1

MOOD DISORDERS
 Topics
o Major Depressive Disorder (MDD)
o Bipolar I Disorder
o Bipolar II Disorder
o Cyclothymia
o Dysthymia
 History
o Jules Falret
 “Folie circulaire”
 Alternating moods of depression and mania
o Karl Kahlbaum
 “Cyclothymia”
 Stages of depression and mania
o Emil Kraeplin
 Manic-depressive psychosis
 Epidemiology
o Incidence and Prevalence
 Mood Disorders are common
 Major Depressive D/O has the highest lifetime prevalence (almost 17%) of
all psychiatric D/O
o Sex
 MDD – 2x greater prevalence in females than in men due to:
1. Hormonal differences
2. Effects of childbirth
3. Difference in psychosocial stressors
4. Behavioral model of learned helplessness
o Age
 MDD
- Mean age: 40 years
- 50% onset at 20-50 yrs
- Increasing in <20 years AT PRESENT due to increased use of alcohol
and drug abuse
 Bipolar I disorder:
- Mean age: 30 years
- Ranges from childhood (5/6) to 50 years
o Marital Factors
 MDD – more in divorced/ separated
 Bipolar I Disorder – more common in divorced and single than married
(due to early onset and marital discord)
o Socio-economic and Cultural Factors
 Bipolar I Disorder
- More in upper class
- More common in persons who did not graduate from college
 Comorbidity
o Mood D/O
 Alcohol use/ abuse
 Panic Disorder
 Obsessive-compulsive D/O
 Social Anxiety D/O
o Substance Use and Anxiety D/O – increase risk for Mood D/O
o MDD and Bipolar D/O
 Males: substance use disorders
 Females: anxiety and eating D/O
 2

 In general, patients with Bipolar D/O have more anxiety and substance use
d/o than MDD
 Etiology
o Biological Factors
 Norepinephrine
 Dopamine
 Serotonin
 Histamine
Mental Relevant neurotransmitters and Effects of disorder in
Illness their functions neurotransmitter
secretion
Neurotransmitter Functions Disorder Effects
Depressio Serotonin Relaxes, Insufficien Lack of
n revitalizes, t positive
improves ↓ messages,
concentratio leading to
n low spirits
Norepinephrine Lifts Insufficien and lack of
emotions t energy
↓
Manic- Various Balances Imbalance Excessively
Depressive Neurotransmitter emotion ↔ fluctuating
Disorder s emotions

o Alterations of Sleep Neurophysiology

 Disturbance in depression
1. Increase in nocturnal awakenings
2. Increase in REM
3. Reduction in total sleep time
4. Increase in core body temp
- Note: 1+2 = reduction in first period of NREM (Reduced NREM
Latency)
o Genetic Factors
 One parent with mood D/O
- 10-25% risk for the child
 Both parents with mood D/O
- 20-50% risk for the child
o Psychosocial Factors
 Life Events and Environmental Stress
- More often precede first than episodes of mood d/o
- Stress accompanying first episode results in long-lasting changes in
brain biology
 Subsequent episodes of mood d/o even without an external stressor
- The life event most often associated with depression is losing a parent
before 11 years old.
- The environment stressor most often associated with depression is loss
of a spouse
- Unemployed persons have 3 times more likely to have symptoms of
MDD
 Personality Factors
- OCD, Histrionic and Borderline are at greater risk for depression than
persons with antisocial or paranoid personality disorder
 Psychodynamics of MDD
o Karl Abraham:
 4 key points:
 3

