Definitions.

Mood disorders encompass a large group

of psychiatric disorders in which pathological moods
and related vegetative and psychomotor disturbances
dominate the clinical picture. Known in previous
editions of DSM as affective disorders, the term mood
disorders is preferred today because it refers to
sustained emotional states, not merely to the external
(affective) expression of the present emotional state.
Mood disorders are best considered as syndromes
(rather than discrete diseases) consisting of a cluster of
signs and symptoms, sustained over a period of weeks
to months, that represent a marked departure from a
person's habitual functioning and tend to recur, often
in periodic or cyclical fashion.
Morbidity and Mortality. Mood disorders, as highly
prevalent and lethal disorders, must command a
greater share in the clinical curriculum of both
psychiatrists and general medical practitioners.
Because most mood disorders are chronically
relapsing conditions, long-term exposure to patients
with these disorders in mood or bipolar clinics should
be obligatory training for young doctors.
Unfortunately, few academic centers have such clinics,
and those that exist are largely devoted to research.
The primary goal of these clinics is the execution of
research protocols rather than the acquisition of
clinical experience in caring for such patients.
The classification of mood disorders is an area which
is fraught with multiple controversies. According to
the ICD-10, the mood disorders are classified as
follows:
1. Manic episode
2. Depressive episode
3. Bipolar mood (affective) disorder
4. Recurrent depressive disorder
5. Persistent mood disorder (including cyclothymia
and dysthymia)
6. Other mood disorders (including mixed affective
episode and recurrent brief depressive disorder).
CLINICAL FEATURES AND DIAGNOSIS
Manic Episode

The life-time risk of manic episode is about 0.8-

1%. This disorder tends to occur in episodes
lasting usually 3-4 months, followed by complete
clinical recovery. The future episodes can be
manic, depressive or mixed.
A manic episode is typically characterised by the
following features (which should last for at least
one week and cause disruption in occupational
and social activities).
Euphoria (mild elevation of mood): An
increased sense of psychological well-being
and happiness, not in keeping with ongoing
events. This is usually seen in hypomania
(Stage I).

Elation (moderate elevation of mood): A feeling

of confidence and enjoyment, along with an
increased psychomotor activity. Elation is
classically seen in mania (Stage II).
Elation (moderate elevation of mood): A feeling
of confidence and enjoyment, along with an
increased psychomotor activity. Elation is
classically seen in mania (Stage II).

Exaltation (severe elevation of mood): Intense

elation with delusions of grandeur; seen in
severe mania (Stage III).
 Ecstasy (very severe elevation of mood): Intense
sense of rapture or blissfulness; typically seen in
delirious or stuporous mania (Stage IV).

Along with these variations in elevation of mood,

expansive mood may also be present, which is an
unceasing and unselective enthusiasm for interacting
with people and surrounding environment. At times,
elevated mood may not be apparent and instead an
irritable mood may be predominant, especially when
the person is stopped from doing what he wants. There
may be rapid, short lasting shifts from euphoria to
depression or irritability.
There is an increased psychomotor
activity, ranging from overactiveness
and restlessness, to manic excitement
where the person is ‘on-the-toe-on-the-
go’, (i.e. involved in ceaseless activity).
The activity is usually goal-oriented
and is based on external environmental
cues. Rarely, a manic patient can go in
to a stuporous state (manic stupor).
Speech and Thought
The person is more talkative than usual; describes
thoughts racing in his mind; develops pressure of
speech; uses playful language with punning,
rhyming, joking and teasing; and speaks loudly.

