Mood Disorders

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Mood Disorders

• Dr Joanna Bennett

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Mood Disorders

• Pervasive alterations in emotions that are
  manifested by depression, mania, or both, and
  interfere with the persons ability to function
  normally

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Mood Disorders

• Major depression 2 or more weeks of sad mood,
  lack of interest in life activities, and other
  symptoms
• Bipolar disorder (formerly called
  manic-depressive illness) mood cycles of mania
  and/or depression and normalcy and other symptoms

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Some related disorders

• Seasonal affective disorder (SAD)
• Postpartum depression
• Postpartum psychosis

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Prevalence

• International studies
• Major depression - 3-16
• Bipolar disorder 0.3-1.5
• Caribbean
• 4.9 (PAHO 2005)
• Community prevalence and risk factors for mood
  disorders are generally unknown

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DSM Diagnostic criteria Major depressive
disorder

• At least one of the following three abnormal
  moods
• significantly interferes with the person's life
• Depressed mood
• Loss of interest pleasure
• Irritable mood (under 18 yrs)
• Occurring most of the day, nearly every day, for
  at least 2 weeks

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Diagnostic criteria Depression

• At least five of the following symptoms should
  have been present during the same 2 week
  depressed period
• Depressed or irritable mood
• Loss of interest pleasure
• Appetite/weight disturbance (gain/loss)
• Sleep disturbances
• Fatigue/loss of energy
• Guilt
• Poor concentration
• Morbid thoughts of death

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Diagnostic criteria Depression

• The symptoms are not due to
• Physical illness, alcohol, medication, or street
  drug use.
• Normal bereavement.
• Bipolar Disorder
• Delusional or Psychotic Disorders

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Mania Signs and symptoms

• Grandiose delusions, inflated sense of
  self-importance
• Racing speech, racing thoughts, flight of ideas
• Impulsiveness, poor judgment, distractibility
• Reckless behavior
• In the most severe cases, delusions and
  hallucinations

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Mania Signs and symptoms

• Increased physical and mental activity and energy
  
• Heightened mood, exaggerated optimism and
  self-confidence
• Excessive irritability, aggressive behavior
• Decreased need for sleep without experiencing
  fatigue

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Types of Bipolar disorder
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Diagnostic criteria Mania

• Persistently elevated, expansive or irritable
  mood, lasting at least 1 week (or any duration if
  hospitalization is necessary)
• 3 (or more) of the symptoms have persisted (4 if
  the mood is only irritable) and have been present
  to a significant degree

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Diagnostic criteria Mania

• inflated self-esteem or grandiosity
• decreased need for sleep
• more talkative than usual or pressure to keep
  talking
• flight of ideas or subjective experience that
  thoughts are racing
• distractibility
• excessive involvement in pleasurable activities

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Nursing diagnosis

• Psychiatrists have formulated clear guidelines
  for categorizing mental disorders (DSM-1V,
  ICD-10) determines interventions
• Nursing diagnosis provides basis for nursing
  intervention
• Systematic collection integration of data to
  formulate Nursing Diagnosis
• The Nurse combines nursing diagnoses and DSM/ICD
  classifications to develop the treatment plan

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Nursing Diagnosis

• Assessment/psychiatric interview/MSE
• Example nursing diagnosis
• Risk for Suicide
• Ineffective Coping
• Hopelessness
• Self-Care Deficit

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Aetiology

• Depression often triggered by stressful life
  events
• Contributing factors
• Intensity and duration of these events
• individuals genetic endowment
• coping skills
• social support network - depression and many
  other mental disorders are broadly described as
  the product of a complex interaction between
  biological and psychosocial factors

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Biological factors

• Focus on alterations in brain function
• Abnormal concentrations of many neurotransmitters
  and their metabolites in urine, plasma, and
  cerebrospinal fluid
• Overactivity of the HPA (hypothalamus-pituitary-ad
  renal) axis - stress
• dysfunction in serotonin (5-HT(1A) receptor
  activity could be due to a hypersecretion of
  cortisol

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Monoamine Hypothesis

• Prevailing hypothesis - depression is caused by
  an absolute or relative deficiency of monoamine
  transmitters in the brain
• Evidence that reserpine, a medication for
  hypertension, caused depression by depleting the
  brain of both serotonin and the three principal
  catecholamines (dopamine, norepinephrine, and
  epinephrine).

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Monoamine Hypothesis

• monoamine hypothesis remains important for
  treatment purposes.
• Many currently available pharmacotherapies that
  relieve depression or mania, or both, enhance
  monoamine activity.
• One of the foremost classes of drugs for
  depression, SSRIs, increase the level of
  serotonin in the brain.

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Psychosocial and Genetic Factors in Depression

• Social, psychological, and genetic factors act
  together to predispose to, or protect against,
  depression.
• many episodes of depression are associated with
  some sort of acute or chronic adversity
• past parental neglect, physical and sexual abuse,
  and other forms of maltreatment impact on both
  adult emotional well-being and brain function

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Psychosocial and Genetic Factors in Depression

• early disruption of attachment bonds can lead to
  enduring problems in developing and maintaining
  interpersonal relationships and problems with
  depression and anxiety.

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Cognitive factors

• how individuals view and interpret stressful
  events contributes to whether or not they become
  depressed.
• the impact of a stressor is moderated by the
  personal meaning of the event or situation
• Increased vulnerability to depression is linked
  to cognitive patterns that predispose to
  distorted interpretations of a stressful event

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Genetic factors in depression Bipolar

• Susceptibility to a depressive disorder 2-4 times
  greater among the first-degree relatives of
  patients with mood disorder
• The risk among first-degree relatives of people
  with bipolar disorder 6-8 times greater.

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Genetic factors in depression Bipolar

• Does not prove a genetic connection.
• First-degree relatives typically live in the same
  environment, share similar values and beliefs,
  and are subject to similar stressors, the
  vulnerability to depression could be due to
  nurture rather than nature

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Treatment

• 50 to 70 of depressed patients who complete
  treatment respond to either antidepressants or
  psychotherapies
• Surveys consistently show that a majority of
  individuals with depression receive no treatment

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Treatment

• The acute phase - 6 to 8 weeks medication
• patients should be seen weekly or biweekly for
  monitoring of symptoms, side effects, dosage
  adjustments, and support
• Psychotherapies during the acute phase for
  depression typically consist of 6 to 20 weekly
  sessions

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Treatment - ECT

• 60 to 70 response rate seen with ECT
• Proposed to be useful with poor response to
  medication
• depression is accompanied by potentially
  uncontrollable suicidal ideas and actions
• The most common adverse effects are confusion and
  memory loss for events surrounding the period of
  ECT treatment.

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Management- Maintenance

• Medication
• acute phase treatment and at least 6 months of
  continued treatment
• TCAs, SSRIs, NARIs, MAOIs,
• St John Wort (Herbal) as effective as
  antidepressants

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Psychosocial interventions depression

• NICE Guidelines (2009)
• Mild depression psychological
• Moderate depression Medication or Psychological
• Severe depression CBT medication

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Drug Treatment - Bipolar

• Lithium Long-term
• Anticonvulsants carbamazipine (not shown to be
  effective in acute treatment)
• Antidepressants SSRIs (inaequate evidence of
  effectiveness)
• Antipsychotics olanzapine, rispiridone
  (effective short-term)

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Psychosocial interventions - Bipolar

• CBT - group /individual
• 12-14 sessions lt depressive episodes
• Family therapy
• psychoeducation, communication skills training,
  and problem-solving skills training.