MOOD is a pervasive and a sustained
feeling tone that is experienced internally
and that influences a person’s behaviour
and perception of the world.
AFFECT is the external manifestation of
mood.
Mood Disorders are a group of clincal
conditions characterized by loss of sense
of control and subjective experience of
distress.
HISTORY
HIPPOCRATES(400BC) used the term
MANIA and MELANCHOLIA to
describe mental disturbances.
JULES FALRET(1854)- la folie
circulaire
Karl Kahlbaum(1882)- used the term
CYCLOTHYMIA
Emil Kraeplin(1899)- Manic
Depressive Psychosis.
Differentiated it from Dementia
Praecox(Schiz)
CLASSIFICATION
MAJOR DEPRESSIVE DISORDER(MDD
MANIA & HYPOMANIA
BIPOLAR DISORDER I
BIPOLAR DISORDER II
DYSTHYMIC DISORDER
CYCLOTHYMIC DISORDER
ATYPICAL BIPOLAR OR DEPRESSIVE
DISORDER
RAPID CYCLERS
OTHERS :
MINOR DEPRESSIVE DISORDER
RECURRENT BRIEF DEPRESSIVE
DISORDER
PRE MENSTRUAL DYSPHORIC
DISORDER
MOOD DISORDER DUE TO MEDICAL
CONDITIONS AND SUBSTANCE
ABUSE
EPIDEMIOLOGY
Life Time Prevalance of
MDD 12%
BIPOLAR DISORDERS 0-4.8%
SEX :
M:F
MDD 1:2
BIPOLAR DISORDERS 1:1
Mania more in men and MDD more in
women
AGE :
Years
MDD 20-50
BIPOLAR 30 (mean age)
MARITAL STATUS :
Divorced or seperated, single.
COMORBIDITY:
1.ALCOHOL ABUSE
2.PANIC DISORDER
3. OCD
4. SOCIAL ANXIETY DISORDER
ETIOLOGY
I. BILOGICAL FACTORS
II. GENETIC FACTORS
III. PSYCHOSOCIAL FACTORS
IV. PSYCHODYNAMIC FACTORS
V. COGNITIVE THEORIES
I.BIOLOGICAL FACTORS :
1.BIOGENIC AMINES:
A. NOREPINEPHRINE :
Decreased sensitivity of Beta
Adrenergic receptors and clinical
antidepressant response indicates
direct role of Nor adrenergic system
in Depression.
B.SERETONIN
C.DOPAMINE :
Its activity may be decreased in
Depression and increased in Mania.
D.ACETYLCHOLINE
E.GABA
F. AMINO ACIDS : GLUTAMATE &
GLYCINE
G. Alterations of Hormonal Regulation:
Increased HPA activity is asso with
Depression.
H. Thyroid dysfunction in Depression :
Elevated TSH.
I. Growth Hormone
L. Prolactin
M.SLEEP NEUROPHYSIOLOGY :
Reduction in total sleep time,
Increased REM, Increased body temp
N.Immunological disturbances.
O.Brain structural changes :
CT & MRI – Abnormal
Hyperintensities in Sub cortical
regions.
Ventricular enlargement
Cortical atrophy.
PET SCAN : Decreased Anterior Brain
Metabolism on left side.
Decreased Cerebral blood flow.
GENETIC FACTORS :
FAMILY STUDIES
ADOPTION STUDIES
TWIN STUDIES
These studies have long documented the
heritability of Modd disorders.
LINKAGE STUDIES : Chromosomes 18q &
22q are the two regions with strongest
evidence for linkage to bipolar disorder.
This disease is said to be Genetically linked
PSYCHOSOCIAL FACTORS :
Life events
Environmental stress
PERSONALITY FACTORS :
OCD, HISTRIONIC, BORDERLINE
Personlaities – Risk for Depression
PSYCHODYNAMIC FACTORS :
Disturbances in the Infant-Mother
relationships during Oral Phase(Below
1yr).
Real or imagined object loss.
Introjection of departed objects is a
defense mechanism.
The lost object- feelings of anger are
directed inward at the self.
