MOOD DISORDERS😊

MOOD DISORDERS

• Hypomania → 4 days

Bipolar

• May show manic or hypomanic symptoms.

• Also called affective disorder

• Predominant abnormality of the mood

• Can be episodic illness

Depression

• Mood can be sad.
• Unipolar:
• abnormality is only in the lower pole.
• No manic, hypomanic, or mixed episodes.
• Only depressive episodes.

• Multiple episodes can occur.

• Mood can be sad or happy/irritable.

• Also known as Major depressive disorder (MDD) in DSM 5.

• Also called a Depressive disorder.

Epidemiology

• Most common mental disorder in India
• National Mental Health Study 2015-16

• Second most common mental disorder in the world.
• Most common in world: Anxiety disorder (specifically phobia).

• More common in F>M
• 2:1
• middle-aged females

Etiology

Biological Factors

• Neurotransmitter
• Earlier belief: 
• ↓ Monoamines (5-HT > NA» DA) → ↑ depression.
• Later link: 
• ↓ Monoamines → ↓ BDNF → ↑ Depression.
• Brain derived Neurotropic Factor
• Mnemonic: Beef Deep Fry kittilel Depression varum

• Endocrinal disturbances
• Hypothyroidism
• Thyroid hormone is used as an augmenting agent in treatment.

Psychological Theories

• Cognitive theory:
• Given by Aaron Beck.
• Patients develop cognitive distortions
• negative automatic thoughts
• Basis for cognitive behavioural therapy.

• Cognitive triad of depression:



• Negative views about self: Worthlessness.
• Negative views about the environment: Helplessness.
• Negative views about the Future: Hopelessness.

Symptoms of Depression

• Cardinal symptoms
• Sad/Depressed mood.
• Interest reduced /Anhedonia.
• Energy is reduced/easy fatigability.

• Mnemonic: SIGE CAPSS
• Sad/Depressed mood.
• Interest reduced /Anhedonia.
• Guilt/worthlessness.
• Energy is reduced/easy fatigability.
• Concentration is reduced.
• Can present as forgetfulness (pseudodementia).
• Appetite change.
• Can be ↓↓ appetite and weight loss.
• Can be ↑↑ appetite and weight gain.
• Significant weight change:
• >5% in a month.
• Psychomotor retardation/agitation.
• Suicidal thoughts or acts.
• Sleeping disturbances.
• Early morning insomnia:
• Waking up ≥2 hours before usual time.
• Hypersomnia.

Diagnosis

• According to DSM 5:
• ≥ 5 symptoms.
• Atleast 1 symptom must be sad mood or anhedonia (1st two)
• Duration of ≥2 weeks.

Recurrent Depressive Disorder

• ≥2 episodes of depression.
• Minimum duration between episodes is 2 months.

Specifiers

1. Depression with Psychotic features

• Depression > Delusion/hallucinations

• Symptoms start with depression.

Mood congruent:

• Content of delusion/hallucination is consistent with depression theme.

• e.g., Delusion of nihilism.

Mood incongruent:

• Content of delusion/hallucination is inconsistent with depression theme.

• e.g., Delusion of grandiosity.

Treatment:

• Antidepressant with antipsychotics.

2. Depression with Melancholic features

• Also known as Involutional melancholia, melancholic depression.

• Very severe kind of depression.

• Usually seen in old age.

• Higher risk of suicide.

Presents with:

• Loss of pleasure in all activities / lack of reactivity.

• Distinct quality of depressed mood (profound despondency/despair).

• Early morning awakening.

• Anorexia/weight loss.

• Mood is worse in the morning.

• Excessive guilt.

• Psychomotor disturbance.

• Mnemonic: Depression with Malam in body → severe

3. Depression with Atypical Features

Uncommon features in depression.

• Weight gain
• increase in appetite.

• Leaden paralysis:
• limbs feel heavy.

• Mood reactivity:
• Mood brightens to positive events.

• Interpersonal rejection sensitivity.

• Hypersomnia
• increase in sleep

• Mnemonic: My WIL High

• Mnemonic: Atypical → heavy limbs ↑ wt → tired → ↑ sleep → sad when rejected and happy in positive → Dot give TC (TCA)

Treatment:

• Responds better to
• SSRIs
• MAOIs
• bupropion.

• Poor response to TCAs.

4. Catatonia

• Depression with catatonic symptoms.

• Symptoms more common in mood disorders than schizophrenia.

5. Postpartum Onset

• Also known as Postpartum depression.

• Depressive symptoms during pregnancy or within 4 weeks of delivery.

• DSM-5 term:
• peripartum onset.

Suicide

• In depression:
• About 10 to 15% of people commit suicide.

• Most common psychiatric disorder associated with suicide:
• Depression.

Treatment of Depression

Psychotherapy

• Treatment using psychological methods.

• Cognitive Behavioural therapy (CBT)
• Has the best evidence.
• Corrects cognitive distortions and maladaptive behaviour.

• Rejoyn (CT -152)
• 1st prescription digital therapeutic approved by FDA for MDD.
• Adjunct to OPD care for patients with MDD,
• age ≥22 years on an antidepressant.

