5. Mood Disorders

Question 1

Define: Mood Disorders (3)

Answer 1

• accurate diagnosis of a mood disorder requires a careful past medical and psychiatric history to detect past mood episodes and to rule out whether these episodes were secondary to substance use, a medical condition, etc
• mood episodes represent a combination of symptoms comprising a predominant mood state that is abnormal in quality or duration (i.e. major depressive, manic, mixed, hypomanic). DSM-5 Criteria for mood episodes are listed below
• types of mood disorders include:
  
  • depressive (major depressive disorder, persistent depressive disorder)
  • bipolar (bipolar I/II disorder, cyclothymia)
  • induced by or due to (“secondary to”) a general medical condition, substance, medication, other psychiatric condition

Question 2

Describe: Medical Workup of Mood Disorder (2)

Answer 2

• routine screening: physical exam, CBC, extended electrolytes, renal, liver and thyroid function tests, drug screen, medications list
• additional screening: B12 (in older people), neurological consultation, chest X-ray, ECG, head imaging

Question 3

Name DSM-5 diagnostic criteria: Major Depressive episode (3)

Answer 3

1. ≥5 of the following symptoms have been present during the same 2 wk period and represent a change from previous functioning; at least one of the symptoms is either 1) depressed mood or 2) loss of interest or pleasure (anhedonia)

Note: do not include symptoms that are clearly attributable to another medical condition

• depressed mood most of the day, nearly every day, as indicated by either subjective report or observation made by others
• markedly diminished interest or pleasure in all, or almost all, activities most of the day, nearly every day
• significant and unintentional weight loss/weight gain, or decrease/increase in appetite nearly every day
• insomnia or hypersomnia nearly every day
• psychomotor agitation or retardation nearly every day
• fatigue or loss of energy nearly every day
• feelings of worthlessness or excessive or inappropriate guilt (which may be delusional) nearly every day (not merely self-reproach or guilt about being sick)
• diminished ability to think or concentrate, or indecisiveness, nearly every day
• recurrent thoughts of death (not just fear of dying), 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 important areas of functioning

C. the episode is not attributable to the direct physiological effects of a substance or a GMC

Question 4

Name DSM-5 criteria: Manic episode (4)

Answer 4

1. a distinct period of abnormally and persistently elevated, expansive, or irritable mood, and abnormally and persistently increased goal-directed activity or energy, lasting ≥1 wk and present most of the day, nearly every day (or any duration if hospitalization is necessary)
2. during the period of mood disturbance and increased energy or activity, ≥3 of the following symptoms have persisted (4 if the mood is only irritable) have been present to a significant degree and represent a noticeable change from usual behaviour
   
   • inflated self-esteem or grandiosity
   • decreased need for sleep (i.e. feels rested after only 3 h of sleep)
   • more talkative than usual or pressure to keep talking
   • flight of ideas or subjective experience that thoughts are racing
   • distractibility (i.e. attention too easily drawn to unimportant or irrelevant external stimuli)
   • increase in goal-directed activity (either socially, at work or school, or sexually) or psychomotor agitation
   • excessive involvement in pleasurable activities that have a high potential for painful consequences (i.e. engaging in unrestrained shopping sprees, sexual indiscretions, or foolish business investments)
3. the mood disturbance is sufficiently severe to cause marked impairment in social/occupational functioning or to necessitate hospitalization to prevent harm to self or others, or there are psychotic features
4. the episode is not attributable to the physiological effects of a substance or another medical condition Note: A full manic episode that emerges during antidepressant treatment but persists at a fully syndromal level beyond the physiological effect of that treatment is sufficient evidence for a manic episode, and therefore, a bipolar I diagnosis

Note: Criteria A-D constitute a manic episode. At least one lifetime manic episode is required for the diagnosis of bipolar I disorder

Question 5

Describe: Hypomanic Episode (3)

Answer 5

• criterion A and B of a manic episode is met, but duration is ≥4 d
• episode associated with an uncharacteristic change in functioning that is observable by others but not severe enough to cause marked impairment in social or occupational functioning or to necessitate hospitalization
• absence of psychotic features (if these are present the episode is, by definition, manic)

Question 6

Describe mixed features of mood disorders (5)

