Mood Disorders: Textbook of Psychiatry

The American Psychiatric Publishing
TEXTBOOK OF PSYCHIATRY
Fifth Edition
Edited by Robert E. Hales, M.D., M.B.A., Stuart C. Yudofsky, M.D., Glen O. Gabbard, M.D.
© 2008 American Psychiatric Publishing, Inc. All rights reserved. www.appi.org
CHAPTER 11
Mood Disorders
John A. Joska, M.D., M.Med.(Psych.), F.C.Psych.(S.A.),
Dan J. Stein, M.D., Ph.D.
Slide show includes…

Topic Headings
Tables and Figures
Key Points
The American Psychiatric Publishing Textbook of Psychiatry, Fifth Edition. Edited by Hales RE, Yudofsky SC, 1
Gabbard GO. © 2008 American Psychiatric Publishing, Inc. All rights reserved. www.appi.org
CHAPTER 11 • Topic Headings
PHENOMENOLOGY OF MOOD DISORDERS Clinical Features of Mania

Classification of Mood Disorders Mental State Examination
DSM-IV-TR and ICD-10 Mood Disturbance in Mania
Boundaries Cognitive, Neurovegetative, and Behavioral Symptoms
Subtypes and Forms of Mood Disorders Duration, Intensity, and Specifiers
Clinical Features of Depression Bipolar I Disorder
Mental State Examination Diagnostic Criteria
Depressed Mood and Anhedonia Single Versus Recurrent Manic Episodes
Cognitive, Neurovegetative, and Behavioral Other Bipolar Disorders
Symptoms Bipolar II Disorder
Duration, Intensity, and Specifiers Cyclothymia
Major Depressive Disorder Bipolar Spectrum Disorder
Diagnostic Criteria Differential Diagnosis of Bipolar Disorders
Single-Episode Versus Recurrent Major Medical Disorders
Depression Mania Secondary to Substance Use
Other Depressive Disorders Mania and Other Psychiatric Disorders
Dysthymia Comorbidity of Mood Disorders
Psychotic Depression Anxiety Disorders
Seasonal Affective Disorder Schizophrenia
Recurrent Brief Depressive Disorder and Minor Personality Disorders
Depressive Disorder Pediatric Mood Disorders
Premenstrual Dysphoric Disorder Depressive Disorders
Adjustment Disorder and Bereavement Bipolar Disorder
Differential Diagnosis of Depressive Disorders Mood Disorders in Old Age
Medical Disorders Age and Illness Presentation
Depression Secondary to Substance Use Depressive Disorders
Depression and Other Psychiatric Disorders Cultural Aspects of Depression
Cross-Cultural Equivalence
Cultural Epidemiology of Depression
Cultural Idioms of Distress (continued)
CHAPTER 11 • Topic Headings (continued)
EPIDEMIOLOGY Anatomical Pathology

Epidemiology of Mood Disorders Neuronal and Glial Pathology
Current and Lifetime Prevalence Rates Molecular and Cellular Neurobiology
Sociodemographic Correlates Neuroplasticity and Cellular Resilience
Risk Factors for Mood Disorders Neuroimmunity and Mood Disorders
Global Burden of Mood Disorders Brain Imaging
Economics of Mood Disorders Structural Imaging
Course of Mood Disorders Functional Imaging
Course of Major Depression Cognitive Processing Models of Depression
Course of Bipolar Disorder Cognitive Deficits in Depression
Cognitive Features of Depression
PATHOGENESIS OF MOOD DISORDERS
Other Psychological Theories of Depression
Evolutionary Aspects of Mood Disorders
Sigmund Freud
Genetics and Inherited Factors
Melanie Klein
Family Studies
John Bowlby
Twin Studies
Adoption Studies SOMATIC INTERVENTIONS FOR MOOD DISORDERS
Molecular Linkage Studies Antidepressants
Linkage Disequilibrium Studies Tricyclics, Tetracyclics, and Monoamine Oxidase
Neurochemistry Inhibitors
Serotonin System Selective Serotonin Reuptake Inhibitors
Norepinephrine System Serotonin–Norepinephrine Reuptake Inhibitors
Dopamine System Other Antidepressants
Neuropeptides in Mood Disorders Mood Stabilizers
Neuroplasticity and Neurotrophic Factors Lithium
Psychoneuroendocrinology Valproate and Carbamazepine
Hypothalamic-Pituitary-Adrenal Axis Other Anticonvulsants
Thyroid Physiology in Depression Antipsychotic Medications
Hypothalamic-Pituitary-Gonadal Axis Use in Mood Disorders
Adverse Effects
(continued)
CHAPTER 11 • Topic Headings (continued)
Electroconvulsive Therapy and Transcranial Psychotherapy for Bipolar Disorder

