Mood (Affective) Disorders

1. Mood (Affective) Disorders Department of Psychiatry 1st Faculty of Medicine Charles University, Prague Head: Prof. MUDr. Jiří Raboch, DrSc.

2. Mood (Affective) Disorders • Mood disorders are very common, their life prevalence is up to 20 %, and they have a high level of morbidity and mortality as well as an immense impact on disabilities worldwide. • The fundamental disturbance is a change in mood or affect, usually to depression (with or without associated anxiety) or to elation. The mood change is usually accompanied by a change in the overall level of activity. • Most of these disorders tend to be recurrent, and the onset of individual episodes is often related to stressful events or situations. • The mood disorders may be subdivided into unipolar and bipolar types: • those that are characterized by depression only • those that are characterized by manic episode either alone or in combination with depression

3. Classification of Mood Disorders International Classification of Diseases (ICD-10) came into use in WHO Member States as from 1994 F30 Manic episode F31 Bipolar affective disorder F32 Depressive episode F33 Recurrent depressive disorder F34 Persistent mood (affective) disorders F38 Other mood (affective) disorders F39 Unspecified mood (affective) disorder

4. Test Methods • Self-reported scales: • Young Mania Rating Scale (YMRS) • Beck scale (depression) • Zung scale (depression) • Interview with physician: • Hamilton scale (HAMD) • Montgomery and Asberg scale (MADRS)

5. F32 Depressive Episode • Pathological sadness • Depressive episode: • depressed mood • loss of interest and enjoyment • reduced energy leading to increased fatigability and diminished activity • marked tiredness after only slight effort • reduced concentration and attention • reduced self-esteem and self-confidence • ideas of guilt and unworthiness • bleak and pessimistic views of the future • ideas or acts of self-harm or suicide, • disturbed sleep and diminished appetite

6. F32 Depressive Episode • Clinical presentation shows marked individual variations • in some cases, anxiety, distress, and motor agitation may be more prominent at times than the depression • the mood change may also be masked (masked depression) by added features such as irritability, excessive consumption of alcohol, histrionic behaviour, and exacerbation of pre-existing phobic or obsessional symptoms, or by hypochondriacal preoccupations. • Depressive episode should last at least 2 weeks (typically several months), but shorter periods may be reasonable if symptoms are unusually severe and of rapid onset. • The lifetime prevalence: 17%; risk of recurrence >50%.

7. F32 Depressive Episode • The lowered mood varies little from day to day, is unresponsive to circumstances and may be accompanied by so-called „somatic“ symptoms: • loss of interest or pleasure in activities that are normally enjoyable (anhedonia) • lack of emotional reactivity to normally pleasurable surroundings and events • waking in the morning 2 hours or more before the usual time • depression worse in the morning • objective evidence of definite psychomotor retardation or agitation • loss of appetite • weight loss • loss of libido

8. F32 Depressive Episode F32 Depressive episode F32.0Mild depressive episode F32.1Moderate depressive episode F32.2Severe depressive episode without psychotic symptoms F32.3Severe depressive episode with psychotic symptoms F32.8Other depressive episodes F32.9Depressive episode, unspecified

9. F32.0 Mild Depressive Episode • Two or three of the above symptoms are usually present. • For mild depressive episode are typical depressed mood, anhedonia and increased fatigability. The afflicted person is usually distressed by the symptoms and has some difficulty in continuing with ordinary work and social activities, but will probably not cease to function completely.

10. F32.1 Moderate Depressive Episode • An individual with moderate depressive episode suffers from more symptoms (four or more of the above symptoms are usually present) of greater severity and will usually have considerable difficulty in continuing with social, work or domestic activities.

