Affective Disorders

Mood vs Affect

Both can change depending on circumstances and situations as well as the state of mind.

Mood disorders are a group of disorders in which the predominant symptom is variability in mood as well as other symptoms.

Affective Disorders

• Major Depressive Disorders
• Dysthymia
• Mania
• Hypomania
• Bipolar Affective Disorders

Major Symptoms:

• Undue sadness
• Reduced energy
• Reduced interest in formerly pleasurable activities

Other Symptoms:

• Reduced concentration
• Reduced social interaction
• Reduced sleep
• Low self-esteem
• Reduced appetite
• Low libido
• Feelings of worthlessness
• Ideas of guilt
• Feelings of hopelessness
• Suicidal ideation or attempt

Duration: At least 2 weeks

Differential Diagnosis

Major Depressive Disorder - DSM 5

• Sad mood OR loss of interest or pleasure (anhedonia)
• Symptoms are present nearly every day, most of the day, for at least 2 weeks
• Symptoms are distinct and more severe than a normative response to significant loss
• PLUS four of the following symptoms:
• Sleeping too much or too little
• Psychomotor retardation or agitation
• Poor appetite and weight loss, or increased appetite and weight gain
• Loss of energy
• Feelings of worthlessness or excessive guilt
• Difficulty concentrating, thinking, or making decisions
• Recurrent thoughts of death or suicide
• Episodic
• Symptoms tend to dissipate over time
• Recurrent
• Once depression occurs, future episodes likely
• Average number of episodes is 4
• Subclinical depression
• Sadness plus 3 other symptoms for 10 days
• Significant impairments in functioning even though full diagnostic criteria are not met

Epidemiology

• Symptom variation across cultures
• Latino cultures: Complaints of nerves and headaches
• Asian cultures: Complaints of weakness, fatigue, poor concentration, aches, and pains
• Smaller distance from the equator (longer day length) and higher fish consumption associated with lower rates of MDD
• Symptom variation across the lifespan
• Children: Stomach and headaches
• Older adults: Distractibility and forgetfulness
• Co-morbidity
• 2/3 of those with MDD will also meet criteria for anxiety disorder at some point
• Major depression has been ranked as the 3rd cause of the burden of disease worldwide in 2008 and projected to be the 1st by 2030
• Lifetime prevalence is 5 to 17%

Types

• Major Depression can be:
• Mild with or without somatic symptoms
• Moderate with or without somatic symptoms
• Severe with or without psychotic symptoms

Other Subtypes

• Atypical depression: Weight gain, hypersomnolence, and increased appetite
• Seasonal Affective Disorder: This is a type of depression triggered by a change in weather, especially in winter or late fall.
• Agitated depression: Restlessness and agitation are prominent features
• Double depression: Depression in a patient with dysthymia.
• Disruptive Mood Dysregulation
• Premenstrual Dysphoric Disorder
• Substance or Medication-Induced Depressive Disorder
• Alcohol
• Phencyclidine
• Other hallucinogen
• Inhalant (Note: does not cause mania/hypomania)
• Opioid (Note: does not cause mania/hypomania)
• Sedative, hypnotic, or anxiolytic
• Amphetamine (or other stimulant)
• Cocaine
• Depression due to another medical disorder
• Unspecified Depressive Disorder

Etiology

• Multifactorial involving genetic, biological, environmental, and psychosocial factors
• Biologic: Abnormalities of neurotransmitters, especially serotonin, norepinephrine, and dopamine. Lower levels of brain GABA
• Environmental: Trauma and abuse, multiple adverse childhood experiences, life events
• Genetic: Twin and adoption studies have shown high concordance rates in monozygotic twins than dizygotic twins, showing heritability
• Cognitive Theory: Cognitive distortion, defined as a person's inaccurate perception of the real world, and it can reinforce negative thoughts and lead to depression.

Management

MDD requires a comprehensive and multifaceted approach guided by the biopsychosocial model, which acknowledges the interplay of biological, psychological, and social factors in its development and maintenance.

Assessment:

• Detailed clinical history:
  • Explore biological vulnerabilities (family history, medical conditions)
  • Examine psychological factors (cognitive patterns, coping mechanisms)
  • Consider social stressors (environmental triggers, interpersonal relationships)
• Mental status examination:
  • Evaluate mood, cognition, affect, and suicidality within the context of biological, psychological, and social aspects
• Physical examination and medical history:
  • Rule out medical conditions mimicking depression
  • Consider potential biological contributions
• Psychological testing:
  • Identify specific cognitive patterns
  • Assess potential psychological factors contributing to MDD

Investigations:

Baseline investigations such as

• Full Blood Count (FBC): Rules out anemia.
• Thyroid Function Tests (TFTs): Checks for thyroid disorders.
• Basic Metabolic Panel (BMP) or Comprehensive Metabolic Panel (CMP): Assesses electrolytes, glucose, and organ function.
• Vitamin B12 and Folate Levels: Identifies nutritional deficiencies.
• Serum Iron and Ferristin: Screens for iron deficiency.
• C-reactive Protein (CRP): Assesses inflammation.
• Lipid Profile: Examines cholesterol levels.
• Urinalysis
• Electrocardiogram (ECG or EKG): Assesses the heart, especially for certain medications.

