DSM-5 Classification of Mood Disorders

 Disruptive Mood Dysregulation Disorder
 Dysthymia (Persistent Depressive Disorder)
 Major Depressive disorder (unipolar depression)

Depressive disorder not otherwise specified (Premenstrual Dysphoric Disorder, Atypical depression, Postnatal depression, Seasonal affective disorder)

  Bipolar II Disorder (Hypomania + Major Depressive disorder)

  Bipolar I Disorder (Mania with Major Depressive disorder)

  Cyclothymic Disorder
Others:, Substance/Medication-Induced mood disorders, mood disorders due to another medical condition.

  

Depressive disorder

The term ‘depression’ is widely used to describe low mood, but in order for a diagnosis of depressive disorder to be made there are a number of key features that must be present for at least 2 weeks

  

ICD-10 criteria for depressive disorder A
Persistent low mood; and/or
Loss of interest or pleasure (anhedonia) Fatigue or low energy (anergia)

B

Reduced concentration and attention Reduced self-esteem and self-confi dence Ideas of guilt and worthlessness Hopelessness about the future

Suicidal thoughts Disturbed sleep Diminished appetite

  

Depressive disorder is also associated with a number of other symptoms that relate to these core diagnostic features. These include psychomotor retardation (slowed movements and thinking) or agitation, loss of libido, constipation and amenorrhoea. This group of symptoms are sometimes referred to as somatic syndrome.

  

The severity of the episode is determined by how many of these features are present

Mild: 2 or more from A + 2 from B Moderate: 2 or more from A + 3 from B Severe: All 3 from A + 4 or more from B

If there has been more than one discrete episode this is termed recurrent depressive disorder.

  

Dysthymia

This term is used to describe longstanding mild depressive symptoms. Dysthymia is often associated with other psychiatric or physical illness and can also co-occur with depression – a condition sometimes termed ‘double depression’.

  

Psychotic depression
Depression at its most severe becomes

psychotic
depressive
perceived
delusional in intensity. The patient may believe that they, or a part of them, is dead (Cotard’s syndrome); they may experience auditory hallucinations, which are often derogatory in nature. Suicide risk is high.

depression (also called psychosis). Worries and misdemeanours become

  

Psychomotor retardation can increase to the point where the person sits motionless and mute –depressive stupor. Th is often used to be fatal (fromdehydration); it now calls for emergency electroconvulsive therapy (ECT).

Psychotic depression must be distinguished from other psychoses. This is based on the presence of other depressive symptoms, and themood congruity of the delusions and hallucinations.

  

Atypical depression

For some individuals depression is associated with increased sleep, increased appetite and phobic anxiety. This is often termed atypical depression and tends to respond better to monoamine oxidase inhibitors (MAOIs) rather than selective serotonin reuptake inhibitors (SSRIs).

  

Reactive and endogenous depression

This dated classification divided depression into ‘reactive depression’, brought on by a stressful life event, and ‘endogenous’ depression, supposedly occurring from within the patient, with no clear external cause. Endogenous depression was thought to be more heritable and more responsive to antidepressant treatment. Research into depression has shown that such a division does not exist, and these terms are rarely used now.

  

Mixed anxiety and depressive disorder

Anxiety symptoms are common in depressive disorder and when symptoms of both disorders are present but not individually sufficient enough to meet criteria for a diagnosis of a mood disorder or an anxiety disorder this is described as a mixed anxiety and depressive disorder.

  

Epidemiology Prevalence: 2-5%
M:F: 1:2
Mean age of onset = late 20s

More common in: women that have 3 children younger than 11 years, lower socioeconomic groups, exposure to loss single (divorced/ separated, widowed, and never married), urban > rural

Depression was 3 times higher in the unemployed.

  

Aetiology
biological, psychological, and social factors

Neurobiological factors: Structural brain changes

Functional brain changes

Neurotransmitter abnormalities Endocrine changes
Genetic factors
Psychological factors

Gender Social factors

  

Differential diagnosis

1. Other psychiatric disorders

2. Neurologicaldisorders

3. Endocrinedisorders

4. Metabolicdisorders

5. Haematologicaldisorders

6. Inf lammatory conditions

7. Infections

8. Medication-related:Antihypertensives

9. Substancemisuse

  

  Management

  Initial assessment

  History: any clear psychosocial precipitants, current social situation, use of drugs / alcohol, past history of previous mood symptoms, previous deliberate self harm DSH/ suicide attempts), previous effective treatments, premorbid personality, family history of mood disorder, physical illnesses, current medication.

  MSE: Focused enquiry about subjective mood symptoms, somatic symptoms, psychotic symptoms, symptoms of anxiety, and thoughts of suicide. Objective assessment of psychomotor retardation/agitation, evidence of DSH, cognitive functioning.
Physical examination: Focused on possible differential diagnoses.
 Baseline investigations

  

Lines of treatment:

Psychotherapy
Pharmacotherapy
Brite light therapy
ECT(Electro Convulsive therapy) Transcranial magnetic stimulation (TMS) Vagus nerve stimulation (VNS)

Deep brain stimulation (DBS)

  

First-line treatment:

CBT
 Antidepressants ECT

Choosing an antidepressant medication

Patient factors Issues of tolerability Symptomatology

  

Treatment failure (second-line treatment)

Note: it is contraindication to combine agents of the same class.

