Mood (Affective) DisordersMood (Affective) DisordersDepartment of PsychiatryDepartment of Psychiatry

11stst Faculty of Medicine Faculty of MedicineCharles University, PragueCharles University, Prague

Head: Prof. MUDr. Jiří Raboch, DrSc.Head: Prof. MUDr. Jiří Raboch, DrSc.

Mood (Affective) DisordersMood (Affective) Disorders Mood disordersMood disorders are very common, their life are very common, their life

prevalence is up to 20 %, and they have a high prevalence is up to 20 %, and they have a high level of morbidity and mortality as well as an level of morbidity and mortality as well as an immense impact on disabilities worldwide.immense impact on disabilities worldwide.

The fundamental disturbance is a The fundamental disturbance is a change in mood change in mood or affector affect, usually to depression (with or without , usually to depression (with or without associated anxiety) or to elation. The mood change associated anxiety) or to elation. The mood change is usually accompanied by a change in the overall is usually accompanied by a change in the overall level of activitylevel of activity..

Most of these disorders tend to be Most of these disorders tend to be recurrentrecurrent, and , and the onset of individual episodes is often related to the onset of individual episodes is often related to stressful events or situations.stressful events or situations.

The mood disorders may be subdivided into The mood disorders may be subdivided into unipolarunipolar and and bipolarbipolar types: types:

1.1. those that are characterized by those that are characterized by depressiondepression only only2.2. those that are characterized by those that are characterized by manicmanic episode either episode either

alone or in combination with alone or in combination with depressiondepression

Classification of Mood DisordersClassification of Mood Disorders

International Classification of Diseases (ICD-International Classification of Diseases (ICD-10) came into use in WHO Member States as 10) came into use in WHO Member States as from 1994from 1994

F30 Manic episode F30 Manic episode F31 Bipolar affective disorder F31 Bipolar affective disorder F32 Depressive episode F32 Depressive episode F33 Recurrent depressive disorder F33 Recurrent depressive disorder F34 Persistent mood (affective) disorders F34 Persistent mood (affective) disorders F38 Other mood (affective) disorders F38 Other mood (affective) disorders F39 Unspecified mood (affective) disorder F39 Unspecified mood (affective) disorder

Test MethodsTest Methods Self-reported scales:Self-reported scales:

• Young Mania Rating Scale (YMRS)Young Mania Rating Scale (YMRS)• Beck scale (depression)Beck scale (depression)• Zung scale (depression)Zung scale (depression)

Interview with physician:Interview with physician:• Hamilton scale (HAMD)Hamilton scale (HAMD)• Montgomery and Asberg scale (MADRS)Montgomery and Asberg scale (MADRS)

F32 Depressive EpisodeF32 Depressive Episode Pathological sadnessPathological sadness

Depressive episode:Depressive episode:• depressed mooddepressed mood• loss of interest and enjoymentloss of interest and enjoyment• reduced energy leading to increased fatigability reduced energy leading to increased fatigability

and diminished activityand diminished activity• marked tiredness after only slight effortmarked tiredness after only slight effort• reduced concentration and attentionreduced concentration and attention• reduced self-esteem and self-confidencereduced self-esteem and self-confidence• ideas of guilt and unworthinessideas of guilt and unworthiness• bleak and pessimistic views of the futurebleak and pessimistic views of the future• ideas or acts of self-harm or suicide,ideas or acts of self-harm or suicide,• disturbed sleep and diminished appetitedisturbed sleep and diminished appetite

F32 Depressive EpisodeF32 Depressive Episode Clinical presentation shows marked individual Clinical presentation shows marked individual

variationsvariations• in some cases, anxiety, distress, and motor agitation in some cases, anxiety, distress, and motor agitation

may be more prominent at times than the depressionmay be more prominent at times than the depression• the mood change may also be masked (masked the mood change may also be masked (masked

depression) by added features such as irritability, depression) by added features such as irritability, excessive consumption of alcohol, histrionic behaviour, excessive consumption of alcohol, histrionic behaviour, and exacerbation of pre-existing phobic or obsessional and exacerbation of pre-existing phobic or obsessional symptoms, or by hypochondriacal preoccupations.symptoms, or by hypochondriacal preoccupations.

