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Mood Disorders
Bruce Shapiro, M.D.
April 6, 2001
Do psychiatrists have mood swings?
What Determines Mood?What Determines Mood?
Harlow and Spitz
Gross Anatomy
Neuroimaging
Regionalization questions
Synapse
Intracellular activities
Brain mediated environment
History...
Mood Disorders
History The Bible (King Saul, Job) Hippocrates - Humoral theory Arateus - Psychological theory 1800’s - Physical diagnosis 1900’s - Psychological diagnosis 1930’s - Somatic interventions 1940’s - Psychoanalysis 1950’s - Psychopharmacology 1980’s - Biological markers 1990’s - Neuroimaging 2000’s - Herbals and magnetism ...
Hippocrates
Mood Disorders
Famous Sufferers ...
Abraham Lincoln
Winston Churchill
Churchill's Black Dog
"Black Dog”: Churchill's name for his depression
Lord Moran: inborn melancholia Periods of solitude Periods of high energy Highly functional
Ernest Hemingway
Suicide - Familial Aspects
A Quote
“In my last severe depression, I took coca again and a small dose lifted me to the heights in a wonderful fashion”
Sigmund Freud
Freud and Mom or Mom and Freud?
Famous Living Bipolars Robert Boorstin, writer, special assistant to President Clinton Rosemary Clooney, singer Dick Cavett, writer, media personality Kitty Dukakis, former First Lady of Massachusetts Patty Duke (Anna Pearce), actor, writer Connie Francis, actor, musician Shecky Greene, comedian Kristy McNichols, actress Kate Millett, writer Charley Pride, musician Axl Rose, musician Ted Turner, entrepreneur, media giant Jonathon Winters, comedian, actor, writer, artist
Famous Living Unipolars
Buzz Aldrin, astronaut Rona Barrett, entertainment reporter, author Art Buchwald, writer Barbara Bush, former U.S. First Lady Ray Charles, musician Eric Clapton, musician Dick Clark, television personality Leonard Cohen, musician, writer Francis Ford Coppola, director Michael Crichton, writer Kathy Conkrite, writer Sheryl Crow, musician Mike Douglas, media personality Tony Dow, actor, director
>>
Famous Living Unipolars
James Farmer, civil rights activist John Kenneth Galbraith, economist, educator, author Mariette Hartley, actor Anthony Hopkins, actor Robert McFarlane, former US National Security Advisor Joan Rivers, comedienne, talk show host Roseanne, actor, writer, comedienne Rod Steiger, actor William Styron, writer James Taylor, musician Livingston Taylor, musician
Mike Wallace, news anchor Marie Osmond, entertainer
Mood Disorders
Classification andDemographics ...
Mood Disorders (DSM-IV)Depressive Disorders
– Major Depressive Disorder (single/recurrent)– Dythymic Disorder– Depressive Disorder, NOS
Bipolar Disorders– Bipolar I– Bipolar II– Cyclothymic Disorder– Bipolar Disorder, NOS
Mood Disorder due to:– Medical condition– Substance induced
Mood Disorders - DSM IV
Unipolar vs BipolarUnipolar Bipolar
Prev 5% 1%Gender F>M F=MOnset 30’s 20’sSuicide 15% 20%Sleep insom hyperRx unipolar bipolar IIIGenetics lower higher
Epidemiology Lifetime risks:
– Major Depression: 6 %
– All mood disorders: 8 %
Prevalence
– Major Depression: (point prevalence approx 5 -6 %)
• Males: 2.6 - 5.5%
• Females: 6.0 - 11.8 %
– Dysthymia: 3 - 4 %
– In primary care practice:
• Major Depression: 4.8 - 9.2 %
• All depressive disorders: 9 - 20 %
Bipolar Disorder: 1.0 - 2.5 %
5 - 15 % of adult depressions are bipolar
Prevalence of Mood Disorders 20% of the U.S. population reports at least
one depressive symptom in a given month 12% report two or more depressive
symptoms in a year Major Depression: 5% in the previous 30
days, Bipolar Disorder - approximately 1 % of the
population
