Mood Disorders

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Mood Disorders

• RCS 6931
• Steven R. Pruett, Ph.D.
• May 31, 2007 (PM)

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Mood Episodes

• Building Blocks of Mood Disorders
• A period of time when a patient feels abnormally
  happy or sad.
• Major Depressive Episode
• 2 weeks in length (see p. 356 of DSM-IV-TR)
• Can take weeks to develop and take up to 4 months
  to resolve if left untreated
• Manic Episode
• 1 week in length (usually requires
  hospitalization) (see p. 362 of DMS-IV-TR)
• Sudden onset. Can last several weeks to several
  months. End is more abrupt than Major Depressive
  Episode

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Mood Episodes

• Mixed Episode
• Has had both Depressive and Manic symptoms for as
  little as 1 week (see p. 365 of DSM-IV-TR)
• Can evolve from a Major Depressive or Manic
  Episode
• Mixed episodes can last weeks to several months
  and may remit to a period with few or no symptoms
  or evolve into a Major Depressive episode less
  common to evolve into a Manic episode
• Hypomanic Episode
• Much like Manic, but briefer and less severe
  (usually does not require hospitalization) (see
  p. 368 of DSM-IV-TR)
• Begin suddenly with rapid escalation of symptoms
  (day or two). Episodes can last several weeks to
  months are usually abrupt on onset and briefer
  than Major Depression Episodes. May be preceded
  or followed by a MDE. 5 15 of individuals
  with a Hypomanic Episode will have a Manic
  Episode later in life.

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Some Diagnostic Specifiers

• Most recent episode
• Mild, Moderate, Severe without Psychotic Feature,
  Severe with Psychotic Features
• Chronic
• With Atypical features
• With Melancholic Features
• With Catatonic Features
• With Postpartum onset
• Recurrent episodes
• With or without full interepisodal recovery
• With rapid cycling
• With seasonal pattern

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Major Depressive Disorder 296.2x

• One or more major depressive episodes with no
  occurrence of the other three.
• Associated with high mortality
• Up to 15 of people diagnosed with Major
  Depressive Disorder commit suicide
• Death rate increase by four times with
  individuals who are 55 years or older and have a
  Major Depressive Disorder
• Comorbid with may other mental illness such as
  substance related disorders, panic disorders,
  OCD, Eating Disorders, and BPD.

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Major Depressive Disorder

• Lifetime risk for Women 10 to 25
• Lifetime risk for Men 5 to 12
• Point prevalence of adult in the community 5 to
  9 for women and 2 to 3 for men.
• Unrelated to ethnicity, education, income or
  marital status.

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Major Depressive Disorder - Course

• Can begin at any time. Average age at onset is
  in the mid-20s.
• Course of Major Depressive Disorder, Recurrent is
  variable.
• Some have isolated episodes separated by many
  years without depressive symptoms
• Others have clusters of episodes
• Others have more frequent episodes as they age

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Major Depressive Disorder - Course

• At least 60 of those individuals with a single
  episode of MDD can expect to have a 2nd
• Those that have 2 episodes have a 70 chance of
  getting a third.
• Those that have 3 episodes have a 90 chance of
  getting a fourth.
• About 5 10 of individuals with MDD, single
  episode will develop a manic episode (Bipolar I
  disorder)
• Familial Pattern 1.5 to 3 time more common
  among 1st degree biological relatives than the
  general pop.

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Major Depressive Disorder

• Diagnostic Criteria
• Single Episode
• Morrison p. 203, DSM-IV-TR p. 375
• Recurrent
• Morrison p. 207, DSM-IV-TR p. 376.
• Treatment
• CBT
• SSRIs -
• Tricyclics
• MAOIs
• ECTs

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Therapy and Depression
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Assessing use of CBT for Depression (from AAFP)
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Bipolar I disorders

• Any cyclic mood disorder that includes at least
  one Manic episode
• Used to be called Manic-Depressive illnesses
• Evenly distributed between the genders
• 1 of adult population
• Bipolar disorder is strongly hereditary
• Substance related disorders are strongly related
  to Bipolar disorders (not just bipolar I)
• Rapid Cycling
• modifier at least 4 episodes in last 12 months
  that meet criteria for Major depressive, Manic,
  Mixed or Hypomanic
• Frequently associated with previous substance
  abuse

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Bipolar episodes

• For an episode to be considered a new episode
• Either represent a change in polarity
• Or be separated from the previous episode by a
  normal period of at least 2 months.
• Note that Manic, Mixed or Hypomanic episodes may
  be precipitated by treatments of a Major
  Depressive Episode.
• Antidepressants, ECT, bright lights can cause a
  rapid change from depression to the other pole.
• However, for a mood episodes to count as a cycle,
  it must arise spontaneously
• (Manic, Hypomanic or Mixed episodes that are
  precipitated by antidepressants, ECTs or bright
  lights cant count as a episode).