Depressive episode should last at least 2 weeks Depressive episode should last at least 2 weeks (typically several months), but shorter periods (typically several months), but shorter periods may be reasonable if symptoms are unusually may be reasonable if symptoms are unusually severe and of rapid onset.severe and of rapid onset.

The lifetime prevalence: 17%The lifetime prevalence: 17%;; risk of recurrence risk of recurrence >50%.>50%.

F32 Depressive EpisodeF32 Depressive Episode

The lowered mood varies little from day to day, is The lowered mood varies little from day to day, is unresponsive to circumstances and may be unresponsive to circumstances and may be accompanied by so-called accompanied by so-called „„somaticsomatic““ symptoms symptoms::• loss of interest or pleasure in activities that are normally loss of interest or pleasure in activities that are normally

enjoyable (anhedonia)enjoyable (anhedonia)

• lack of emotional reactivity to normally pleasurable lack of emotional reactivity to normally pleasurable surroundings and eventssurroundings and events

• waking in the morning 2 hours or more before the usual timewaking in the morning 2 hours or more before the usual time

• depression worse in the morningdepression worse in the morning

• objective evidence of definite psychomotor retardation or objective evidence of definite psychomotor retardation or agitationagitation

• loss of appetiteloss of appetite

• weight lossweight loss

• loss of libidoloss of libido

F32 Depressive EpisodeF32 Depressive Episode

F32 F32 Depressive episodeDepressive episode

F32.0F32.0 Mild depressive episode Mild depressive episode

F32.1F32.1 Moderate depressive episode Moderate depressive episode

F32.2F32.2 Severe depressive episode without Severe depressive episode without psychotic symptoms psychotic symptoms

F32.3F32.3 Severe depressive episode with Severe depressive episode with psychotic symptoms psychotic symptoms

F32.8F32.8 Other depressive episodes Other depressive episodes

F32.9F32.9 Depressive episode, unspecified Depressive episode, unspecified

F32.0 Mild Depressive EpisodeF32.0 Mild Depressive Episode

Two or three of the above symptoms are Two or three of the above symptoms are usually present. usually present.

For For mild depressive episodemild depressive episode are typical are typical depressed mood, anhedonia and increased depressed mood, anhedonia and increased fatigability. The afflicted person is usually fatigability. The afflicted person is usually distressed by the symptoms and has some distressed by the symptoms and has some difficulty in continuing with ordinary work difficulty in continuing with ordinary work and social activities, but will probably not and social activities, but will probably not cease to function completely. cease to function completely.

F32.1 Moderate Depressive F32.1 Moderate Depressive EpisodeEpisode

An individual with An individual with moderate depressive moderate depressive episodeepisode suffers from more symptoms suffers from more symptoms (f(four or more of the above symptoms are our or more of the above symptoms are usually presentusually present)) of greater severity and of greater severity and will usually have considerable difficulty in will usually have considerable difficulty in continuing with social, work or domestic continuing with social, work or domestic activities.activities.

F32.2 Severe Depressive Episode F32.2 Severe Depressive Episode without Psychotic Symptomswithout Psychotic Symptoms

In a In a severe depressive episodesevere depressive episode, the , the sufferer usually shows considerable distress sufferer usually shows considerable distress or agitation. Loss of self-esteem or feelings or agitation. Loss of self-esteem or feelings of uselessness or guilt are likely to be of uselessness or guilt are likely to be prominent, and suicide is a distinct danger prominent, and suicide is a distinct danger in particularly severe cases. in particularly severe cases. ;; a number of a number of "somatic" symptoms are usually present."somatic" symptoms are usually present.• Agitated depressionAgitated depression

• Major depressionMajor depression

• Vital depression Vital depression

F32.3F32.3 Severe Depressive Episode Severe Depressive Episode with Psychotic Symptomswith Psychotic Symptoms

Psychotic symptoms may be present, such asPsychotic symptoms may be present, such as• delusions (ideas of sin, poverty or imminent disasters)delusions (ideas of sin, poverty or imminent disasters)• hallucinations (defamatory or accusatory voices or of hallucinations (defamatory or accusatory voices or of

rotting filth or decomposing flesh)rotting filth or decomposing flesh)• depressive stupordepressive stupor

Severe ordinary social activities are impossibleSevere ordinary social activities are impossible When the psychotic symptoms are consistent When the psychotic symptoms are consistent

with the patient’s mood, they are referred to as with the patient’s mood, they are referred to as mood congruentmood congruent, when they are inconsistent, , when they are inconsistent, they are referred as they are referred as mood incongruentmood incongruent..

