Mood Disorders: Causes, Prevalence, and Socio-Cultural Factors

IN THE NAME OF GOD

Mood Disorders SARA DEHBOZORGI

Mood can be defined as a pervasive and sustained emotion or feeling tone that influences a person s behavior and colors his or her perception of being in the world. Disorders of mood (sometimes called affective disorders make up an important category of psychiatric illness consisting of depressive disorder, bipolar disorder, and other disorders.

EPIDEMIOLOGY Incidence and Prevalence Mood disorders are common. Major depressive disorder has the highest lifetime prevalence (almost 17 percent) of any psychiatric disorder. The lifetime prevalence rate for major depression is 5 to 17 percent. The annual incidence of bipolar illness is considered generally to be less than 1 percent.

Sex Independent of country or culture, is the twofold greater prevalence of major depressive disorder in women than in men. The reasons for the difference are hypothesized to involve hormonal differences, the effects of childbirth, differing psychosocial stressors for women and for men, and behavioral models of learned helplessness. In contrast to major depressive disorder, bipolar I disorder has an equal prevalence among men and women. Manic episodes are more common in men, and depressive episodes are more common in women. When manic episodes occur in women, they are more likely than men to present a mixed picture (e.g., mania and depression).

Age The onset of bipolar I disorder is earlier than that of major depressive disorder. The age of onset for bipolar I disorder ranges from childhood (as early as age 5 or 6 years) to 50 years or even older in rare cases, with a mean age of 30 years. The mean age of onset for major depressive disorder is about 40 years, with 50 percent of all patients having an onset between the ages of 20 and 50 years. Major depressive disorder can also begin in childhood or in old age.

Socio-cultural Depressive Disorders : More common among single & divorced persons. No correlation with socioeconomic status. No difference between races or religious groups

Etiology of depression 1-Serotonin - The most commonly associated with depression 2- Norepinephrine 3- Dopamine 4-Cognitive 5-Learned helplessness 6-Stressful life events

Elements of Cognitive Theory

Risk Factors for Major Depression History of depression Chronic medical illness Female gender Being single or divorced Brain damage Alcohol abuse Use of certain medications Stressful life events

Personality Factors No single personality trait or type uniquely predisposes a person to depression; all humans, of whatever personality pattern, can and do become depressed under appropriate circumstances. Persons with certain personality disorders (OCPD, histrionic, and borderline) may be at greater risk for depression than persons with antisocial or paranoid personality disorder. The latter can use projection and other externalizing defense mechanisms to protect themselves from their inner rage. No evidence indicates that any particular personality disorder is associated with later development of bipolar

Genetic in depression MDD 2-3X more frequent in relatives of those with depression than gen population -more frequent in first degree

DSM-5 defines several subtypes of BD: Bipolar-I (BD-I) Bipolar-II (BD-II) Cyclothymic disorder Otherwise specified/unspecified bipolar and related disorder (BD-OS) Medication/substance induced BD BD due to another medical condition

Major Depressive Disorder: one MDE Bipolar I Disorder: one manic or mixed episode Bipolar II Disorder: MDE and hypomanic episode Dysthymic Disorder: 2 yrs of depressive symptoms, but never met criteria for MDE Cyclothymia : 2yrs history, hypomanic episodes, never met criteria for MDE

BD-I is classified under mood disorders and characterized in its classic form by cyclic changes between mania and major depressive episodes. Other subtypes of BD include episodes of major depression with hypomania (BD-II), multiple episodes of hypomania with depressed mood but without clear episodes of major depression (cyclothymia), and subthreshold (i.e., shorter) episodes of mania or hypomania with or without depression (other specified bipolar and related disorders, BD-OS).

DSM5 Diagnostic Criteria for MDD At least five of the following symptoms out of nine: One of the symptoms must be (1) Depressed mood and/or (2) loss of interest 1.Depressed mood most of the day. 2.Diminished interest or pleasure in all or most activities. 3.Significant unintentional weight loss or gain or decrease or increase in appetite. 4.Insomnia or sleeping too much. 5.Agitation or psychomotor retardation noticed by others.