Later, there is ‘ flight of ideas’ (rapidly produced

speech with abrupt shifts from topic to topic, using
external environmental cues. Typically the connections
between the shifts are apparent). When the 'flight’
becomes severe, incoherence may occur. A less severe
and a more ordered ‘flight’, in the absence of pressure
of speech, is called ‘prolixity’.
There can be delusions (or ideas) of grandeur
(grandiosity), with markedly inflated self-esteem.
Delusions of persecution may sometimes develop
secondary to the delusions of grandeur (e.g. I am so
great that people are against me). Hallucinations (both
auditory and visual), often with religious content, can
occur (e.g. God appeared before me and spoke to me).
Since these psychotic symptoms are in keeping with
the elevated mood state, these are called mood
congruent psychotic features.
Distractibility is a common feature and results in rapid
changes in speech and activity, in response to even
irrelevant external stimuli.
Goal-directed Activity
The person is unusually alert, trying to do many things
at one time. In hypomania, the ability to function
becomes much better and there is a marked increase in
productivity and creativity. Many artists and writers
have contributed significantly in such periods. As past
history of hypomania and mild forms of mania is often
difficult to elicit, it is really important to take
additional historical information from reliable
informants (e.g. family members).
In mania, there is marked increase in activity with
excessive planning and, at times, execution of multiple
activities. Due to being involved in so many activities
and distractibility, there is often a decrease in the
functioning ability in later stages. There is marked
increase in sociability even with previously unknown
people. Gradually this sociability leads to an
interfering behaviour though the person does not
recognize it as abnormal at that time. The person
becomes impulsive and disinhibited, with sexual
indiscretions, and can later become hypersexual and
promiscuous.
Due to grandiose ideation, increased sociability,
overactivity and poor judgement, the manic person is
often involved in the high-risk activities such as
buying sprees, reckless driving, foolish business
investments, and distributing money and/or personal
articles to unknown persons.
Other Features

Sleep is usually reduced with a decreased

need for sleep. Appetite may be increased
but later there is usually decreased food
intake, due to marked overactivity. Insight
into the illness is absent, especially in
severe mania. Psychotic features such as
delusions, hallucinations which are not
understandable in the context of mood
disorder (called mood incongruent
psychotic features), e.g. delusions of
control, may be present in some cases.
Depressive Episode

The life-time risk of depression in males is 8-

12% and in females is 20-26%. However, the
life-time risk of major depression (or
depressive episode) is about 8%.
The typical depressive episode is characterized
by the following features (which should last
for at least two weeks for a diagnosis to be
made):

14
Depressed Mood
The most important feature is the sadness of
mood or loss of interest and/or pleasure in
almost all activities (pervasive sadness),
present throughout the day (persistent
sadness). This sadness of mood is
quantitatively as well as qualitatively
different from the sadness encountered in
‘normal’ sadness or grief.
The depressed mood varies little from day to
day and is often not responsive to the
environmental stimuli.
The loss of interest in daily activities
results in social withdrawal, decreased
ability to function in occupational and
interpersonal areas and decreased
involvement in previously pleasurable
activities. In severe depression, there may
be complete anhedonia (inability to
experience pleasure).
Depressive Ideation/Cognition
Sadness of mood is usually associated with
pessimism, which can result in three common types
of depressive ideas. These are:
a. Hopelessness (there is no hope in the future).
b. Helplessness (no help is possible now).
c. Worthlessness (feeling of inadequacy and
inferiority).
The ideas of worthlessness can lead to self-reproach
and guilt-feelings. The other features are difficulty in
thinking, difficulty in concentration, indecisiveness,
slowed thinking, subjective poor memory, lack of
initiative and energy.
Often there are ruminations (repetitive, intrusive
thoughts) with pessimistic ideas. Thoughts of death
and preoccupation with death are not uncommon.
Suicidal ideas may be present. In severe cases,
delusions of nihilism (e.g. ‘world is coming to an end’,
‘my brain is completely dead’, ‘my intestines have
rotted away’) may occur.
Psychomotor Activity
In younger patients (< 40 year old), retardation is
more common and is characterised by slowed thinking
and activity, decreased energy and monotonous voice.
In a severe form, the patient can become stuporous
(depressive stupor).
In the older patients (e.g. post-menopausal women),
agitation is commoner. It often presents with marked
anxiety, restlessness (inability to sit still, hand
wriggling, picking at body parts or other objects) and a
subjective feeling of unease.
Anxiety is a frequent accompaniment of depression.
Irritability may present as easy annoyance and
frustration in day-to-day activities, e.g. unusual anger
at the noise made by children in the house.
Biological Functions
Disturbance of biological functions is common, with
insomnia (or sometimes increased sleep), loss of
appetite and weight (or sometimes hyperphagia and
weight gain), and loss of sexual drive.
Somatic Syndrome in Depression (ICD-10)
a. Significant decrease in appetite or weight
b. Early morning awakening, at least 2 (or more)
hours before the usual time of awakening
c. Diurnal variation, with depression being worst
in the morning
d. Pervasive loss of interest and loss of reactivity to
pleasurable stimuli
e. Psychomotor agitation or retardation.
Psychotic Features

