Mood Disorders. Mental Problems Related to Mood l Mood episodes l Mood Disorders l Specifiers.

Mood DisordersMood Disorders

Mental Problems Mental Problems Related to MoodRelated to Mood

Mood episodes Mood Disorders Specifiers

MoodMood

Sustained emotion that colors the way we view life.

Mood D/O’s seen in 20% of women and 10% of men*

50% of typical mental health practice

Male Risk FactorsMale Risk Factors

Isolation Anhedonia Limited Physical Activity Limited Self-reflection Denial/Pessimistic

Mood DisordersMood Disorders Major Depressive Episode Dysthymic Depressive Disorder NOS Manic Episode Bipolar I Bipolar II Cyclothymic Bipolar Disorder NOS

Other Mood DisordersOther Mood Disorders

Mood Disorder due to GMC? Substance-Induced Mood Disorder Mood Disorder NOS

Other causes of Depressive Other causes of Depressive and Manic Symptomsand Manic Symptoms

Schizoaffective Disorder Cognitive Disorders with depressed mood Adjustment Disorder with Depressed Mood Personality Disorders Bereavement

SpecifiersSpecifiers

With Atypical Features* With Melancholic Features With Catatonic Features With Postpartum Onset

Course of Recurrent Course of Recurrent EpisodesEpisodes

With/without Full Interepisode Recovery With Rapid Cycling With Seasonal Pattern

Major Depressive EpisodeMajor Depressive Episode

Quality of depressed mood Duration Symptoms Impairments Exclusions

Depressive SymptomsDepressive Symptoms

Depressed mood Anhedonia Lost appetite and weight Insomnia Psychomotor retardation Agitation Suicidal ideation

Theories of DepressionTheories of Depression

Cognitive (Beck) Learning (Seligman) Neuroendocrine Circadian Rhythm Hypotheses Neurotransmitter

Cognitive Aspects of Cognitive Aspects of DepressionDepression

Pessimism (underestimates likelihood of success)

Lack of Self-esteem (underestimate the value of past achievements)

“It doesn’t matter” (responses won’t make a difference)

Biased judgement (toward negativism)

Neuroendocrine Neuroendocrine AbnormalitiesAbnormalities

Hypercorticolism (dysfunction in HAP axis) Dexamethasone suppression test

– basis of test-diagnostic and treatment marker

– procedure

– Problems

– Utility?

Blunting of plasma growth hormone Blunting of serotonin-mediated increase in plasma

prolactin

Circadian Rhythm Circadian Rhythm AbnormalitiesAbnormalities

Patterns of insomnia and hypersomnia Diurnal fluctuations in mood Seasonal pattern depression (ultradian) Abnormalities in sleep architecture Impact of:

– antidepressants on sleep architecture– phototherapy– reset biological clocks (endogenous zeitgebers)

Medication: Placebo?Medication: Placebo?

Kirsh et al (1999) 80 % Placebo Saperstein (1996) 50% Placebo Leuchter et al (2002) changes in brain activation APA (1998) Equal to Psychotherapy

– More cost effective

– Less side effects

Prescription privledges?– http://www.apa.org/apags/profdev/prespriv.html

Pharmalogical TreatmentsPharmalogical Treatments“Trials”“Trials”

Tricyclic antidepressants ($15/month)– Imipramine, Noratriptyline, Desipramine & Amitriptyline

MAO Inhibitors*- ($15/month)– Nardil, Parnate & Marplan: 4-5 week build-up

Heterocyclic antidepressants ($50-120/month)– 4 to 8 weeks to produce effect– SSRI’s (Prozac, Zoloft, Celexa)– Dopamine specific reuptake inhibitors (Wellbutrin)

Lithium (for Bipolar D/O)

Response to Response to Pharmacological TreatmentPharmacological Treatment

Typical 3 part response– Sleep improves– Energy increases– Mood improves

Suicide potential greatest after energy increases, but before mood improves

Who Rx’s most antidepressants?– Problems?

Consider side effect profile

Predictors of Response to Predictors of Response to Antidepressant MedicationAntidepressant Medication

Positive– Gradual onset– Anorexia with weight loss– Middle, Late Insomnia– Psychomotor retardation

Negative– Multiple prior episodes– Delusions & more “complicated” problems

Outcome of Antidepressant Outcome of Antidepressant TreatmentTreatment

Average duration of MDD= 6 months 66% with MDD recover within 1 year and

80% recover within 2 years Among recovered patients, 33% will relapse

in 1 year; 75% will relapse in 5 years Double depression (MDD + Dysthymia)

doubles relapse rate Only 15% of hospitalized will not relapse

Critical Treatment Critical Treatment ComponentsComponents

Psychoeducation– Ex. Abrupt stopping can cause severe side effects and

intensify the depressive symptoms. Increased structure Decreased stress Rapport and instillation of hope Psychotherapy and pharmacotherapy is most effective,

especially for severe levels of depression– 80% of pts. receiving some combination of therapy and

medication made significant improvements (Little, et al, 1999 AJP: 155)

