Mood Disorders

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Mood Disorders

• Bruce Shapiro, M.D.
• April 6, 2001

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Do psychiatrists have mood swings?
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What Determines Mood?
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Harlow and Spitz
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Gross Anatomy
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Neuroimaging
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Regionalization questions
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Synapse
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Intracellular activities
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Brain mediated environment
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History...
Mood Disorders
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History

• The Bible (King Saul, Job)
• Hippocrates - Humoral theory
• Arateus - Psychological theory
• 1800s - Physical diagnosis
• 1900s - Psychological diagnosis
• 1930s - Somatic interventions
• 1940s - Psychoanalysis
• 1950s - Psychopharmacology
• 1980s - Biological markers
• 1990s - Neuroimaging
• 2000s - Herbals and magnetism ...

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Hippocrates
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Mood Disorders

• Famous Sufferers ...

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Abraham Lincoln
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Winston Churchill
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Churchill's Black Dog

• "Black Dog Churchill's name for his
  depression
• Lord Moran inborn melancholia
• Periods of solitude
• Periods of high energy
• Highly functional

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Ernest Hemingway
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Suicide - Familial Aspects
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A Quote

• In my last severe depression, I took coca again
  and a small dose lifted me to the heights in a
  wonderful fashion

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Sigmund Freud
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Freud and Mom or Mom and Freud?
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Famous Living Bipolars

• Robert Boorstin, writer, special assistant to
  President Clinton
• Rosemary Clooney, singer
• Dick Cavett, writer, media personality
• Kitty Dukakis, former First Lady of Massachusetts
  
• Patty Duke (Anna Pearce), actor, writer
• Connie Francis, actor, musician
• Shecky Greene, comedian
• Kristy McNichols, actress
• Kate Millett, writer
• Charley Pride, musician
• Axl Rose, musician
• Ted Turner, entrepreneur, media giant
• Jonathon Winters, comedian, actor, writer, artist
  

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Famous Living Unipolars

• Buzz Aldrin, astronaut
• Rona Barrett, entertainment reporter, author
• Art Buchwald, writer
• Barbara Bush, former U.S. First Lady
• Ray Charles, musician
• Eric Clapton, musician
• Dick Clark, television personality
• Leonard Cohen, musician, writer
• Francis Ford Coppola, director
• Michael Crichton, writer
• Kathy Conkrite, writer
• Sheryl Crow, musician
• Mike Douglas, media personality
• Tony Dow, actor, director
• 
  gtgt

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Famous Living Unipolars

• James Farmer, civil rights activist
• John Kenneth Galbraith, economist, educator,
  author
• Mariette Hartley, actor
• Anthony Hopkins, actor
• Robert McFarlane, former US National Security
  Advisor
• Joan Rivers, comedienne, talk show host
• Roseanne, actor, writer, comedienne
• Rod Steiger, actor
• William Styron, writer
• James Taylor, musician
• Livingston Taylor, musician
• Mike Wallace, news anchor
• Marie Osmond, entertainer

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Mood Disorders

• Classification and
• Demographics ...

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Mood Disorders (DSM-IV)

• Depressive Disorders
• Major Depressive Disorder (single/recurrent)
• Dythymic Disorder
• Depressive Disorder, NOS
• Bipolar Disorders
• Bipolar I
• Bipolar II
• Cyclothymic Disorder
• Bipolar Disorder, NOS
• Mood Disorder due to
• Medical condition
• Substance induced

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Mood Disorders - DSM IV
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Unipolar vs Bipolar

• Unipolar Bipolar
• Prev 5 1
• Gender FgtM FM
• Onset 30s 20s
• Suicide 15 20
• Sleep insom hyper
• Rx unipolar bipolar III
• Genetics lower higher

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Epidemiology

• Lifetime risks
• Major Depression 6
• All mood disorders 8
• Prevalence
• Major Depression (point prevalence approx 5 -6
  )
• Males 2.6 - 5.5
• Females 6.0 - 11.8
• Dysthymia 3 - 4
• In primary care practice
• Major Depression 4.8 - 9.2
• All depressive disorders 9 - 20
• Bipolar Disorder 1.0 - 2.5
• 5 - 15 of adult depressions are bipolar

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Prevalence of Mood Disorders

• 20 of the U.S. population reports at least one
  depressive symptom in a given month
• 12 report two or more depressive symptoms in a
  year
• Major Depression 5 in the previous 30 days,
• Bipolar Disorder - approximately 1 of the
  population
• Increase in cohort post 1940
• Younger age of onset

