Lesson 3 MOOD DISODRERS [Autosaved].pptx

conditions in mental health

1. MOOD DISORDERS EUNICE MUVINDI

2. INTRODUCTION Mood disorders are highly prevalent, have high morbidity, and are associated with early mortality and suicide. They are among the world’s most disabling illnesses, as documented in The Global Burden of Disease (Murray and Lopez 1996).

3. Core Concept People with this diagnosis have an abnormal mood characterized by: Depression Mania, or Both symptoms in alternating fashion The abnormal mood may or may not impair the person’s social or occupational functioning.

4. Approximately 8% of adults will experience major depression at some time in their lives. Approximately 1% will experience bipolar disorder. The onset of mood disorders usually occurs during adolescence. Worldwide , major depression is the leading cause of years lived with disability, and the fourth cause of disability adjusted life years (DALYs). Mood disorders have a major economic impact through associated health care costs as well as lost work productivity . Hospitalization rates for bipolar disorder in general hospitals are increasing among women and men between 15 and 24 years of age. Individuals with mood disorders are at high risk of suicide

5. Gender and mood disorders Depressive disorders account for close to 41.9% of the disability from neuropsychiatric disorders among women compared to 29.3% among men . Gender bias occurs in the treatment of psychological disorders. Doctors are more likely to diagnose depression in women compared with men, even when they have similar scores on standardized measures of depression or present with identical symptoms. Female gender is a significant predictor of being prescribed mood altering psychotropic drugs. Gender differences exist in patterns of help seeking for psychological disorder. Women are more likely to seek help from and disclose mental health problems to their primary health care physician while men are more likely to seek specialist mental health care and are the principal users of inpatient care.

6. Definitions Depression Unusually sad, gloomy, and dejected mood, or Markedly diminished interest and pleasure in everyday activities that is distinctly different from the person’s non-depressed state. Mania Unusually and persistently elevated, expansive, or irritable mood that is distinctly different from the person’s non-manic state Marked impairment, requires hospitalization Hypomania Less severe variant of mania; no hospitalization

7. Gender and mood disorders Studies have consistently documented higher rates of depression among women than among men: the female-to-male ratio averages 2:1.3 Women are 2 to 3 times more likely than men to develop dysthymia .

8. DSM-5 bipolar and related disorders Bipolar I disorder Bipolar II disorder Cyclothymic disorder Substance/medication-induced bipolar and related disorder Bipolar and related disorder due to another medical condition Other specified bipolar and related disorder Unspecified bipolar and related disorder

9. DSM-5 depressive disorders Disruptive mood dysregulation disorder Major depressive disorder, single episode Major depressive disorder, recurrent episode Persistent depressive disorder (dysthymia) Premenstrual dysphoric disorder Substance/medication-induced depressive disorder Depressive disorder due to another medical condition Other specified depressive disorder Unspecified depressive disorder

10. Diagnostic Criteria for Manic Episode a. A distinct period of abnormally and persistently elevated, expansive, or irritable mood and abnormally and persistently increased activity or energy, lasting at least 1 week and present most of the day, nearly every day (or any duration if hospitalization is necessary).

11. Diagnostic Criteria for Manic Episode b . During the period of mood disturbance and increased energy or activity, three (or more) of the following symptoms (four if the mood is only irritable) are present to a significant degree and represent a noticeable change from usual behavior: 1. Inflated self-esteem or grandiosity. 2. Decreased need for sleep. 3. More talkative than usual or pressure to keep talking. 4. Flight of ideas or subjective experience that thoughts are racing. 5. Distractibility . 6. Increase in goal-directed activity or psychomotor agitation. 7. Excessive involvement in activities that have a high potential for painful consequences.

12. Diagnostic Criteria for Manic Episode c . The mood disturbance is sufficiently severe to cause marked impairment in social or occupational functioning or to necessitate hospitalization to prevent harm to self or others, or there are psychotic features. d . The episode is not attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication, other treatment) or to another medical condition.