Tricyclic AntidepressantsTricyclic Antidepressants

MOA: inhibit the NE reuptake Try for 6 months then taper if Sx. abate MUST monitor

– mood– weight– BP changes (usually lower)– compliance

Trycyclic Side EffectsTrycyclic Side Effects

Muscarinic receptor blockade (anticholinergic)– dry mouth, constipation, sedation, fatigue– Loss of libido and/or sexual dysfunction– Imipramine, Nortriptyline and Desipramine

Histimic receptor blockade– sedation and weight gain

Alpha-adrenergic receptor blockade– Postural hypotension– Confusion and delirium in the elderly

Sx. of TCA withdrawalSx. of TCA withdrawal

Loose stools Urinary frequency Headache Hypersalivation

SSRIsSSRIs

Becoming most widely prescribed antidepressants

Relatively benign side effect profile Examples: Prozac (Fluoxetine) and Zoloft

(Sertraline); Lexapro (Escitalopram) Very popular in primary care Also used with OCD and Anxiety D/Os

DopamineDopamine

Dysfunctional mesolimbic pathway & hypoactive D1 receptors

Associated with lower levels in depression and higher levels in mania

Ldopa (PD) leads to depression Tyrosine, Amphetamine & Wellbutrin

reduce Dep. Sx. and increase Dopamine

ProzacProzac

Advantages– Most limited and transient side effect profile– little sedation, weight gain and hypotension– minimal overdose risk

Disadvantages– long half life, psychotic Sx.-drug interactions,

child/adolescent contraindications and expensive $ (110/month)

Prozac continuedProzac continued

Drug-Drug Interactions– Increases plasma levels of TCA’s and

neuroleptics– Hypermetabolic syndrome with MAOI’s

Side Effects– GI, anxiety, insomnia, headaches, tremor,

agitation, insomnia, anorexia, loss of libido and or sexual dysfuntion

– Least likely to cause sedation

Symptoms of Serotonin Symptoms of Serotonin WithdrawalWithdrawal

Flu-like (fatigue, nausea, loose stools) Lightheadedness/dizziness Uneasiness/restlessness Sleep and sensory disturbances Headache

Dx. Confirmed when Sx. remit after restarting SSRI (usually 12-24 hours)

Electroconvulsive TherapyElectroconvulsive Therapy

Controversies Progress Side effects Efficacy

Women & DepressionWomen & Depression

Higher rates of physical and sexual abuse

Needs– More Prevention

– More Research of barriers to treatment

– More research on differential risk

Women 2x likely to be diagnosed, especially younger women

Depression is misdiagnosed 30 to 50 % of the time

70% of Rx’s given to women, often without proper monitoring

Depression and African Depression and African AmericansAmericans

Higher risk due to SES Misdiagnosis

– Mistrust of medical system– Cultural barriers– Primary reliance on family and church– “Masked” by medical conditions, somatic

complaints or substance abuse– SES limiting access to medical care

African American Attitudes African American Attitudes toward depressiontoward depression(National Mental Health Association, 1996)(National Mental Health Association, 1996)

63% (vs. 54%) “depression is a personal weakness” Only 31% believed depression is a health problem Only 20% said they would seek treatment Only 25% connected change in eating habits or sleep with

depression; 16% irritability Only 33% said they would take medication for depression

(vs. 69% of general population) 67% believed prayer & faith alone would successfully treat

depression “almost all of the time or some of the time.”

Depression and the ElderlyDepression and the Elderly

Depression is NOT a normal part of aging, although 58% of elders believe this

6 million affected, most women, < 10% tx’d 15% in community vs. 25% in ECFs Often misinterpreted as medical condition Elders with comorbid depression have 50% higher health care

costs; Depression is often secondary 40% experience reoccurrence Only 38% believe it is a “health problem” Only 42% would seek professional help ECT efficacious Polypharmacy & Undermedication

Suicide & the ElderlySuicide & the Elderly

Most at risk, 50% higher; 2/3 are due to untreated depression

20-25% of all suicides occur in the elderly EA men over 80 are 6x more likely Many have recently visited their PCP

– 20% the same day– 40% within one week– 70% within one month

SuicideSuicide• Incidence

• History

• Age/Gender/Race?

• Marital Status

• Life Stress

• Psychiatric Disorders

• Parasuicidal behaviors

• Children & Adolescents

• Assessment & Prevention

• Contracts----Baker Act