MOOD DISORDER

I. DEFINITION:
- A mood is defined as a pervasive and sustained feeling tone that is endured internally and which
impacts nearly all aspects of a person’s behaviour in the external world.
- Mood disorders are described by marked disruptions in emotions
- It is a disorder in which a person experiences long periods of extreme happiness, extreme sadness, or
both.
- These are common psychiatric disorders leading to an increase in morbidity and mortality.

II. TYPES:
 BIPOLAR DISORDER
1. Bipolar I
2. Bipolar II
3. Cyclothymia
4. Hypomania

 MAJOR DEPRESSIVE DISORDER

1. Disruptive mood dysregulation
2. Persistent depressive
3. Premenstrual dysphoric

1. BIPOLAR DISORDER
 BIPOLAR I
 A syndrome in which a complete set of mania symptoms has occurred lasting for at least one week or
required hospitalization.
 Elevated mood with three or more of the following symptoms- increased goal-directed activity,
grandiosity, a diminished need for sleep, distractibility, racing thoughts, increased/pressured speech,
and reckless behaviour.
 If the mood is irritable instead of elevated, four or more of the aforementioned symptoms are needed
to meet the criteria for a manic episode.

 BIPOLAR II
 Consists of current or past major depressive episodes interspersed with current or past hypomanic
periods of at least four days duration.

 CYCLOTHYMIA
 Subthreshold bipolar trait or temperament with low-grade affective manifestations of the sub-
threshold major depression and mild hypomania.
 Diagnosed in adults who experience at least 2 years of both hypomanic and depressive periods without
ever meeting criteria for mania, hypomania, or major depression.
 For a child or an adolescent to be diagnosed with cyclothymia, these episodes should last over 1 year.

 HYPOMANIA
 A non-psychotic, milder, or subthreshold manic state of short duration lasting for at least four
consecutive days and without marked social and occupational impairment.
 It requires elevated mood with (three or more of symptoms) or irritable mood (with four or more of
the following symptoms) - increased goal-directed activity, grandiosity, a diminished need for sleep,
distractibility, racing thoughts, increased/pressured speech, and reckless behaviours.

 According to the International Classification of Diseases 11th Revision (ICD-11), cyclothymia and
hypomania are considered as a prodrome of bipolar disorders, and per DSM 5, hypomania is a
component of bipolar II disorder.
2. MAJOR DEPRESSIVE DISORDER
Diagnosed by the presence of 5 out of the 9 symptoms existing over a period of 2 weeks.
 sad mood
 Insomnia
 feelings of guilt
 decreased energy levels
 decreased concentration
 decreased appetite
 decrease in pleasurable activities (anhedonia)
 increased or decreased psychomotor activity
 recurrent suicidal ideation/acts of self-harm/suicide attempt

 DISRUPTIVE MOOD DYSREGULATION DISORDER

 mostly seen in children and adolescents with frequent anger outbursts and irritability out of proportion
to the situation
 PERSISTENT DEPRESSIVE DISORDER (PDD)
“DYSTHYMIA”
 A depressed mood that is not severe enough to meet the criteria for major depression. PDD is defined
as the depressed mood for at least two years in adults and one year in children and adolescents
 PREMENSTRUAL DYSPHORIC DISORDER
 Characterized by irritability, anxiety, depression, and emotional lability occurring in a week before the
onset of menses followed by resolution of the symptoms after onset.

ADDITION FOR TYPES (SUMMARY)

LOW MOOD
 Major Depressive Disorder
 Diagnosed by the presence of 5 out of the 9 symptoms existing over a period of 2 weeks.
• sad mood
• Insomnia
• feelings of guilt
• decreased energy levels
• decreased concentration
• decreased appetite
• decrease in pleasurable activities (anhedonia)
• increased or decreased psychomotor activity
• recurrent suicidal ideation/acts of self-harm/suicide attempt

HIGH MOOD
 Mania
 3 or more of the following Symptoms
 For at least 2 weeks causing significant impairment.
• Distractible
• Irresponsibility/ irritability/ impulsiveness
• Grandiose
• Flight of ideas
• Sleep decrease
• Talkative

 Hypomania
• 3 or more of the symptoms under mania.
• For at least 4 days
• No significant impairment
 Bipolar 1
• Requires only one episode of mania, although often includes hypomania and major depressive disorder
 Bipolar 2
• requires at least 0ne episode of hypomania and one episode of major depression.

NEUTRAL
 Cyclothymic disorder
 Alternating periods of hypomanic symptoms and depressive symptoms without actually meeting
criteria for hypomania and depression
 2 years
 Treatment with lithium and, antypical antipsychotics
 Persistent Depressive disorder
 “Dysthymic d/o”
 Depressed mood and SIGECAPS without meeting full MDD criteria
 For 2 years
 Persistent Depressive disorder
 Mood and anxiety symptoms
 3 months after stressor, typically resolving after 6 months

III. PATHOPHYSIOLOGY
Depression
- A complex neuropsychiatric disorder represented by severe anhedonia, sad mood, feelings of guilt,
suicidality, and cognitive impairment.

CHRONIC STRESS
- Primary risk factors for development of depressive disorder.

Pathophysiology of stress
- Results from over activation of the hypothalamic-pituitary-adrenal (HPA) axis, which results in
glucocorticoid cortisol level increase.

Neuronal plasticity
- Also plays a significant role in the pathophysiology of mood disorder.
Example:
- Patients with poor social support show signs of impaired neuronal plasticity, predisposing them to
mood disorder.