1. Disturbance in infant-mother relationship in oral phase (10-18 mos.)

predisposes to subsequent depression
2. Depression can be linked to a real or imagined object loss
3. Introjection of the departed object is a defense mechanism invoked to
deal with the distress connected with the object’s loss
4. Because the lost object is regarded with the mixture of love nad hate,
feelings of anger are directed inward at the self
o Melanie Klein
 Depression as involving aggression towards loved ones
o Edward Bibring
 Regarded depression as a phenomenon that sets in when a person becomes
aware of the discrepancy between extraordinary high ideals and inability
to meet those goals
o Edith Jacobson
 Saw depression as similar to a powerless, helpless child victimized by a
tormenting parent
o Silvano Arieti
 Many depressed people have lived their lives for someone else rather than
themselves
o Heinz Kohut
 Self-psychological theory
 The developing self has specific needs that must be met by parents to give
the child a positive sense of self-esteem and self-cohesion
o John Bowlby
 Damaged early attachments and traumatic separation in childhood
predisposes to depression
 Adult losses are said to revive the traumatic childhood loss and so
precipitate adult depressive episodes
 Psychodynamics of Mania
o Most theorists view mania as a defense against underlying depression
o Karl Abraham
 Believed that manic episodes may reflect an inability to tolerate a
developmental tragedy such as loss of a parent
 Result from a tyrannical superego – intolerable self criticism and then
replaced by eutphoric satisfaction
o Bertram Lewin
 Regarded the manic patient’s ego as overwhelmed by pleasurable
impulses, such as sex or by feral impulses such as aggression
o Melanie Klein
 Mania as a defensive reaction to depression, using manic defenses such as
omnipotence in which the person develops delusions of grandeur
o Cognitive Theory
 Aaron Beck
 Triad
1. View of the self
2. View of the environment
3. View of the future
o Learned Helplessness
 Connects depressive phenomena to the experience of uncontrollable
events
 E.g. shocked dogs
DSM-IV-TR Diagnostic Criteria for Major Depressive Episode
A. ≥ 5 out of 9 present during same 2 week period and represent a change from
previous functioning; at least 1 of the symptoms is either 1 or 2.
1. Depressed mood
2. Markedly diminished interest or pleasure
 4

3. Significant weight loss/ weight gain

4. Insomnia/ hypersomnia nearly every day
5. Psychomotor retardation or agitation
6. Fatigue or loss of energy
7. Feelings of worthlessness or excessive or inappropriate guilt
8. Diminished concentration
9. Recurrent thoughts of death
B. Exclusion of Mixed Episode
C. Impairment in functioning
D. Substance or Medical d/o exclusion
E. Symptoms are not accounted for bereavement
DSM-IV-TR Diagnostic Criteria for Manic Episode
A. A distinct period of abnormally and persistently elevated, expansive or irritable
mood, lasting at least one week (or any duration if hospitalization is necessary)
B. 3 or more of the following, 4 if mood is only irritable:
1. Inflated self esteem/grandiosity
2. Decreased need for sleep
3. More talkative than usual or pressure to keep talking
4. Flight of ideas/racing thoughts
5. Distractibility
6. Increase in goal directed activity/ psychomotor agitation
7. Excessive involvement in pleasurable activities that have a high potential for
painful consequences
C. Exclusion of Mixed Episode
D. Impairment in functioning
E. Substance or Medical d/o exclusion
DSM-IV-TR Diagnostic Criteria for Hypomanic Episode
A. A distinct period of abnormally and persistently elevated, expansive or irritable
mood, lasting through at least 4 days, that is clearly different from the usual non-
depressed mood
B. 3 or more, 4 if mood is only irritable
C. Unequivocal change in functioning that is uncharacteristic of the person when not
symptomatic
D. The disturbance in mood and the change in functioning are observable by others
E. Episode is not severe enough to cause marked impairment in functioning
F. Substance/general medical condition exclusion
DSM-IV-TR Diagnostic Criteria for Mixed Episode
A. Both manic and depressive symptoms are there every day for at least 1 week
DSM-IV-TR Diagnostic Criteria for Dysthymic D/O
A. Depressed mood for most of the day, for most days than not, as indicated by
subjective account or observation by others, for at least 2 years
B. Presence while depressed of 2 or more
1. Poor appetite/ overeating
2. Insomnia/ hypersomnia
3. Low energy/ fatigue
4. Low self-esteem
5. Poor concentration/ difficulty making decisions
6. Hopelessness
C. The person has never without symptoms in A & B for more than 2 months at a
time
D. No MDE present within 1st 2 years of disturbance
E. Exclusion of Manic episode, mixed, hypomania and cyclothymia
F. Exclusion of psychotic disorder
G. Exclusion of Substance/ General Medical Condition
DSM-IV-TR Diagnostic Criteria for Cyclothymic D/O
A. For at least 2 years, the presence of numerous periods of hypomanic and
depressive symptoms that do not meet criteria for a MDE
 5