11. F32.2 Severe Depressive Episode without Psychotic Symptoms • In a severe depressive episode, the sufferer usually shows considerable distress or agitation. Loss of self-esteem or feelings of uselessness or guilt are likely to be prominent, and suicide is a distinct danger in particularly severe cases. ; a number of "somatic" symptoms are usually present. • Agitated depression • Major depression • Vital depression

12. F32.3Severe Depressive Episode with Psychotic Symptoms • Psychotic symptoms may be present, such as • delusions (ideas of sin, poverty or imminent disasters) • hallucinations (defamatory or accusatory voices or of rotting filth or decomposing flesh) • depressive stupor • Severe ordinary social activities are impossible • When the psychotic symptoms are consistent with the patient’s mood, they are referred to as mood congruent, when they are inconsistent, they are referred as mood incongruent. • Single episodes of: • major depression with psychotic symptoms • psychogenic depressive psychosis • psychotic depression • reactive depressive psychosis

13. F33 Recurrent Depressive Disorder • Recurrent depressive disorder is characterized by repeated episodes of depression without any history of independent episodes of mood elevation and overactivity. • Recovery is usually complete between episodes, but a substantial part of patients will have a recurrence and about 30% may develop a persistent depression. • The lifetime prevalence - about 10—20 %; women:men 2:1. • The risk of suicide (approximately 10—15%. • Seasonal affective disorder - onset of mood symptoms is connected with changes of seasons, with depression typically occurring during the winter months and remissions or changes from depression to mania occurring during the spring.

14. remission recovery severity of depression relapse recurrence no depression relapse response symptoms progression of illness syndrome 6-12 weeks 4-9 months 1 or more years treatment stage time F33 Recurrent Depressive Disorder Kupfer 1991

15. F33 Recurrent Depressive Disorder F33 Recurrent depressive disorder F33.0Recurrent depressive disorder, current episode mild F33.1Recurrent depressive disorder, current episode moderate F33.2Recurrent depressive disorder, current episode severe without psychotic symptoms F33.3Recurrent depressive disorder, current episode severe with psychotic symptoms F33.4Recurrent depressive disorder, currently in remission F33.8Other recurrent depressive disorders F33.9Recurrent depressive disorder, unspecified

16. F30 Manic Episode F30 Manic episode F30.0Hypomania F30.1Mania without psychoticsymptoms F30.2Mania with psychotic symptoms F30.8Other manic episodes F30.9Manic episode, unspecified

17. F30.0Hypomania • Hypomania is characterized by • persistent mild elevation of mood for at least several days • increased energy and activity • usually marked feelings of well-being and both physical and mental efficiency • Increased sociability, talkativeness, overfamiliarity, increased sexual energy, and a decreased need for sleep are often present but not to the extent that they lead to severe disruption of work or result in social rejection. There are no hallucinations or delusions

18. F30.1 Mania without Psychotic Symptoms • Mania without psychotic symptoms: • last for at least 1 weak • mood is elevated out of keeping with individual’s circumstances and may vary from carefree joviality to almost uncontrollable excitement • elation is accompanied by increased energy, resulting in overactivity, pressure of speech, and a decreased need for sleep • normal social inhibition are lost, attention cannot be sustained, and there is often marked distractibility • self-esteem is inflated, and grandiose or over-optimistic ideas are freely expressed • perceptual disorders may occur • the individual may embark on extravagant and impractical schemes, spend money recklessly, or become aggressive, amorous, or factious in inappropriate circumstances.

19. F30.2 Mania with Psychotic Symptoms • Mania with psychotic symptoms represents a more severe form of mania: • inflated self-esteem and grandiose ideas may develop into delusions, and irritability and suspiciousness into delusions of persecution • in severe cases, grandiose or religious delusions of identity or role may be prominent, and flight of ideas and pressure of speech may result in the individual becoming incomprehensible • sustained physical activity and excitement may result in aggression or violence, and neglect of eating, drinking, and personal hygiene may result in dangerous states of dehydration and self neglect • Mania with: • mood-congruent psychotic symptoms • mood-incongruent psychotic symptoms • Manic stupor

20. F31 Bipolar Affective Disorder • Bipolar affective disorder is characterized by repeated, at least two episodes in which the patient’s mood and activity levels are significantly disturbed (manic or depressive syndromes, patients who suffer only from repeated episodes of mania are comparatively rare). • The first episode may occur at any age from childhood to old age. • The frequency of episodes and the pattern of remissions and relapses are both very variable. • The lifetime prevalence is between 0,5 an 1 %. Suicidality – about 19%. Comorbidity with alcohol and drug abuse • The rapid-cycling specifier identifies those patients who have had at least four episodes of a major depressive, manic, or mixed episode during the past 12 months.