Mania is a defensive reaction to
depression.
COGNITIVE FACTORS :
Depression results from specific
Cognitive distortions.
Aaron Beck postulated COGNITIVE
TRIAD of Depression :
1. Views about the self – Negative
self precept
2. About the environment – Hostile
and demanding
3. About the future – Expectation of
suffering & failure.
CLINICAL FEATURES
MAJOR DEPRESSIVE DISORDER :
Five or more of the following, most of
the day and/or nearly every day,
including at least symptom 1 or 2:
1. Depressed mood
• Sad, empty, weepy; irritable, angry
2. Loss of interest or pleasure in
previously enjoyable
activities(Anhedonia)
3. Change in weight or appetite
4. Sleep changes
5. Noticeable change in movement
6. Fatigue
7. Feelings of worthlessness or guilt
8. Impaired cognition or volition
9. Repeated thoughts of death or suicide,
or planned or attempted suicide
The five symptoms must occur in the
same two weeks
MANIC EPISODE
One week of persistently high,
expansive, or irritable mood, and 3
of:
Grandiose self-esteem
Lower sleep need
Overly talkative
Racing thoughts
Easily distracted
Increased activity or agitation
High risk activities
MANIC EPISODE
Mixed episode
One week of both manic and major
depressive symptoms with rapidly
alternating moods
Common symptoms:
• Agitation
• Insomnia
• Irregular appetite (binge-fast)
• Delusions
• Thoughts of suicide
Hypomanic episode
Mood disturbance does not critically
impair ability to work or maintain
social responsibilities
Response pattern is uncharacteristic
Not euthymia
Bipolar disorders
Bipolar I Disorder
• One or more manic or mixed episodes
• Usually one or more major depressive
episodes
• Subcategorized based on the character
of the most recent episode
Most recent episode depressed
Most recent episode manic
Most recent episode mixed
Bipolar disorders…
Bipolar II Disorder
• One or more major depressive episodes
• One or more hypomanic episodes
• NO manic or mixed episode
Cyclothymic Disorder
• Two years of alternating hypomanic and
depressive symptoms
• No remission of more than two months
• NO major depressive, manic, or mixed
episodes
Dysthymic Disorder
• Two years of chronically depressed mood
• Two additional depression symptoms
(appetite, sleep, energy, concentration, low
self-esteem, hopeless feelings)
RAPID CYCLING –
Rapid cycling Bipolar I disorder
Female
Atleast 4 episodes of Modd Disturbance within
12 month period.
Mood Disorder Specifiers
These specifiers may be applied to mood
disorder diagnoses, where appropriate:
• Mild/moderate/severe w/o psychotic features
• With:psychotic/ catatonic/ melancholic/
atypical features (m-older, a-younger)
• In remission/chronic/seasonal pattern
• With postpartum onset- Symptoms within
4weeks of postpartum, inclde Psychotic
symptoms(postpartum psychosis)
Mood Disorder Specifiers
These specifiers may be applied to mood
disorder diagnoses, where appropriate:
• Mild/moderate/severe w/o psychotic features
• With:psychotic/ catatonic/ melancholic/
atypical features (m-older, a-younger)
• In remission/chronic/seasonal pattern
• With postpartum onset- Symptoms within
4weeks of postpartum, inclde Psychotic
symptoms(postpartum psychosis)
TREATMENT
TREATMENT OF MDD
Various antidepressants altering levels of
central neurotransmitters are available to
treat depression.
Their overall effectiveness: 65-70%
Mild to moderate depressive episode:
SSRIs.
Severe depression: antidepressants with
broader spectrum of effects, like SNRI or
TCA and E.C.T
ANTIDEPRESSANTS
NE Reuptake Inhibitors
Desipramine
75-300mg
Drowsiness, insomnia, OSH, agitation,
CA, weight gain anticholinergic,
Overdose may be fatal.
Dose titration is needed..
Nortriptyline
40-200mg
Drowsiness, , Ortho static
Hypeotension, weight gain, Cardiac
Arrhythmias,
Overdose may be fatal. Dose titration
is needed.