About 15-20% of depressed patients have psychotic

symptoms such as delusions, hallucinations, grossly
inappropriate behaviour or stupor. The psychotic
features can be either mood-congruent (e.g. nihilistic
delusions, delusions of guilt, delusions of poverty,
stupor) which are under standable in the light of
depressed mood, or can be mood-incongruent (e.g.
delusions of control) which are not directly related to
depressive mood.
Bipolar Mood (or Affective) Disorder
This disorder, earlier known as manic depressive
psychosis (MDP), is characterised by recurrent
episodes of mania and depression in the same patient
at different times. These episodes can occur in any
sequence. The patients with recurrent episodes of
mania (unipolar mania) are also classified here as they
are rare and often resemble the bipolar patients in their
clinical features.
Causes
Bipolar disorder affects men and women equally. It
most often starts between ages 15 and 25. The exact
cause is not known. But it occurs more often in
relatives of people with bipolar disorder.
In most people with bipolar disorder, there is no clear
cause for the periods (episodes) of extreme happiness
and high activity or energy (mania) or depression and
low activity or energy (depression). The following
may trigger a manic episode:
• Childbirth
• Medicines such as antidepressants or steroids
• Periods of not being able to sleep (insomnia)
• Recreational drug use
Symptoms
The manic phase may last from days to months. It
may include these symptoms:
Easily distracted
Excess involvement in activities
Little need for sleep
Poor judgment
Poor temper control
Reckless behavior and lack of self-control, such as
drinking, drug use, sex with many partners, gambling
and spending sprees
Very irritable mood, racing thoughts, talking a lot,
and false beliefs about self or abilities
The depressive episode may include these symptoms:
Daily low mood or sadness
Problems concentrating, remembering, or making
decisions
Eating problems such as loss of appetite and weight
loss, or overeating and weight gain
Fatigue or lack of energy
Feelings of worthlessness, hopelessness, or guilt
Loss of pleasure in activities once enjoyed
Loss of self-esteem
Thoughts of death or suicide
Trouble getting to sleep or sleeping too much
Pulling away from friends or activities that were once
enjoyed
People with bipolar disorder are at high risk of
suicide. They may use alcohol or other substances.
This can make the bipolar symptoms worse and
increase the risk of suicide.
Episodes of depression are more common than
episodes of mania. The pattern is not the same in all
people with bipolar disorder:
Depression and mania symptoms may occur together.
This is called a mixed state.
Symptoms may also occur right after each other. This
is called rapid cycling.

