all ages

MDD ALL ages

Sociocultural:

MDD--- Single, divorced

Etiology

Biological:- Biogenic amines :

dopamine, serotonin, noradrenaline.

( HVA) , ( 5-HIAA), ( MHPG)

in urine , blood and CSF.

MDD --- DEC 5-HIAA

VIOLENCE, SUICIDE--- DEC 5-HIAA

DEP---- DEC DOPAMINE

MANIA --- INC DOPAMINE

Etiology

Biological:

- Neuroendocrine abnormalities

HTPA axis, dec TSH, GH, FSH, LH AND nocturnal secretion of melatonin.

- Immunity , dec in both dep, mania.

Etiology

Biological:- Sleep : in depression delayed sleep onset, multiple

awakening, short REM latency with inc. 1st REM .

Sleep deprivation--- AD- KINDLING- GENETIC.- Neuroanatomical.

Etiology

Psychosocial:

- psychoanalytical.

- Cognitive.

- Learned helplessness.

- Stressful life events.

INVSTIGATION

- DST.

- CT, MRI

- RATING SCALES

- Bech, zung, MADRS.

- RORSCHACH.

- TAT

Clinical Pictures

Depressive episode.

Manic episode.

Hypomanic

Bipolar I,II,III

Rapid cycler

Ultra rapid cycler

Melncholic depression

Seasonal or recurrent dep

Clinical Pictures

Postpartum onset .Atypical dep. Hysterical dysphoriaCatatoniaPseudodementiaDepression in children.DysthymiaDouble depression.Cyclothymic.Psychotic depressionchronicNOS ( recurrent brief, premenstrual).

Differential diagnosis

Organic br. ( tumor, myxedema madness, mercury)

SIMSCHIZOPHRENIAGRIEFPDSCHIZOAFFECTIVESLEEP DISORDERSANXIETY, SOMATOFORM,

Course & Prognosis

MDD --- 15% SUICIDEMDD --- NATURAL HISTORY 10 MS.75% of have 2nd episode of

depression, in 6ms.Average no of dep episodes is 5.50%recover,30%partial recover, 20%

chronic.45%manic recurs, last 3 m , average

10 in life .

Treatment

MDD

AD

ECT

PSYCHOLOGICAL

BAD

MOOD STAB.

AD

ECT

PSYCHOLOGICAL

When should ECT be considered?

- Suicidality, dangerousness.- Failure to respond to several Ads- Threatening acute symptoms.- Agitation, psychotic.- Intolerable S E OF AD- History of +ve response to ECT.- Medical condition precluding the use of

Ads.

PHASES OF DEPRESSION TREATMENT

Acute Treatment (4 –6 weeks)

Goal is to eliminate signs and symptoms of depression;

Select antidepressant based on target symptoms, medical/psychiatric history, drug interactions, side effects

After 4-6 weeks reassess adequacy of response If no response or partial response, increase

dose of medication or switch to another antidepressant

PHASES OF DEPRESSION TREATMENT

Acute Treatment (4 –6 weeks)

Goal is to eliminate signs and symptoms of depression;

Select antidepressant based on target symptoms, medical/psychiatric history, drug interactions, side effects

After 4-6 weeks reassess adequacy of response If no response or partial response, increase

dose of medication or switch to another antidepressant

PHASES OF TREATMENTContinuation Treatment (6 months)

Goal is to prevent relapse following symptomatic recovery/remission

Continue full therapeutic antidepressant dose for 6 months after symptoms abate

At the end of continuation phase, antidepressant should be tapered gradually to avoid discontinuation symptoms

If symptoms recur, patient is likely to respond to same antidepressant previously prescribed; continue medication for 6 months at therapeutic dose

Common Side Effect of Antidepressants

TCA : dry mouth, constipation, drowsiness, orthostatic hypotension, weight gain,,++ IOP.

Bupropion, seizure, agitation,insomnia.Trazodone: sedation, priapism.SSRI: insomnia, agitation, headache, nausea.

Fluxetine ( akathesia). Paroxetine , dry mouth.

Venlafaxine: hypertension, nausea.Mirtazepine: wt gain and sedation.MAOI --- TYRMINE, SSRI,LETHALITY : TCA OVERDOSE, serotenorgig

syndrome

Hot Items in Choosing medications in DepressionPsychotic dep--- AP +AD, ECT

Melancholic ----- AD + ECT( REC)

Atypical ---------- SSRI

Seasonal -------- AD + phototherapy

Postpartum ------ ? BAD, in hospital

Hot Items in Choosing medications in Depression

risk Lower moderate higher

Breast feeding TCA, Flupenthexol Amoxipen, mianserine, mirtazepine, SSRI, trazodone

MAOI, VENLAFAXINE

CVS SSRI,Mianserine, mirtazepine, trazodone

MAOI, TCA, venlafaxine

diabetus SSRI,TRAZODONE, VENLAFAXINE

FLUXETINE, MIANSERINE, MIRTAZEPINE, TCA

MAOI

Hot Items in Choosing medications in Depression

risk Lower moderate higher

OLD AGE VENLAFAXINE, MIRTAZEPINE, SSRI, VENLAFAXINE

MAOI, MIANSERINE, TRAZODONE

TCA

PREGNANCY

?// TRYPTOPHAN TCA,MAOI,MERTIZAPINE,VENLAFAXINE,MIANSERINE

RENAL MIANSERINE,TCA,TRAZODONE,TRYPTOPHAN

SSRI,MIRTEZAPINE,MAOI, DULEXTINE

VENLAFAXINE, FLUXETINE

Hot Items in Choosing medications in Depression

risk Lower moderate higher

Epilepsy MAOI, SSRI, DULOXETINE, MIANSERINE, MIRTAZEPINE, TCA, VENLAFAXINE

AMOXIPINE, MAPROTILINE

GLAUCOMA

MAOI, TRAZODONE VENLAFAXINE

SSRI, DELUXTINE, MIRTAZEPINE

TCA

LIVER MIANSERINE,PAROXETINE

DULOXETINE,MIRTAZEPIMNE, SSRI,TCA, VENLAFAXINE

MAOI

Mood Stabilizers

lamotrigine/Lamictal lithium quetiapine/Seroquel divalproex/Depakote  carbamazepine/Tegretol olanzapine/Zyprexa oxcarbazepine/Trileptal omega-3 fatty acids /fish oil clozapine atypical (2nd generation)

 antipsychotics

LTG LITH

VPK CRB OXC OM3 OLZ QUTIP ARIP

experience ++ ++ ++ ++ + + +Ad effect ++ + + + + + + ++ +Short term se ++ + + +Few long term risk ++ + +++ ?No wt + + + +Low cost ++ ++ ++ + + +Fast antimanic + ++ ++maintenance + + + + ++ +pregnancy ? ? ?Breast feeding usa usa ++

Thank you