Answer 6

• an episode specifier in bipolar or depression that indicates the presence of both depressive and manic symptoms concurrently, classified by the disorder and primary mood episode component (i.e. bipolar disorder, current episode manic, with mixed features)
• clinical importance due to increased suicide risk and appropriate treatment
• if found in patient diagnosed with major depression, high index of suspicion for bipolar disorder
• while meeting the full criteria for a major depressive episode, the patient has on most days ≥3 of criteria B for a manic episode
• while meeting the full criteria for a manic/hypomanic episode, the patient has on most days ≥3 of criteria A for a depressive episode (the following criterion A cannot count: psychomotor agitation, insomnia, difficulties concentrating, or weight changes)

Question 7

Name DSM-5 diagnostic criteria: Major Depressive Disorder (MDD) (3)

Answer 7

1. presence of a major depressive episode (MDE)
2. the MDE is not better accounted for by schizoaffective disorder and is not superimposed on schizophrenia, schizophreniform disorder, delusional disorder, or psychotic disorder NOS
3. there has never been a manic episode or a hypomanic episode

Note: This exclusion does not apply if all of the manic-like, or hypomanic-like episodes are substance or treatment-induced or are due to the direct physiological effects of another medical condition

• specifiers: with anxious distress, mixed features, melancholic features, atypical features, mood- congruent psychotic features, mood-incongruent psychotic features, catatonia, peripartum onset, seasonal pattern
• single vs. recurrent is an episode descriptor that carries prognostic significance. Recurrent is classified as the patient having two or more distinct MDE episodes; to be considered separate the patient must have gone 2 consecutive months without meeting criteria

Question 8

Describe epidemiology: Major Depressive Disorder (MDD) (2)

Answer 8

• lifetime prevalence: 12%
• peak prevalence age 15-25 yr (M:F = 1:2)

Question 9

Describe etiology: Major Depressive Disorder (MDD) (9)

Answer 9

• biological
  
  • genetic: 65-75% MZ twins; 14-19% DZ twins, 2-4 fold increased risk in first-degree relatives
  • neurotransmitter dysfunction: decreased activity of 5-HT, NE, and DA at neuronal synapse; changes in GABA and glutamate; various changes detectable by fMRI
  • neuroendocrine dysfunction: abnormal HPA axis activity
  • neuroanatomy and neurophysiology: decreased hippocampal volume, increased size of ventricles; decreased REM latency and slow-wave sleep; increased REM length
  • immunologic: increased pro-inflammatory cytokines IL-6 and TNF
  • secondary to medical condition, medication, substance use disorder
• psychosocial
  
  • cognitive (i.e. distorted schemata, Beck’s cognitive triad: negative views of the self, the world, and the future)
  • environmental factors (i.e. job loss, bereavement, history of abuse or neglect, early life adversity)
  • comorbid psychiatric diagnoses (i.e. anxiety, substance abuse, developmental disability, dementia, eating disorder)

Question 10

Name risk factors: Major Depressive Disorder (MDD) (7)

Answer 10

• sex: F>M, 2:1
• family history: depression, alcohol abuse, suicide attempt or completion
• childhood experiences: loss of parent before age 11, negative home environment (abuse, neglect)
• personality: neuroticism, insecure, dependent, obsessional
• recent stressors: illness, financial, legal, relational, academic
• lack of intimate, confiding relationships or social isolation
• low socioeconomic status

Question 11

Describe: Clinically-Significant Depressive Symptoms in the Elderly (6)

Answer 11

• affects about 15% of community residents >65 yr old; up to 50% in nursing homes
• high suicide risk due to social isolation, chronic medical illness, decreased independence
• suicide peak: males aged 80-90; females aged 50-65
• low mood or dysphoria may not be a reliable indicator of depression in those >70 yr
• often present with somatic complaints (i.e. changes in weight, sleep, energy; chronic pain) or anxiety symptoms
• may have prominent cognitive changes after onset of mood symptoms (dementia syndrome of depression)

Question 12

Describe tx: Major Depressive Disorder (MDD) (5)

Answer 12

• lifestyle: increased aerobic exercise, mindfulness-based stress reduction
• biological: SSRIs, SNRIs, other antidepressants, somatic therapies
• psychological
  