13. Diagnostic Criteria for Hypomanic Episode a . A distinct period of abnormally and persistently elevated, expansive, or irritable mood and abnormally and persistently increased activity or energy, lasting at least 4 consecutive days and present most of the day, nearly every day. b . During the period of mood disturbance and increased energy and activity, three (or more) of the following symptoms (four if the mood is only irritable) have persisted, represent a noticeable change from usual behavior, and have been present to a significant degree: 1. Inflated self-esteem or grandiosity. 2. Decreased need for sleep (e.g., feels rested after only 3 hours of sleep). 3. More talkative than usual or pressure to keep talking.

14. Diagnostic Criteria for Hypomanic Episode 4. Flight of ideas or subjective experience that thoughts are racing. 5. Distractibility (i.e., attention too easily drawn to unimportant or irrelevant external stimuli), as reported or observed. 6. Increase in goal-directed activity or psychomotor agitation. 7. Excessive involvement in activities that have a high potential for painful consequences .

15. Diagnostic Criteria for Hypomanic Episode c . The episode is associated with an unequivocal change in functioning that is uncharacteristic of the individual when not symptomatic. d . The disturbance in mood and the change in functioning are observable by others. e . The episode is not severe enough to cause marked impairment in social or occupational functioning or to necessitate hospitalization. If there are psychotic features, the episode is, by definition, manic. f . The episode is not attributable to the physiological effects of a substance.

16. Diagnostic Criteria for Major Depressive Episode a . Five (or more) of the following symptoms have been present during the same 2week period and represent a change from previous functioning; at least one of the symptoms is either (1) depressed mood or (2) loss of interest or pleasure. 1. Depressed mood most of the day, nearly every day, as indicated by either subjective report or observation made by others. 2. Markedly diminished interest or pleasure in all, or almost all, activities most of the day, nearly every day.

17. Diagnostic Criteria for Major Depressive Episode 3. Significant weight loss when not dieting or weight gain, or decrease or increase in appetite nearly every day. 4. Insomnia or hypersomnia nearly every day. 5. Psychomotor agitation or retardation nearly every day. 6. Fatigue or loss of energy nearly every day. 7. Feelings of worthlessness or excessive or inappropriate guilt

18. Diagnostic Criteria for Major Depressive Episode 8.Diminished ability to think or concentrate, or indecisiveness, nearly every day. 9. Recurrent thoughts of death, recurrent suicidal ideation without a specific plan, or a suicide attempt or a specific plan for committing suicide. b. The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning. c. The episode is not attributable to the physiological effects of a substance or to another medical condition.

19. BIPOLAR I DISORDER A. Criteria have been met for at least one manic episode The manic episode may have been preceded by and may be followed by hypomanic or major depressive episodes. B. The occurrence of the manic and major depressive episode(s) is not better explained by schizoaffective disorder, schizophrenia, schizophreniform disorder, delusional disorder, or other specified or unspecified schizophrenia spectrum and other psychotic disorder. B.

20. BIPOLAR II DISORDER For a diagnosis of bipolar II disorder, it is necessary to meet the criteria for a current or past hypomanic episode and the following criteria for a current or past major depressive episode. A. Criteria have been met for at least one hypomanic episode and at least one major depressive episode. B. There has never been a manic episode. C. The occurrence of the hypomanic episode(s) and major depressive episode(s) is not better explained by schizoaffective disorder, schizophrenia, schizophreniform disorder, delusional disorder, or other specified or unspecified schizophrenia spectrum and other psychotic disorder. D. The symptoms of depression or the unpredictability caused by frequent alternation between periods of depression and hypomania causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.

21. Bipolar Disorders (Summary) a. Bipolar I Disorder Must have at least one Manic Episode Most Bipolar I clients also have had a Major Depressive Episode b. Bipolar II Disorder At least one Hypomanic Episode, plus At least one Major Depressive Episode c. Cyclothymic Disorder Repeated mood swings, but None severe enough to be called Major Depressive Episodes or Manic Episode d. Bipolar Disorder NOS Client has bipolar symptoms that do not meet the criteria for the bipolar diagnoses above

22. AETIOLOGY

23. AETIOLOGY 1. Biological Factors “Serotonin : SSRIs  depilation leads to depression and suicide Dopamine: ↓DA in depression 2. Brain Imaging: CT Scan: Ventricular enlargement in Bipolar I MRI: Major depression  smaller caudate and frontal lobes PET: ↓decrease blood flow in cerebral cortex

24. AETIOLOGY (cont.) 3. Neuroendocrine regulation Adrenal gland  50% ↑ cortisol in depression Somatostatin (growth hormone inhibiting hormone): inhibits GABA, ACTH & TSH: depression lower whereas in mania increased.

