Mood Disorders Mood Disorders
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