  • individual therapy (CBT, interpersonal, supportive), group therapy, family therapy
• social: vocational rehabilitation, social skills training
• experimental: magnetic seizure therapy, deep brain stimulation, ketamine

Question 13

Describe biological tx: Major Depressive Disorder (MDD) (7)

Answer 13

• 1st line pharmacotherapy: sertraline, escitalopram, venlafaxine, mirtazapine
• for partial response, optimize the dose or add augmenting agent (bupropion, quetiapine-XR, aripiprazole, lithium)
• for non-response, change class of antidepressant
• typical response to antidepressant treatment:
  
  • physical symptoms improve at 2 wk
  • mood/cognition by 4 wk
  • if no improvement after 4 wk at the highest tolerated therapeutic dosage, alter regimen
• ECT Electroconvulsive Therapy: currently fastest and most effective treatment for MDD. Consider in severe, psychotic or treatment-resistant cases
• Repetitive Transcranial Magnetic Stimulation (rTMS): current data support efficacy equivalent to medications (but not to ECT) with good safety and tolerability
• phototherapy: especially if seasonal component, shift work, sleep dysregulation

Question 14

Describe prognosis: Major Depressive Disorder (MDD) (3)

Answer 14

• one year after diagnosis of MDD without treatment:
  
  • 40% of individuals still have symptoms that are sufficiently severe to meet criteria for MDD
  • 20% continue to have some symptoms that no longer meet criteria for MDD
  • 40% have no symptoms

Question 15

Name DSM-5 diagnostic criteria: Persistent Depressive Disorder (9)

Note: in DSM-IV-TR this was referred to as Dysthymia

Answer 15

1. depressed mood for most of the day, for more days than not, as indicated either by subjective account or observation by others, for ≥2 yr

Note: in children and adolescents, mood can be irritable and duration must be at least 1 yr

1. presence, while depressed, of ≥2 of the following:
   
   • poor appetite or overeating
   • insomnia or hypersomnia
   • low energy or fatigue
   • low self-esteem
   • poor concentration or difficulty making decisions
   • feelings of hopelessness
2. during the 2 yr period (1 yr for children or adolescents) of the disturbance, the person has never been without the symptoms in criteria A and B for more than 2 mo at a time
3. criteria for a major depressive disorder may be continuously present for 2 yr
4. there has never been a manic episode or a hypomanic episode, and criteria have never been met for cyclothymic disorder
5. the disturbance is not better explained by a persistent schizoaffective disorder, schizophrenia, delusional disorder, or other specified or unspecified schizophrenia spectrum and other psychotic disorder
6. the symptoms are not due to the direct physiological effects of a substance or another medical condition
7. the symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning

specifiers

• with anxious distress, mixed features, melancholic features, atypical features, mood-congruent psychotic features, mood-incongruent psychotic features, catatonia, peri-partum onset, seasonal pattern
• partial remission, full remission
• early onset <21 yr of age), late onset (>21 yr of age)
• with pure dysthymic syndrome (full criteria for MDE have not been met in at least preceding 2 yr), with persistent MDE (full criteria for MDE have been met throughout preceding 2 yr)
• with intermittent MDEs, with current episode: full criteria for a MDE are currently met, but there have been periods of at least 8 weeks in at least the preceding 2 years with symptoms below the threshold for a full MDE
• with intermittent MDEs, without current episode: full criteria for a MDE are not currently met, but there has been one or more major depressive episodes in at least the preceding 2 years.
• specify current severity: mild, moderate, severe

Question 16

Describe epidemiology: Persistent Depressive Disorder (1)

Answer 16

• lifetime prevalence: 2-3%; M=F

Question 17

Describe tx: Persistent Depressive Disorder (1)

Answer 17

• psychological
  
  • traditionally, psychotherapy was the principal treatment for persistent depressive disorder; recent evidence suggests some (but generally inferior) benefit for pharmacological treatment. Combinations of the two may be most efficacious
• biological
  
  • antidepressant therapy: SSRIs (i.e. sertraline, escitalopram), TCAs (i.e. nortiptyline)

Question 18

Define: Postpartum Postpartum (4)