25. AETIOLOGY (cont.) 4. Genetic Factors Family studies: 1st degree relatives of bipolar I than i.e . One parent 25%; both parents 50-75% Adoption studies: Bipolar I Identical twins>non-identical twins 33-50 %; Major depression identical twins>non-identical twins 10-25% Linkage studies: Bipolar I  chromosomes 5,11,18

26. AETIOLOGY (cont.) 6 . Psychosocial Factors Life events & environment stress e.g. losing a parent before age 11 or loss of a spouse or job. Personality factor: OCD, Histrionic PD, Borderline PD Psychodynamic factors: Depression: (a) Infant-mother relationship (oral phase), (b) Real/imagined object loss, (c) Introjections of the departed object, and (d) Direct feeling of anger inward. Mania: a defence against underlying depressions.

27. AETIOLOGY (cont.) 7.Cognitive theory: Depressogenic schemata (Aaron Beck): (a) Self- a negative, (b) Environment- hostile & demanding, and (c) Future-expectation of suffering & failures. Therapy is to modify these distortions. 8. Learned Helplessness: depressive phenomena to the experience of uncontrolled events (Seligman) .

28. Gender Differences Depression is far more common among women than men. Women are also more prone than men to experience recurrent depressive episodes. Both biological and social factors play a part in these patterns. For example, women who experience severe premenstrual mood changes are more vulnerable to other mood disorders including postpartum depression. For bipolar disorder, men and woman are equally represented. About 25% of people who are depressed are also bipolar.

29. Culture Differences Depression may differ from culture to culture with regard to age of onset, symptoms, course, etc. For example, in many non-Western cultures, depression is more likely to be experienced in somatic (through not feeling well in the body), rather than affective terms (feelings emotionally low).

30. Depression Psychopharmacology Selective Serotonin Reuptake inhibitor (SSRI) Fluoxetine Sertraline Paroxetine SSRIs act by increasing the extracellular level of serotonin by limiting its reabsorption into the presynaptic cell, increasing the level of serotonin in the synaptic cleft. Treatment

31. Tricyclic Antidepressants Amitriptyline Imipramine Increase levels of norepinephrine and serotonin

32. Monoamine Oxidase Inhibitors Moclobamide Phenelzine

33. If suicidal Suicide risk first two weeks Relatives keep medication Prescribe 3 day supply at a time Suicidal watch

34. Psychotherapy Cognitive Behavioral Therapy Rehabilitation

35. INDICATIONS poor response to adequate pharmacotherapy unable to tolerate side effects of antidepressants depressive stupor, not eating or drinking Electroconvulsive Therapy

36. severe suicidal risk severe depression with delusions, retardation severe post partum depression. Electroconvulsive Therapy

37. Intervene where appropriate e.g. Financial – Social Dimension Fund Legal – Social Worker can assist Establish Social support Support Groups like Friendship bench Social Management

38. Antipsychotics (Mania episode) e.g. Haloperidol Olanzapine Other Antipsychotics e.g. Fluphenazine Decanoate In poor compliance Bipolar Affective Disorder

39. First episode mainly antipsychotic Drugs. If episodes recur frequently disrupting function need for Prophylaxis - Use mood stabilizers Principles in management

40. Mood Stabilizers Multiple Episodes Requiring Prophylaxis Lithium Carbonate Carbamazepine Sodium Valproate

41. Lithium Carbonate Follow-up Bloods Lithium, TFT,U&E Once stable 3 monthly than 6monthly Monitor Therapeutic Range 0.8-1.5 Mania phase 0.6-1.2 prophylaxis >1.5 toxicity

42. Psycho education to patient and relatives. Supportive Psychotherapy Psychotherapy

43. Appoint Power of Attorney or Appoint Curator Bonis Supervision of Treatment –Poor insight Social Management

44. Lithium Toxicity Cyclothymic disorder Dysthmic disorder Suicide risk assessment Homework

45. THE END