Mood Mood disordersdisorders

Dr.Saman Anwar FarajDr.Saman Anwar Faraj

M.B.Ch.B, F.I.B.M.S(PSYCHIATRY)M.B.Ch.B, F.I.B.M.S(PSYCHIATRY)

Mood DisorderMood Disorder

Mood change is the main psycho Mood change is the main psycho pathological feature.pathological feature.

The abnormality is more intense and The abnormality is more intense and persistent than normal variation in mood persistent than normal variation in mood and often lead to problems in occupational and often lead to problems in occupational and social functioning.and social functioning.

Mood disorderMood disorder mood disordermood disorder is the term given for a group of is the term given for a group of

diagnoses in the diagnoses in the DSM IV TR disordersdisorders in ICD 10. in ICD 10. English psychiatrist English psychiatrist Henry Maudsley proposed an proposed an

overarching category of overarching category of affective disorderaffective disorder. The . The term was then replaced by term was then replaced by mood disordermood disorder, as the , as the latter term refers to the underlying or longitudinal latter term refers to the underlying or longitudinal emotional state, whereas the former refers to the emotional state, whereas the former refers to the external expression observed by others.external expression observed by others.

Two groups of mood disorders are broadly Two groups of mood disorders are broadly recognized; the division is based on whether the recognized; the division is based on whether the person has ever had a person has ever had a manic or or hypomanic episode. Thus, there are depressive disorders, of episode. Thus, there are depressive disorders, of which the best known and most researched is which the best known and most researched is major depressive disorder commonly called commonly called clinical depression or major depression, and clinical depression or major depression, and bipolar disorder, formerly known as "manic , formerly known as "manic depressive" and described by intermittent periods depressive" and described by intermittent periods of manic and of manic and depressed episodes. episodes.

Classification of mood Classification of mood disordersdisorders

DSM-IV-TR describes the following DSM-IV-TR describes the following

episodesepisodes::

1-Major Depressive Episode: lasts for 2 1-Major Depressive Episode: lasts for 2 weeksweeks

2-Manic Episode: one week2-Manic Episode: one week3-Hypomanic Episode: four days 3-Hypomanic Episode: four days 4-Mixed Episode: one week 4-Mixed Episode: one week

Classification of Mood Classification of Mood DisordersDisorders

cont’dcont’d Major Depressive DisorderMajor Depressive Disorder Bipolar I Disorder= having a clinical course Bipolar I Disorder= having a clinical course

of one or more manic episodes and, of one or more manic episodes and, sometimes, major depressive episodes.sometimes, major depressive episodes.

Bipolar II Disorder: episodes of major Bipolar II Disorder: episodes of major depression and hypomaniadepression and hypomania

Dysthymic Disorder : 2yearsDysthymic Disorder : 2years Cyclothymiacs DisorderCyclothymiacs Disorder

Epidemiology of mood disorders;Epidemiology of mood disorders; 19.3% of the general population develops 19.3% of the general population develops

a mood disorder (14.7% men, 23.9% a mood disorder (14.7% men, 23.9% women) women)

21.3% of women & 12.7%of men develop 21.3% of women & 12.7%of men develop major depression.major depression.

Average age of onset for bipolar illness is Average age of onset for bipolar illness is mid to late twenties.mid to late twenties.

Average age of onset of depression is mid Average age of onset of depression is mid thirties.thirties.

Bipolar disorder occurs more in high Bipolar disorder occurs more in high socioeconomic groups. socioeconomic groups.

Mania and depression are manifested by Mania and depression are manifested by symptoms involving the effective, symptoms involving the effective, cognitive, Physical, social, and spiritual cognitive, Physical, social, and spiritual aspects of the individual. aspects of the individual.

Major depressive disorderMajor depressive disorder Common disorder, with a lifetime prevalence of Common disorder, with a lifetime prevalence of

about 15% ,perhaps as high as 25% in women.about 15% ,perhaps as high as 25% in women. The incidence of major depressive disorder is The incidence of major depressive disorder is

also high in primary care patients ,in whom it also high in primary care patients ,in whom it approaches 10%, and in medical inpatients , in approaches 10%, and in medical inpatients , in whom it approaches 15%.whom it approaches 15%.