Magnetic Stimulation Psychoeducation
Electroconvulsive Therapy Cognitive-Behavioral Therapy
Transcranial Magnetic Stimulation Family Therapy
Novel and Other Somatic Treatments Interpersonal and Social Rhythm Therapy
Hypothalamic-Pituitary-Adrenal Axis Treatments
INTEGRATIVE MANAGEMENT OF MOOD
Thyroid System Treatments
DISORDERS
Testosterone and Gonadal Hormones
Major Depressive Disorder
Vagus Nerve Stimulation
Treatment Guidelines in Major Depression
Deep Brain Stimulation
Combined Medication and Psychotherapeutic
PSYCHOTHERAPY FOR MOOD DISORDERS Approaches
Cognitive-Behavioral Therapy Medication Combination and Augmentation
The Cognitive Model Bipolar Disorder
CBT Strategies and Techniques Treatment Guidelines in Bipolar Disorder
Cognitive-Behavioral Analysis Treatment of Bipolar Disorder in Women of
Interpersonal Psychotherapy Childbearing Age
IPT Theory Other Issues in Treatment of Mood Disorders
IPT Technique Treatment in Children and Adolescents
Psychodynamic Psychotherapy Treatment in the Elderly
Principles of Psychodynamic Therapy
CONCLUSION
Psychodynamic and Psychoanalytic Approach
to Depression
CHAPTER 11 • Tables and Figures
Figure 11–1. Summary of mood disorders, specifiers, and relationships.

Table 11–1. DSM-IV-TR diagnostic criteria for major depressive episode
Table 11–2. DSM-IV-TR diagnostic criteria for dysthymic disorder
Table 11–3. DSM-IV-TR criteria for seasonal pattern specifier
Table 11–4. DSM-IV-TR research criteria for premenstrual dysphoric disorder
Table 11–5. Some medical conditions that may cause depression
Table 11–6. Some substances and medications that may cause depression
Table 11–7. DSM-IV-TR diagnostic criteria for manic episode
Table 11–8. DSM-IV-TR diagnostic criteria for bipolar I disorder, single manic episode
Table 11–9. DSM-IV-TR diagnostic criteria for bipolar II disorder
Table 11–10. DSM-IV-TR diagnostic criteria for cyclothymic disorder
Table 11–11. Some conditions that may cause mania
Table 11–12. Some substances and medications that may cause mania
Table 11–13. Studies of current and lifetime prevalence of mood disorders
Table 11–14. Currently available antidepressants: activity, indications, adverse effects, and dosing
Table 11–15. Selective serotonin reuptake inhibitors (SSRIs): activity, prescribing notes, and dosing
Figure 11–2. Strategies for the treatment of major depression (nonpsychotic).
Figure 11–3. Strategies for the treatment of bipolar disorder (hypomanic/manic episode).
Summary Key Points
Assessment of mood disorders requires both a cross-sectional and a longitudinal review. Figure 11–1
summarizes mood disorders according to episode features and specifiers.
Figure 11–1. Summary of mood disorders, specifiers, and relationships.
The DSM-IV-TR diagnostic criteria for major depressive episode are listed in Table 11–1.
TABLE 11–1. DSM-IV-TR diagnostic criteria for major depressive episode
Dysthymic disorder is a common depressive condition with a lifetime prevalence of up to 6% of the
population. It is characterized by milder depressive symptoms than in major depression that persist
for at least 2 years, with a symptom-free period of only 2 months in each year (Table 11–2).
TABLE 11–2.
DSM-IV-TR diagnostic
criteria for dysthymic
disorder
Seasonal affective disorder (SAD) is a recent entry to the diagnostic system (Rosenthal et al. 1984). It is now
classified as a mood disorder specifier—with seasonal pattern. In major depressive disorder, a seasonal
pattern may occur in up to one-third of cases (Table 11–3).
TABLE 11–3. DSM-IV-TR criteria for seasonal pattern specifier
Premenstrual mood symptoms are common, and about 3%–9% of women meet criteria for
premenstrual dysphoric disorder (PMDD). PMDD is characterized by the onset of severe symptoms,
with at least one mood symptom, in the late luteal phase of the menstrual cycle, with remission
during the early follicular phase (Table 11–4).
TABLE 11–4.
DSM-IV-TR
research
criteria for
premenstrual
dysphoric
disorder
Many medical conditions may be associated with
depression. Some of these are listed in Table 11–5.
The mechanism of association may be a result of
the condition itself (such as hypothyroidism), a
reaction to having a medical condition, a result of
the medical treatment of the condition, or a
combination of these factors.
TABLE 11–5. Some medical

