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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