Answer 18

• transient period of mild depression, mood instability, anxiety, decreased concentration; considered to be normal in response to fluctuating hormonal levels, the stress of childbirth, and the increased responsibilities of motherhood
• occurs in 50-80% of mothers; begins 2-4 d postpartum, usually lasts 48 h, can last up to 10 d
• does not require psychotropic medication
• usually mild or absent: feelings of inadequacy, anhedonia, thoughts of harming baby, suicidal thoughts

Question 19

Describe clinical features: Major Depressive Disorder with peripartum onset (Postpartu Depression) (4)

Answer 19

• MDD with onset during pregnancy or within 4 wk following delivery
• typically lasts 2-6 mo; residual symptoms can last up to 1 yr
• may present with psychosis (rare, 0.2% – more frequent with post-partum mania)
• severe symptoms may include complete disinterest in baby, suicidal and infanticidal ideation

Question 20

Describe epidemiology: Major Depressive Disorder with peripartum onset (Postpartum Depression) (1)

Answer 20

• occurs in up to 10% of mothers, risk of recurrence 50%

Question 21

Describe risk factors: Major Depressive Disorder with peripartum onset (Postpartum Depression) (2)

Answer 21

• previous history of a mood disorder (postpartum or otherwise), family history of mood disorder
• psychosocial factors:
  
  • stressful life events
  • unemployment
  • marital conflict
  • lack of social support
  • unwanted pregnancy
  • colicky or sick infant

Question 22

Name risk factors: Major Depressive Disorder with peripartum onset (Postpartum Depression) (2)

Answer 22

• previous history of a mood disorder (postpartum or otherwise), family history of mood disorder
• psychosocial factors: stressful life events, unemployment, marital conflict, lack of social support, unwanted pregnancy, colicky or sick infant

Question 23

Describe tx: Major Depressive Disorder with peripartum onset (Postpartum Depression) (3)

Answer 23

• psychotherapy (Cognitive behavioral therapy (CBT) or ​Interpersonal psychotherapy (IPT))
• short-term safety of maternal SSRIs for breastfeeding infants established; long-term effects unknown
• if depression severe or psychotic symptoms present, consider ECT

Question 24

Describe prognosis: Major Depressive Disorder with peripartum onset (Postpartum Depression) (2)

Answer 24

• impact on child development: increased risk of cognitive delay, insecure attachment, behavioural disorders
• treatment of mother improves outcome for child at 8 mo through increased mother-child interaction

Question 25

Define: Bipolar 1 Disorder (4)

Answer 25

• disorder in which at least one manic episode has occurred
• if manic symptoms lead to hospitalization, or if there are psychotic symptoms, the diagnosis is BP I
• commonly accompanied by at least 1 MDE but not required for diagnosis
• time spent in mood episodes: 53% asymptomatic, 32% depressed, 9% cycling/mixed, 6% hypo/ manic

Question 26

Define: Bipolar 1 Disorder (5)

Answer 26

• disorder in which there is at least 1 MDE, 1 hypomanic episode, and no manic episodes
• while hypomania is less severe than mania, Bipolar II is not a “milder” form of Bipolar I
• time spent in mood episodes: 46% asymptomatic, 50% depressed, 1% cycling/mixed, 2% hypo/ manic
• Bipolar II is often missed due to the severity and chronicity of depressive episodes and low rates of spontaneous reporting and recognition of hypomanic episodes.
• Bipolar II is quite often missed and many patients are symptomatic for up to a decade before accurate diagnosis and treatment

Question 27

Describe: Classification of bipolar disorders (2)

Answer 27

• classification of bipolar disorder involves describing the disorder (I or II) and the current or most recent mood episode as either manic, hypomanic, or depressed
• specifiers:
  
  • with anxious distress
  • depressed with mixed features
  • hypo/manic with mixed features
  • melancholic features
  • atypical features
  • mood-congruent or -incongruent psychotic features
  • catatonia
  • peripartum onset
  • seasonal pattern
  • rapid cycling (4+ mood episodes in 1 yr)

Question 28

Describe epidemiology: Bipolar Disorders (2)

Answer 28

• lifetime prevalence: 1% BD I, 1.1% BD II, 2.4% Subthreshold BD; M:F = 1:1
• age of onset: teens to 20s, usually MDE first, manic episode 6-10 years after, average age of first manic episode:32 yr