conditions that may cause
depression
The most widespread substance of abuse, alcohol, is a
common and independent cause of depressive illness.
Patients whose alcohol abuse leads to depression will
commonly experience a remission of depressive
symptoms after cessation of alcohol use without
antidepressant treatment. Other causes of depression
secondary to substance and medication use are listed
in Table 11–6.
TABLE 11–6. Some substances and

medications that may cause depression
The presentation of mania is varied.
Central to mania, hypomania, or mixed
episodes is the presence of either
elevated, irritable, or expansive mood
(Table 11–7).
TABLE 11–7. DSM-IV-TR diagnostic

criteria for manic episode
(continued)
TABLE 11–7. (continued)
The diagnostic criteria for bipolar I disorder are listed in Table 11–8. The presence of any past or
present manic episode is sufficient to meet criteria.
TABLE 11–8. DSM-IV-TR diagnostic criteria for bipolar I disorder, single manic episode
A diagnosis of bipolar II
disorder requires the
presence of hypomanic and
major depressive episodes
(Table 11–9). Bipolar II
disorder should be considered
in patients who have atypical
features, who abuse
substances as a form of
self-medication, or who have
chaotic relationships. A life
chart may be helpful.
TABLE 11–9. DSM-IV-TR

diagnostic criteria for
bipolar II disorder
Cyclothymia is characterized by a 2-year history of changing mood, with both depressive and hypomanic
symptoms (Table 11–10).
TABLE 11–10. DSM-IV-TR diagnostic criteria for cyclothymic disorder
The emergence of mania or hypomania in the
presence of a medical disorder may result
from the disorder itself or the associated
treatment (Table 11–11). The emergence of a
manic episode in an individual older than 35
years should raise the level of suspicion for
an underlying medical cause.
TABLE 11–11. Some conditions

that may cause mania
The use of substances early in the
course of bipolar disorder is common
(Table 11–12). Furthermore, the use of
substances may predict an earlier onset
of bipolar disorder and a worse course.
TABLE 11–12. Some substances

and medications that may cause
mania
Selected studies assessing the current and lifetime prevalence of depression and bipolar disorder in the
general population are presented in Table 11–13.
TABLE 11–13. Studies of current and lifetime prevalence of mood disorders
Antidepressants are classified according to their activity at monoamine receptors (Table 11–14).
TABLE 11–14. Currently available antidepressants: activity, indications, adverse effects, and
dosing
(continued)
TABLE 11–14. (continued)
The SSRIs are a group of drugs with similar but not identical effects. They are safer in overdose than are TCAs.
Activities and dosing are shown in Table 11–15.
TABLE 11–15. Selective serotonin reuptake inhibitors (SSRIs): activity, prescribing notes, and
dosing
The Texas Medication Algorithm Project
strategies for the treatment of
nonpsychotic major depression are shown
in Figure 11–2 (Trivedi et al. 2004).
FIGURE 11–2. Strategies for the

