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1. MOOD DISORDERS

2. Intended Learning Objectives ILOs : At the end of this chapter students should be able to: Define bipolar disorder. Recognize presentations of bipolar disorder in either a depressive or manic episode. Know the etiology, epidemiology, clinical picture, differential diagnosis and management of bipolar disorder. Identify the etiology, epidemiology, clinical picture, differential diagnosis and management of bipolar disorder.

3. Mood Disorders Types: Bipolar affective disorder. Unipolar affective disorder (Depressive disorders).

4. Depressive Disorders Epidemiology: Risk and prevalence The lifetime prevalence of developing major depressive disorder is about 17% overall; the prevalence in women is roughly twice the prevalence in men. The rate of completed suicide is 10% to 15%

5. Depressive Disorders Epidemiology: Age of onset. The age of onset can range from childhood to old age; the mean age of onset is about 30 years old.

6. Depressive Disorders Etiology: Psycho-socio-biological Model: 1. Biological: Evidence for genetic etiology derived from Family studies

7. Depressive Disorders Etiology: Psycho-socio-biological Model: 1. Biological: Neurochemical factors: A number of neurotransmitters, including the monoamines NE, dopamine, and 5-HT.

8. Depressive Disorders Etiology: Psycho-socio-biological Model: 1. Biological: Neuroendocrine regulation Appears to be related to mood disorders. Hypothyroidism may mimic depression, and hyperthyroidism may mimic mania

9. Depressive Disorders Etiology: Psycho-socio-biological Model: 2. Psycho-Social: Loss of self-esteem: Thinking that one is helpless, unworthy, or useless Loss of loved object: As loss of parent prior to 11 years Cognitive theory: negative view of self, their future, and the world

10. Depressive Disorders Clinical picture: I. Physiological symptoms: Diminished appetite, fatigue and loss of energy. Weight loss. Loss of libido. Sleep disturbances: such as insomnia, early morning awakening and interrupted sleep.

11. Depressive Disorders Clinical picture: I. Physiological symptoms: Pains may be inform of (headache, back pain or any kind of pain). Digestive upsets, loss of appetite, loss of weight. (Sometimes-atypical symptoms occur e.g. (increased appetite, hypersomnia ). Sometimes disturbed sleep and appetite called vegetative symptoms

12. Depressive Disorders Clinical picture: II. Psychological symptoms Depressed mood and sadness (sometimes there is diurnal variation, which means that the symptoms are more severe in the morning). Loss of interest and lack of enjoyment.

13. Depressive Disorders Clinical picture: II. Psychological symptoms Sense of emptiness, helplessness, hopelessness, worthlessness, pessimism, death wishes, suicidal thoughts, loss of self-esteem, self -blame and guilt. Psychotic symptoms may be found in severe cases as: Delusions: of guilt, nihilism, poverty, hypochondriasis , Hallucinations: auditory, visual etc. ( All delusions or hallucination are mood congruent )

14. Depressive Disorders Clinical picture: III. Other symptoms include: Behavioral symptoms Negligence of self-care. Social withdrawal may be suicidal attempts Motor, cognitive symptoms Difficulty in attention and concentration. Slow thinking, Psychomotor retardation or agitation. Impaired social and occupational functioning

15. Depressive Disorders Management of depression : Hospitalization if: Suicidal risk, refusal of food or medication. Severe agitation or retardation, psychotic symptoms, severe depression.

16. Depressive Disorders Pharmaco -Therapy Tricyclic Antidepressants (TCAs) e .g. Imipramine, Amitriptyline Dose: 75 – 300 mg/day). Selective Serotonin Reuptake Inhibitors (SSRIs) e.g. Fluoxetine (20 mg), Fluvoxamine (100-300 mg), Sertraline (50-200 mg) & Citalopram (20-60 mg), Paroxetine (20-60mg).

17. Depressive Disorders Pharmaco -Therapy Selective Serotonin Norepinephrine Inhibitors (SNRIs) e.g . Venlafaxine 75mg-150mg. Antipsychotic drugs in case of severe depression or psychotic features as quitapine 200-600mg daily .

18. Depressive Disorders Electro-Convulsive Therapy (ECT): Brain Synchronization Therapy (BST) Severe cases, psychotic symptoms. Refractory to drug treatment, suicidal symptoms. Severe agitation or retardation. 6-12 Sessions

19. Depressive Disorders Psycho-social therapy: Cognitive therapy, to eliminate negative thoughts. Supportive psychotherapy. Social, marital and family therapy. Patient education.

20. Depressive Disorders Phases of treatment Acute phase: 4- 6 weeks Continuation phase: 6-8 months Prophylaxis: Long-term treatment to prevent recurrence. Explain to the patient and relatives that: Expected side effects of drugs, Improvement will build up over two or three weeks. ECT is very safe and is reserved for severe cases and suicidal patients.

21. Depressive Disorders Prognosis: Depression is a recurrent disorder in about 50% of cases.

22. Bipolar affective disorders Bipolar affective disorder, also known as manic-depressive illness, is a mental characterized by periods of elevated mood (mania) and period of depression. bipolar I Bipolar II

23. DSM-5: Bipolar I Disorder: Duration: • Manic episode: 1 wk + • Major depressive episode: 2 wk + Symptoms: Manic or hypomanic episodes • Abnormally ↑ or irritable mood (required) • ↓ Need for sleep • Pressured speech • Racing and expansive thoughts • Distractibility • Hyperactivity • Impulsivity/high risk activities +/- psychotic symptoms in mania only Depressive episodes • Like that for major depressive disorder 23

24. Epidemiology: Life time risk of manic episode is 1% Prevalence in males and females is the same Mean age of onset is about 17- 25 years

25. Etiology: Genetics: B. Biological factors: Monoamine theory states that increased levels of noradrenaline, serotonin and dopamine

26. Etiology: C. Psychosocial factors: The first manic episodes are often precipitated by life events and sleep deprivation are important precipitating factors.

27. Manic Episodes Management: I. Short term management: (for 6 months) A. Hospitalization: high risk of harm to self or others B. ECT / BST: For excitement or if there is poor response to treatment. 8- 12 settings (3 times weekly)

28. Manic Episodes Management: I. Short term management: (for 6 months) Mild cases can be treated in outpatient clinics. C. Pharmacotherapy : Mood stabilizing agents a. Lithium: Traditionally the first-line treatment for bipolar disorder.

29. Manic Episodes Management: C. Pharmacotherapy : Mood stabilizing agents b. Valproate : Dose: 15- 30 mg/kg Antipsychotics:

30. Manic Episodes Management: D. Psychotherapy: Usually after symptoms resolution. Cognitive therapy . Behaviour therapy to maintain regular pattern of daily activities.

31. Manic Episodes Management: Psychoeducation on etiology, signs and symptoms, importance of compliance Family therapy: To work on impact of manic symptoms on family and resolve interpersonal problems . Long term management: To prevent relapse and recurrence

32. Thank You