Prepared by : Hisham M. El Mudallal Ibrahim H. Rabea Mohamed Z. Aish Supervised by :

1. Mood Disorders: Depression and Mania Prepared by : Hisham M. El Mudallal Ibrahim H. Rabea Mohamed Z. Aish Supervised by : Dr. Abd Al Kareem Radwan

2. Presentation Objectives • Introduction • Classification • Epidemiology • Etiology • Comorbidity • Unipolar disorders • Bipolar disorder • Diagnostic criteria • Management • Course and prognoses • References

3. Introduction • Normal mood: every person experiences from time a change in his mood, which is related to everyday life events. • This is considered normal as long as it is appropriate to the event. • Mood is considered abnormal when it is excessively depressible or related out of proportion to the life experience.

4. Definition • Mood disorders (affective disorders): are a group of disorders characterized by disturbance in regulation of emotion, ranging from intense elation or irritability to severe depression. • These disorders often result in personal suffering, family distress, interpersonal and occupational impairment, an untold social costs.

5. Classification of mood disorders 1- Depressive Disorders : • major Depression Disorder (unipolar depression or clinical depression) • Atypical depression • catatonic depression • melancholic depression • postpartum depression • psychotic major depression • seasonal affective disorders • Dysthymia (double depression) • Depressive disorders not otherwise specified • recurrent brief depression • minor depressive disorder

6. Classification of mood disorders cont. 2- Bipolar Disorders (manic depression): • Bipolar I • Bipolar II • Cyclothymic • Bipolar disorder not otherwise specified 3- Substance-induced mood disorders: a. Alcohol induced M.D. b. Benzodiazepine M.D.

7. Epidemiology • 2% of the general population develop a mood disorder • Major depression fourth leading cause of disease burden in the world (WHO 2002) • 21% of women and 13% of men develop major depression. Ratio M:F ≈ 1:2 • Age of onset for major depression disorder ≈ 25 • Depression occurs more frequently in lower socioeconomic groups. • Bipolar disorders occurs more frequently in higher socioeconomic groups. • Age of onset of bipolar disorder ≈ 20 • Prevalence of bipolar disorder ≈ 1% . Ratio M:F ≈ 2:3

8. Etiologic Factors Related to mood disorders 1- Neuron biologic factors: • Altered neurotransmission (biochemical influences): abnormalities in various neurotransmitters as decrease in norepinephrine, low levels of serotonin in the brain, decrease in dopamine • Neuroendocrine dysregulation: hypothalamus, pituitary, adrenal, thyroid, and growth hormone. • Genetic transmission (heredity) • first degree relatives with mood disorders. (at least 3 times higher) • concordance between identical twins is high.

9. Etiology cont. 2- Psychological factors: • Psychoanalytic theory: depression is a result of loss - mania is a defense against depression. • Cognitive theory: depression is a result of negative processing of thoughts. • Learned helplessness: depression is a result of apperceived lack of control over events. • Life events and stress theory: significant life events cause stress, which results in depression or mania. • Personality theory: personality characteristics predispose an individual to mood disorders.

10. 3- Social and environmental factors: • Adverse childhood experiences lead to depressive disorders in adult life • Depression is more common in divorced men. • Women, who were caring for 3 or more children under the age of 11, unemployed and without a confiding relationship, were at high risk of having depression. • High rates of depression are seen in clients with chronic or painful physical illnesses

11. Comorbidity With Other Disorders • Symptoms of anxiety are common in depressive disorder. • Depressive features are quite frequent in: generalized anxiety disorder, panic disorder, obsessive-compulsive disorder, schizophrenia, schizoaffective disorder, eating disorder and personality disorder. • Substance-use disorders are common in person with mood disorder. • The incidence of depressive disorder is quite high in medical illness such as: chorea, parkinson's disease, epilepsy, stroke, migrant, myocardial Infraction, endocrinal disorders, viral infections and rheumatoid arthritis.

12. 1- Depressive Disorders • Major depressive disorder (MDD): (unipolar or clinically depression) • Is condition characterized by along-lasting depressed mood or marked loss of interest or pleasure (anhedonia) in all or nearly all activities. • Children and adolescents with MDD may be irritable instead of sad.