treatment of major depression
(nonpsychotic).
Note. SSRI = selective serotonin reuptake inhibitor (fluoxetine, sertraline,

paroxetine, citalopram); BUPSR = bupropion sustained release; NEF =
nefazodone; VLFXR = venlafaxine extended release; MRT = mirtazapine;
TCA = tricyclic antidepressant; MAOI = monoamine oxidase inhibitor;
ECT = electroconvulsive therapy.
*Consider TCA/VLF if not tried.
**Lithium, thyroid, buspirone.
***Skip if lithium augmentation has already failed.
†
Most studied combination.
Source. Trivedi et al. 2004. Algorithms are revised as new data become
available; consult the Texas Implementation of Medication Algorithms
(TIMA) Web site (http://www.dshs.state.tx.us/mhprograms/TIMA.shtm)
for the most recent versions.
The Texas Medication Algorithm Project
treatment strategies for hypomania/
mania in bipolar disorder are presented
in Figure 11–3.
FIGURE 11–3. Strategies for the

treatment of bipolar disorder
(hypomanic/manic episode).
Note. AC = anticonvulsant; AAP = atypical antipsychotic; CONT =

continuation treatment; DVP = divalproex; ECT = electroconvulsive
therapy; Li = lithium; OLZ = olanzapine; OXC = oxcarbazepine;
QTP = quetiapine; RIS = risperidone; TPM = topiramate; VPA =
valproate; ZIP = ziprasidone.
Source. Suppes et al. 2001. Algorithms are revised as new data become
available; consult the Texas Implementation of Medication Algorithms
(TIMA) Web site (http://www.dshs.state.tx.us/mhprograms/TIMA.shtm)
for the most recent versions.
CHAPTER 11 • Key Points
 Depression is a symptom of a syndrome that may have many causes.

 Bipolar disorders can be difficult to diagnose because of the inability to
detect past and future episodes.
 The clinical features of depression across cultures may vary, including
expressions such as loneliness and somatic complaints.
 Major depression is common, with a lifetime prevalence of about 10%. It also
causes about twice as much disability as any other medical condition.
 Major depression is a chronic and recurring illness, with relapses occurring in
at least half of patients.
 The causes of depression are multifactorial and usually include genetic and
environmental contributions.
 Treatment of major depression consists of selecting an appropriate
antidepressant and giving consideration to an effective psychotherapy.
 Bipolar disorders should be treated with mood stabilizers first, with the
addition of other agents if response is unsatisfactory.

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The American Psychiatric Publishing

Slide show includes…

PHENOMENOLOGY OF MOOD DISORDERS Clinical Features of Mania

EPIDEMIOLOGY Anatomical Pathology

Electroconvulsive Therapy and Transcranial Psychotherapy for Bipolar Disorder

Figure 11–1. Summary of mood disorders, specifiers, and relationships.

Figure 11–1. Summary of mood disorders, specifiers, and relationships.

TABLE 11–1. DSM-IV-TR diagnostic criteria for major depressive episode

TABLE 11–3. DSM-IV-TR criteria for seasonal pattern specifier

TABLE 11–5. Some medical

TABLE 11–6. Some substances and

TABLE 11–7. DSM-IV-TR diagnostic

TABLE 11–9. DSM-IV-TR

TABLE 11–10. DSM-IV-TR diagnostic criteria for cyclothymic disorder

TABLE 11–11. Some conditions

TABLE 11–12. Some substances

TABLE 11–13. Studies of current and lifetime prevalence of mood disorders

FIGURE 11–2. Strategies for the

Note. SSRI = selective serotonin reuptake inhibitor (fluoxetine, sertraline,

FIGURE 11–3. Strategies for the

Note. AC = anticonvulsant; AAP = atypical antipsychotic; CONT =

 Depression is a symptom of a syndrome that may have many causes.

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