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Genetics

• Unipolar
• Dizygotic 30
• Monozygotic 50
• Family history 25
• Bipolar
• Dizygotic 30
• Monozygotic 80
• Family history 50

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Gender differences

• Bipolar - no difference
• Unipolar - Female gt Male
• ?genetic
• sociocultural
• alcoholism/substance abuse

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Mood Disorders Across the Lifespan

• Infancy - Spitz and Harlow
• Childhood - depressive equivalents
• Adolescence - major onset substance abuse
• Adulthood - major onset
• Geriatric - multiple symptoms pseudodementia
  differential medical diagnoses

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Predisposing factors

• Prior mood disorder or moodswings
• Positive family history
• Female gender
• Severe prolonged stress
• Recent loss
• Postpartum period
• Medical co-morbidity
• Current alcohol/substance abuse

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Prognosis

• Major Depression recurrence rates
• 1 episode 50 - 60
• 2 episodes 70
• 3 episodes 90
• Untreated episode 6-12 months
• 20-30 chronicity
• Episode length and frequency shorter episodes
  with increasing frequency
• Treatment yields good results

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Mood Disorders

• Clinical Syndromes ...

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HypomaniaWhat does it feel like?

• At first when I'm high, it's tremendous...ideas
  are fast...like shooting stars you follow until
  brighter ones appear...all shyness disappears,
  the right words and gestures are suddenly
  there...uninteresting people, things, become
  intensely interesting. Sensuality is pervasive,
  the desire to seduce and be seduced is
  irresistible. Your marrow is infused with
  unbelievable feelings of ease, power, well-being,
  omnipotence, euphoria...you can do
  anything...but, somewhere this changes.

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ManiaWhat does it feel like?

• The fast ideas become too fast and there are far
  too many...overwhelming confusion replaces
  clarity...you stop keeping up with it--memory
  goes. Infectious humor ceases to amuse. Your
  friends become frightened...everything is now
  against the grain...you are irritable, angry,
  frightened, uncontrollable, and trapped.

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Clinical Mania

• A sustained period of behavior that is different
  from usual
• Increased energy, activity, restlessness,
• Racing thoughts and rapid talking
• Excessive "high" or euphoric feelings
• Extreme irritability and distractibility
• Decreased need for sleep
• Unrealistic beliefs in one's abilities and powers
  
• Uncharacteristically poor judgment
• 
  gtgt

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Clinical Mania

• Reckless behavior
• Increased suspiciousness/paranoid ideation
• Increased sexual drive
• Abuse of drugs, particularly cocaine, alcohol,
  and sleeping medications
• Flight of ideas
• Provocative, intrusive, or aggressive behavior
• Possibly delusions (paranoid/grandiose/religious)
• Possibly hallucinations
• Denial that anything is wrong

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Cycle Length
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Bipolar Frequency of Recurrence
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Hypomania

• Inflated self-esteem
• Decreased need for sleep
• More talkative than usual
• Excessive involvement in pleasurable activities
  that have a high potential for painful
  consequences (e.g., the person engages in
  unrestrained buying sprees, sexual indiscretions,
  or foolish business investments)
• Increased activity
• No major life disruption
• No need for hospitalization
• No psychotic symptoms

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Cyclothymia

• Alternating hypomania and
• non-major depression
• At least 2 years in duration

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DepressionWhat does it feel like?

• I doubt completely my ability to do anything
  well. It seems as though my mind has slowed down
  and burned out to the point of being virtually
  useless....I am haunted...with the total, the
  desperate hopelessness of it all... Others say,
  "It's only temporary, it will pass, you will get
  over it," but of course they haven't any idea of
  how I feel, although they are certain they do. If
  I can't feel, move, think, or care, then what on
  earth is the point?

