Title: Mood (Affective) Disorders
1Mood (Affective) Disorders
- Department of Psychiatry
- 1st Faculty of Medicine
- Charles University, Prague
- Head Prof. MUDr. Jirí Raboch, DrSc.
2Mood (Affective) Disorders
- Mood disorders are very common, their life
prevalence is up to 20 , and they have a high
level of morbidity and mortality as well as an
immense impact on disabilities worldwide. - The fundamental disturbance is a change in mood
or affect, usually to depression (with or without
associated anxiety) or to elation. The mood
change is usually accompanied by a change in the
overall level of activity. - Most of these disorders tend to be recurrent, and
the onset of individual episodes is often related
to stressful events or situations. - The mood disorders may be subdivided into
unipolar and bipolar types - those that are characterized by depression only
- those that are characterized by manic episode
either alone or in combination with depression
3Classification of Mood Disorders
- International Classification of Diseases (ICD-10)
came into use in WHO Member States as from 1994 - F30 Manic episode
- F31 Bipolar affective disorder
- F32 Depressive episode
- F33 Recurrent depressive disorder
- F34 Persistent mood (affective) disorders
- F38 Other mood (affective) disorders
- F39 Unspecified mood (affective) disorder
4Test Methods
- Self-reported scales
- Young Mania Rating Scale (YMRS)
- Beck scale (depression)
- Zung scale (depression)
- Interview with physician
- Hamilton scale (HAMD)
- Montgomery and Asberg scale (MADRS)
5F32 Depressive Episode
- Pathological sadness
- Depressive episode
- depressed mood
- loss of interest and enjoyment
- reduced energy leading to increased fatigability
and diminished activity - marked tiredness after only slight effort
- reduced concentration and attention
- reduced self-esteem and self-confidence
- ideas of guilt and unworthiness
- bleak and pessimistic views of the future
- ideas or acts of self-harm or suicide,
- disturbed sleep and diminished appetite
6F32 Depressive Episode
- Clinical presentation shows marked individual
variations - in some cases, anxiety, distress, and motor
agitation may be more prominent at times than the
depression - the mood change may also be masked (masked
depression) by added features such as
irritability, excessive consumption of alcohol,
histrionic behaviour, and exacerbation of
pre-existing phobic or obsessional symptoms, or
by hypochondriacal preoccupations. - Depressive episode should last at least 2 weeks
(typically several months), but shorter periods
may be reasonable if symptoms are unusually
severe and of rapid onset. - The lifetime prevalence 17 risk of recurrence
gt50.
7F32 Depressive Episode
- The lowered mood varies little from day to day,
is unresponsive to circumstances and may be
accompanied by so-called somatic symptoms - loss of interest or pleasure in activities that
are normally enjoyable (anhedonia) - lack of emotional reactivity to normally
pleasurable surroundings and events - waking in the morning 2 hours or more before the
usual time - depression worse in the morning
- objective evidence of definite psychomotor
retardation or agitation - loss of appetite
- weight loss
- loss of libido
8F32 Depressive Episode
- F32 Depressive episode
- F32.0 Mild depressive episode
- F32.1 Moderate depressive episode
- F32.2 Severe depressive episode without psychotic
symptoms - F32.3 Severe depressive episode with psychotic
symptoms - F32.8 Other depressive episodes
- F32.9 Depressive episode, unspecified
9F32.0 Mild Depressive Episode
- Two or three of the above symptoms are usually
present. - For mild depressive episode are typical depressed
mood, anhedonia and increased fatigability. The
afflicted person is usually distressed by the
symptoms and has some difficulty in continuing
with ordinary work and social activities, but
will probably not cease to function completely.
10F32.1 Moderate Depressive Episode
- An individual with moderate depressive episode
suffers from more symptoms (four or more of the
above symptoms are usually present) of greater
severity and will usually have considerable
difficulty in continuing with social, work or
domestic activities.
11F32.2 Severe Depressive Episode without Psychotic
Symptoms
- In a severe depressive episode, the sufferer
usually shows considerable distress or agitation.