An almost universal observation , is the two-fold An almost universal observation , is the two-fold greater prevalence of the disorder in women greater prevalence of the disorder in women than in men.than in men.

The reasons for this difference have been The reasons for this difference have been hypothesized to involve hormonal differences, hypothesized to involve hormonal differences, the effect of childbirth, and differing the effect of childbirth, and differing psychosocial stresses for women and for men.psychosocial stresses for women and for men.

Major depressive disorderMajor depressive disorder

The mean age of onset is about 40 years ; 50% of all The mean age of onset is about 40 years ; 50% of all patients have an onset between age of 20-50 .patients have an onset between age of 20-50 .

Although uncommonly, MDD can also begin in childhood Although uncommonly, MDD can also begin in childhood or in old age.or in old age.

Some recent studies suggest that the incidence of MDD Some recent studies suggest that the incidence of MDD may be increasing among people less than 20 years old.may be increasing among people less than 20 years old.

MDD occurs most often in people without close MDD occurs most often in people without close interpersonal relationships or in those who are divorced interpersonal relationships or in those who are divorced or separated .or separated .

No correlation have been found between socio-economic No correlation have been found between socio-economic status and MDDstatus and MDD

EtiologyEtiology Although the etiology of MDD is ambiguous and complex, it Although the etiology of MDD is ambiguous and complex, it

can be divided into three main groups: can be divided into three main groups: biological ,genetic ,and psychosocial.biological ,genetic ,and psychosocial.

1.1. Biological factors:Biological factors: a. Biogenic amines :norepinephrine , and serotonin are the a. Biogenic amines :norepinephrine , and serotonin are the

most implicated.most implicated. b. Other neuro-chemical factors: GABA ,and neuroactive b. Other neuro-chemical factors: GABA ,and neuroactive

peptides particularly vasopressin, and the endogenous peptides particularly vasopressin, and the endogenous opiates.opiates.

c. Neuro-endocrine regulation :adrenal , thyroid and growth c. Neuro-endocrine regulation :adrenal , thyroid and growth hormone.hormone.

d. brain imaging abnormalities: still inconclusive.d. brain imaging abnormalities: still inconclusive.2.2. Genetic factors :Genetic factors : genetic data strongly indicate that significant genetic genetic data strongly indicate that significant genetic

factor is involved in the development of mood disorders. factor is involved in the development of mood disorders. First degree relatives of MDD are 1.5-2.5 times more likely to First degree relatives of MDD are 1.5-2.5 times more likely to have bipolar I disorder, and 2-3 times to have MDD. The have bipolar I disorder, and 2-3 times to have MDD. The concordance rate for MZ twins is about 50% while in DZ concordance rate for MZ twins is about 50% while in DZ twins is 10-25%.twins is 10-25%.

3. Psychosocial factors :3. Psychosocial factors : a- life events and environmental stress:a- life events and environmental stress: The life event most often associated The life event most often associated

with a person later development of with a person later development of depression is losing a parent before the depression is losing a parent before the age of 11. The environmental stressor age of 11. The environmental stressor most often associated with the onset of an most often associated with the onset of an episode is the loss of a spouse.episode is the loss of a spouse.

b- Family.b- Family. c- premorbid personality factors.c- premorbid personality factors. d- learned helplessness.d- learned helplessness. e- cognitive theory. e- cognitive theory.

Signs and symptomsSigns and symptoms

Two hallmarks of depression Two hallmarks of depression symptoms key to establishing a symptoms key to establishing a diagnosis are:diagnosis are:

1.1. Loss of interest in normal daily Loss of interest in normal daily activities You lose interest in or activities You lose interest in or pleasure from activities that you pleasure from activities that you used to enjoy. used to enjoy.

2.2. Depressed mood. You feel sad, Depressed mood. You feel sad, helpless or hopeless, and may helpless or hopeless, and may have crying spells. have crying spells.

Signs and Symptoms Signs and Symptoms Cont’d Cont’d

3. Sleep disturbances3. Sleep disturbances Insomnia or Sleeping too much Insomnia or Sleeping too much

Waking in the middle of the night Waking in the middle of the night or early in the morning and not or early in the morning and not being able to get back to sleep. being able to get back to sleep.

