mood disorders.ppt
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Mood (Affective) DisordersDepartment of Psychiatry
1stFaculty of Medicine
Charles University, PragueHead: Prof. MUDr. Ji Raboch, DrSc.
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Mood (Affective) Disorders
Mood disordersare very common, their life
prevalence is up to 20 %, and they have a highlevel of morbidity and mortality as well as animmense impact on disabilities worldwide.
The fundamental disturbance is a change in moodor affect, usually to depression (with or without
associated anxiety) or to elation. The mood changeis usually accompanied by a change in the overalllevel of activity.
Most of these disorders tend to be recurrent, andthe onset of individual episodes is often related tostressful events or situations.
The mood disorders may be subdivided intounipolarand bipolartypes:
1. those that are characterized by depressiononly
2. those that are characterized by manicepisode eitheralone or in combination with depression
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Classification of Mood Disorders
International Classification of Diseases (ICD-10) came into use in WHO Member States asfrom 1994
F30 Manic episodeF31 Bipolar affective disorder
F32 Depressive episode
F33 Recurrent depressive disorder
F34 Persistent mood (affective) disordersF38 Other mood (affective) disorders
F39 Unspecified mood (affective) disorder
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Test Methods
Self-reported scales: Young Mania Rating Scale (YMRS) Beck scale (depression)
Zung scale (depression)
Interview with physician:
Hamilton scale (HAMD)
Montgomery and Asberg scale (MADRS)
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F32 Depressive Episode
The lowered mood varies little from day to day, isunresponsive to circumstances and may beaccompanied by so-calledsomaticsymptoms:
loss of interest or pleasure in activities that are normallyenjoyable (anhedonia)
lack of emotional reactivity to normally pleasurablesurroundings and events
waking in the morning 2 hours or more before the usual time
depression worse in the morning
objective evidence of definite psychomotor retardation oragitation
loss of appetite
weight loss
loss of libido
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F32 Depressive Episode
F32 Depressive episodeF32.0 Mild depressive episode
F32.1 Moderate depressive episode
F32.2 Severe depressive episode withoutpsychotic symptoms
F32.3 Severe depressive episode withpsychotic symptoms
F32.8 Other depressive episodesF32.9 Depressive episode, unspecified
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F32.0 Mild Depressive Episode
Two or three of the above symptoms areusually present.
For mild depressive episodeare typicaldepressed mood, anhedonia and increased
fatigability. The afflicted person is usuallydistressed by the symptoms and has somedifficulty in continuing with ordinary workand social activities, but will probably not
cease to function completely.
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F32.1 Moderate DepressiveEpisode
An individual with moderate depressiveepisodesuffers from more symptoms(four or more of the above symptoms areusually present) of greater severity andwill usually have considerable difficulty incontinuing with social, work or domesticactivities.
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F32.2 Severe Depressive Episodewithout Psychotic Symptoms
In a severe depressive episode, thesufferer usually shows considerable distressor agitation. Loss of self-esteem or feelingsof uselessness or guilt are likely to beprominent, and suicide is a distinct dangerin particularly severe cases. ; a number of"somatic" symptoms are usually present.
Agitated depression Major depression
Vital depression
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F32.3 Severe Depressive Episodewith Psychotic Symptoms
Psychotic symptoms may be present, such as delusions (ideas of sin, poverty or imminent disasters) hallucinations (defamatory or accusatory voices or of
rotting filth or decomposing flesh) depressive stupor
Severe ordinary social activities are impossible When the psychotic symptoms are consistent
with the patients mood, they are referred to asmood congruent, when they are inconsistent,they are referred as mood incongruent.
Single episodes of: major depression with psychotic symptoms psychogenic depressive psychosis psychotic depression reactive depressive psychosis
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F33 Recurrent Depressive Disorder
Recurrent depressive disorderis characterized by
repeated episodes of depression without any historyof independent episodes of mood elevation andoveractivity.
Recovery is usually complete between episodes, buta substantial part of patients will have a recurrence
and about 30% may develop a persistentdepression. The lifetime prevalence - about 1020 %;
women:men 2:1. The risk of suicide (approximately 1015%.