Increase in cohort post 1940 Younger age of onset
Genetics
Unipolar– Dizygotic: 30%– Monozygotic: 50%– Family history: 25%
Bipolar– Dizygotic: 30%– Monozygotic: 80%– Family history: 50%
Gender differences
Bipolar - no difference
Unipolar - Female > Male– ?genetic– sociocultural– alcoholism/substance abuse
Mood Disorders: Across the Lifespan
Infancy - Spitz and Harlow Childhood - depressive equivalents Adolescence - major onset;
substance abuse Adulthood - major onset Geriatric - multiple symptoms;
pseudodementia; differential medical diagnoses
Predisposing factors Prior mood disorder or moodswings Positive family history Female gender Severe prolonged stress Recent loss
Postpartum period
Medical co-morbidity
Current alcohol/substance abuse
Prognosis
Major Depression recurrence rates: 1 episode: 50 - 60%2 episodes: 70%3 episodes: 90%
Untreated episode: 6-12 months 20-30 % chronicity Episode length and frequency: shorter
episodes with increasing frequency Treatment yields good results
Mood Disorders
Clinical Syndromes ...
Hypomania:What does it feel like?“At first when I'm high, it's tremendous...ideas
are fast...like shooting stars you follow until brighter ones appear...all shyness disappears, the right words and gestures are suddenly there...uninteresting people, things, become intensely interesting. Sensuality is pervasive, the desire to seduce and be seduced is irresistible. Your marrow is infused with unbelievable feelings of ease, power, well-being, omnipotence, euphoria...you can do
anything...but, somewhere this changes”.
Mania:What does it feel like?“The fast ideas become too fast and there
are far too many...overwhelming confusion replaces clarity...you stop keeping up with it--memory goes. Infectious humor ceases to amuse. Your friends become frightened...everything is now against the grain...you are irritable, angry, frightened, uncontrollable, and trapped”.
Clinical Mania A sustained period of behavior that is different
from usual Increased energy, activity, restlessness, Racing thoughts and rapid talking Excessive "high" or euphoric feelings Extreme irritability and distractibility Decreased need for sleep Unrealistic beliefs in one's abilities and powers Uncharacteristically poor judgment
>>
Clinical Mania Reckless behavior Increased suspiciousness/paranoid ideation Increased sexual drive Abuse of drugs, particularly cocaine, alcohol, and
sleeping medications
Flight of ideas Provocative, intrusive, or aggressive behavior Possibly delusions (paranoid/grandiose/religious) Possibly hallucinations
Denial that anything is wrong
Cycle Length
Bipolar: Frequency of Recurrence
Hypomania Inflated self-esteem
Decreased need for sleep
More talkative than usual
Excessive involvement in pleasurable activities that have a high potential for painful consequences (e.g., the person engages in unrestrained buying sprees, sexual indiscretions, or foolish business investments)
Increased activity
No major life disruption
No need for hospitalization
No psychotic symptoms
Cyclothymia
Alternating hypomania and
non-major depression
At least 2 years in duration
Depression:What does it feel like?“I doubt completely my ability to do anything
well. It seems as though my mind has slowed down and burned out to the point of being virtually useless....[I am] haunt[ed]...with the total, the desperate hopelessness of it all... Others say, "It's only temporary, it will pass, you will get over it," but of course they haven't any idea of how I feel, although they are certain they do. If I can't feel, move, think, or care, then what on earth is the point?”