4. Impaired thinking or 4. Impaired thinking or concentrationconcentration

Trouble concentrating or making Trouble concentrating or making decisions.decisions.

Problems with memory.( difficulty Problems with memory.( difficulty with short term memory). with short term memory).

Signs and Symptoms Signs and Symptoms Cont’dCont’d

5. Changes in weight 5. Changes in weight An increased or reducedAn increased or reduced 6. Fatigue or slowing of body 6. Fatigue or slowing of body

movements. movements. lack of energy. lack of energy. Feel as tired in the morning.Feel as tired in the morning. Have trouble getting out of bed. Have trouble getting out of bed. Feel like you're doing everything Feel like you're doing everything

in slow motion, or you may in slow motion, or you may speak in a slow, monotonous speak in a slow, monotonous tone. tone.

Signs and Symptoms Signs and Symptoms Cont’dCont’d

7. 7. Low self-esteemLow self-esteem Feel worthless.Feel worthless. Excessive guilt. Excessive guilt. Pessimism, poor self-esteem. Pessimism, poor self-esteem. Self-criticism Self-criticism

8. Agitation8. Agitation You may seem restless, agitated, You may seem restless, agitated,

irritable and easily annoyed. irritable and easily annoyed. Difficulty controlling your temper.Difficulty controlling your temper.

Signs and Symptoms Signs and Symptoms Cont’dCont’d

99. Physical complaints, such as . Physical complaints, such as gastrointestinal problems (indigestion, gastrointestinal problems (indigestion, constipation or diarrhea), headache and constipation or diarrhea), headache and backache. Many people with depression backache. Many people with depression also have symptoms of anxiety.also have symptoms of anxiety.

Children, teens may react differently to Children, teens may react differently to depression. depression.

Kids may pretend to be sick, worry that Kids may pretend to be sick, worry that a parent is going to die, perform poorly a parent is going to die, perform poorly in school, refuse to go to school, or in school, refuse to go to school, or exhibit behavioral problems. exhibit behavioral problems.

Signs and Symptoms Signs and Symptoms Cont’dCont’d

10. Less interest in sex. 10. Less interest in sex.

11. Thoughts of death.11. Thoughts of death. A persistent negative view of A persistent negative view of

yourself, your situation and the yourself, your situation and the future. thoughts of death, dying future. thoughts of death, dying or suicide. or suicide.

Differential diagnosisDifferential diagnosis

1.1.Medical disorders:Medical disorders: Endocrine disorders, infections, metabolic disorders , Endocrine disorders, infections, metabolic disorders ,

nutritional deficiencies, connective tissue diseases , nutritional deficiencies, connective tissue diseases , drugs (steroids , contraceptive pills, analgesics,..),drugs (steroids , contraceptive pills, analgesics,..),……etc.……etc.

2. 2. Neurological disorders:Neurological disorders: brain tumors, infections, head brain tumors, infections, head injury , epilepsy ,etc.injury , epilepsy ,etc.

3. 3. Mental disorders:Mental disorders: anxiety disorders, bipolar disorder, anxiety disorders, bipolar disorder, schizoaffective disorder, schizophrenia, substance schizoaffective disorder, schizophrenia, substance abuse,abuse, Dementias and pseudodementia Dementias and pseudodementia

44. Uncomplicated bereavement.. Uncomplicated bereavement.

Depressive disordersDepressive disorders Diagnosticians recognize several subtypes or Diagnosticians recognize several subtypes or

course specifiers: course specifiers:

Atypical depression is characterized by mood is characterized by mood reactivity (paradoxical anhedonia) and positivity, reactivity (paradoxical anhedonia) and positivity, significant significant weight gain or increased appetite or increased appetite ("comfort eating"), excessive sleep or ("comfort eating"), excessive sleep or somnolence (somnolence (hypersomnia), a sensation of ), a sensation of heaviness in limbs known as leaden paralysis, heaviness in limbs known as leaden paralysis, and significant social impairment as a and significant social impairment as a consequence of hypersensitivity to perceived consequence of hypersensitivity to perceived interpersonal rejection. .