Seasonal affective disorder- onset of moodsymptoms is connected with changes of seasons,with depression typically occurring during the wintermonths and remissions or changes from depressionto mania occurring during the spring.
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F33 Recurrent Depressive Disorder
Kupfer 1991
severit
yofdepression
time
6-12weeks
4-9months
1 or moreyears
no depression
symptoms
syndrome
treatment stage
response
relapse
remission
relapse recurrence
recovery
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F33 Recurrent Depressive Disorder
F33 Recurrent depressive disorderF33.0 Recurrent depressive disorder, current episode
mild
F33.1 Recurrent depressive disorder, current episode
moderateF33.2 Recurrent depressive disorder, current episode
severe without psychotic symptoms
F33.3 Recurrent depressive disorder, current episode
severe with psychotic symptomsF33.4 Recurrent depressive disorder, currently in
remission
F33.8 Other recurrent depressive disorders
F33.9 Recurrent depressive disorder, unspecified
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F30 Manic Episode
F30 Manic episodeF30.0 Hypomania
F30.1 Mania without psychotic symptoms
F30.2 Mania with psychotic symptomsF30.8 Other manic episodes
F30.9 Manic episode, unspecified
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F30.0 Hypomania
Hypomaniais characterized by persistent mild elevation of mood for at least
several days
increased energy and activity
usually marked feelings of well-being and bothphysical and mental efficiency
Increased sociability, talkativeness,overfamiliarity, increased sexual energy,
and a decreased need for sleep are oftenpresent but not to the extent that theylead to severe disruption of work or resultin social rejection. There are no
hallucinations or delusions
F30 1 M i ith t P h ti
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F30.1 Mania without PsychoticSymptoms
Mania without psychotic symptoms: last for at least 1 weak
mood is elevated out of keeping with individualscircumstances and may vary from carefree joviality toalmost uncontrollable excitement
elation is accompanied by increased energy, resulting inoveractivity, pressure of speech, and a decreased need forsleep
normal social inhibition are lost, attention cannot besustained, and there is often marked distractibility
self-esteem is inflated, and grandiose or over-optimisticideas are freely expressed
perceptual disorders may occur
the individual may embark on extravagant and impracticalschemes, spend money recklessly, or become aggressive,amorous, or factious in inappropriate circumstances.
F30 2 M i ith P h ti
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F30.2 Mania with PsychoticSymptoms
Mania with psychotic symptomsrepresents amore severe form of mania: inflated self-esteem and grandiose ideas may develop into
delusions, and irritability and suspiciousness into delusionsof persecution
in severe cases, grandiose or religious delusions of identity
or role may be prominent, and flight of ideas and pressure ofspeech may result in the individual becomingincomprehensible
sustained physical activity and excitement may result inaggression or violence, and neglect of eating, drinking, andpersonal hygiene may result in dangerous states of
dehydration and self neglect
Mania with: mood-congruent psychotic symptoms mood-incongruent psychotic symptoms
Manic stupor
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F31 Bipolar Affective Disorder Bipolar affective disorderis characterized by
repeated, at least two episodes in which the patientsmood and activity levels are significantly disturbed(manic or depressive syndromes, patients who sufferonly from repeated episodes of mania arecomparatively rare).
The first episode may occur at any age from childhoodto old age. The frequency of episodes and the pattern of
remissions and relapses are both very variable. The lifetime prevalence is between 0,5 an 1 %.
Suicidalityabout 19%. Comorbiditywith alcohol anddrug abuse
The rapid-cycling specifieridentifies those patientswho have had at least four episodes of a majordepressive, manic, or mixed episode during the past
12 months.