B. The person has not been without the symptoms for more than 2 months at a time
Specifiers for Mood D/O
 Severity (mild, moderate, severe)
 Psychotic features (mood congruent/mood incongruent)
 Remission specifiers
o Partial remission
 Symptoms present but full criteria not met, OR
 Period without significant symptoms < 2 months following end of episode
o Full remission
 No significant signs or symptoms during past 2 months
 Melancholic Features
o Depression characterized by severe anhedonia, early morning awakening,
weight loss and profound feelings of guilt (often over trivial events”
o “Endogenous depression”
 Associated with changes in ANS and endocrine functions
 Atypical Features
o Overeating and oversleeping referred as Reversed vegetative symptoms/
hysteroid dysphoria
o As compared with typical depression, patients have younger age of onset,
more comorbid panic d/o, substance abuse/ dependence and somatization
disorder
 Catatonic Features
o The clinical picture is dominated by at least 2 of the following:
1. Motoric immobility as evidenced by catalepsy (including waxy flexibility)
or stupor
2. Excessive motor activity (that is apparently purposeless and not influenced
by external stimuli)
3. Extreme negativism (an apparently motiveless resistance to all instructions
or maintenance of a rigid posture against attempts to be moved) or mutism
4. Peculiarities of voluntary movement as evidenced by posturing
stereotyped movements, prominent mannerisms or prominent grimacing
5. Echolalia or echopraxia
 Postpartum Onset
o Onset within 4 weeks postpartum
 Rapid cycling
o At least 4 episodes in previous 12 months
 Seasonal pattern
o Regular temporal relationship between onset and remissions with particular
time of year
Clinical Features
 Depressive Episodes
o 2/3 of depressed patients contemplate suicide
o 10-15% commit suicide
o Common complaints
 Insomnia
 Decreased appetite
 Weight loss
 Reduced energy
 Anxiety
o 50% diurnal variation
o Depression in Children
 School phobias, excessive clinging to parents
o Depression in Adolescents
 Poor academic performance, substance abuse, antisocial behavior, sexual
promiscuity, truancy, running away
 6

o Depression in Older People

 Low socioeconomic status
 Loss of a spouse
 Concurrent physical illness
- Underdiagnosed by physicians
Course and Prognosis
 MDD
o Untreated lasts 6-13 months
o Treated last about 3 months
o 5-10% have manic episodes 6-10 years after first MDE
o Hospitalized for first episode
1. 50% chance of recovery within first year
2. 25% RECURRENCE within 6 months
3. 30-50% recurrence in 2 years
4. 50-75% recurrence in 5 years
 Bipolar I disorder
o Most often starts with depression
o Most patients experience mania and depression
o 10-20% experience only manic episodes
o Untreated manic episode lasts about 3 months
o Poorer prognosis than MDE
Differential Diagnosis
 MDE
o Grief/bereavement
o Anxiety disorder
o Substance use
 Bipolar I Disorder
o Psychotic disorders
Treatment
 Goals
o Safety
 Psychotherapy
o Psychodynamic – understanding past conflicts
o Cognitive – alterations of target thoughts
o Interpersonal – interpersonal problems
 Pharmacotherapy
o Antidepressants
1. TCA
2. SSRI’s
3. SNRI
 Effects of Antidepressants
Classes TCAs MAOI’s SSRIs SNRIs
Kinds Conventional antidepressants Atypical antidepressants
Benefits Have good Commonly used Have Have a more specific
treatment effects to cure atypical become classification of
on depression depression (with first-line neurotransmitters,
symptoms, such symptoms such medication Number of transmitters
as early as over eating, for treating to be affected is fewer
awakening, over-sleeping, depression; and side effects are
morning anxiety weight gain, have few considerably reduced
and weight loss. highly reactive side effects; since it targets
Have similar emotions, low risk transmitters which
functions to marked anxiety cause depression,
SSRIs and improve sleeping
sleeplessness) pattern, with less effect
 7

on sexual functions
Draw- Anticholinergic Weight gain, Anxiety, Dizziness, sleepiness
backs side-effects (such dizziness, sleep insomnia,
as dry mouth, disturbances, nausea,
hand tremors, decreased sexual headaches,
blurred vision, functions and decreased
weight gain, swelling of legs sexual
urinary retention and ankles functions,
and constipation) weight loss
Decreased sexual Activating
functions rather than
sedating;
may trigger
mania
among
people with
bipolar
disorder

o Bipolar I, Bipolar II disorders

 Lithium
 Carbamazepine
 Divalproic sodium