6.Fatigue or loss of energy. 7.Feelings of worthlessness or excessive guilt 8.Diminished ability to think or concentrate, or indecisiveness. 9.Recurrent thoughts of death, recurrent suicidal ideation without a specific plan or a suicide attempt. The symptoms must persist for two weeks. The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning. The symptoms are not due to the direct physiological effects of a substance or a general medical condition.

Specifier With anxious distress With mixed features With melancholic features With atypical features With mood congruent psychotic features With mood incongruent psychotic features With Catatonia With peripartum onset With seasonal pattern

suicide 10 to 15 percent of all depressed patients commit suicide, and about two-thirds have suicidal ideation. Depressed patients with psychotic features occasionally consider killing a person as a result of their delusional systems. The most severely depressed patients often lack the motivation or the energy to act in an impulsive or violent way. Patients with depressive disorders are at increased risk of suicide as they begin to improve and regain the energy needed to plan and carry out a suicide (paradoxical suicide).

It is usually clinically unwise to give a depressed patient a large prescription for a large number of antidepressants, especially tricyclic drugs, at the time of their discharge from the hospital. Similarly, drugs that may be activating, such as fluoxetine, may be prescribed in such a way that the energizing qualities are minimized (e.g., be given a benzodiazepine at the same time).

Depressive disorders as a continuum Depressive disorders exist on a continuum, are classified on the basis of severity, pervasiveness, and presence or absence of mania . At the mildest end are adjustment disorders with depressed mood, which are mild, selflimited, and occur in response to a clear stressor. Other specified depression, which has sufficient duration (at least 2 weeks) and impairment, but fewer symptoms than major depression, also referred to as minor or subsyndromal depression, and is diagnosed in the presence of depressed mood, anhedonia, or irritability, and up to three symptoms of

Persistent depressive disorder Persistent depressive disorder, which in DSM-5 replaces dysthymic disorder, is a chronic depressive condition with fewer symptoms than major depression, but lasts a minimum of 1 year.

DSM-V Diagnostic Criteria Persistent depressive disorder Presence, while depressed, of two (or more) of the following : 1- poor appetite or overeating 2- insomnia or hypersomnia 3- low energy or fatigue 4- low self-esteem 5- poor concentration or difficulty making decisions 6- feelings of hopelessness B-During the 2-year period (1 year for children or adolescents)the person has never been without the symptoms for more than 2 months at a time.

C-No major depressive episode has been present during the first 2 years of the disturbance .i.e., the disturbance is not better accounted for by chronic MDD Note: There may have been a previous major depressive episode provided there was a full remission (no significant signs or symptoms for 2 months) before development of the dysthymic disorder. Note: After the initial 2 years of dysthymic disorder, there may be superimposed episodes of major depressive disorder

D- There has never been a manic episode ,a mixed episode, or a hypomanic episode, and criteria have never been met for cyclothymic disorder. E-The disturbance does not occur exclusively during the course of a chronic psychotic disorder, such as schizophrenia or delusional disorder. Specify if: Early Onset: if onset is before age 21 years Late Onset: if onset is age 21 years or older

Bipolar disorders Two types of bipolar disorders : A- Bipolar I : occurrence of manic or mixed episode with or without a major depressive episode B- Bipolar II : at least one major depressive episode with at least one hypomanic episode

DSM5 diagnostic criteria of manic episode In DSM-5, a manic episode is described as a distinct period of abnormally and persistently elevated, expansive, or irritable mood and abnormally and persistently increased activity or energy level lasting at least 7 consecutive days and present most of the day, nearly every day. During the period of mood disturbance, three (or more) of the symptoms mentioned for manic episode have persisted (four if the mood is only irritable) and have been present to a significant degree

Other symptoms of mania are: Inflated self-esteem or grandiosity Decreased need for sleep (e.g., feels rested after only 3 hours of sleep) More talkative than usual or pressure to keep talking Flight of ideas or subjective experience that thoughts are racing Distractibility (e.g., attention too easily drawn to unimportant or irrelevant external stimuli), as reported or observed Increase in goal-directed activity or psychomotor agitation Excessive involvement in activities that have a high potential for painful consequences

Bipolar Disorder II BD-II is characterized in DSM-5 by at least one major depressive episode and at least one hypomanic episode (hypomania should last at least 4 consecutive days).