Psychotic depression is the term for a major is the term for a major depressive episode, particularly of melancholic depressive episode, particularly of melancholic nature, where the patient experiences psychotic nature, where the patient experiences psychotic symptoms such as symptoms such as delusions or, less commonly, or, less commonly, hallucinations. These are most commonly mood-. These are most commonly mood-congruent (content coincident with depressive congruent (content coincident with depressive themes).themes).

Catatonic depression is a rare and severe form is a rare and severe form of major depression involving disturbances of of major depression involving disturbances of motor behavior and other symptoms. Here the motor behavior and other symptoms. Here the person is mute and almost stuporose, and person is mute and almost stuporose, and either immobile or exhibits purposeless or even either immobile or exhibits purposeless or even bizarre movements. Catatonic symptoms also bizarre movements. Catatonic symptoms also occur in occur in schizophrenia, a , a manic episode, or be , or be due to neuroleptic malignant syndrome.due to neuroleptic malignant syndrome.

Postpartum depressionPostpartum depression is listed as a course is listed as a course specifier in DSM-IV-TR; it refers to the intense, specifier in DSM-IV-TR; it refers to the intense, sustained and sometimes disabling depression sustained and sometimes disabling depression experienced by women after giving birth. experienced by women after giving birth. Postpartum depression, which has incidence Postpartum depression, which has incidence rate of 10–15%, typically sets in within three rate of 10–15%, typically sets in within three months of labour, and lasts as long as three months of labour, and lasts as long as three months months

Seasonal affective disorderSeasonal affective disorder is a specifier. Some is a specifier. Some people have a seasonal pattern, with depressive people have a seasonal pattern, with depressive episodes coming on in the autumn or winter, and episodes coming on in the autumn or winter, and resolving in spring. The diagnosis is made if at resolving in spring. The diagnosis is made if at least two episodes have occurred in colder least two episodes have occurred in colder months with none at other times over a two-year months with none at other times over a two-year period or longer.period or longer.

DysthymiaDysthymia, which is a chronic, milder mood , which is a chronic, milder mood disturbance where a person reports a low mood disturbance where a person reports a low mood almost daily over a span of at least two years. almost daily over a span of at least two years. The symptoms are not as severe as those for The symptoms are not as severe as those for major depression, although people with major depression, although people with dysthymia are vulnerable to secondary episodes dysthymia are vulnerable to secondary episodes of major depression (sometimes referred to as of major depression (sometimes referred to as double depressiondouble depression). ).

Recurrent brief depressionRecurrent brief depression (RBD), (RBD), distinguished from Major Depressive distinguished from Major Depressive Disorder primarily by differences in Disorder primarily by differences in duration. People with RBD have depressive duration. People with RBD have depressive episodes about once per month, with episodes about once per month, with individual episodes lasting less than two individual episodes lasting less than two weeks and typically less than 2–3 days. weeks and typically less than 2–3 days. Diagnosis of RBD requires that the episodes Diagnosis of RBD requires that the episodes occur over the span of at least one year occur over the span of at least one year and, in female patients, independently of and, in female patients, independently of the menstrual cycle. People with clinical the menstrual cycle. People with clinical depression can develop RBD, and vice depression can develop RBD, and vice versa, and both illnesses have similar risks.versa, and both illnesses have similar risks.

Minor depressionMinor depression, which refers to a , which refers to a depression that does not meet full criteria depression that does not meet full criteria for major depression but in which at least for major depression but in which at least two symptoms are present for two weeks. two symptoms are present for two weeks.

TreatmentTreatment

Treatment have those gallsTreatment have those galls::Risk AssessmentRisk AssessmentEnsure the safety of the patientsEnsure the safety of the patientsEnsure complete diagnostic evaluationEnsure complete diagnostic evaluationEnsure treatment of the immediate Ensure treatment of the immediate

symptoms and the future of the patients.symptoms and the future of the patients.HospitalizationHospitalization::For diagnostic evaluation, suicide and For diagnostic evaluation, suicide and

homicide risk, dehydration and homicide risk, dehydration and starvation, loss of social support.starvation, loss of social support.