Treatment of Choice

• Combination of pharmacotherapy + psychotherapy has a higher response.

• Single therapy alone is often sufficient.

• Mild cases: CBT.

• Moderate or severe cases: Drugs plus CBT.

Electroconvulsive therapy (ECT)

Cognitive Functions

• Mental processes of knowing and becoming aware.

• Impaired in neurocognitive disorder.

Basic Mental Functions

Orientation

• Awareness of self and surroundings.

• With respect to time, place, and person.

• Disorientation is seen in cases of delirium.

Attention

• Ability to attend to a specific stimulus without getting distracted.

• Test to assess attention:
• Digit repetition / Digit span test.

Digit forward test	Digit backward test
Patient should repeat the digits given in a forward direction.	Patient should repeat the digits given in a backward direction.
Normal: Repeat 5-7 digits to prove intact attention.	Normal: Repeat 3-5 digits to prove intact attention.
Better test among both.	ㅤ

Concentration

• Sustained attention, i.e., attention for a longer time.

• Test for checking concentration:
• Serial 7s Subtraction Test or (100-7) test.
• Patient is asked to subtract 7 from 100.
• Continue subtracting 7 from the answers.

• Concentration is intact if the patient is able to do it correctly up to 5 times.

Memory

Higher Mental Functions

• If the basic mental functions are intact,

• higher mental functions are checked.

Abstract Thinking

• Ability to understand hidden meanings and concepts.

Test

Judgment

• Making the right decision after analyzing the choices.

• Test judgment:
• A hypothetical situation is given to the patient.
• Example:
• Patient is asked what he will do if the neighbor's house catches fire.
• Answers by saying he will add more fuel to the fire.
• This means that he has impaired judgment.

• Impaired judgment is seen in psychosis like schizophrenia.

Insight

• Insight is the awareness of illness.

• Sometimes, a psychiatric patient who is ill may not be aware of their illness.

Grades of Insight:

• Grade 1: Complete Denial
• No awareness of illness.
• Complete denial of any mental health issue.

• Grade 2: Partial Denial
• Slight awareness of being ill.
• Simultaneous denial of illness.

• Grade 3: External Attribution
• Awareness of illness is present.
• Illness is attributed to external, physical, medical, or unknown causes.

• Grade 4: Intellectual Insight
• Aware that illness is due to own irrational thoughts or emotions.
• Does not apply this knowledge to bring behavioral change.
• Example: Patient knows they have depression but refuses to take medication.

• Grade 5: True Emotional Insight
• Highest level of insight.
• Awareness of illness due to own irrational thoughts or emotions.
• Willing to change behavior accordingly.
• Example: Patient takes medicine, attends therapy, and works to improve lifestyle.

Important Information

• Psychiatric illnesses are divided into neurosis and psychosis.
• In neurosis, insight is present.
• In psychosis, insight is absent.

Classifications in Psychiatry

• Based on symptoms.

ICD-11

• International Statistical Classification of Diseases, 11th revision.

• By WHO.

• For all disorders including medicine, surgery, dermatology, OBG etc.

DSM-5

• Diagnosis and Statistical Manual of Mental disorders, 5th Edition.

• By American Psychiatric Association.

• Exclusive for mental disorders.

• In India, both of these are followed.

Organic vs Functional Disorders

Organic disorders

• Psychiatric symptoms following a visible cause.

• E.g. Following a head injury, CT scan shows injury.

• Conditions:
• Delirium
• Dementia
• Amnestic disorders

Functional disorders

• No visible cause.

• E.g., Depression.

• Further divided into:
• Neurosis
• Psychosis

Difference between Neurosis and Psychosis

Disorder

• The criteria below should be fulfilled to call it a disorder.

BIPOLAR DISORDERS

• Episodes of Mania, depression, hypomania, and mixed episodes are seen.

• Bipolar disorder usually affects the age groups of 15-25 years.

• Mixed episodes:
• Symptoms fluctuate between depression and mania.

• Bipolar I disorder:
• At least 1 episode of Mania + 1 episode of Depression.
• M = F
• A single episode of mania is considered bipolar disorder I
• (ICD 11 & DSM 5).

• Bipolar II disorder:
• At least 1 episode of Hypomania + 1 episode of Depression.
• F > M

Epidemiology

• Bipolar I disorder Prevalence is 1%.

• Dopamine is increased in mania.

Etiology

• Genetic Factors:
• Chromosomes 18q, 22q (Strongest evidence), and 21q.

Mania: Symptoms

• Mnemonic: ME DIG FAST
• Mood euphoric/ Irritable.
• Energy ↑.
• Distractibility.
• Impulsivity
• Hypersexuality
• Overspending
• Over socialization
• Over religious
• Grandiosity/ Inflated self-esteem.
• ↓light of ideas.
• my name is john, ring, rong, kong
• Activity level ↑.
• Sleep ↓ (decreased need).
• Talkativeness.

Diagnosis

• Mood elation + increased energy.

• Plus ≥3 other symptoms.