21. F31 Bipolar Affective Disorder F31 Bipolar affective disorder F31.0Bipolar affective disorder, current episode hypomanic F31.1Bipolar affective disorder, current episode manic without psychotic symptoms F31.2Bipolar affective disorder, current episode manic with psychotic symptoms F31.3Bipolar affective disorder, current episode mild or moderate depression F31.4Bipolar affective disorder, current episode severe depression without psychotic symptoms F31.5Bipolar affective disorder, current episode severe depression with psychotic symptoms F31.6Bipolar affective disorder, current episode mixed F31.7Bipolar affective disorder, currently in remission F31.8Other bipolar affective disorders F31.9Bipolar affective disorder, unspecified

22. F34 Persistent Mood (Affective) Disorders • Persistent mood disorders are persistent and usually fluctuating disorders of mood in which individual episodes are not sufficiently severe to warrant being described as hypomanic or even mild depressive episodes. • Lasting more than 2 years F34 Persistent mood (affective) disorders F34.0Cyclothymia F34.1Dysthymia F34.8Other persistent mood (affective) disorders F34.9Persistent mood (affective) disorder, unspecified

23. F34.0 Cyclothymia • For cyclothymia persistent instability of mood, involving periods of mild depression and mild elation is typical. • This instability usually develops early in adult life and pursues a chronic course, although the mood may be normal and stable for months at a time. • The mood swings are usually perceived by the individual as being unrelated to life events.

24. F34.1 Dysthymia • Dysthymiarepresents a chronic, milder form of depression which does not fulfill the criteria for recurrent depressive disorder especially in terms of severity. • Sufferers usually have periods of days or weeks when they describe themselves as well, but most of the time they feel tired and depressed. • It usually begins in adult life and lasts for at least several years, sometimes indefinitely. • The lifetime prevalence is approximately 3%, and it is more common in women.

25. F34.1 Dysthymie • dysthymie: mírná chronická deprese • epidemiologie: celoživotní prevalence kolem 3% • etiopatogeneze: faktory genetické i vnější • léčba: jako u depresivní poruchy – kognitivně-bahaviorální psychoterapie, antidepresiva

26. Treatment of Depression • Various antidepressants altering levels of central neurotransmitters are available to treat depression. • Their overall effectiveness: 65-70% • Mild to moderate depressive episode: SSRIs. • Severe depression: antidepressants with broader spectrum of effects, like SNRI or TCA. • Patients with insomnia or anorexia may do better with more sedating medication (mirtazapine, trazodon) • Patients with lethargy, hypersomnia, weight gain and lower levels of tension and anxiety may prefer the less sedating medications such as bupropion, reboxetin or stimulating SSRIs. • IMAOs or RIMA should be tried in refractory patients or patients with atypical depression.

27. Treatment of Depression • Drug trials should last 4 to 8 weeks. • No response within 4 weeks of treatment - the dose should be increased or the patient should be switched to another drug. • In partial responders - augmentation strategy; coadministration of lithium carbonate or trijodthyronine. • Psychotic patient - adding on neuroleptics. • Anxious or agitated patients (also to improve the sleep quality) - benzodiazepine coadministration for a short period of time. • Lithium prophylaxis is an option to antidepressants. • Supportive psychotherapy.

28. Treatment of Depression • First episode of depression - the drug should be continued for another 16-20 weeks after the patient is thought to be well (continuation treatment to prevent recurrence). • The medication should be tapered gradually because many patients experience some mild withdrawal effects. • Patients with recurrent depression need long-term maintenance therapyto prevent relapses. • Electroconvulsive therapy (ECT) is the treatment of choice for some patients with very severe depression, with high potential for suicide or other selfdestroying behaviour and for pregnant women. • Other biological methods: • phototherapy (seasonal affective disorder) • sleep deprivation • repetitive transcranial magnetic stimulation (rTMS).

29. Treatment of Mania • Mood stabilizers: • lithium (0.6—1.2 mEq/L) • carbamazepine (6—12 mg/L) • valproate (50—125 mg/L) • Anticonvulsants: • gabapentine • topiramate • lamotrigine • Agitated or psychotic patient – coadministartion of • antipsychotics of second generation (olanzapine, risperidone) • benzodiazepines (lorazepam, clonazepam) • ECT