Loss of self-esteem or feelings of uselessness or
guilt are likely to be prominent, and suicide is
a distinct danger in particularly severe cases.
a number of "somatic" symptoms are usually
present. - Agitated depression
- Major depression
- Vital depression
12F32.3 Severe Depressive Episode with Psychotic
Symptoms
- Psychotic symptoms may be present, such as
- delusions (ideas of sin, poverty or imminent
disasters) - hallucinations (defamatory or accusatory voices
or of rotting filth or decomposing flesh) - depressive stupor
- Severe ordinary social activities are impossible
- When the psychotic symptoms are consistent with
the patients mood, they are referred to as mood
congruent, when they are inconsistent, they are
referred as mood incongruent. - Single episodes of
- major depression with psychotic symptoms
- psychogenic depressive psychosis
- psychotic depression
- reactive depressive psychosis
13F33 Recurrent Depressive Disorder
- Recurrent depressive disorder is characterized by
repeated episodes of depression without any
history of independent episodes of mood elevation
and overactivity. - Recovery is usually complete between episodes,
but a substantial part of patients will have a
recurrence and about 30 may develop a persistent
depression. - The lifetime prevalence - about 1020
womenmen 21. - The risk of suicide (approximately 1015.
- Seasonal affective disorder - onset of mood
symptoms is connected with changes of seasons,
with depression typically occurring during the
winter months and remissions or changes from
depression to mania occurring during the spring.
14F33 Recurrent Depressive Disorder
Kupfer 1991
15F33 Recurrent Depressive Disorder
- F33 Recurrent depressive disorder
- F33.0 Recurrent depressive disorder, current
episode mild - F33.1 Recurrent depressive disorder, current
episode moderate - F33.2 Recurrent depressive disorder, current
episode severe without psychotic symptoms - F33.3 Recurrent depressive disorder, current
episode severe with psychotic symptoms - F33.4 Recurrent depressive disorder, currently in
remission - F33.8 Other recurrent depressive disorders
- F33.9 Recurrent depressive disorder, unspecified
16F30 Manic Episode
- F30 Manic episode
- F30.0 Hypomania
- F30.1 Mania without psychotic symptoms
- F30.2 Mania with psychotic symptoms
- F30.8 Other manic episodes
- F30.9 Manic episode, unspecified
17F30.0 Hypomania
- Hypomania is characterized by
- persistent mild elevation of mood for at least
several days - increased energy and activity
- usually marked feelings of well-being and both
physical and mental efficiency - Increased sociability, talkativeness,
overfamiliarity, increased sexual energy, and a
decreased need for sleep are often present but
not to the extent that they lead to severe
disruption of work or result in social rejection.
There are no hallucinations or delusions
18F30.1 Mania without Psychotic Symptoms
- Mania without psychotic symptoms
- last for at least 1 weak
- mood is elevated out of keeping with individuals
circumstances and may vary from carefree
joviality to almost uncontrollable excitement - elation is accompanied by increased energy,
resulting in overactivity, pressure of speech,
and a decreased need for sleep - normal social inhibition are lost, attention
cannot be sustained, and there is often marked
distractibility - self-esteem is inflated, and grandiose or
over-optimistic ideas are freely expressed - perceptual disorders may occur
- the individual may embark on extravagant and
impractical schemes, spend money recklessly, or
become aggressive, amorous, or factious in
inappropriate circumstances.
19F30.2 Mania with Psychotic Symptoms
- Mania with psychotic symptoms represents a more
severe form of mania - inflated self-esteem and grandiose ideas may
develop into delusions, and irritability and
suspiciousness into delusions of persecution - in severe cases, grandiose or religious delusions
of identity or role may be prominent, and flight
of ideas and pressure of speech may result in the
individual becoming incomprehensible - sustained physical activity and excitement may
result in aggression or violence, and neglect of
eating, drinking, and personal hygiene may result
in dangerous states of dehydration and self
neglect - Mania with
- mood-congruent psychotic symptoms
- mood-incongruent psychotic symptoms
- Manic stupor
20F31 Bipolar Affective Disorder
- Bipolar affective disorder is characterized by
repeated, at least two episodes in which the
patients mood and activity levels are
significantly disturbed (manic or depressive
syndromes, patients who suffer only from repeated
episodes of mania are comparatively rare). - The first episode may occur at any age from
childhood to old age. - The frequency of episodes and the pattern of
remissions and relapses are both very variable. - The lifetime prevalence is between 0,5 an 1 .
Suicidality about 19. Comorbidity with alcohol
and drug abuse - The rapid-cycling specifier identifies those
patients who have had at least four episodes of a
major depressive, manic, or mixed episode during
the past 12 months.
