Mood-web...............................pppt

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1. Mood Disorders

2. Archetypes
•Depression
–Major Depression
•Mania
–Bipolar Disorder (Manic-Depression)

5. Phenomenology:
The Mental Status Exam
•General Appearance
•Emotional
•Thought
•Cognition
•Judgment and Insight
•Reliability

6. General Appearance
•Depression
•Mania

7. Emotions: Depression
•Mood
–Dysphoric
–Irritable, angry
–Apathetic
•Affect
–Blunted, sad, constricted

8. Emotions: Mania
•Mood
–Euphoric
–Irritable
•Affect
–Heightened, dramatic, labile

9. Thought: Depression
•Process
–Slowed processing
•Thought blocking
•Content
•Everything’s awful
•Guilty, self-deprecating
•Delusional

10. Thought: Mania
•Process
–Rapid
–Pressured speech
–Loosening of Associations
•Content
–Grandiose
–Delusions

11. Cognition
•Depression
–Poor attention
–Registration
–Effort
–“Pseudodementia”
•Mania
–Distractible
–Concentration
–May seem brighter, more clever

12. Insight and Judgment
•Depression
–Unrealistically negative
•Mania
–Unrealistically positive
–Or just plain bad

15. Diagnosis and Criteria
•Episodes Versus Disorders

16. Episodes
•Major depressive
•Manic
•Mixed
•Hypomanic

17. Major Depressive Episode
•Time
–2 weeks
•Change
–From previous functioning
•Symptoms
–5 or more
–1 has to be depressed mood or anhedonia
•Global Criteria

18. Symptoms of Major Depressive
Episode
•“Sig E Caps”
–Sleep
–Interest
–Guilt
–Energy
–Concentration
–Appetite
–Psychomotor retardation
–Suicide
•5 or more

19. Manic Episode
•Time
–1 week
•Symptom list
–3 or more
•Global Criteria

20. Symptoms of Manic Episode
–Grandiosity
–Decreased need for sleep
–Pressured Speech
–Flight of Ideas
–Distractibility
–Increased Activity/Agitation
–Risky Activities
•3 or more

21. The Disorders

22. Major Depressive Disorder
•“Classic Depression”
•Major Depressive
Episode
•Rule outs
–Some other disorder
–History of
mania/hypomania

23. Bipolar Disorder I
•Classic “Manic-Depression”
•At least one
–Manic or,
–Mixed episode

24. Epidemiology
•Depression
–5-7%
–2:1 ♀:♂
–$53 billion/year in US
–World: most costly
(developed)

25. Epidemiology
•Bipolar Disorders
–1%
–~1:1 ♀:♂

26. Etiology and Pathophysiology

27. Genetics
•Family studies
–Higher rates
–Breed true?
•Twin Studies
–Mono:Di ~4:1
•Linkage studies
–Numerous (? Consistency)
–Recent: Zubenko, Am J Genetics

28. Social/Environmental
•Response to Loss
–ex. Animal models
•Other stress
–Ex. Learned helplessness
•What is role of social stress?
–Ex. Nemeroff et al.

29. Neurotransmission
•Neurochemical hypotheses
–Catecholamine hypothesis
•Norepinephrine
–Ex. Axelrod
–Depletions models
•Serotonin
–Refinements
•Imbalances
•Receptors
•2
nd
messengers

30. Neuroimaging
•Stroke data
–Dominant frontal
–Basal ganglia
•Fx Imaging

31. Other Physiological Findings
•Neurophysiology
–Circadian rhythms and sleep
•Neuroendocrine
–HPA axis
•DST

32. Differential Diagnosis
“We’re not living happily
ever after any more”

33. Differential Diagnosis
•Psychiatric Disorders
•Medical Disorders
•Substance Induced
•Reactive disorders
–Adjustment disorders
–Normal reactions

35. Comorbidity
•Anxiety disorders
•Substance abuse
•Psychotic disorders
•Personality disorders
•Depression in the
medically ill.

36. Comorbidity

37. Course and Prognosis of Mood
Disorders

38. Course and Prognosis of Mood
Disorders
•Recovery
•Relapse
•Recurrence

40. 0
10
20
30
40
50
60
70
80
90
0.5 1 2 4 5
Recovery

42. Predictors
•# Episodes
•Length of episodes
•Symptoms
–# and type
•Comorbidity

43. Risk of Suicide
•Depression
–10-15% severe (hosp) pts

44. “It is unfortunate
that I didn’t get
your care earlier,
Mrs. Perkins.”
Treatment

45. Treatment
•Depression
–Pharmacological
–Psychotherapy
–Other somatic treatments

46. Antidepressants

47. Antidepressants
•1
st
generation
–Monoamine Oxidase Inhibitors (MAOIs)
–Tricyclic Antidepressants (TCAs)
•2
nd
–Serotonin reuptake Inhibitors (SSRIs)
–Other specifics (Buproprion, Trazodone)
•3
rd
–Venlafaxine, Mirtazapine, Nefazodone

48. Mechanisms of action
•Monoamine Action
–Increase
•Norepinephrine
•Serotonin
–Various mechanisms
•Inhibition of catabolism (MAOIs)
•Reuptake inhibition (TCAs, SSRIs, Venlafaxine)
•Direct effects (agonism/antagonism) (some 3
rd
gen)

49. Side effects
•Predicable
–Anticholinergic
–Antihistaminic
–Serotonergic
•Idiopathic

50. Choice of antidepressant
•Best?
•Fastest?
•Predictors of response
–Past history
–Family history
•Major difference
–Side effects

51. Treatment failure
•Inadequate dose
•Inadequate time
•Nonadherence

53. Strategies for failure
•Choices
–Increase dose?
–Augment?
–New drug?
Lithium
Thyroid hormone
Stimulants
Atypical Antipsychotics
2
nd
Antidepressant

54. Long term treatment
•Recurrent depression (3+)
•Chronic depression (2 years)
•Double depression
•Others

55. Psychotherapy
•Cognitive behavioral
therapy
•Interpersonal therapy
•Others

56. Medications versus therapy
•Severe depression
•Moderate depression
•Combination treatment
•Prevention

57. Other treatments
•ECT
•TMH
•Vagal nerve stimulation

58. ECT
•Maybe the best.
•Medication failure
•Real serious
depression
•Time sensitive
•So why don’t we give
everybody ECT?

59. Bipolar Disorder
•Lithium
•Antipsychotics
•Anticonvulsants

60. Lithium
•First line
•Best for mania
•2 weeks for effect
•Therapeutic index
•Side effects
•Acute and preventive

61. Anticonvulsants
•Sodium Valproate
•Carbamazapine
•Lamotrigine
•Gabapentin
•Antimanic
•Antidepressant
•Prevention
•Side effects

62. Antipsychotics
•Atypical (olanzapine)
•Classic
•May be as effective
•Early and late effect

63. Sedatives
•Acute use

64. Other Diagnoses

65. Other Episodes
•Mixed
•Hypomanic

66. Other Mood Disorders
•Dysthymic Disorder
•Cyclothymic Disorder
•Bipolar II
•Due to a generalized medical condition
•Substance Induced
•NOS