Question 29

Patients with bipolar disorder are at higher risk for suicide when? (1)

Answer 29

when they switch from mania to depression, especially as they become aware of consequences of their behaviour during the manic episode

Question 30

Name risk factors: Bipolar Disorders (1)

Answer 30

• genetic: 60-65% of bipolar patients have family history of a major mood disorder, especially bipolar disorder

Question 31

Name clinical features of MDE history favouring bipolar over unipolar diagnosis (9)

Answer 31

• early age of onset (<25 yr)
• increased number of MDEs
• psychotic symptoms
• postpartum onset
• anxiety disorders (especially separation, panic)
• antidepressant failure due to early “poop out” or hypomanic symptoms
• early impulsivity and aggression
• substance abuse
• cyclothymic temperament

Question 32

Describe tx: Bipolar Disorders (4)

Answer 32

• lifestyle:
  
  • psychoeducation regarding cycling nature of illness
  • ensure regular check ins
  • develop early warning system
  • “emergency plan” for manic episodes
  • promote stable routine (sleep, meals, exercise)
• biological: lithium, anticonvulsants, antipsychotics, ECT (if resistant); monotherapy with antidepressants should be avoided
• psychological: supportive psychotherapy, CBT, IPT or interpersonal social rhythm therapy, family therapy
• social:
  
  • vocational rehabilitation
  • consider leave of absence from school/work
  • assess capacity to manage finances
  • drug and EtOH cessation
  • sleep hygiene
  • social skills training
  • recruitment and education of family members

Question 33

Describe biological tx: Bipolar Disorders (6)

Answer 33

• mood stabilizers vary in their ability to “treat” (reduce symptoms acutely) or “stabilize” (prevent relapse and recurrence) manic and depressive symptoms; multi-agent therapy is common
• treating mania: lithium, divalproex, carbamazepine (2nd line), SGA, ECT, benzodiazepines (for acute agitation)
• preventing mania: same as above but usually at lower dosages, minus ECT and benzodiazepines
• treating depression: lithium, lurasidone, quetiapine, lamotrigine, antidepressants (only with mood stabilizer), ECT
• preventing depression: same as above plus aripiprazole, divalproex (note: quetiapine first line in treating bipolar II depression)
• mixed episode or rapid cycling: multi-agent therapy: lithium or divalproex + SGA (lurasidone, aripiprazole)

Question 34

In bipolar disorders, ___ is among few agents with proven efficacy in preventing suicide attempts and completions

Answer 34

Lithium

Question 35

Describe use of monotherapy with antidepressants in patients with bipolar depression (1)

Answer 35

Monotherapy with antidepressants should be avoided in patients with bipolar depression as patients can switch from depression into mania

Question 36

Name The 4 L’s for Bipolar Depression (1)

Answer 36

Lithium, Lamotrigine, Lurasidone, SeroqueL

Question 38

Describe course and prognosis: Bipolar Disorders (6)

Answer 38

• high suicide rate (15% mortality from suicide), especially in mixed states
• BD I and II are chronic conditions with a relapsing and remitting course featuring alternating manic and depressive episodes; depressive symptoms tend to occur more frequently and last longer than manic symptoms
• can achieve high level of functioning between episodes
• may switch rapidly between depression and mania without any period of euthymia in between
• high recurrence rate for mania – 90% will have a subsequent episode in the next 5 yr
• long term follow-up of BD I – 15% well, 45% well with relapses, 30% partial remission, 10% chronically ill

Question 39

Describe diagnosis: Cyclothymia (4)

Answer 39

• presence of numerous periods of hypomanic and depressive symptoms (not meeting criteria for full hypomanic episode or MDE) for ≥2 yr; never without symptoms for >2 mo
• never have met criteria for MDE, manic or hypomanic episodes
  
  • symptoms not better explained by any psychotic disorder (including schizoaffective, schizophrenia, schizophreniform, delusional disorder, or other specified/unspecified)
• symptoms are not due to the direct physiological effects of a substance or GMC
• symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning

Question 40

Describe tx: Cyclothymia (3)

Answer 40

• similar to Bipolar I:
  
  • mood stabilizer ± psychotherapy
  • avoid antidepressant monotherapy
  • treat any comorbid substance use disorder