Mood Disorders

Introduction

Scope of Depression - can be seen as a psychiatric disorder, normal emotion, or as a symptom.

Mood Disorders

Subtypes of bipolar disorder include bipolar (can be mixed, manic, or depressed) and cyclothymia (having highs and lows)

Subtypes of depression include major depression (includes single episode and recurrent) and dysthymia (low-grade chronic depression i.e., 2 years)

Bipolar Disorder Þ (1) Bipolar: manic, depressed, mixed; (2) Cyclothymia: highs and lows

Depression Þ (1) Major Depression: single, recurrent; (2) Dysthymia: chronic low grade

Global Burden of Disease Study - 5 of top 10 causes of disability worldwide are psychiatric

including bipolar, major depression, schizophrenia, dysthymia.

Treatment of Depression (economics): $43.7 million total spent on depression

$24 million in reduced productive capacity and excess absenteeism
$12.4 million in medical, psychiatric, pharmacologic care
$7.3 million in depression related suicide

Epidemiology

19% of the general population will meet diagnostic criteria for a mood disorder; higher in females than men

Major depression: 17% of general population - 21% female, 13 % male.

Manic depression: 1.6%of general population - 1.7% female, 1.6% male.

Dysthymia - low grade depression: 6.4% of general population - 8% female, 4.8% male.

Birth cohort effect of depression - Ý prevalence over generations; genetic anticipation; Ý severity, ß age of onset

Lack of Recognition

Patient Factors: only 1 in 3 with depression seeks medical attention

lack of awareness; difficulty communicating symptoms, social stigma

Physician factors: depression often masked by somatic complaints; patient denial; comorbidity

Common Reasons for Missed Diagnosis: discounting depressive symptoms due to life difficulties, coexisting disease, poor general medical health; believing that the anxious mood excludes a depressive disorder; failing to ask about manic/hypomanic symptoms; assuming that being older is depressing; assuming that if patient is not sad he/she is not depressed.

Consequence of Missed Diagnosis: 15% will commit suicide; ß physical, social and role functioning; Ý absenteeism; ß productivity

DSM IV Definition of Major Depression

Depressed mood and/or loss of interest or pleasure for 2 weeks AND

Four of the following symptoms (3 if both depressed mood and loss of interest or pleasure).

physical: insomnia, loss of appetite, fatigue, psychomotor retardation, agitation.

psychological: low self esteem/guilt, poor concentration/indecisiveness, thoughts of death, suicide ideation.

Presentation: pain complaints, fatigue, anxiety, irritability, lack of interest/pleasure (anhedonia)

can also manifest as GI problems, sleep problems, marital problems; most complaints are GI, or CNS disorders

Ý depression in patients with diseases - general population 6%, Parkinson’s, cancer (47%), stroke (49%), MI, cancer, etc.

Differential Diagnosis of depression

Other Conditions that Present with Symptoms of Depression: grief reaction or situational adjustment, substance abuse (15% in general population), general medical disorder, nonmood psychiatric disorder (bulimia, anorexia, panic disorder), primary mood disorder (major depression, dysthymia, bipolar), prescribed medications (antihypertensive, steroid)

Major Depression vs. Grief Reaction

Major depression : guilt or blame, more than 6 months, patient may be incapacitated, may be suicidal
Grief reaction: guilt and self-blame, less than 6 months, patient is not incapacitated, no suicidal tendencies

Depression vs. Dementia

Depression: no neurologic deficit, ß memory, ß attention and concentration, orientation relatively preserved, minor confusion, depressed affect, anxious, patient not influenced by suggestion. A trial course of antidepressants can be beneficial for this disorder

Dementia: neurologic deficit, ß memory, ß attention and concentration, orientation is confused, depressed affect, not anxious, patient is influenced by suggestion

Depression and Anxiety/Panic disorder

Depressive episode may accompany anxiety or panic disorder, may precede or follow
Depression becomes a more severe disorder with greater impairment if concurrent with anxiety/panic disorder
May not respond to antidepressants right away

Depression and Somatization

More depressed patients have medically unexplained somatic complaints
Joint pain, headache, backache, abdominal pain are common

Dysthymic Disorder: DSM IV Diagnostic Definition

2 years of numerous depression symptoms

same symptoms as depression, not as many symptoms needed, milder

different courses of depressive illness: dysthymic disorder, single episode, major depression with interepisode recovery, partial remission, double depression (dysthymic disorder with depression episode on top of it)

Manic Disorders

characterized by a high (euphoria), then low (depression)

Type I (hypomania): energetic, extroverted, assertive

Differential Diagnosis: idealized norm substance abuse, borderline, 3 to 4 months

Type II (mania): euphoric-grandiose, paranoid-irritable, hyperactive

Differential Diagnosis: schizophrenia, substance abuse, metabolic disorder

Type III (psychosis): paranoid, delusional, confusion

Differential Diagnosis: schizoprenia, substance abuse, metabolic disorder

Highs can be pleasant (euphoria or high) or unpleasant (anxiety, irritable, hyperactive).

Bipolar Disease

Bipolar type I = mania and severe depression
Bipolar type II = hypomania and severe depression

Suicide

suicide rates due to depressive disorders: 2/3 of depressed patients exhibit suicidal tendencies

10-15% commit suicide in depression, 10% in schizoprenia, 20% in manic-depressive disorder

Risk Factors for suicide: older, male, caucasian, current alcohol/substance abuse, living alone, history of suicidal ideation or attempts, physical illness or poor general medical health, feeling of hopelessness (sensitive to suicide)

When asking about suicide: his technique is to ease into it - no mention of suicide, ask about future, whether

sometimes they feel hopeless, do you ever think about hurting yourself, etc.