Sadness vs Clinical Depression
Intensity Duration Neurovegetative changes Self esteem changes Normal Grief vs. Depressive Illness
Depressive Disorders - DSM - IV
Major Depressive Disorder (296.xx)
Dysthymic Disorder (300.4) Depressive Disorder NOS (311) Mood Disorder due to general
medical condition (293.83) Substance-Induced mood
disorder (293.83)
Clinical Depression Loss of the ability to experience pleasure Unexplained or prolonged sadness or
crying spells Significant changes in appetite and sleep
patterns Diurnal variation of mood Irritability, anger, worry, agitation,
anxiety Pessimism, indifference A sense of hoplessness/helplessness
Clinical Depression Loss of energy, persistent lethargy,
pathological fatigue Feelings of guilt, worthlessness Inability to concentrate,
indecisiveness Social withdrawal Difficulty with personal hygiene Unexplained aches and pains May have delusions or hallucinations Recurring thoughts of death or suicide
Other Specifiers
Catatonic Features With Melancholic Features With Atypical Features With Postpartum Onset
Physical Symptom Indicators
Fatigue Pain Sleep disturbances GI disorders (IBS)
– unexplained by medical testing
Atypical Presentations
Anxiety/panic symptoms Irritability Hysterical symptoms Hypochondriacal symptoms Unexplained pain syndromes Substance abuse presentations “Personality disorder”
Dysthymia
This disorder is characterized by a chronic state of depression, exhibited by a depressed mood on most days for at least 2 years. (1 year in children and adolescents).
There are no psychotic symptoms .
Dysthymia: symptoms and duration
poor appetite or overeating insomnia or hypersomnia low energy or fatigue low self-esteem poor concentration or difficulty
making decisions feelings of hopelessness
Dysthymic individuals must not have gone for more than 2 months
without experiencing two or more of these symptoms
Mood Disorders
Suicide ...
Suicide Rates in Mood Disorders
Unipolar: 15 %
Bipolar: 20 %
Suicide Risk Factors
Clinical depression Suicidal ideation Self oriented (non-manipulative) Available lethal method Male>Female White>black Elderly Loss with alcohol/substance abuse
Suicide Rates
Suicide - Clusters
Mood Disorders
CausesandTreatments ...
Psychological Models
Psychoanalytic Interpersonal Cognitive Behavioral/learned
helplessness
Treatment: Psychological Individual Psychotherapy
– Psychodynamic/Psychoanalytic– Cognitive– Interpersonal– Supportive
Group Therapy Couples Therapy Family Therapy
Biological Models
Genetic Neurotransmitter dysfunction Neuroendocrine dysfunction Chronobiological Sensitization/Kindling
Serotonergic pathways
Neurotransmission
Neurons
Basic Synapse
Serotonin Synapse
Reuptake pump
Synaptic Interactions
Synaptic Transmission
Biological Markers in Major Depression
DST
TRH/TSH
Shortened REM latency
Treatment: Biological
Antidepressants Antipsychotics (typical, atypical) Mood stabilizers (thymoleptics) Augmentation strategies Herbal Phototherapy ECT rTMS
Mood Stabilizing Medications
Lithium carbonate/citrate Tegretol (carbamazepine) Depakote (valproic acid) Neurontin (gabapentin) Lamictal (lamotrigine) Klonopin (clonazepam) Zyprexa (olanzapine)
Antidepressant Medication Antidepressant medications are non-
addictive. Another antidepressant can be tried
should the first have unacceptable side-effects.
Antidepressants take time to work Physical symptoms are more likely to
respond before psychological symptoms Undulating improvement
Antidepressant medications
TCA’s (imipramine, nortriptyline, desopramine) MAOI’s (phenelzine, tranylcypromine, meclobemide) SSRI’s (fluoxetine, sertraline, paroxetine, fluvoxamine,
citalopram) SNRI’s (venlafaxine) CRI’s (buprorion) Alpha2 adrenergic antagonists (mirtazapine) Serotonin2A antagonists and serotonin reuptake
inhibitors (trazodone, nefazodone) Modified amino acids (SAMe) Psychostimulants Augmentation strategies (Li, T3, buspirone, anxiolytics )
Electroconvulsive Therapy (ECT)
History Indications Efficacy Adverse effects Safety
rTMS
Integrative Treatments
Nature AND Nurture In major syndromes: combinations
of medication and psychotherapy Treat the individual Never give up