Mood (Affective) Disorders

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Mood (Affective) Disorders

• Department of Psychiatry
• 1st Faculty of Medicine
• Charles University, Prague
• Head Prof. MUDr. Jirí Raboch, DrSc.

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Mood (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

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Classification 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

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Test 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)

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F32 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

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F32 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.

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F32 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

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F32 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

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F32.0 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.

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F32.1 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.

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F32.2 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

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F32.3 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

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F33 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.

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F33 Recurrent Depressive Disorder
Kupfer 1991
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F33 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

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F30 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

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F30.0 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

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F30.1 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.

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F30.2 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

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F31 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.

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F31 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

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F34 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

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F34.0 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.

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F34.1 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.

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F34.1 Dysthymie

• dysthymie mírná chronická deprese
• epidemiologie celoživotní prevalence kolem 3
• etiopatogeneze faktory genetické i vnejší
• lécba jako u depresivní poruchy
  kognitivne-bahaviorální psychoterapie,
  antidepresiva

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Treatment 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.

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Treatment 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.

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Treatment 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).

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Treatment 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