21F31 Bipolar Affective Disorder
- F31 Bipolar affective disorder
- F31.0 Bipolar affective disorder, current episode
hypomanic - F31.1 Bipolar affective disorder, current episode
manic without psychotic symptoms - F31.2 Bipolar affective disorder, current episode
manic with psychotic symptoms - F31.3 Bipolar affective disorder, current episode
mild or moderate depression - F31.4 Bipolar affective disorder, current episode
severe depression without psychotic symptoms - F31.5 Bipolar affective disorder, current episode
severe depression with psychotic symptoms - F31.6 Bipolar affective disorder, current episode
mixed - F31.7 Bipolar affective disorder, currently in
remission - F31.8 Other bipolar affective disorders
- F31.9 Bipolar affective disorder, unspecified
22F34 Persistent Mood (Affective) Disorders
- Persistent mood disorders are persistent and
usually fluctuating disorders of mood in which
individual episodes are not sufficiently severe
to warrant being described as hypomanic or even
mild depressive episodes. - Lasting more than 2 years
- F34 Persistent mood (affective) disorders
- F34.0 Cyclothymia
- F34.1 Dysthymia
- F34.8 Other persistent mood (affective) disorders
- F34.9 Persistent mood (affective) disorder,
unspecified
23F34.0 Cyclothymia
- For cyclothymia persistent instability of mood,
involving periods of mild depression and mild
elation is typical. - This instability usually develops early in adult
life and pursues a chronic course, although the
mood may be normal and stable for months at a
time. - The mood swings are usually perceived by the
individual as being unrelated to life events.
24F34.1 Dysthymia
- Dysthymia represents a chronic, milder form of
depression which does not fulfill the criteria
for recurrent depressive disorder especially in
terms of severity. - Sufferers usually have periods of days or weeks
when they describe themselves as well, but most
of the time they feel tired and depressed. - It usually begins in adult life and lasts for at
least several years, sometimes indefinitely. - The lifetime prevalence is approximately 3, and
it is more common in women.
25F34.1 Dysthymie
- dysthymie mírná chronická deprese
- epidemiologie celoživotní prevalence kolem 3
- etiopatogeneze faktory genetické i vnejší
- lécba jako u depresivní poruchy
kognitivne-bahaviorální psychoterapie,
antidepresiva
26Treatment of Depression
- Various antidepressants altering levels of
central neurotransmitters are available to treat
depression. - Their overall effectiveness 65-70
- Mild to moderate depressive episode SSRIs.
- Severe depression antidepressants with broader
spectrum of effects, like SNRI or TCA. - Patients with insomnia or anorexia may do better
with more sedating medication (mirtazapine,
trazodon) - Patients with lethargy, hypersomnia, weight gain
and lower levels of tension and anxiety may
prefer the less sedating medications such as
bupropion, reboxetin or stimulating SSRIs. - IMAOs or RIMA should be tried in refractory
patients or patients with atypical depression.
27Treatment of Depression
- Drug trials should last 4 to 8 weeks.
- No response within 4 weeks of treatment - the
dose should be increased or the patient should be
switched to another drug. - In partial responders - augmentation strategy
coadministration of lithium carbonate or
trijodthyronine. - Psychotic patient - adding on neuroleptics.
- Anxious or agitated patients (also to improve the
sleep quality) - benzodiazepine coadministration
for a short period of time. - Lithium prophylaxis is an option to
antidepressants. - Supportive psychotherapy.
28Treatment of Depression
- First episode of depression - the drug should be
continued for another 16-20 weeks after the
patient is thought to be well (continuation
treatment to prevent recurrence). - The medication should be tapered gradually
because many patients experience some mild
withdrawal effects. - Patients with recurrent depression need long-term
maintenance therapy to prevent relapses. - Electroconvulsive therapy (ECT) is the treatment
of choice for some patients with very severe
depression, with high potential for suicide or
other selfdestroying behaviour and for pregnant
women. - Other biological methods
- phototherapy (seasonal affective disorder)
- sleep deprivation
- repetitive transcranial magnetic stimulation
(rTMS).
29Treatment of Mania
- Mood stabilizers
- lithium (0.61.2 mEq/L)
- carbamazepine (612 mg/L)
- valproate (50125 mg/L)
- Anticonvulsants
- gabapentine
- topiramate
- lamotrigine
- Agitated or psychotic patient coadministartion
of - antipsychotics of second generation (olanzapine,
risperidone) - benzodiazepines (lorazepam, clonazepam)
- ECT