5-HT Reuptake Inhibitors
Citalopram
20-60mg.
All SSRIs may cause insomnia, agitation,
sedation, GI distress, and sexual
dysfunction Many SSRIs inhibit various
cytochrome P450 isoenzymes.
They are better tolerated than tricyclics
and have high safety in overdose.
Shorter half-life SSRIs may be associated
with discontinuation symptoms when
abruptly stopped.
OTHER SSRIs
Escitalopram 10-20mg
Fluoxetine 10-40mg
Fluvoxamine 100-300mg
Paroxetine 20-50mg
Sertraline 50-150mg
NE and 5-HT Reuptake Inhibitors
Amitriptyline
75-300mg
Drowsiness, OSH, CA, weight gain,
anticholinergic,
Overdose may be fatal. Dose
titration is needed.
Imipramine
75-300mg
Drowsiness, insomnia and agitation,
OSH, CA, GI distress, weight gain,
anticholinergica Overdose may be
Venlafaxine / Desvenlafaxine(50-100)
150-375mg mg
Sleep changes, GI distress,
discontinuation syndrome Higher
doses may cause hypertension.
Dose titration is needed.
Abrupt discontinuation may result in
discontinuation symptoms.
Duloxetine 30-60mg
GI distress, discontinuation
syndrome
Pre- and Postsynaptic Active
Agents
Mirtazapine
15-30mg
Sedation, weight gain,
No sexual dysfunction.
Dopamine Reuptake Inhibitor
Bupropion :
200-400mg
Insomnia or agitation, GI distress
Twice-a-day dosing with sustained
release.
No sexual dysfunction or weight gain
Mixed Action Agents
Amoxapine 100-600mg
Drowsiness, insomnia/agitation, CA,
weight gain, OSH, anticholinergic
Movement disorders may occur. Dose
titration is needed.
Clomipramine 75-300mg
Drowsiness, weight gain,
Dose titration is needed.
Trazodone
150-600mg Drowsiness, OSH, CA, GI
distress, weight gain, Priapism is possible.
Treatment of Depression
Onset of Action – Takes atleast 5 to 7 days for the
drug to act
First episode of depression - the drug should be
continued for another 16-20 weeks after the patient
is thought to be well (continuation treatment to
prevent recurrence).
The medication should be tapered gradually because
many patients experience some mild withdrawal
effects.
Educate the patient and family members about the
side effects
Treatment of Acute Mania
DOSE BLOOD
LEVELS
• Lithium 900-1200mg 0.6-1.2mEq/l
• carbamazepine 600-1200mg 4-12 microgm/l
• valproate 750-2500mg
• Clonazepam/Lorazepam
• Typical & Atypical Antipsychotics
Atypical Antipsychotics :
OLANZEPINE
RISPERIDONE
QUITIEPINE
ZIPRASIDONE
ARIPIPRAZOLE
TREATMENT OF
ACUTE BIPOLAR DEPRESSION
ANTIDEPRESSANTS
AD + MOOD STABILIZER ( or Anti
Psychotic)
ECT
OTHERS :
Calcium channel Antagonists –
Verapamil
Gabapentin, Topiramate etc.
MAINTAINANCE TREATMENT
LITHIUM
CARBAMAZEPINE
VALPROATE
LAMOTRIGINE- Prophylactic
Antidepressant
Thyroid Supplementation
OTHER THERAPIES :
1. COGNITIVE THERAPY
2. INTERPERSONAL THERAPY
3.BEHAVIOURAL THERAPY
4.FAMILY THERAPY
5.SLEEP DEPRIVATION
6.PHOTO THERAPY or LIGHT THERAPY
(SAD)
7.ECT
8.TRANS CRANIAL MAGNETIC STIMULATION
Postpartum “Baby Blues”
Time of Onset – 3 to 5 daysafter
Delivery
Symptoms : Mood Lability
Sadness
Dysphoria
Subjective Confusion
Tearfulness
Due to :
1.Rapid changes in women’s
2.Hormonal levels
3.Stress of Child birth
4.Awareness of increased
responsibility that motherhood
brings
No professional treatment is required
Education and support for the new
Mother
POSTPARTUM DEPRESSION
Onset : Within 12weeks after
Delivery
Symptoms : Depressed Mood
Excessive Anxiety
Insomnia
Change in Weight
Increases the risk of MDD
Syndrome described in Fathers is
characterized by Mood changes during
wife’s Pregnancy or delivery.