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Sadness vs Clinical Depression

• Intensity
• Duration
• Neurovegetative changes
• Self esteem changes
• Normal Grief vs. Depressive Illness

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Depressive Disorders - DSM - IV

• Major Depressive Disorder (296.xx)
• Dysthymic Disorder (300.4)
• Depressive Disorder NOS (311)
• Mood Disorder due to general medical condition
  (293.83)
• Substance-Induced mood disorder (293.83)

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Clinical Depression

• Loss of the ability to experience pleasure
• Unexplained or prolonged sadness or crying spells
• Significant changes in appetite and sleep
  patterns
• Diurnal variation of mood
• Irritability, anger, worry, agitation, anxiety
• Pessimism, indifference
• A sense of hoplessness/helplessness

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Clinical Depression

• Loss of energy, persistent lethargy, pathological
  fatigue
• Feelings of guilt, worthlessness
• Inability to concentrate, indecisiveness
• Social withdrawal
• Difficulty with personal hygiene
• Unexplained aches and pains
• May have delusions or hallucinations
• Recurring thoughts of death or suicide

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Other Specifiers

• Catatonic Features
• With Melancholic Features
• With Atypical Features
• With Postpartum Onset

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Physical Symptom Indicators

• Fatigue
• Pain
• Sleep disturbances
• GI disorders (IBS)
• unexplained by medical testing

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Atypical Presentations

• Anxiety/panic symptoms
• Irritability
• Hysterical symptoms
• Hypochondriacal symptoms
• Unexplained pain syndromes
• Substance abuse presentations
• Personality disorder

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Dysthymia

• This disorder is characterized by a chronic state
  of depression, exhibited by a depressed mood on
  most days for at least 2 years. (1 year in
  children and adolescents).
• There are no psychotic symptoms
• .

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Dysthymia symptoms and duration

• poor appetite or overeating
• insomnia or hypersomnia
• low energy or fatigue
• low self-esteem
• poor concentration or difficulty making decisions
  
• feelings of hopelessness
• Dysthymic individuals must not have gone for more
  than 2 months without experiencing two or more of
  these symptoms

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Mood Disorders

• Suicide ...

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Suicide Rates in Mood Disorders

• Unipolar 15
• Bipolar 20

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Suicide Risk Factors

• Clinical depression
• Suicidal ideation
• Self oriented (non-manipulative)
• Available lethal method
• MalegtFemale
• Whitegtblack
• Elderly
• Loss with alcohol/substance abuse

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Suicide Rates
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Suicide - Clusters
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Mood Disorders

• Causes
• and
• Treatments ...

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Psychological Models

• Psychoanalytic
• Interpersonal
• Cognitive
• Behavioral/learned helplessness

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Treatment Psychological

• Individual Psychotherapy
• Psychodynamic/Psychoanalytic
• Cognitive
• Interpersonal
• Supportive
• Group Therapy
• Couples Therapy
• Family Therapy

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Biological Models

• Genetic
• Neurotransmitter dysfunction
• Neuroendocrine dysfunction
• Chronobiological
• Sensitization/Kindling

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Serotonergic pathways
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Neurotransmission
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Neurons
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Basic Synapse
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Serotonin Synapse
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Reuptake pump
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Synaptic Interactions
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Synaptic Transmission
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Biological Markers in Major Depression

• DST
• TRH/TSH
• Shortened REM latency

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Treatment Biological

• Antidepressants
• Antipsychotics (typical, atypical)
• Mood stabilizers (thymoleptics)
• Augmentation strategies
• Herbal
• Phototherapy
• ECT
• rTMS

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Mood Stabilizing Medications

• Lithium carbonate/citrate
• Tegretol (carbamazepine)
• Depakote (valproic acid)
• Neurontin (gabapentin)
• Lamictal (lamotrigine)
• Klonopin (clonazepam)
• Zyprexa (olanzapine)

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Antidepressant Medication

• Antidepressant medications are non-addictive.
• Another antidepressant can be tried should the
  first have unacceptable side-effects.
• Antidepressants take time to work
• Physical symptoms are more likely to respond
  before psychological symptoms
• Undulating improvement

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Antidepressant medications

• TCAs (imipramine, nortriptyline, desopramine)
• MAOIs (phenelzine, tranylcypromine, meclobemide)
• SSRIs (fluoxetine, sertraline, paroxetine,
  fluvoxamine, citalopram)
• SNRIs (venlafaxine)
• CRIs (buprorion)
• Alpha2 adrenergic antagonists (mirtazapine)
• Serotonin2A antagonists and serotonin reuptake
  inhibitors (trazodone, nefazodone)
• Modified amino acids (SAMe)
• Psychostimulants
• Augmentation strategies (Li, T3, buspirone,
  anxiolytics )

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Electroconvulsive Therapy (ECT)

• History
• Indications
• Efficacy
• Adverse effects
• Safety

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rTMS
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Integrative Treatments

• Nature AND Nurture
• In major syndromes combinations of medication
  and psychotherapy
• Treat the individual
• Never give up