MOOD DISORDERS NCMH Lecture
Mood, Affect and Mood Disorder
Mood - is a pervasive and sustained and sustained
feeling that is experienced internally and that
influences a person’s behavior and perception of the
world
Affect - is the external expression of mood
Mood disorders - are group of clinical conditions
characterized by loss of that sense of control and
subjective experience of great distress
Categories of Mood Disorder
- Major Depressive Disorder (MDD) or unipolar
depression
- Bipolar disorder (BPD) - mania and depression
- Three additional categories:
- Hypomania
- Cyclothymia
- Dysthymia
Historical Consideration
- In the old testament depression was depicted in
the story of King Saul which is an equivalent of
Ajax suicide in Homer’s Iliad
- 400 BC, Hippocrates used terms mania and
melancholia to describe mental disturbances
- 1854, Jules Falret described folie circulaire-
patients experiencing alternating moods of
depression and mania
- Karl Kahlbaum - terme “cyclothymia”
- In 1899 - Emil Kraepelin - “involutional
melancholia” - i.e. mood disorder that begins in
late adulthood
Epidemiology
Lifetime prevalence:
- Major depressive episode - 5—17%
- Dysthymic disorder - average of 3-6%
- Minor depressive disorder - 10%
- Recurrent brief depressive disorder - 16%
- Bipolar I disorder - 0-2.4%
- Bipolar II disorder - 0.3-4.8%
- Cyclothymia - 0.5-6.3%
Sex - females have two-fold greater prevalence of
MDD than males. Why?
- Hormonal differences
- Effects of childbirth
- Differing psychosocial factors for men and women
In BPD - equal prevalence among sexes
- Manic episodes are more common in men, and
depressive episodes are more common in women.
- Women - mixed episode and rapid cyclers
Comorbidity
Most frequent disorders:
- Alcohol abuse or dependence
- Panic disorder
- Obsessive-Compulsive Disorder
- Social Anxiety Disorder
Age - the onset of BPD is earlier than that if MDD
- Mean age of onset:
- BPD - 5 to 50 y/o; mean age of 30 y/o
- MDD - 20-50 y/o; mean age of 40 y/o
- Increasing incidence of MDD in <20 y/o due to
increased use of alcohol and drugs of abuse
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Marital Status - MDD and BPD occur more common
in separated/divorced and single persons
Socio-economic and Cultural factors - no correlation
between this factor and that with MDD. Higher
incidence among upper socio-economic groups
Etiology
Biological factors:
- Biogenic amines - norepinephrine, serotonin and
dopamine. The first two are the most implicated in
the pathophysiology of depression
- Other neurotransmitters- Ach, GABA, Glutamate,
and Glycine
- Alterations of hormonal regulation
- Thyroid axis activity
Genetic factors
- Family studies
- Adoption studies
- Twin studies
Psychosocial factors
- Life events and environmental stresses
- Personality factors
- Psychodynamic factors in depression
Diagnosis
- DSM V Criteria for Major Depressive Episode
A. Five or more of the following symptoms have been
present during the same two-week period and
represent a change from previous functioning and
at least one of the symptoms either: (1) depressed
mood or (2) loss of interest or pleasure
1) depressed mood most of the day, nearly
everyday as indicated by either subjective report (e.g., feels
sad or empty) or observation made by others (e.g., appears
tearful)
2) markedly diminished interest or pleasure in all
or almost all activities most of the day, nearly every day
3) significant weight loss when not dieting or
weight gain (>5% body weight in a month) or decrease or
increase in appetite
4) insomnia or hypersomnia
5) psychomotor agitation or retardation
6) fatigue or loss of energy
7) feelings of worthlessness or excessive or
inappropriate guilt
8) Diminished ability to think or concentrate or
indecisiveness
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
impairment in social, occupational, or other areas
of functioning
C. T h e e p i s o d e i s n o t a t t r i b u t a b l e t o t h e
physiological effects of a substance or to another
medical condition
*Note: Criteria A-C represent a major depressive
episode
*Note: Responses to a significant loss (e.g.,
bereavement, financial ruin, loses from a natural
disasters serious medical illness or disability) may
include the feelings of intense sadness, rumination
about the loss, insomnia, poor appetite, and weight
loss noted in Criterion A, which may resemble a
depressive episode
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MOOD DISORDERS NCMH Lecture
D. The occurrence of the MDD is not better explained
by schizoaffective disorder, schizophrenia,
schizopreniform disorder, delusional disorder or
other specified and unspecified schizophrenia
spectrum and other psychotic disorders.
E. There has never been a manic episode or
hypomanic episode.
- DSM V Criteria for a Bipolar I Disorder
- For a diagnosis of a Bipolar I disorder, it is
necessary to meet the following criteria for a
manic episode. the manic episode may have