Fathers are effected by added
responsibility, diminished sexual outlet,
decreased attention from wife.
TREATMENT :
Caution - Risk of transmitting Ads to New
Borns during Lactation.
CHARACTERSTIC BABY BLUES POSTPARTUM DEP
INCIDENCE 30-75% of women 10-15%
who give birth
Time of Onset 3-5days after delivery Within 3-6months
Duration Days to weeks Months to years if
untreated
Asso Stressors NO YES
Sociocultural Influene NO YES
CHARACTERSTIC BABY BLUES POSTPARTUM DEPR
FAMILY HISTORY OF NO YES
MOOD DISORDER
TEARFULNESS YES YES
MOOD LABILITY YES OFTEN PRESENT,
UNIFORMLY DEPRESSED
ANHEDONIA NO OFTEN
SLEEP DISTUBANCE SOMETIMES ALWAYS
SUICIDAL THOUGHTS NO SOMETIMES
THOUGHTS OF RARELY OFTEN
HARMING THE BABY
FEELINGS OF GUILT ABSENT PRESENT
PREMENSTRUAL
DYSPHORIC DISORDER
Symptoms present during the last
week of LUTEAL PHASE of Menstrual
cycle and Remit after FOLLICULAR
PHASE and absent in the Post
Menses Period.
SYMPTOMS :
1.Depressed Mood
2.Hopelessness
3.Anxiety
4.Lability of Mood
5.Decreased intrest in activities
6.Anger and irritability
7.Confusion
8.Sleep Disturbances
9.Social withdrawl
10.Breast tenderness
11.Headache , Muscle pain, Abdominal
bloating
12.Weight gain
TREATMENT : SUPPORT & SSRIs
Postpartum Psychosis
(Puerperal Psychosis)
Onset : Within 2-3 weeks(8 wks of
Delivery)
Incidence: 1-2/1000 child births
Symptoms :
1.Fatigue
2.Insomnia
3.Restlessness
4.Emotional lability
5.Depression
6.Delusion
7.Confusion
8.Incoherent/Irrelevant talk
9.Ideas of Suicide or Infanticide
TREATMENT :
Anti depressants
Lithium
Anti Psychotics
Caution : No Anti psychotics to breast
feedin women
Extra care to Suicidal pt
Psychotherapy
Increased support from Husband & Family
members
SUICIDE
Epidemology
Indian Statistics
Death due to suicides >1lakh/year
Suicide rate in last 2 yrs increased from
7.9 to10.3 per 100,000
Wide variation in suicide rates within
country- southern states like
kerala,Karnataka, AP & TN, >15 while
northern states of Punjab,UP, Bihar & JK
suicide rate is <3 ( higher literacy, better
reporting, lower external aggression,
higher socio.economic status & higher
expectations are possible explanations)
SUICIDE: A MULTI-FACTORIAL EVENT
Psychiatric Illness
Co-morbidity
Personality Neurobiology
Disorder/Traits
Impulsiveness
Substance
Use/Abuse
Hopelessness
Suicide
Severe Medical
Illness Family History
Access To Weapons Psychodynamics/
Psychological Vulnerability
Life Stressors Suicidal
Behavior
SOMATIC TREATMENTS
ECT Evidence for short-term reduction of
suicide, but not long-term.
Benzodiazepines May reduce risk by treating anxiety
Antidepressants A mainstay treatment of suicidal patients
with depressive illness / symptoms. No
conclusive evidence of suicide reduction
Lithium and Lithium has a demonstrated anti-suicide
Anti-convulsants effect; anticonvulsants do not
Antipsychotics Evidence for Clozapine reducing suicidality
in schizophrenia and schizo-affective
disorders
THANK YOU