Single episodes of: Single episodes of: • major depression with psychotic symptomsmajor depression with psychotic symptoms• psychogenic depressive psychosispsychogenic depressive psychosis• psychotic depressionpsychotic depression• reactive depressive psychosis reactive depressive psychosis

F33 Recurrent Depressive Disorder F33 Recurrent Depressive Disorder Recurrent depressive disorderRecurrent depressive disorder is characterized is characterized

by repeated episodes of depression without any by repeated episodes of depression without any history of independent episodes of mood elevation history of independent episodes of mood elevation and overactivity.and overactivity.

Recovery is usually complete between episodes, but Recovery is usually complete between episodes, but a substantial part of patients will have a recurrence a substantial part of patients will have a recurrence and about 30% may develop a persistent depression. and about 30% may develop a persistent depression.

The lifetime prevalence - about 10—20 The lifetime prevalence - about 10—20 %; %; women:men 2:1.women:men 2:1.

The risk of suicide (approximately 10—15%.The risk of suicide (approximately 10—15%.

Seasonal affective disorderSeasonal affective disorder - onset of mood - onset of mood symptoms is connected with changes of seasons, symptoms is connected with changes of seasons, with depression typically occurring during the winter with depression typically occurring during the winter months and remissions or changes from depression months and remissions or changes from depression to mania occurring during the spring. to mania occurring during the spring.

F33 Recurrent Depressive DisorderF33 Recurrent Depressive Disorder

Kupfer 1991

severity

of d

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time

6-12 weeks

4-9 months

1 or more years

pro

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of illn

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no depression

symptoms

syndrome

treatment stage

response

relapse

remission

relapse recurrence

recovery

F33 Recurrent Depressive DisorderF33 Recurrent Depressive Disorder

F33 F33 Recurrent depressive disorderRecurrent depressive disorder

F33.0F33.0 Recurrent depressive disorder, current episode Recurrent depressive disorder, current episode mild mild

F33.1F33.1 Recurrent depressive disorder, current episode Recurrent depressive disorder, current episode moderate moderate

F33.2F33.2 Recurrent depressive disorder, current episode Recurrent depressive disorder, current episode severe without psychotic symptoms severe without psychotic symptoms

F33.3F33.3 Recurrent depressive disorder, current episode Recurrent depressive disorder, current episode severe with psychotic symptoms severe with psychotic symptoms

F33.4F33.4 Recurrent depressive disorder, currently in Recurrent depressive disorder, currently in remission remission

F33.8F33.8 Other recurrent depressive disorders Other recurrent depressive disorders

F33.9F33.9 Recurrent depressive disorder, unspecified Recurrent depressive disorder, unspecified

F30 Manic EpisodeF30 Manic Episode

F30 F30 Manic episodeManic episode

F30.0F30.0 Hypomania Hypomania

F30.1F30.1 Mania without psychoticMania without psychotic symptoms symptoms

F30.2F30.2 Mania with psychotic symptoms Mania with psychotic symptoms

F30.8F30.8 Other manic episodes Other manic episodes

F30.9F30.9 Manic episode, unspecifiedManic episode, unspecified

F30.0F30.0 HypomaniaHypomania

HypomaniaHypomania is characterized by is characterized by • persistent mild elevation of mood for at least persistent mild elevation of mood for at least

several daysseveral days• increased energy and activityincreased energy and activity• usually marked feelings of well-being and both usually marked feelings of well-being and both

physical and mental efficiencyphysical and mental efficiency Increased sociability, talkativeness, Increased sociability, talkativeness,

overfamiliarity, increased sexual energy, overfamiliarity, increased sexual energy, and a decreased need for sleep are often and a decreased need for sleep are often present but not to the extent that they present but not to the extent that they lead to severe disruption of work or result lead to severe disruption of work or result in social rejection. There are no in social rejection. There are no hallucinations or delusions hallucinations or delusions