13. Symptoms of Depression: “Space Drugs" Sleep disturbance: insomnia or hypersomnia nearly everyday. Pleasure/interest: (lack of) anhedonia in things that normally enjoy. Agitation: psychomotor agitation nearly everyday. Concentration: diminished ability to think or concentration, or indecisiveness. Energy: fatigue or loss of energy nearly everyday Depressed mound: most of day Retardation movement: psychomotor retardation nearly everyday Appetite disturbance: decreased or increased appetite and weight change. Guilt: feeling of worthlessness or excessive or inappropriate guilt. Suicidal thought: recurrent thoughts of death and suicidal ideation.

14. Mental Status Examination • General appearance: psychomotor retardation, decreased activity level, spontaneous movements, stooped posture and sad facid expression. • Mood/Affect: depressed mood and he sees the world through dark glasses. • Speech: slow, monotonous, answers in brief, • Perception:Hallucination, and illusions may occur in depression • Thought: negative thought about themselves, the world and the future. • preoccupation with thoughts of loss, worthlessness, guilt and death. • suicidal ideation is present in 213 of patients. • the patient may have delusions of guilt or poverty. • process: thinking is slow and difficult, the patient may take along time to answer a question.

15. Mental Status Examination cont. • Orientation: usually oriented to place, time and person • Memory:most of patients complain of forgetfulness and poor concentration. • Judgment/Insight: depressed patients emphasize their symptoms, they are said to have excessive insight into their condition. • Reliability:Information from depressed patients tend to emphasize the bad and minimize the good. • Impulse control: 213 of depressed patients have suicide thoughts, and about 10-15% actually complete suicide.

16. Diagnostic criteria • DSM IV criteria for major depression. • Five (or more) of the symptoms have been present during the same two week period and represent a change from previous functioning, depressed mood or anhedonia should be one of them.

17. Subtypes of Major depressive disorder • Atypical depression: is characterized by mood reactivity (ability to react to positive stimuli) and significant went gainer increased appetite, hypersomnia, a sensation of heaviness in limbs (leaden paralysis), and significant social impairment as a consequence of hypersensitivity to perceived interpersonal rejection. • Melancholic depression: is characterized by a loss of pleasure in most or all activities, a failure of reactivity to pleasurable stimuli, a worsening of symptoms in the morning hours, early morning waking, psychomotor, retardation, excessive went loss, excessive guilt.

18. Subtypes of major depressive disorder (cont.) • Psychotic major depression: major depressive episodes, where the patient experiences psychotic symptoms such as delusions, hallucinations. • Catatonic depression: is a rare and severe form of major depression involving disturbances motor behavior, stupporose, immobile. • Post-partum depression: depression following the birth of a child, usually occurs within 4 weeks of the birth and having symptoms of depression. • Seasonal affective disorder (winter depression): some people have a seasonal pattern, a depressive episodes coming or in the autumn or winter, and resolving in spring, the diagnosis is made if at least 2 periods have occurred in colder months c none at other times over a two-year period or longer.

19. Dysthymic Disorder (double depression) • Chronic mood disorder includes depression most of the day for most days for 2 years in adults and 1 year children and adolescents. • Diagnosis: 1- Depression for most of day for a period not less than 2 years. During the period of depression 2 or more of the following symptoms:- • loss or increase appetite. • insomnia or hypersomnia • loss of energy or exhaustion. • low self esteem and inadequacy • Difficulty c concentration, memory, and decision making.

20. Dysthymic Disorder (cont.) 2- Absence of episodes of mania, mixed, hypomania or major depression. 3- The symptoms cause clinical problems, social and vocational. Notice: • It is difficult to differential between major depression and dysthymia because the symptoms are the same. In major depression the performance of person is decreasing significantly, but in dysthymia less severe and its effect on the performance is less and may continue for years. • It is believed that 50% of dysthymic pt. will have major depression later.

21. Depressive Disorder not otherwise specified: Any depressive disorder that does not meet the criteria for a specific disorder. It includes: • Recurrent brief depression: depressive episodes once per month at least one year, with individual episodes lasting less than 2 weeks and typically less than 2-3 days. • Minor depressive disorder: depression that does not meet full criteria for major depression but in which at least two symptoms are present for 2 weeks.

22. Bipolar Disorders (manic depression) A mood disorder described by alternating periods of mania and depression. Mania: It is mood disorder characterized by abnormal elevated expanded or irritable mood. • onset of mania usually rapid, the patient is unaware of his inappropriate behavior without regard to social or moral conventions.