been preceded by and may be followed by
hypomanic or major depressive episodes
A. A distinct period if abnormally and persistently
elevated, expansive, or irritable mood lasting at
least 1 week (or any duration if hospitalization is
necessary)
B. During the period of mood disturbance, three or
more of the following symptoms have persisted
(four if the mood is only irritable) 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
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 pleasurable activities
that have a high potential for painful consequences
C. The mood disturbance is sufficiently severe to
cause marked impairment in occupational
functioning, or to necessitate hospitalization to
prevent harm to self or others, or there are
psychotic features.
D. T h e e p i s o d e i s n o t a t t r i b u t a b l e t o t h e
physiological effects of a substance
E. The symptoms are not due to the direct
physiological effects of another medical condition
The criteria for a hypomanic episode is almost similar
for manic episode except that the former had lesser
duration (at least 4 days) compared to the latter
The criteria for a mixed episode includes both major
depressive episode and manic episode
Bipolar I - mania + depression
- mania only
Bipolar II - hypomania + depression
Clinical Features: Depressive Episodes
- A depressed mood and loss of interest or pleasure
are the key symptoms of depression
- About 2/3 of depressed patients contemplate
suicide, and 10-15% commit suicide
- Depression in Children and Adolescents:
- School phobia and excessive clinging to parent
- Poor academic performance, substance abuse,
antisocial behavior's sexual promiscuity,
truancy and running away
- Depression in Older People:
- Correlated with low socio-economic status, loss
of a spouse, concurrent physical illness and
social isolation
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Clinical Features: Manic Episodes
- An elevated, expansive or irritable mood is the
hallmark of a manic episode
- Mania in Adolescents:
- Often diagnosed as antisocial PD or
schizophrenia
- Symptoms may include psychosis, alcohol or
other substance abuse, suicide attempts,
academic problems, philosophical brooding,
OCD symptoms, multiple somatic complaints,
marked irritability resulting in fights and other
antisocial behaviors
Differential Diagnoses
- Medical disorders
- Neurological disorders
- Mental disorders
Course and Prognosis: MDD
- 1st depressive episode occurs before 40 y/o in
about 50% of patients
- An untreated episode lasts 6-13 months; most
treated episodes last about 3 months
- Tends to be chronic, and patients tend to relapse
- Prognostic indicators
- Good indicators:
- Mild episodes
- Absence of psychotic symptoms
- Short hospital stay
- Good history of solid friendships during
adolescence
- Stable family functioning
- Generally sound social functioning for the 5
years preceding the illness
- Absence of co-morbid psychiatric disorder
and of a personality disorder
- Advanced age of onset
- Poor indicators:
- Presence of a co-existing dysthymic disorder
- Alcohol abuse and other substances
- Anxiety disorder symptoms
- History of one or more depressive episode
Course and Prognosis: Bipolar Disorder
- Course: Bipolar disorder most often starts with
depression (75% - women and 67% in men) and is
a recurring disorder
- 10-20% have only manic episodes
- The manic episodes typically have rapid onset
and may evolve over few weeks
- An untreated manic episode lasts about 3
months
- A person who has a single manic episode, 90%
are likely to have another episode
- As the disorder progresses, time between
episodes often decreases
- 5-15% have four or more episodes in one year -
rapid cyclers
- Prognosis: Bipolar I disorder have a poorer
prognosis than do patients with MDD
- About 40-50% may have a second manic
episode within the 2 years of the 1st episode
- About 7% do not have recurrence of symptoms;
45% have more than one episode, and 40% have
a chronic disorder
- Patients may have 2-30 manic episodes, mean
number - 9
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MOOD DISORDERS NCMH Lecture 3

- On long-term follow-up, 15%-well; 45%-well but

with multiple relapses; 30%-partial remission
and 10%-chronically ill

Treatment
- Several goals of treatment:
- Patient safety must be guaranteed
- Complete diagnostic evaluation of the patient is
necessary
- Treatment plan that addresses not only the
immediate symptoms but also the patient’s
prospective well-being should be initiated
- Hospitalization
- Pharamcotherapy
- MDD: SSRI’s or other antidepressants
- Bipolar: Mood stabilizers and/or atypical
antipsychotics (Quetiapine)
- Psychosocial therapy
- Cognitive therapy
- Interpersonal therapy
- Behavioral therapy
- Psychoanalytically-oriented therapy
- Family therapy
- Vagal Nerve Stimualtion
- Transcranial Magnetic Stimualtion
- Sleep Deprivation
- Phototherapy and other somatic therapy
- (ECT)

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