F30.1 Mania without Psychotic F30.1 Mania without Psychotic SymptomsSymptoms

Mania without psychotic symptoms:Mania without psychotic symptoms:• last for at least 1 weaklast for at least 1 weak• mood is elevated out of keeping with individual’s mood is elevated out of keeping with individual’s

circumstances and may vary from carefree joviality to circumstances and may vary from carefree joviality to almost uncontrollable excitementalmost uncontrollable excitement

• elation is accompanied by increased energy, resulting in elation is accompanied by increased energy, resulting in overactivity, pressure of speech, and a decreased need for overactivity, pressure of speech, and a decreased need for sleepsleep

• normal social inhibition are lost, attention cannot be normal social inhibition are lost, attention cannot be sustained, and there is often marked distractibilitysustained, and there is often marked distractibility

• self-esteem is inflated, and grandiose or over-optimistic self-esteem is inflated, and grandiose or over-optimistic ideas are freely expressedideas are freely expressed

• perceptual disorders may occurperceptual disorders may occur• the individual may embark on extravagant and impractical the individual may embark on extravagant and impractical

schemes, spend money recklessly, or become aggressive, schemes, spend money recklessly, or become aggressive, amorous, or factious in inappropriate circumstances. amorous, or factious in inappropriate circumstances.

F30.2 Mania with Psychotic F30.2 Mania with Psychotic SymptomsSymptoms

Mania with psychotic symptomsMania with psychotic symptoms represents a represents a more severe form of mania:more severe form of mania:• inflated self-esteem and grandiose ideas may develop into inflated self-esteem and grandiose ideas may develop into

delusions, and irritability and suspiciousness into delusions delusions, and irritability and suspiciousness into delusions of persecutionof persecution

• in severe cases, grandiose or religious delusions of identity in severe cases, grandiose or religious delusions of identity or role may be prominent, and flight of ideas and pressure of or role may be prominent, and flight of ideas and pressure of speech may result in the individual becoming speech may result in the individual becoming incomprehensibleincomprehensible

• sustained physical activity and excitement may result in sustained physical activity and excitement may result in aggression or violence, and neglect of eating, drinking, and aggression or violence, and neglect of eating, drinking, and personal hygiene may result in dangerous states of personal hygiene may result in dangerous states of dehydration and self neglectdehydration and self neglect

Mania with:Mania with:• mood-congruent psychotic symptomsmood-congruent psychotic symptoms• mood-incongruent psychotic symptomsmood-incongruent psychotic symptoms

Manic stuporManic stupor

F31 Bipolar Affective DisorderF31 Bipolar Affective Disorder Bipolar affective disorderBipolar affective disorder is characterized by is characterized by

repeated, at least two episodes in which the patient’s repeated, at least two episodes in which the patient’s mood and activity levels are significantly disturbed mood and activity levels are significantly disturbed (manic or depressive syndromes, patients who suffer (manic or depressive syndromes, patients who suffer only from repeated episodes of mania are only from repeated episodes of mania are comparatively rare).comparatively rare).

The first episode may occur at any age from childhood The first episode may occur at any age from childhood to old age.to old age.

The frequency of episodes and the pattern of The frequency of episodes and the pattern of remissions and relapses are both very variable.remissions and relapses are both very variable.

The lifetime prevalence is between 0,5 an 1 The lifetime prevalence is between 0,5 an 1 %. %. SuicidalitySuicidality – about 19%. – about 19%. ComorbidityComorbidity with alcohol and with alcohol and drug abusedrug abuse

The The rapid-cycling specifierrapid-cycling specifier identifies those patients identifies those patients who have had at least four episodes of a major who have had at least four episodes of a major depressive, manic, or mixed episode during the past depressive, manic, or mixed episode during the past 12 months.12 months.

