MOOD DISORDER

DR ABDUL RAZAK OTHMAN

PAKAR PSIKIATRI UD56
HOSPITAL KUALA LUMPUR
 Major depression
 Bipolar disorder
- in depressed phase
- in manic phase
 Dysthymia
 Mood disorder due to general medical
condition
 Substance-induced mood disorder
Mood Disorder
Aetiology
Genetic
 Depression
1st degree relative 10-15% (unipolar)
2% (bipolar)
 Bipolar disorder
1st degree relative 10-15% (unipolar)
10% (bipolar)
Early development
 Parental discord in childhood
 Childhood abuse

Personality
 Neuroticism

Environmental factors
 Recent stressful life events
 Lack of social support
Vulnerability factor (Brown & Harris,1978)
 Loss of mother before age of 11
 Not working outside the home
 Having no one to confide in
 Having the care of young children ( 3
children aged under 14 years)
DEPRESSION
5 or > of the following symptoms present
for 2 weeks (based on DSM IV)
 Depressed mood most of the day, nearly
everyday
 Markedly diminished interest or pleasure
in all/almost all activities
 Decrease/increase in appetite; significant
weight loss or weight gain
 Insomnia/hypersomnia
 Psychomotor agitation or retardation
 Fatigue or loss of energy
 Feelings of worthlessness or
excessive/inappropriate guilt
 Diminished ability to think or concentrate,
or indecisiveness
 Recurrent thoughts of death, suicide
ideation, suicide attempt
+/- psychotic features
- hallucination
- delusion
=> mood congruent
 PNEMONIC
 S leep
 I nterest
 G uilt feeling
 E nergy
 C oncentration
 A ppetite
 P sychomotor
 S uicide
Mental state examination
 General description
 Stoopedposture, downcast gaze, frowning
 Psychomotor retardation / agitation
 Mood and affect
 Depressed
 Speech
 Decreased rate and volume of speech
 Delayed responses to questions
 Respond to question with single words
 perceptual disturbance
 Mood-congruent hallucination
 Theme: guilt, sinfulness, worthlessness, poverty,
failure etc
 Thought
 Mood-congruent delusion
 Negative view of self, world and future

 Cognitive function
 Poor memory, impaired attention and concentration
=> pseudodementia
 Insight - good
Management
 Biological
- pharmacotherapy
- electroconvulsive therapy

 Psychological
Pharmacotherapy
Antidepressant
 Tricyclic antidepressant
(TCA)  Dose (mg)
 Prothiaden  25-150

 Imipramine  25-150

 Amitriptylline  25-100

 Clomipramine  25-100
 Selective serotonin reuptake inhibitor
(SSRI)
Dose (mg)
 Fluoxetine (Prozac) 20-60
 Sertraline (Zoloft) 50-200
 Fluvoxamine (Luvox) 50-300
 Escitalopram (Lexapro) 10-20
 others
Dose(mg)
 Venlafexine (Efexor XR) 75-150
 Mirtazapine (Remeron) 15-45
 Moclobomide (Aurorix) 300-600
 Duloxetine (Cymbalta) 60-90
Side-effects : TCA
 Anti-cholinergic
 Dry mouth, blurred vision, tachycardia,
glaucoma, constipation, urinary retention,
sexual dysfunction, cognitive impairment
 Anti-adrenergic
 Drowsiness, postural hypotension, sexual
dysfunction
 Anti-histaminic
 Drowsiness, weight gain
 Membrane-stabilising properties
 Cardiac conduction defects, cardiac
arrythmia, epileptic seizures
 Others
 Rash, oedema, elevated liver enzymes
Side-effects : SSRI
 Gastrointestinal
 Nausea, dry mouth, diarrhoea, constipation,
dyspepsia, bloating, flatulence
 Uncommon: vomiting, weight loss
 Central nervous system
 Headache, insomnia, dizziness, anxiety,
fatigue, tremor, somnolence
 Others
 Sexual dysfunction
Anxiolytic
 Lorazepam, alprazolam