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F31 Bipolar Affective Disorder
F31 Bipolar affective disorder
F31.0 Bipolar affective disorder, current episode hypomanic
F31.1 Bipolar affective disorder, current episode manic withoutpsychotic symptoms
F31.2 Bipolar affective disorder, current episode manic withpsychotic symptoms
F31.3 Bipolar affective disorder, current episode mild ormoderate depression
F31.4 Bipolar affective disorder, current episode severedepression without psychotic symptoms
F31.5 Bipolar affective disorder, current episode severedepression with psychotic symptoms
F31.6 Bipolar affective disorder, current episode mixed
F31.7 Bipolar affective disorder, currently in remission
F31.8 Other bipolar affective disorders
F31.9 Bipolar affective disorder, unspecified
F34 Persistent Mood (Affective)
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F34 Persistent Mood (Affective)Disorders
Persistent mood disordersare persistent andusually fluctuating disorders of mood in whichindividual episodes are not sufficiently severe towarrant being described as hypomanic or even milddepressive episodes.
Lasting more than 2 years
F34 Persistent mood (affective) disorders
F34.0 Cyclothymia
F34.1 Dysthymia
F34.8 Other persistent mood (affective) disorders
F34.9 Persistent mood (affective) disorder, unspecified
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F34.0 Cyclothymia
For cyclothymiapersistent instability ofmood, involving periods of mild depressionand mild elation is typical.
This instability usually develops early inadult life and pursues a chronic course,although the mood may be normal andstable for months at a time.
The mood swings are usually perceived bythe individual as being unrelated to lifeevents.
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F34.1 Dysthymia
Dysthymiarepresents a chronic, milderform of depression which does not fulfillthe criteria for recurrent depressivedisorder especially in terms of severity.
Sufferers usually have periods of days orweeks when they describe themselves aswell, but most of the time they feel tiredand depressed.
It usually begins in adult life and lasts forat least several years, sometimesindefinitely.
The lifetime prevalence is approximately
3%, and it is more common in women.
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F34.1 Dysthymie
dysthymie: mrn chronick deprese
epidemiologie: celoivotn prevalencekolem 3%
etiopatogeneze: faktory genetick i vnj
lba: jako u depresivn poruchy kognitivn-bahaviorln psychoterapie,antidepresiva
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Treatment of Depression
Various antidepressantsaltering levels of central
neurotransmitters are available to treatdepression.
Their overall effectiveness: 65-70% Mild to moderate depressive episode: SSRIs.
Severe depression: antidepressants with broaderspectrum of effects, like SNRI or TCA. Patients with insomnia or anorexia may do better
with more sedating medication (mirtazapine,trazodon)
Patients with lethargy, hypersomnia, weight gainand lower levels of tension and anxiety mayprefer the less sedating medications such asbupropion, reboxetin or stimulating SSRIs.
IMAOs or RIMA should be tried in refractory
patients or patients with atypical depression.
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Treatment of Depression
Drug trials should last 4 to 8 weeks.
No response within 4 weeks of treatment - thedose should be increased or the patient should beswitched to another drug.
In partial responders - augmentation strategy;
coadministration of lithium carbonate ortrijodthyronine.
Psychotic patient - adding on neuroleptics.
Anxious or agitated patients (also to improve the
sleep quality) - benzodiazepine coadministrationfor a short period of time.
Lithium prophylaxis is an option toantidepressants.
Supportive psychotherapy.
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Treatment of Depression
First episode of depression - the drug should be
continued for another 16-20 weeks after the patientis thought to be well (continuation treatmenttoprevent recurrence).
The medication should be tapered gradually becausemany patients experience some mild withdrawal
effects. Patients with recurrent depression need long-term
maintenance therapyto prevent relapses. Electroconvulsive therapy (ECT)is the treatment of
choice for some patients with very severedepression, with high potential for suicide or otherselfdestroying behaviour and for pregnant women.
Other biological methods: phototherapy (seasonal affective disorder)
sleep deprivation repetitive transcranial magnetic stimulation (rTMS).
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Treatment of Mania
Mood stabilizers: lithium (0.61.2 mEq/L) carbamazepine (612 mg/L) valproate (50125 mg/L)
Anticonvulsants: gabapentine topiramate lamotrigine
Agitated or psychotic patient
coadministartion of antipsychotics of second generation
(olanzapine, risperidone) benzodiazepines (lorazepam, clonazepam)
ECT