F31 Bipolar Affective DisorderF31 Bipolar Affective DisorderF31 F31 Bipolar affective disorderBipolar affective disorder

F31.0F31.0 Bipolar affective disorder, current episode hypomanic Bipolar affective disorder, current episode hypomanic

F31.1F31.1 Bipolar affective disorder, current episode manic without Bipolar affective disorder, current episode manic without psychotic symptoms psychotic symptoms

F31.2F31.2 Bipolar affective disorder, current episode manic with Bipolar affective disorder, current episode manic with psychotic symptoms psychotic symptoms

F31.3F31.3 Bipolar affective disorder, current episode mild or Bipolar affective disorder, current episode mild or moderate depression moderate depression

F31.4F31.4 Bipolar affective disorder, current episode severe Bipolar affective disorder, current episode severe depression without psychotic symptoms depression without psychotic symptoms

F31.5F31.5 Bipolar affective disorder, current episode severe Bipolar affective disorder, current episode severe depression with psychotic symptoms depression with psychotic symptoms

F31.6F31.6 Bipolar affective disorder, current episode mixed Bipolar affective disorder, current episode mixed

F31.7F31.7 Bipolar affective disorder, currently in remission Bipolar affective disorder, currently in remission

F31.8F31.8 Other bipolar affective disorders Other bipolar affective disorders

F31.9F31.9 Bipolar affective disorder, unspecified Bipolar affective disorder, unspecified

F34 Persistent Mood (Affective) F34 Persistent Mood (Affective) Disorders Disorders

Persistent mood disordersPersistent mood disorders are persistent and are persistent and usually fluctuating disorders of mood in which usually fluctuating disorders of mood in which individual episodes are not sufficiently severe to individual episodes are not sufficiently severe to warrant being described as hypomanic or even mild warrant being described as hypomanic or even mild depressive episodes.depressive episodes.

Lasting more than 2 yearsLasting more than 2 years

F34 F34 Persistent mood (affective) disordersPersistent mood (affective) disorders F34.0F34.0 Cyclothymia Cyclothymia F34.1F34.1 Dysthymia Dysthymia F34.8F34.8 Other persistent mood Other persistent mood ((affectiveaffective)) disorders disorders F34.9F34.9 Persistent mood Persistent mood ((affectiveaffective)) disorder, disorder,

unspecified unspecified

F34.0 CyclothymiaF34.0 Cyclothymia

For For cyclothymiacyclothymia persistent instability of persistent instability of mood, involving periods of mild depression mood, involving periods of mild depression and mild elation is typical.and mild elation is typical.

This instability usually develops early in This instability usually develops early in adult life and pursues a chronic course, adult life and pursues a chronic course, although the mood may be normal and although the mood may be normal and stable for months at a time. stable for months at a time.

The mood swings are usually perceived by The mood swings are usually perceived by the individual as being unrelated to life the individual as being unrelated to life events.events.

F34.1 DysthymiaF34.1 Dysthymia

DysthymiaDysthymia represents a chronic, milder represents a chronic, milder form of depression which does not fulfill form of depression which does not fulfill the criteria for recurrent depressive the criteria for recurrent depressive disorder especially in terms of severity. disorder especially in terms of severity.

Sufferers usually have periods of days or Sufferers usually have periods of days or weeks when they describe themselves as weeks when they describe themselves as well, but most of the time they feel tired well, but most of the time they feel tired and depressed. and depressed.

It usually begins in adult life and lasts for It usually begins in adult life and lasts for at least several years, sometimes at least several years, sometimes indefinitely.indefinitely.

The lifetime prevalence is approximately The lifetime prevalence is approximately 3%, and it is more common in women.3%, and it is more common in women.

F34.1 DysthymieF34.1 Dysthymie dysthymiedysthymie: mírná chronická deprese: mírná chronická deprese epidemiologieepidemiologie: celoživotní prevalence : celoživotní prevalence

kolem 3%kolem 3% etiopatogenezeetiopatogeneze: faktory genetické i vnější: faktory genetické i vnější léčbaléčba: jako u depresivní poruchy – : jako u depresivní poruchy –

kognitivně-bahaviorální psychoterapie, kognitivně-bahaviorální psychoterapie, antidepresivaantidepresiva

Treatment of DepressionTreatment of Depression Various Various antidepressantsantidepressants altering levels of central altering levels of central

neurotransmitters are available to treat neurotransmitters are available to treat depression.depression.