26
Exams and Tests
Ask whether other family members have bipolar
disorder
Ask about your recent mood swings and for how long
you have had them
Perform a thorough exam and order lab tests to look
for other illnesses that may be causing symptoms that
resemble bipolar disorder
Talk to family members about your symptoms and
overall health
Ask about any health problems you have and any
medicines you take
Watch your behavior and mood
27
COURSE AND PROGNOSIS
Bipolar mood disorder has an earlier age of onset
(third decade) than recurrent depressive (unipolar)
disorder. Unipolar depression, on the other hand, is
common in two age groups: late third decade and fifth
to sixth decades.
An average manic episode lasts for 3-4 months while a
depressive episode lasts from 4-6 months.
Unipolar depression usually lasts longer than bipolar
depression. With rapid institution of treatment, the
major symptoms of mania are controlled within 2
weeks and of depression within 6-8 weeks.
Nearly 40% of depressives with episodic course
improve in 3 months, 60% in 6 months and 80%
improve within a period of one year. 15-20% of
patients develop a chronic course of illness, which
may last for two or more years.
Some patients with bipolar mood disorder have more
than 4 episodes per year; they are known as rapid
cyclers. About 70-80% of all rapid cyclers are women.
When phases of mania and depression alternate very
rapidly (e.g. in matter of hours or days), the condition
is known as ultra-rapid cycling.
Some of the factors associated with rapid cycling
include the use of antidepressants (especially tricyclic
antidepressants), low thyroxin levels, female gender,
pattern of illness, and the presence of neurological
disease.
Some Prognostic Factors in Mood Disorders
Good Prognostic Factors
1. Acute or abrupt onset
2. Typical clinical features
3. Severe depression
4. Well-adjusted premorbid personality
5. Good response to treatment.
Poor Prognostic Factors
1. Co-morbid medical disorder, personality dis order
or alcohol dependence
2. Double depression (acute depressive episode
superimposed on chronic depression or dysthymia)
3. Catastrophic stress or chronic ongoing stress
4. Unfavourable early environment
5. Marked hypochondriacal features, or mood-
incongruent psychotic features
6. Poor drug compliance.
MANAGEMENT
Antidepressants are the treatment of choice for a vast
majority of depressive episodes.
The usual starting dose is about 75-150 mg of
imipramine equivalent. The clinical improvement is
assessed after about two weeks. In case of
nonimprovement, the dose can usually be increased up
to 300 mg of imipramine equivalent. It should be
remembered that it may take up to 3 weeks before any
appreciable response may be noticed. Before stopping
31
or changing a drug, the particular drug should be given
in a therapeutically adequate dose for at least 6 weeks.
Imipramine, amitriptyline and other related drugs are
called tricyclic antidepressants.
The newer antidepressants such as selective serotonin
reuptake inhibitors (fluoxetine, sertraline,citalopram)
have very little anti cholinergic side effects and, hence,
are generally safer drugs to use in elderly patients with
benign hyper trophy of prostate.
For the first, uncomplicated, depressive episode, the
patient should receive full therapeutic dose of the
chosen antidepressant for a period of 6-9 months, after
achieving full remission. It is wise to taper the anti
depressant medication, when the treatment is to be
stopped after the continuation phase.
There are three main phases of treatment:
i. Acute treatment (till remission occurs),
ii. Continuation treatment (from remission till end of
treatment), and
iii. Maintenance treatment (to prevent further
recurrences).
Maintenance treatment may be indicated in the
following patients:
i. Partial response to acute treatment.
ii. Poor symptom control during the continuation
treatment.
iii. More than 3 episodes (90% chances of recurrence).
iv. More than 2 episodes with early age of onset, or
recurrence within 2 years of stopping antidepressants,
or severe and/or life-threatening depression, or family
history of mood disorder.
v. Chronic depression (> 2 years) or double
depression.
About 20-35% of depressed patients are refractory to
antidepressant medication. The management of a
treatment refractory depressed patient is best done by
a psychiatrist, often at a tertiary care centre. These
patients may require one of the following alternatives:
i. A change of antidepressant,
ii. Combination of two types of antidepressants,
iii. Augmentation with lithium,
iv. Augmentation with antipsychotics,
v. Electroconvulsive therapy, or
vi. Use of newer and experimental techniques.
One type of depression, namely delusional depression
(depression with psychotic features), is usually
refractory to antidepressants alone. The treatments of
choice in this condition include:
i. An antidepressant with ECT, or
ii. An antidepressant with antipsychotics, or
iii. An antidepressant with lithium.
Lithium has traditionally been the drug of choice for
the treatment of manic episode (acute phase) as well as
for prevention of further episodes in bipolar mood
disorder.
Antipsychotics are an important adjunct in the
treatment of mood disorder. The commonly used drugs
include risperidone, olanzapine, quetiapine,
haloperidol, and aripiprazole. It is customary to use
the atypical antipsychotics first, before considering the
older typical antipsychotics.
Some of the indications include:
1. Acute manic episode
2. Along with mood stabilisers for the first few
weeks, before the effect of mood stabilisers becomes
apparent.
3. Where mood stabilisers are not effective, not
indicated, or have significant side-effects.
4. Given parenterally for emergency treatment of
mania.
5. Recently, there has been some early evidence that
atypical antipsychotics (e.g. olanzapine) might have
some mood stabilising properties.
The other mood stabilisers which are used in the
treatment of bipolar mood disorders include:
Sodium valproate. The dose range is usually 1000-
3000 mg/day (the therapeutic blood levels are 50-125
mg/ml).
The dose range of carbamazepine is 600-1600 mg/day
(the therapeutic blood levels are 4-12 mg/ml).
Lorazepam and clonazepam are used for the treatment
of manic episode alone rarely; however, they have
been used more often as adjuvants to antipsychotics.
Cognitive behaviour therapy aims at correcting
depressive negative cognitions (ideations) such as
hopelessness, worthlessness, helplessness and
pessimistic ideas, and replacing them by new
cognitive and behavioural responses.
The short-term psychoanalytic psychotherapies aim at
changing the personality itself rather than just
ameliorating the symptoms.
Group psychotherapy can be useful in mild cases of
depression. It is a very useful method of
psychoeducation in both recurrent depressive disorder
and bipolar disorder.