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Bipolar I Disorder

• Not uncommon to have the Manic episode first in
  the Bipolar I disorder. Large majority of
  patients will have a Major Depressive Episode
  later on.
• Bipolar I Disorder, Single Manic Episode 296.0x
• If the individual has had at least one previous
  Manic, Major Depressive, Mixed episode and is
  currently in a Manic phase
• Bipolar I Disorder, Most Recent Episode Manic
  296.4x

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Bipolar I Disorder

• If the individual has had at least one previous
  Manic, Major Depressive, Mixed episode and is
  currently in a Hypomanic phase (first episode
  cannot be Hypomanic)
• Bipolar I Disorder, Most Recent Episode Hypomanic
  296.40
• If the individual has had at least one previous
  Manic, Major Depressive, Mixed episode and is
  currently in a Mixed phase
• Bipolar I Disorder, Most Recent Episode Mixed
  269.6x
• Mixed episode designation probably underutilized

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Bipolar I Disorder

• If the individual has had at least one previous
  Manic, or Mixed episode and is currently in a
  Major Depressive phase
• Bipolar I Disorder, Most Recent Episode Depressed
  296.5x
• Probably the most common designation since nearly
  all Bipolar I patients will get this diagnosis at
  least once in their lives.
• If the individual has had at least one previous
  Manic, or Mixed episode and is in one of the
  episodes but there is currently insufficient
  information to determine which subtype
• Bipolar I Disorder, Most Recent Episode
  Unspecified 296.7

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Bipolar II disorder 296.89

• Recent term AND concept
• Bipolar II never leads to psychosis and
  subsequently does not lead to hospitalization
• Recurrent Major Depressive Episodes associated
  with Hypomanic Episodes
• Mood episodes must arise spontaneously (cant
  count Hypomanic Episodes that are precipated by
  antidepressants, ECTs or bright lights).
• Women are more likely to get a Bipolar II
  disorder
• Prevalence less than 1 of general adult
  population

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Bipolar Disorders

• Treatment
• Mood stabilizing Medication
• LiCO3 (Lithium Carbonate)
• Tegretol (carbamazepine
• Depakote/Depakene (valproic acid)
• Zyprexa (olanzapine)
• Lamictal (lamotrigine)
• Abilify (aripiprazole)

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Dysthymic Disorder 300.4

• Chronically depressed mood for more days than not
  for at least 2 years.
• Depressive personality disorders
• Depressive Neurosis
• Cannot have a Major Depressive Episode in the
  first 2 years
• If it does then the Dx is Major Depressive
  Disorder, Chronic
• Cannot have a Manic, Mixed or Hypomanic episode.

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Dysthymic Disorder

• Diagnostic Criteria
• Morrison p. 223-224, DSM-IV-TR p. 380-381
• Treatment
• Antidepressant psychopharmacology
• CBT
• Interpersonal Psychotherapy (focused)
• Cognitive Behavioral Analysis System of
  Psychotherapy

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Cyclothymic Disorder 301.13

• Chronically either elated or depressed, but never
  meet the full criteria for a Manic, Mixed or
  Major Depressive Episode.
• Was once considered a personality disorder
• Begins usually early in life
• Equally common in men and women
• Lifetime prevalence 0.4 1. About 3 to 5 in
  mood disorder clinics.
• About a 15 to 50 risk that the individual will
  develop a Bipolar I or II disorder.

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Cyclothymic Disorder

• Diagnostic Criteria
• Morrison p. 227, DSM-IV-TR p. 400.
• Treatment
• Mood stabilizers (similar to Bipolar disorders)
• Psychotherapy
• Understand the nature of the disorder and learn
  to seek help when necessary
• Modify thoughts or behaviors that exacerbate or
  trigger symptoms
• Learn to live with extremes in mood
• Create manageable daily routines
• Improve choices and interactions in interpersonal
  and social relationships

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Mood Disorder Due to a General Medical Condition
293.83

• Many medical conditions can cause depression
  (some manic as well)
• Must be evidence from history, physical
  examination or lab findings that the mood
  disturbance is the direct physiological
  consequence of a general medical condition.
• Cannot make the diagnosis if the mood disturbance
  occurs only during a period of delirum.

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Mood Disorder Due to a General Medical Condition

• Diagnostic Criteria
• See Morrison p. 229 230, DSM-IV-TR p. 404
• Treatment
• Take care of medical condition causing the mood
  disturbance

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Substance-Induced Mood Disorder

• Alcohol 292.89
• All other substances 292.84
• Mood disorder has developed during or within a
  month of substance intoxication or withdrawal

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Substance-Induced Mood Disorder

• Diagnostic Criteria
• Morrison p. 233, DSM-IV-TR, p. 409
• Treatment
• Detox
• Psychopharmacology
• Substance Abuse Treatment

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Depressive Disorder NOS 311

• Minor depressive disorder
• Postpsychotic depressive disorder of
  Schizophrenia
• Major Depressive Episode superimposed on a
  psychosis
• Premenstrual Dysphoric Disorder
• Recurrent Brief Depressive Disorder
• Undiagnosed Depression

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Bipolar Disorder NOS 296.80

• Patients dont meet the criteria for better
  defined bipolar disorder can be coded Bipolar
  Disorder NOS
• Recurrent Hypomanic Episodes
• Manic Episode superimposed on a psychosis
• Undiagnosed mania

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Mood Disorder NOS 296.90

• Code should be used infrequently only to be
  used when there is insufficient information to
  make a more complete diagnosis.

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Specifiers for most recent episode

• With Atypical Features
• With Catatonic Features
• With Melancholic Features
• With Postpartum onset

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Specifiers for course or recurrent episodes

• With and without full interepisode recovery
• With rapid cycling
• With seasonal pattern
• See Table 5.1 on Morrison p. 244.