It is necessary that every patient, whom It is necessary that every patient, whom we suspect to have mood disorders, we suspect to have mood disorders, should be thoroughly assessed by should be thoroughly assessed by careful and full history and mental state careful and full history and mental state examination. The notes of the social examination. The notes of the social worker and clinical psychologists should worker and clinical psychologists should be studied too. The necessary be studied too. The necessary investigations to exclude other possible investigations to exclude other possible causes should be done including full causes should be done including full blood count, drug screening , hormonal blood count, drug screening , hormonal essays including thyroid function tests, essays including thyroid function tests, EEG, CT scan and if necessary other EEG, CT scan and if necessary other neuroimaging techniques. neuroimaging techniques. 2424

The line of management depends on The line of management depends on whether the disorder is acute or chronic, whether the disorder is acute or chronic, bipolar unipolar, recurrent or a single bipolar unipolar, recurrent or a single episode. episode.

The choice of the treatment method The choice of the treatment method should be made by discussion with the should be made by discussion with the patient, his relatives and individual patient, his relatives and individual physician. physician.

The treatment methods include:The treatment methods include:

Psychological Psychological

Pharmacological Pharmacological

Physical Physical 2525

TreatmentTreatment Psychosocial TherapyPsychosocial Therapy::Cognitive therapy: was developed originally by Aaron Cognitive therapy: was developed originally by Aaron

Beck. Focuses on cognitive distortions postulated Beck. Focuses on cognitive distortions postulated to be present in MDD. It works by helping patients to be present in MDD. It works by helping patients identify and test negative cognitions; develop identify and test negative cognitions; develop alternative, flexible, and positive ways of thinking; alternative, flexible, and positive ways of thinking; and rehearse new cognitive and behavioural and rehearse new cognitive and behavioural responses.responses.

Interpersonal therapy: was developed by Gerald Interpersonal therapy: was developed by Gerald Klerman, focuses on one or two of the patient’s Klerman, focuses on one or two of the patient’s current interpersonal problems. It is based on two current interpersonal problems. It is based on two assumptions. First, current interpersonal problems assumptions. First, current interpersonal problems are likely to have their roots in early dysfunctional are likely to have their roots in early dysfunctional relationships. Personality factors need to be relationships. Personality factors need to be addressed and does not deal with dynamics of the addressed and does not deal with dynamics of the patient’s problems.patient’s problems.

TreatmentTreatmentPsychosocial TherapyPsychosocial Therapy:cont:cont Behaviour Therapy: is based on the hypothesis that Behaviour Therapy: is based on the hypothesis that

maladaptive behavioural patterns result in a maladaptive behavioural patterns result in a person’s receiving little positive feedback and person’s receiving little positive feedback and perhaps outright rejection from society.perhaps outright rejection from society.

Psychoanalytically Oriented Therapy: the aims Psychoanalytically Oriented Therapy: the aims include improvement in interpersonal trust, include improvement in interpersonal trust, intimacy, coping mechanisms, the capacity to intimacy, coping mechanisms, the capacity to grieve and the ability to experience a wide range grieve and the ability to experience a wide range of emotions. of emotions.

Family Therapy: is indicated if the disorder Family Therapy: is indicated if the disorder jeopardizes a patient’s marriage or family jeopardizes a patient’s marriage or family functioning or if the mood disorder is promoted or functioning or if the mood disorder is promoted or maintained by the family situationmaintained by the family situation

TreatmentTreatment PharmacotherapyPharmacotherapy::

All current available antidepressants may take up to 3 All current available antidepressants may take up to 3 to 4 weeks to exert significant therapeutic effects. to 4 weeks to exert significant therapeutic effects.

Patient Education: patient should be educated about Patient Education: patient should be educated about the illness, benefit of drugs, side effects. Avoid the illness, benefit of drugs, side effects. Avoid providing patients with large prescriptions due to the providing patients with large prescriptions due to the risk of suicide.risk of suicide.

Alternatives to drug therapy: ECT is used when a Alternatives to drug therapy: ECT is used when a patient is unresponsive to pharmacotherapy or the patient is unresponsive to pharmacotherapy or the clinical situation is so severe that the rapid clinical situation is so severe that the rapid improvement seen with ECT is needed. Occasionally improvement seen with ECT is needed. Occasionally it is treatment of choice such as older depressed it is treatment of choice such as older depressed patients. Phototherapy use in seasonal mood patients. Phototherapy use in seasonal mood disorder. disorder.