Treatment Phases:

1. Acute Phase:

Aims for rapid symptom remission and improved functioning.

• Multimodal approach: Combines evidence-based interventions addressing biological, psychological, and social factors.
• Pharmacotherapy: First-line treatment with antidepressants targeting neurotransmitter imbalances (biological aspect).
• Psychotherapy: Individual therapy like CBT or IPT to address negative thinking patterns and maladaptive behaviors (psychological aspect).
• Lifestyle interventions: Promoting healthy sleep, regular exercise, and balanced nutrition to optimize biological and psychological well-being.
• Social support: Encouraging connection with supportive family and friends (social aspect).
• Consideration of co-occurring conditions: Address any medical or psychiatric disorders influencing the depressive episode.
• Electroconvulsive Therapy (ECT): Highly effective for severe, treatment-resistant depression or in cases with high suicide risk.
• Transcranial Magnetic Stimulation (TMS): Non-invasive brain stimulation therapy, used for MDD not responding to medications.

2. Continuation Phase:

Aims to prevent relapse for 6-12 months.

• Continuation of effective interventions from the acute phase, gradually adjusting based on individual needs and response.
• Regular monitoring for relapse signs and medication side effects.

3. Maintenance Phase:

Aims to prevent future depressive episodes for 2-5 years or longer.

• Lower doses of medication or psychotherapy may be sufficient.
• Regular follow-up visits with the psychiatrist for ongoing support and monitoring.

INDICATIONS FOR ECT

• Depression unresponsive to multiple antidepressant trials
• Depression with life-threatening symptoms such as refusal to eat or drink
• Suicidality
• Depression in the post-partum period
• Severe depression with psychosis

• Three forms:
• Bipolar I, Bipolar II, and Cyclothymia
• Mania defining feature of each
• Differentiated by severity and duration of mania
• Usually involve episodes of depression alternating with mania
• Depressive episode required for Bipolar II, but not Bipolar I
• Mania
• State of intense elation or irritability
• Hypomania (hypo = “under”; hyper = “above”)
• Symptoms of mania but less intense
• Does not involve significant impairment, mania does

Types

• Bipolar I
• At least one episode of mania
• Bipolar II
• At least one major depressive episode with at least one episode of hypomania
• Cyclothymic disorder (Cyclothymia)
• Milder, chronic form of bipolar disorder
• Lasts at least 2 years in adults, 1 year in children/adolescents
• Numerous periods with hypomanic and depressive symptoms
• Does not meet criteria for mania or major depressive episode
• Symptoms do not clear for more than 2 months at a time
• Symptoms cause significant distress or impairment

• Distinctly elevated or irritable mood for most of the day nearly every day
• Abnormally increased activity and energy
• At least three of the following are noticeably changed from baseline (four if mood is irritable):
• Increase in goal-directed activity or psychomotor agitation
• Unusual talkativeness; rapid speech
• Flight of ideas or subjective impression that thoughts are racing
• Decreased need for sleep
• Increased self-esteem; belief that one has special talents, powers, or abilities
• Distractibility; attention easily diverted
• Excessive involvement in activities that are likely to have undesirable consequences, such as reckless spending, sexual behavior

For a manic episode:

• Symptoms last for 1 week or require hospitalization or include psychosis
• Symptoms cause significant distress or functional impairment

For a hypomanic episode:

• Symptoms last at least 4 days
• Clear changes in functioning that are observable to others, but impairment is not marked
• No psychotic symptoms

Mania	Hypomania
> 3 manic symptoms	> 3 manic symptoms
At least 1 week of feeling euphoric, expansive, or irritable	At least 4 days of feeling euphoric, expansive, or irritable
Abnormally, persistently elevated, expansive, or irritable mood	Distinct period of persistently elevated, expansive, or irritable mood
At least one of these is true: - Hospitalization is needed - Psychotic features - Marked impairment in occupational functioning, usual social activities, or relationships with others	Does not require hospitalization No psychotic features Not severe enough to cause marked functioning impairment Unequivocal change in functioning Uncharacteristic of person when not symptomatic

Epidemiology

• Prevalence rates lower than MDD
• 1% in U. S.; 0.6% worldwide for Bipolar I
• 0.4% – 2% for Bipolar II
• 4% for Cyclothymia
• Average age of onset in 20s
• No gender differences in rates of bipolar disorders – Women experience more depressive episodes
• Severe mental illness
• A third unemployed a year after hospitalization (Harrow et al., 1990)
• Suicide rates high (Angst et al., 2002)

Etiology

• Genetics
• Social factors: stress and trauma
• Substance abuse
• Major life changes
• Biological factors, brain changes

Management

• Good history
• Physical examination to exclude organic causes
• Biopsychosocial management
• Biological: MOOD STABILIZERS
• Lithium
• Carbamazepine
• Sodium valproate
• Antipsychotics
• Psychological: Psychotherapy
• Others: ECT