MENTAL STATUS EXAMINATION General Description Mood, Affect, and Feelings Speech Perceptual Disturbances Thought Sensorium and Cognition Memory Impulse control

Mixed episode DSM5 diagnostic criteria A. The criteria are met both for a Manic Episode and for a Major Depressive Episode (except for duration) nearly every day during at least a 1-week period B. The mood disturbance is sufficiently severe to cause marked impairment in occupational functioning or in usual social activities or relationships with others, or to necessitate hospitalization to prevent harm to self or others, or there are psychotic features.

Hypomanic episode DSM5 diagnostic criteria A. A distinct period of persistently elevated, expansive, or irritable mood, lasting throughout at least 4 days, that is clearly different from the usual non-depressed mood: B. During the period of mood disturbance, three (or more) of the symptoms mentioned for manic episode have persisted (four if the mood is only irritable) and have been present to a significant degree. C. The episode is associated with an unequivocal change in functioning that is uncharacteristic of the person when not symptomatic. D. The disturbance in mood and the change in functioning are observable by others

E. The episode is not severe enough to cause marked impairment in social or occupational functioning, or to necessitate hospitalization, and there are no psychotic features. F. The symptoms are not due to the direct physiological effects of a substance or a general medical condition Note: Hypomanic-like episodes that are clearly caused by somatic antidepressant treatment should not count toward a diagnosis of Bipolar II Disorder.

Rapid- cycling Bipolar Disorder >= 4 depressive, manic, hypomanic or mixed episodes within 12 months, more chronic, mostly occur in women, no known familial or hereditary distribution.

DSM5 diagnostic criteria of cyclothymic disorder A- For at least 2 years, the presence of numerous periods with hypomanic symptoms and numerous periods with depressive symptoms that do not meet criteria for a Major Depressive Episode. Note: In children and adolescents, the duration must be at least 1 year. B- During the above 2-year period ,the person has not been without the symptoms in Criterion A for more than 2 months at a time. C- No Major Depressive Episode, Manic Episode, or Mixed Episode has been present during the first 2 years of the disturbance.

Coexisting Disorders Anxiety Alcohol Dependence Other Substance-Related Disorders Medical Conditions

Predictive for Bipolar Disorder:

COURSE AND PROGNOSIS An untreated depressive episode lasts 6 to 13 months; most treated episodes last about 3 months. As the course of the disorder progresses, patients tend to have more frequent episodes that last longer. Over a 20-year period, the mean number of episodes is five or six.

DEVELOPMENT OF MANIC EPISODES. About 5 to 10 percent of patients with an initial diagnosis of major depressive disorder have a manic episode 6 to 10 years after the first depressive episode. Major depressive disorder is not a benign disorder. It tends to be chronic, and patients tend to relapse.

Bipolar I disorder most often starts with depression (75 percent of the time in women, 67 percent in men) and is a recurring disorder. persons who have a single manic episode, 90 percent are likely to have another. As the disorder progresses, the time between episodes often decreases. Patients with bipolar I disorder have a poorer prognosis than do patients with major depressive disorder.

TREATMENT Hospitalization Psychosocial Therapy Cognitive Therapy Interpersonal Therapy Behavior Therapy Psychoanalytically Oriented Therapy Family Therapy

combination of psychotherapy and pharmacotherapy is the most effective treatment for major depressive disorder. Either pharmacotherapy or psychotherapy alone is effective, at least in patients with mild major depressive episodes.

Vagal Nerve Stimulation Transcranial Magnetic Stimulation Sleep Deprivation Phototherapy

Pharmacotherapy Antidepressant Medications: SSRI SNRI TCA MAOI Bupropion Mirtezapine Agomelatine

Antidepressant treatment should be maintained for at least 6 months or the length of a previous episode. when episodes are less than 21/2 years apart, prophylactic treatment for 5 years is probably indicated. Another factor suggesting prophylactic treatment is the seriousness of previous depressive episodes. Episodes that have involved significant suicidal ideation or impairment of psychosocial functioning may indicate that clinicians should consider prophylactic treatment.

Mood stabilizer Valproate Lithium Carbamazepin Lamotrigin Topiramate Gabapantin