Treatment should continue for at leas Treatment should continue for at leas 6 months after remission.6 months after remission.

Prophylactic treatment should be used Prophylactic treatment should be used in recurrent cases, suicidal ideation in recurrent cases, suicidal ideation and impaired psychosocial and impaired psychosocial functioningfunctioning

Augmentation is used when treatment Augmentation is used when treatment fails: Lithium, Liothyrnine, L fails: Lithium, Liothyrnine, L tryptophan. tryptophan.

In mild depression psychotherapy In mild depression psychotherapy is is the first line treatment and the first line treatment and pharmacological therapy is not pharmacological therapy is not recommended routinely as first line recommended routinely as first line therapy. therapy.

In moderate to sever depression In moderate to sever depression when other treatments for two weeks when other treatments for two weeks fail antidepressants should be first line fail antidepressants should be first line treatment. treatment.

In In dysthymia dysthymia antidepressants could be antidepressants could be used as first line treatment. used as first line treatment.

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Tricyclic antidepressants: Tricyclic antidepressants:

These drugs have many side effects These drugs have many side effects including anticholinergic effects, including anticholinergic effects, hypotension and tachycardia and hypotension and tachycardia and cardiac toxicity which makes them cardiac toxicity which makes them dangerous in toxicity and overdoses.dangerous in toxicity and overdoses.

Tricyclic antidepressants should not be Tricyclic antidepressants should not be used as first line treatment in mild to used as first line treatment in mild to moderate depression. moderate depression.

They are They are recommended for severely recommended for severely ill inpatients. ill inpatients.

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Specific serotonin reuptake Specific serotonin reuptake inhibitorsinhibitors::

Including fluoxitine, paroxitine, Including fluoxitine, paroxitine, fluvoxamine, citalopram, sertraline, fluvoxamine, citalopram, sertraline, escitalopram.escitalopram.

They are recommended by NICE as first They are recommended by NICE as first line pharmacological treatment of line pharmacological treatment of depression because they have less side depression because they have less side effects compared to tricyclic effects compared to tricyclic antidepressants. They are relatively antidepressants. They are relatively safer in overdoses. However they might safer in overdoses. However they might lead to gastric irritation, nausea, lead to gastric irritation, nausea, vomiting, headache, increased anxiety vomiting, headache, increased anxiety and sexual dysfunction. and sexual dysfunction.

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Specific serotonin reuptake Specific serotonin reuptake inhibitorsinhibitors::

They cause decreased arousal, drive They cause decreased arousal, drive and difficulty reaching orgasm. These and difficulty reaching orgasm. These side effects might lead to side effects might lead to noncompliance. noncompliance.

The initial increased anxiety might lead The initial increased anxiety might lead to suicide. to suicide.

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Monoamine oxidase inhibitors Monoamine oxidase inhibitors MAOIs :MAOIs :

They are used for atypical depression They are used for atypical depression with reversed biological symptoms as with reversed biological symptoms as increased appetite and weight. It is increased appetite and weight. It is recommended by NICE for those who do recommended by NICE for those who do not respond to SSRIs. The ireversible not respond to SSRIs. The ireversible MAOIs have serious interaction with MAOIs have serious interaction with drugs and food containing tyramine. drugs and food containing tyramine.

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Monoamine oxidase inhibitors Monoamine oxidase inhibitors MAOIs :MAOIs :

The reversible MAOIs as Meclobemide The reversible MAOIs as Meclobemide has less risk of interaction but has less risk of interaction but therapeutically less effective. therapeutically less effective.

Those drugs lead to postural Those drugs lead to postural hypotension , overstimulation, sexual hypotension , overstimulation, sexual dysfunction, weight gain and possibly dysfunction, weight gain and possibly addiction. addiction.