• Duration of ≥1 week.

• Can be mania with psychotic symptoms
• mood congruent/incongruent

Hypomania

• Symptoms similar to mania but less severe.
• Not severe enough for marked social/occupational impairment.

• No flight of ideas or psychotic symptoms.

• Duration is ≥4 days.

• No need for hospitalization.

Mixed Episode

• Patient experiences both manic and depressive symptoms.

• Duration is ≥ 7 days.

Treatment of the Bipolar Disorder

• Depends on the phase of illness: Acute vs. Maintenance.

Acute Manic or Hypomanic Episode

• First step:
• Stop the antidepressant.

• Benzodiazepines:
• Can be used initially to calm the patient.

Medications (First line):

• Antipsychotics:
• Mnemonic: SCAN QR A-Z CAPIL
• Olanzapine
• Quetiapine
• Risperidone
• Aripiprazole
• Ziprasidone
• Cariprazine
• Asenapine
• Paliperidone
• ILoperidone
• Used especially if psychotic symptoms are present

• Valproate:
• Multiple MOA
• Gaba transaminase ⛔
• Ca, Na channel blocker
• Rapid onset of action and better tolerability
• Surpassed Lithium in acute mania
• Used in dysphoric mania
• Can cause adverse effects like:
• Liver damage
• Pancreatitis
• PCOD → Gender specific S/E
• Can be given but not recommended
• Mnemonic: vaLP → LP → Liver, Pancreas , PCOD

• Lithium
• Onset of drug action: 1–3 weeks
• Prototypical mood stabilizer
• Used in euphoric mania

• Pregnancy:
• Antipsychotics are safest.
• Valproate (Avoid):
• Teratogenic (Neural tube defect).
• Lithium:
• Teratogenic (Ebstein Anomaly),
• but risk is low (1:1000).

• Severe symptoms:
• Lithium + Antipsychotic.
• Valproate + Antipsychotic.

Treatment of Acute Depression (Bipolar Depression)

• Do not use antidepressants alone.

• Risk of switch to mania if only antidepressants are given.

• Drugs used:
• Lithium, Lamotrigine (depression > mania).
• Quetiapine, Lurasidone.
• Olanzapine + Fluoxetine combination.
• Antidepressant + Mood stabiliser (Lithium, Valproate, Lamotrigine).

• Lamotrigine:
• Safer in pregnancy than valproate, CBZ, and Lithium.

Maintenance (Prophylaxis)

• Indicated after ≥2 episodes or a single severe manic episode.

• Treatment of choice: Lithium > valproate

• Minimum duration is 2 years.

Rapid Cycling Bipolar disorder

• Patient has ≥4 episodes (mania/hypomania/depression) in 1 year.

Factors favouring occurrence:

• Female sex, Borderline hypothyroidism, Menopause

• Temporal lobe dysrhythmias

• Substance abuse

• Long-term, aggressive use of antidepressants

Treatment:

• Valproate

• Lamotrigine

Other Mood Disorder

Persistent Mood Disorders

Dysthymia

• Mild depressive symptoms, not enough for a full depressive episode.

• Minimum duration is 2 years.

• Functional impairment is not severe.

Double depression:

• Person with dysthymia develops depression.

Cyclothymia

• Milder form of bipolar disorder.

• Manic and depressive symptoms occur but not severe enough for diagnosis.

• Functional impairment is not severe.

• Duration is ≥ 2 years.

Psychiatry Aspects of Pregnancy

Postpartum blues (baby blues)

• 30 to 75% of women after childbirth.

• Onset: 3 to 5 days after childbirth.

• Symptoms:
• Mild,
• transient sadness,
• irritability,
• sleep disturbances.

• Treatment:
• No professional treatment needed,
• just supportive care.

Postpartum Psychosis

• 0.1-0.2% after childbirth.

• Initial symptoms: Insomnia, tearfulness, mood lability, fatigue.

• Can lead to delusions or hallucinations.

• Treatment:
• Psychiatric emergency.
• Antipsychotics + lithium.
• +/- anti-depressant.

Suicide

• Rate in India: 12.4 per 1 lakh population (2022 NCRB).

• Most common method:
• Hanging > poisoning.

• Psychiatric disorder with highest risk:
• Depressive > Schizophrenia

Important risk factors

• Previous suicide attempts.

• Hopelessness.

Other risk factors

• Mnemonic: Mad Persons
• Male sex.
• Age > 45 years, Abuse.
• Depression.
• Previous attempt (highest)
• Excess alcohol or substance abuse.
• Rational thinking loss (psychosis).
• Social support lacking.
• Organized plan (suicide note).
• No spouse, no job.
• Sickness (chronic).

• Family history of suicide.

Suicide and schizophrenia

Paradoxical Suicide

• Suicide attempt during initial stages of treatment or recovery.

• Due to gain of energy.

Copycat Suicide

• Mimicry of another suicide method.

• Knowledge from local sources or media.

• Common in adolescence.

Para Suicide

• Self-injurious behaviour.

• No intent to kill themselves.

• Seen in borderline personality disorders.