Hypnotic
 diazepam, midazolam, zolpidem
Electroconvulsive therapy
Indication
 High risk of suicide
 Depressive stupor
 Danger to physical health ( not drinking
enough to maintain adequate renal
function)
 Postpartum depression
 Unsuccessful medication
Psychological
 Supportive psychotherapy
 Dynamic psychotherapy
 Cognitive therapy
BIPOLAR MOOD DISORDER
 Bipolar I
manic episode + depressive episode

 Bipolar II
hypomanic episode + depressive episode
Manic episode
 Distinct period of abnormally and
persistently elevated, expansive or irritable
mood, lasting at least one week
 3 or > of following symptoms have
persisted
 Inflatedself-esteem or grandiosity
 Decreased need for sleep
 More talkative than usual, pressure to keep
talking
 Flight of ideas
 Distractibility
 Increase in goal-directed activity /
psychomotor agitation
 Excessive involvement in pleasurable
activities that have a high potential for painful
consequences (eg: engaging in unrestrained
buying sprees, sexual indiscretions, or foolish
business investments)
 The mood disturbance is sufficiently
severe to cause marked impairment in
occupational functioning or in usual social
activities or relationship with others, or to
necessitate hospitalization to prevent harm
to self or others, or there are psychotic
features
 PNEMONIC
 D istractability
 I ndiscretion
 G randiosity
 F light of ideas
 A ctivity increased
 S leep deficit
 T alkativeness
Mental state examination
 General description
 exited,talkative, overfriendly, sometimes amusing
 excessive make-up, bright clothing

 Mood and affect

 Euphoric and infectious
 Irritable
 Labile
Uninvolved people may not recognize the unusual
nature of patient’s mood but those who know the
patient recognize it as abnormal
 Speech
 Loud voice, pressure of speech, cannot be interrupted
and difficult to end
 Clang association

 Perceptual disturbance
 75% has delusion
 Grandiose, a/w great wealth, extraordinary abilities or
power
 Thought
 Flight of ideas
 Impaired judgement
 Poor insight
Hypomanic episode
 A distinct period of persistently elevated,
expansive, or irritable mood, lasting
throughout at least 4 days, that is clearly
different from the usual nondepressed
mood
 Not severe enough to cause marked
impairment in social or occupational
functioning, or to necessitate
hospitalization and no psychotic features
Management
 Acute manic episode
- antipsychotic + mood stabilizer

 Prophylaxis
- mood stabilizer
Mood stabilizer
 Lithium
 Anticonvulsant
 Sodiumvalproate (Epilim)
 Carbamazepine (Tegretol)

 Atypical antipsychotic
 Olanzapine (Zyprexa)
 Quetiapine (Seroquel)
 Dose
- depends on the plasma level
Lithium
 Start with 200mg bd, check level after 5-7
days
 Acute phase: 0.8-1.2 mmol/l
prophylaxis : 0.6-0.8 mmol/l
Sodium valproate
 Start with 200mg – 400mg bd, check level after
3-5 days
 Plasma level: 50-100mg/l

Carbamazepine
 Start with 200mg bd until 600-1000 mg/day
 Paras plasma: 8-12mg/l
Side-effects
 Lithium
 Acute: tremor, diarrhoea, nausea and
vomiting.
 chronic: hypothyroidism, impaired renal
function
 Sodium valproate
 Sedation, tremor, weight gain
 Carbamazepine
 Nausea and vomiting, rashes, sedation,
neutropenia
 Steven-Johnson’s syndrome
DYSTHYMIA
 Depressed mood for most of the day, for at
least 2 years
 Presence while depressed, of 2 or > of
following
1) poor appetite or overeating
2) insomnia or hypersomnia
3) low energy or fatigue
 4) low self-esteem
5) poor concentration or difficulty making
decisions
6) feelings of hopelessness

 No major depressive episode has been

present during the first 2 years of
disturbances
Organic causes of depression
 Carcinoma
 Infection
 Dementia
 Stroke
 Diabetes
 Thyroid disorder
 SLE
Drugs that induce depression
 Antihypertensive
 Oral contraceptives
 Anticonvulsants
 Corticosteroids
 L-dopa
 Calcium-channel blockers
THANK YOU
docrazak35@yahoo.com
019-2740061