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Serotonin and noradrenaline Serotonin and noradrenaline reuptake inhibitors SNRIs:reuptake inhibitors SNRIs:

Venlafaxine and duloxetene. Venlafaxine and duloxetene. Venlafaxine is more potent than SSRIs Venlafaxine is more potent than SSRIs and recommended by NICE for severely and recommended by NICE for severely depressed patients with monitoring the depressed patients with monitoring the blood pressure. blood pressure. Doluxetene is not as potent as Doluxetene is not as potent as Venlafaxine and it might lead to initial Venlafaxine and it might lead to initial nausea. nausea. Both drugs lead to nausea, Both drugs lead to nausea, hypertension, increased anxiety and hypertension, increased anxiety and sexual dysfunctionsexual dysfunction. .

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Other antidepressants:Other antidepressants:

reboxetene: is selective reboxetene: is selective noradrenaline reuptake inhibitor. It noradrenaline reuptake inhibitor. It has anticholinergic side effects and has anticholinergic side effects and sexual dysfunction. Neverthelss it sexual dysfunction. Neverthelss it is well tolerated but evidence of its is well tolerated but evidence of its effectiveness is scarce. effectiveness is scarce.

mirtazepine: is mirtazepine: is αα 2 adrenoceptor 2 adrenoceptor antagonist. It cause sedation and antagonist. It cause sedation and weight gain. Therefore it liked by weight gain. Therefore it liked by patients with insomnia and disliked patients with insomnia and disliked by obese patients. by obese patients.

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Other antidepressants:Other antidepressants:

Mianserine is a tetracyclic drug and Mianserine is a tetracyclic drug and is is αα2 adrenoceptor antagonist. It is 2 adrenoceptor antagonist. It is less popular now because of less popular now because of agranulocytosis. agranulocytosis.

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Treatment resistant depression:Treatment resistant depression:

Augmetation therapy:Augmetation therapy:

Antidep and psychtherapyAntidep and psychtherapy

Antidep and atypical antipsychoticAntidep and atypical antipsychotic

Antidep and thyroid hormone Antidep and thyroid hormone

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ManiaMania

DefinationDefination Mania is a Greek word mean Mania is a Greek word mean

madness. madness. The term used to describe a The term used to describe a

syndrome involving sustained syndrome involving sustained and pathological elevation of and pathological elevation of mood accompanied by other mood accompanied by other changes such as disturbances of changes such as disturbances of physical energy , sleep and physical energy , sleep and appetite with psychotic features.appetite with psychotic features.

Definition.. Cont’dDefinition.. Cont’d

Bipolar Affective Disorder (BAD) Bipolar Affective Disorder (BAD) is an episodic illness , where is an episodic illness , where

periods of normal psychological periods of normal psychological functioning are interrupted at functioning are interrupted at intervals by periods of either intervals by periods of either mania or depression.mania or depression.

Definition.. Cont’dDefinition.. Cont’d Bipolar 1 disorderBipolar 1 disorder previously previously

called Manic Depressive Illness called Manic Depressive Illness characterizes with episode of characterizes with episode of mania and depression or mania mania and depression or mania only.only.

Bipolar 2 disorderBipolar 2 disorder characterized characterized with depression and few with depression and few hypomania episode.hypomania episode.

Features of a Manic Features of a Manic Episode Episode 

1. 1. Emotional symptomsEmotional symptoms Extreme irritability & Extreme irritability &

distractibility .distractibility . Excessive "high" or euphoric Excessive "high" or euphoric

feelings.feelings. Emotional liability between Emotional liability between

anger and euphoria.anger and euphoria.

Features of a Manic Features of a Manic Episode Episode 

2. 2. Cognitive symptomsCognitive symptoms Inflated self esteem and grandiosity.Inflated self esteem and grandiosity. Reported self confident, capable and Reported self confident, capable and

can do things better than other.can do things better than other. Unrealistic belief in one's own Unrealistic belief in one's own

abilities  and achievementabilities  and achievement Delusion of grandeur that they are Delusion of grandeur that they are

famous, gift, and extraordinary.famous, gift, and extraordinary. Thought flow, flight of ideaThought flow, flight of idea Poor judgment regarding personal, Poor judgment regarding personal,

social, occupation and activities. social, occupation and activities. 