Partial responders Prevention of relapse: 9m

  

Prognostic factors
Good outcome: Acute onset, earlier age

of onset.

Poor outcome: Insidious onset, elderly, residual symptoms, low self- confidence, comorbidity (alcohol or drug problems, personality disorders, physical illness), lack of social supports.

  

Bipolar disorder

Bipolar disorder is a relapsing and

remitting condition that is characterized

by the presence of periods of elated mood

(mania/hypomania) and depressed

mood, although the presence of elated

mood alone is sufficient for the diagnosis to be made.

  

mania

A. Mood that is predominantly elevated, expansive

or irritable and defi nitely abnormal for the individual concerned.
B. At least three of the following must be present (four if the mood is merely irritable):
1 Increased activity or physical restlessness.
2 Increased talkativeness (‘pressure of speech’).

3 Flight of ideas or the subjective experience of

thoughts racing.

  

4 Loss of normal social inhibitions resulting in

behaviour inappropriate to the circumstances.

5 Decreased need for sleep.

6 Infl ated self-esteem or grandiosity.

7 Distractibility or constant changes in activity

or plans.

8 Behaviour that is ill advised or reckless and

whose risks the subject does not recognize, e.g. spending sprees, foolish enterprises,

reckless driving.

9 Marked sexual energy or sexual indiscretions.

    

DDx. For mania

Hypomania

•Schizophrenia, schizoaffective disorder, delusional disorder, other psychotic disorders •Anxiety disorders •ADHD/conduct disorder •Alcohol or drug misuse (e.g. stimulants, hallucinogens, opiates)

•Physical illness (e.g. hyper/hypothyroidism, …etc)

•Other antidepressant treatment or drug-related causes.

•Agitated depression •anxiety disorders •Substance misuse/physical illness/medication- related (as for Mania)

  

  

 Mixed episodes

  The occurrence of both manic/hypomanic and depressive symptoms in a single episode, present every day for at least 1 week

  Typical presentations include:
 Depression plus overactivity/pressure of speech
 Mania plus agitation and reduced energy/libido
Dysphoria plus manic symptoms (with exception of elevated mood)

  Rapid cycling (f luctuating between mania and
depression 4 or more episodes/yr) N.B. (Ultra-rapid)
cycling refers to the situation when fluctuations are over days or even hours.

    

  

Management
Points to notes:
 Danger to self
 Danger to others
 Total inability to function  Total loss of control

 Medical conditions that warrant medication monitoring Issues affecting management decisions:
 Psychotic symptoms
 Catatonic symptoms

 Risk of suicide
 Risk of violence
 Substance-related disorders

  

Treatment of acute manic episodes

First-line treatment

 Lithium remains the first-line treatment for acute mania

 Antipsychotics:

 Benzodiazepines

ECT

Use of anticonvulsants (second-line/augmentation or bipolar spectrum):

 Carbamazepine
 Sodium valproate  Lamotrigine

  

  Treatment of depressive episodes: as in unipolar depression

  Prophylaxis

  Primary aim: Prevention of recurrent episodes

  Indications: Any patient who has had at least 2 episodes in 5 ys

  First-line treatment: Lithium

  Second-line treatments

  Carbamazepine, Sodium valproate, anticonvulsants

  Other such as lamotrigine, gabapentin, and topiramate

  Alternative/augmentative agents

  Up to date: FDA has approved lurasidone, already indicated for schizophrenia, to treat major depressive episodes in adults with bipolar disorder.

  

 Cyclothymia

Clinical features:

  Persistent instability of mood, with numerous periods of mild depression and mild elation.

  The mood swings are usually perceived by the individual as being unrelated to life events.

  In DSM-5 the symptoms must have been present for at least 2 years, with no period lasting longer than 2 months in which they have been at a normal state, and no mixed episodes may have occurred.

  Prevalence was 3-6% in general population. Age of onset: usually early adulthood (i.e. teens or 20s).

  Management: as in management of bipolar.

    

  

Other aspects of mood disorders

Postnatal depression

Postnatal depression tends to start within a month of delivery; one in seven mothers are affected. The symptoms are unremarkable, with the negative thoughts tending to focus on the woman’s perceived failings as a mother or on her baby’s well-being. Physical exhaustion exacerbates matters.

• Before prescribing antidepressants, check whether the mother is breastfeeding.

  

Premenstrual syndrome

Up to 80% of women suffer from symptoms in the days before their period: irritability, depression, abdominal bloating and breast tenderness. However, a specific premenstrual syndrome has proved difficult to validate (and is not included in ICD-10).

• There is limited evidence that drug treatments are successful but SSRI treatment during the premenstrual period is gaining an evidence base.

  

Seasonal affective disorder (SAD)

Symptoms are generally mild to moderate with low self-esteem, hypersomnia, fatigue, increased appetite and weight gain, and decreased social and occupational functioning.

prevalence of SAD is estimated at 5%, M:F = 1:5.

 Management: Light therapy, Pharmacological Best evidence for fluoxetine