Their overall effectiveness: 65-70%Their overall effectiveness: 65-70% Mild to moderate depressive episode: SSRIs.Mild to moderate depressive episode: SSRIs. Severe depression: antidepressants with broader Severe depression: antidepressants with broader

spectrum of effects, like SNRI or TCA.spectrum of effects, like SNRI or TCA. Patients with insomnia or anorexia may do better Patients with insomnia or anorexia may do better

with more sedating medication (mirtazapine, with more sedating medication (mirtazapine, trazodon)trazodon)

Patients with lethargy, hypersomnia, weight gain Patients with lethargy, hypersomnia, weight gain and lower levels of tension and anxiety may and lower levels of tension and anxiety may prefer the less sedating medications such as prefer the less sedating medications such as bupropion, reboxetin or stimulating SSRIs. bupropion, reboxetin or stimulating SSRIs.

IMAOs or RIMA should be tried in refractory IMAOs or RIMA should be tried in refractory patients or patients with atypical depression.patients or patients with atypical depression.

Treatment of DepressionTreatment of Depression Drug trials should last 4 to 8 weeks.Drug trials should last 4 to 8 weeks. No response within 4 weeks of treatment - the No response within 4 weeks of treatment - the

dose should be increased or the patient should be dose should be increased or the patient should be switched to another drug.switched to another drug.

In partial responders - augmentation strategy; In partial responders - augmentation strategy; coadministration of lithium carbonate or coadministration of lithium carbonate or trijodthyronine.trijodthyronine.

Psychotic patient - adding on neuroleptics. Psychotic patient - adding on neuroleptics. Anxious or agitated patients (also to improve the Anxious or agitated patients (also to improve the

sleep quality) - benzodiazepine coadministration sleep quality) - benzodiazepine coadministration for a short period of time.for a short period of time.

Lithium prophylaxis is an option to Lithium prophylaxis is an option to antidepressants.antidepressants.

Supportive psychotherapySupportive psychotherapy..

Treatment of DepressionTreatment of Depression First episode of depression - the drug should be First episode of depression - the drug should be

continued for another 16-20 weeks after the patient continued for another 16-20 weeks after the patient is thought to be well (is thought to be well (continuation treatmentcontinuation treatment to to prevent recurrence).prevent recurrence).

The medication should be tapered gradually because The medication should be tapered gradually because many patients experience some mild withdrawal many patients experience some mild withdrawal effects. effects.

Patients with recurrent depression need long-term Patients with recurrent depression need long-term maintenance therapymaintenance therapy to prevent relapses. to prevent relapses.

Electroconvulsive therapy (ECT)Electroconvulsive therapy (ECT) is the treatment of is the treatment of choice for some patients with very severe choice for some patients with very severe depression, with high potential for suicide or other depression, with high potential for suicide or other selfdestroying behaviour and for pregnant women.selfdestroying behaviour and for pregnant women.

Other biological methods:Other biological methods:• phototherapy (seasonal affective disorder)phototherapy (seasonal affective disorder)• sleep deprivationsleep deprivation• repetitive transcranial magnetic stimulation (rTMS).repetitive transcranial magnetic stimulation (rTMS).

Treatment of ManiaTreatment of Mania Mood stabilizers:Mood stabilizers:

• lithium (0.6—1.2 mEq/L)lithium (0.6—1.2 mEq/L)• carbamazepine (6—12 mg/L)carbamazepine (6—12 mg/L)• valproate (50—125 mg/L)valproate (50—125 mg/L)

Anticonvulsants:Anticonvulsants:• gabapentinegabapentine• topiramatetopiramate• lamotriginelamotrigine

Agitated or psychotic patient – Agitated or psychotic patient – coadministartion ofcoadministartion of• antipsychotics of second generation antipsychotics of second generation

(olanzapine, risperidone)(olanzapine, risperidone)• benzodiazepines (lorazepam, clonazepam)benzodiazepines (lorazepam, clonazepam)

ECTECT