Features of a Manic Features of a Manic Episode Episode 

3. 3. Behavioral symptomsBehavioral symptoms Increased talkativeness, agitation, Increased talkativeness, agitation,

excessive involvement in excessive involvement in pleasurable activities.pleasurable activities. Wearing bright color, unusual dress & Wearing bright color, unusual dress &

heavy makeup. heavy makeup. Productivity, creative involves in Productivity, creative involves in

project with negatives consequences. project with negatives consequences. Decreased sleep, Increased sex drive  Decreased sleep, Increased sex drive  Substance abuse.  Substance abuse.  Provocative or noxious behavior  Provocative or noxious behavior  Denial of problem.  Denial of problem. 

   

HypomaniaHypomania

Is somewhat similar to mania, a less Is somewhat similar to mania, a less extreme mood state, hypomania is extreme mood state, hypomania is defined as an elevated mood during defined as an elevated mood during which (1) no hospitalization has ever which (1) no hospitalization has ever been necessary and (2) no state of been necessary and (2) no state of delusional or other psychotic thinking delusional or other psychotic thinking ever coincided with the elevated mood. ever coincided with the elevated mood.

Hypomania are not sever enough to Hypomania are not sever enough to cause impairment in social and cause impairment in social and occupational function.occupational function.

Hypomania may feel good to the person Hypomania may feel good to the person who experiences it. Thus, even when who experiences it. Thus, even when family and friends learn to recognize the family and friends learn to recognize the mood swings, the individual often will mood swings, the individual often will deny that anything is wrongdeny that anything is wrong

Mixed affective episodeMixed affective episode

In the context of bipolar disorder, a mixed In the context of bipolar disorder, a mixed state is a condition during which state is a condition during which symptoms of mania and clinical symptoms of mania and clinical depression occur simultaneously.depression occur simultaneously.

TreatmentTreatment 1. 1. MedicationsMedications

A. Mood stabilizer is the first line A. Mood stabilizer is the first line of treatment for manic episodes. of treatment for manic episodes. E.g. LithiumE.g. Lithium

Mood regulators Anti-seizure Mood regulators Anti-seizure medications, such as valproic acid medications, such as valproic acid (Depakene),and lamotrigine (Depakene),and lamotrigine (Lamictal). (Lamictal).

Antipsychotic medications such as Antipsychotic medications such as risperidone (Risperdal), risperidone (Risperdal), olanzapine (Zyprexa) or Seroquel.olanzapine (Zyprexa) or Seroquel.

Treatment….Cont’dTreatment….Cont’d

Mood StabilizeMood Stabilize Adverse EffectsAdverse Effects Special ConcernsSpecial Concerns

Lithium carbonateLithium carbonate(Eskalith CR, Lithobid)(Eskalith CR, Lithobid)

Gastrointestinal Gastrointestinal distress, lethargy or distress, lethargy or sedation, tremor,sedation, tremor,

Hypothyroidism,Hypothyroidism,diabetes insipidus,diabetes insipidus,renal disease renal disease

valproic acid valproic acid (Depakote, Depakene (Depakote, Depakene

Sedation, platelet Sedation, platelet dysfunction, liver dysfunction, liver disease, alopecia, disease, alopecia, weight gain weight gain

Elevated liver enzymes Elevated liver enzymes or liver disease, drug-or liver disease, drug-drug interactions, bone drug interactions, bone marrow suppression marrow suppression

Carbamazepine Carbamazepine (Tegretol) (Tegretol)

Suppressed WBC, Suppressed WBC, dizziness, drowsiness, dizziness, drowsiness, rashes, liver toxicity rashes, liver toxicity (rarely) (rarely)

Drug-drug interactions, Drug-drug interactions, bone marrow bone marrow suppression suppression

TreatmentsTreatments3. Electroconvulsive therapy (ECT)3. Electroconvulsive therapy (ECT)

ECT may also be considered to ECT may also be considered to treat acute episodes when treat acute episodes when medical conditions, including medical conditions, including pregnancy, make the use of pregnancy, make the use of medications too risky. ECT is a  medications too risky. ECT is a  highly effective treatment for highly effective treatment for severe depressive, manic, and/or severe depressive, manic, and/or mixed episodes. mixed episodes.

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