23. How to Diagnosis: DSM IV criteria a. Abnormal and persistent elevated, expensive or irritable mood for at least one week. b. During the period of mood disturbance, presence of 3(or more) of the following symptoms: 1. Inflated self esteem orgrandrosity. 2. decreased need for sleep. 3. more talkative than usual or pressure to keep talking. 4. distractibility. 5. increase in goal-directed activity or psychomotor agitation. 6. flight of ideas or racing.

24. Mental state examination • General appearance:hyperactive, dress in colorful but inappropriate clothes. • Mode/Affect: mood is elevated, expensive, express feeling without restraint, Elation, Euphoria, and grander. • Speech: pressure speech, rapid and difficult to interrupt. • Thought: Delusions of grandiosity and persecution, thinking is rapid, flight of idea. • Perception: Hallucination may occur, as religious or sexual type. • Orientation: oriented to time, place and person. • Concentration: poor and are easily distracted by environmental stimuli. • Memory: is usually intact. • Insight/Judgment: is impaired • impulse control: Impulsive behavior is common, suicide sometimes. • Reliability: Information not reliable.

25. Hypomanic Episode The same symptoms of mania but with different in period and severity (hypomania is less severity and longer period) it is characterized by: • A distinct period of persistently elevated, expensive, or irritable mood, lasting thought at least 4 days, that is clearly different from the usual non depressed mood. • During the period of mood disturbance, 3 (or more) of the following symptoms have persisted (4 if the mood is only irritable): • Inflated self esteem • decreased need for sleep • distractibility • flight of ideas • more talkative than usual • increase in goal-directed activity or psychomotor agitation. • excessive involvement in pleasurable activities that have a high potential for painful consequence.

26. Hypomanic Episode Cont. • The episode is associated with an unequivocal in functioning that is un characteristic of the person when not symptomatic. • The disturbance in mood and the change in functioning are observable by others. • The episode is not severe enough to cause marked impairment in social or occupational functioning or to necessitate hospitalization, and there are no psychotic feature. • The symptoms are not due to the direct physiological effects of a substance.

27. Subtypes of Bipolar disorder • Cyclothymic Disorder: chromic mood disturbance of at least 2 years' duration. Many episodes of hypomanic symptoms and depressive symptoms that do not meet criteria for a major depressive episode. • There symptoms are less severe or intense than those in major depression or manic episode.

28. Subtypes of Bipolar disorder cont. • Bipolar I: is distinguish by the presence or history of one or more manic episodes or mixed episodes with or without major depressive episodes. • Bipolar II: consisting of recurrent intermittent hypomanic and depressive episodes. • Bipolar disorder not otherwise specified: indicates that the patient suffers from some symptoms in the bipolar spectrum but does not fully quality for any of the three formal bipolar mentioned above.

29. Management of mood disorders 1- Hospitalization: may require at the onset of disorder • to control symptoms • to safety of the p1. 2- Pharmacotherapy: - antidepressant: TCA'S - MAO'S -SSRI'S • lithium carbonate - Depakine -Tegretol 3- Psychotherapy - psychoeducation - family therapy - cognitive – Behavioral therapy - interpersonal and social therapy

30. 3- Substance – induced mood disorders: Mode disorders occurs due to direct physiologic effects of psychoactive drug, or other chemical substance, substance intoxication or withdrawal. • Alcohol – induced mood disorders: Alcoholism. • Benzodiazepine – induced mood disorders: longterm (chronic) used.

31. Course and programs of mood disorder: • Depressive episode usually last for 6 months. • The presence of residual symptoms such as somatic symptoms and poor sleep increase the risk of recurrence. • The death rate in clients with depressive disorder is higher. • 11-17% of client with severe depression eventually commit suicide • Clients with younger age of onset show better recovery. • The length of manic episode varies from 3-13 months • Prognosis is much better with treatment • The most serious complication is suicide, and substance abuse.

32. Nursing Interventions • Maintaing supportive contact with the client • provide quite, non-stimulating environment. • encourage client to actively engage in life and relationships. • assist with ADL'S / hygiene / grooming as needed. • Assist client to identify previous coping skills • Identify client's needs • remove harmful objects/protect from self-harm, others. • assist with problem solving / decision making • assist client to set limits on own behavior • educate about disorder and medication compliance • monitoring for side effects of drugs

33. References: • Katherine M. Fortinasl and Patricia A. Holoday-worret (1996) psychiatric Mental Health Nursing, Newyork, Tornto, 1st edition. • Rob Newell and Kevin Gournay. (2009) Mental Health Nursing, New York, Tornto, 2nd edition.