Mild to moderate impairment

- causes depression

Severe impairment
- Causes mania

BIPOLAR DISORDER
 Characterized by episodes of mania and depression, which may alternate, although many patients have
a predominance of one or the other.
 Exact cause is still unknown, but heredity, changes in level of brain neurotransmitters, and
physiological factors may be involved.
 Imbalance of cholinergic and catecholaminergic neuronal activity.
 It is also related to inositol disorder
MAJOR DEPRESSIVE DISORDER
Monoamine Hypothesis

Seasonal affective disorder

 Related mostly to light.
 Prevalent even in mid-latitude places with mild winters
 Prolonged periods of overcast weather can also exacerbate SAD
 Can be a serious disorder and may require hospitalization
 Lack of serotonin

Premenstrual dysphoric disorder

 The exact cause is unknown.
Following hypothesis:
 Alteration in the level of estrogen and progesterone starting from the midluteal phase. Either there is
altered estrogen: progesterone ratio or diminished progesterone level.
 Neuroendocrine factors:
-serotonin
-endorphins
-y-aminobutyric acid (GABA)

IV. SIGNS AND SYMPTOMS

- Irritability, aggression or hostility
- An ongoing sad, empty or anxious mood
- Changes in appetite or weight
- Changes in sleep patterns/ unstable body clock
- Difficulty in concentrating
- Increased (agitation) or decreased psychomotor activity
- Delusions and hallucination (severe cases)

V. DRUGS
1. LITHIUM
(Eskalith, Lithobid)
- Mood stabilizing drug
- Primary Drug of Choice for bipolar disorders and is effective in treating 60% to 80% of patients
exhibiting mania and hypomania.
MOA: Inhibits intracellular proteins (PKC, MARCKS and GSK-3 – antimanic effects
PHARMACOKINETICS: Well absorbed, not metabolized and completely eliminated unchanged by renal
clearance. Has an extremely NARROW THERAPEUTIC INDEX
 ADVERSE EFFECTS: headache, dry mouth, polydipsia, polyuria, polyphagia, GI distress, fine hand
tremor, dizziness, fatigue, dermatologic reactions, and sedation.
SAFETY: Classified as Class D drug (legal to use during pregnancy, but may cause birth defects) and is one of
only thirty known teratogenic drugs.

2. TRICYCLIC ANTIDEPRESSANTS
MOA: Inhibition of neurotransmitter reuptake
*Serotonin, Norepinephrine and other neurotransmitter (TCA, amoxapine)
1st generation TCA: Imipramine, Amitryptyline (sedative)
- But Amitryptyline is NOT USED due to dry mouth, blurry vision, and post hypertension
2nd generation:
- Selective serotonin reuptake inhibitors (SSRIs) – Fluoxetine (Prozac), sertraline and
citalopram
- Serotonin NE reuptake inhibitors (SNRIs)- Venlafaxine, duolaxetine
PHARMACOKINETICS: Well absorbed upon oral administration. Lipophilic, thus, readily penetrate into
the CNS. Metabolized by hepatic microsomal system. TCAs are excreted as inactive metabolites.
ADVERSE EFFECTS: Blurred vision, xerostomia, urinary retention, sinus tachycardia, constipation. Can
cause orthostatic hypotension
INTERACTIONS: Ethanol & other CNS depressant- toxic sedation
MAO INHIBITOR- enhancement: hypertension, hyperpyrexia, convulsions
SAFETY: Under pregnancy category C

3. ATYPICAL ANTIDEPRESSANTS
Bupropion
-MOA: Weak dopamine and norepinephrine reuptake inhibitor
-PK: metabolized by CYP2B6
-SE: Dry mouth, sweating, nervousness, tremor.
-INT: Patients at risk for seizure, and those who have eating disorder
-SAFETY: Pregnancy category B

Mirtazapine
-MOA: Enhances serotonin and norepinephrine neurotransmission
-AE: Increased appetite, weight gain and sedation
-SAFETY: Pregnancy category C

4. MONOAMINE OXIDASE INHIBITORS

- Block monoamine oxidase enzymes that breaks down serotonin and norepinephrine
*Slightly more effective than tricyclics
- MOA: Form stable complexes with the enzyme. Inactivates monoamines that leak from a synaptic
vesicle.
- increased stores of norepinephrine, serotonin and dopamine
- PK: Well absorbed after oral administration. Hepatically metabolized and excreted rapidly in urine.
- AE: drowsiness, orthostatic hypotension, blurred vision, dry mouth and constipation.
- INT: The use of MAOI with other antidepressants

-The four MAOIs currently available for the treatment of depression include
 Phenelzine
 Tranylcypromine
 Isocarboxazid
 Selegiline [Note: Selegiline is also used for the treatment of Parkinson disease. It is the only
antidepressant available in a transdermal delivery system.]
-SAFETY: Pregnancy category C
 Newer medications such as intravenous and intranasal ketamine (esketamine) have shown positive
results in the treatment of mood disorders. Ketamine has also shown utility in rapidly reducing suicidal
ideation though effects require repeat treatments and are not long-lasting.

REFERENCE
Pcol book- Lippincott reviews (FOR DRUGS)
https://www.aafp.org/afp/2008/0915/p772.html (SAFETY)
https://www.ncbi.nlm.nih.gov/books/NBK558911/ (MOOD DISORDER)

GROUP 1
ABUAN, Aira Louise
AGUILAR, Jericho Allenm
CEZAR, Angel Mae
CORPUZ, Asther Joe
DACANAY, Aggie
NIPAL, Angelica Mae
PAWILEN, Brianne
SENOJA, Arlette Fae
TIAMSIN, Bless