Intended learning objectives (ILOs)

By the end of this lecture, the candidate will be able to:

 Define mood disorders.

 Recognize different types of mood disorders.

 Know the clinical picture, etiology and management of bipolar

affective disorders.
Definition of mood disorders
 Mood disorders are a group of clinical conditions
characterized by primary disturbances of the mood along the
happy-sad axis.

 Patients with elevated mood demonstrate expansiveness,

flight of ideas, decreased sleep, and grandiose ideas.

 Patients with depressed mood experience a loss of energy

and interest, feelings of guilt, difficulty in concentrating, loss
of appetite, and thoughts of death or suicide.

 These disorders virtually always result in impaired

interpersonal, social, and occupational functioning.
Types:
 Bipolar affective disorder.
 Depressive disorders.
 Bipolar Affective Disorder

 Also known as manic-depressive illness, is a mental

disorder characterized by periods of elevated mood
(mania) and periods of depression.
 Patients with both manic and depressive episodes
or with manic episodes alone are diagnosed with
bipolar disorder.
 The signs and symptoms tend to recur, often in
periodic or cyclical fashion.
 Criteria to diagnose
• Depressive episode 2 weeks with at • Manic episode 1 week with at least 4
least 4 criteria of the following: criteria:
Depressed mood Elated mood
Decreased interest Flights of ideas
Decreased energy Hyper-talkative
Decreased Motor activity Hyper-active
Decreased concentration Easily distracted
Decreased Sleep satisfaction Decreased need to sleep
Decreased appetite Hyper-sexual
Decreased self esteem Grandiose
Guilt Hyper-sociable
suicide Reckless spending, driving
• Mixed episode 2 weeks of symptoms • Hypomanic episode 4 days with 3
of both mania & depression criteria only
 Recurrent mood disorders
Recurrent depressive disorder Bipolar I disorder: manic episodes alternating
(unipolar): episodes of depression with depressive episodes
recurring periodically

Bipolar II disorder: hypomanic episodes

alternating with depressive episodes

Persistent mood disorders

Dysthymia: depressive Hyperthymia: manic symptoms persisting for more than 2
symptoms persisting for years
more than 2 years
Cyclothymia: alternating symptoms persisting for more
than 2 years with no periods of normal mood in between
 Etiology

Genetic

Monoamine theory

Serotonin Dopamine
(Affect) (Motive)

Noradrenaline
(Energy)

Psychosocial
 Management

Where to treat?
hospitalize if there is risk (suicide – aggression – neglect -abuse) else treat in
community
When? How long to treat?
guidelines recommend one year after symptom remission
Who to involve in treatment?
family and patient should be educated about the disorder
Why to treat? Goals:
 Response (symptoms decrease) Remission (symptoms vanish)
 Relapse (symptoms recur) and Recurrence prevention
What tools to use to treat? Strategies:
 Psychotherapy: social rhythm – Cognitive – Behavior – Family therapy
 Pharmacotherapy: mood stabilizers – BZD - antipsychotic
 Electro-Convulsive Therapy
 Mood stabilizers

medication mechanism Side effect interactions

Lithium 2nd messenger Hypothyroid, renal dysfn., SNRIs, SSRIs,

modulator Neuroleptic malignant aripiprazole, NSAIDs
syndrome
(cardiac malformations if
given in pregnancy)

Valproate Na channel Liver dysfn. SNRIs, SSRIs,

blocker (fetal valproate syndrome Aripiprazole, asprin
GABAergic FVS if given in pregnancy) Enzyme inhibitor
agent
Carbamazepine Na channel Blood dyscrasias, SNRIs, SSRIs,
blocker arrythmia Aripiprazole, asprin
Serotonergic (spina bifida if given in Enzyme inducer
agent pregnancy)
 Benzodiazepine:
 Clonazepam and Lorazepam
 Used as adjunctive treatment of acute manic
agitation, aggression and insomnia.

Short acting Long acting

Drug Alprazolam (xanax) tablets Bromazepam (calmepam) 1.5 mg or 3
0.25 mg or 0,5 mg mg

Side effects Day time sedation with long acting

Rebound of symptoms after withdrawal
High abuse potential
Teratogenic effect
Induction of hepatic coma in patients with liver cirrhosis
Suppression of respiration in patients with severe chest disease
Antipsychotics:

 They have antimanic and mood-stabilizing effects.

 Along with mood stabilizers for rapid control of agitated
or psychotic patients
 Conventional antipsychotics (e.g. haloperidol,
chloropromazine).
 Atypical antipsychotics are preferred as; olanzapine (10-
20 mg/day), risperidone (4-6 mg/ day), quetiapine (300-
600mg/day), ziprazidone, aripiprazole (15-30mg/day).
 Psychotherapy

Social rhythm therapy Cognitive therapy to challenge

grandiose thoughts.
Behavior therapy to maintain regular
assumes that disruption of pattern of daily activities.
body rhythms and
Psychoeducation on etiology, signs and
interpersonal conflicts cause symptoms, importance of compliance,
kindling phenomena, so identify new episodes early, drugs
educate family and plan (dose, duration, side effects, and
daily routine. toxicity), limit caffeine and alcohol
intake, regularity in rhythms of activity
and wakefulness, sleep hygiene, eating
12 sessions (1/week), and exercising.
1 hour each Family therapy: To resolve
interpersonal problems.
 Electro-Convulsive Therapy

 Severe cases, psychotic symptoms.

 Refractory to drug treatment, suicidal symptoms.

 Severe agitation and excietment.

 6-12 Sessions

 Patient need some investigations before the sessions: at

least ECG and consultation of anesthesia.
Take home message:
 Mood disorders are a group of clinical conditions characterized
by primary disturbances of the mood along the happy-sad axis
 Types: Bipolar affective disorder and Depressive disorders.
 Patients with both manic and depressive episodes or with
manic episodes alone are diagnosed with bipolar disorder.
 hospitalize if there is risk (suicide – aggression – neglect –
abuse) else treat in community
 Strategies:
●Psychotherapy: social rhythm – Cognitive – Behavior – Family
therapy
●Pharmacotherapy: mood stabilizers – BZD – antipsychotic
●Electro-Convulsive Therapy
Case presentation

A 14-year-old boy is brought to the emergency department after

being found in the basement of his home by his parents during
the middle of a school day. The parents came home after
receiving a call from the school reporting that their son had not
attended school for 4 days. The boy was furiously working on a
project he claimed would solve the fuel crisis. He had started
returning home from school after his parents left for work
because his science teacher would no longer let him use the
school laboratory other than during regular class time. The
patient was involved in an altercation with the school janitor after
being asked to leave the school because it was so late. The boy
claimed that the janitor was a foreign spy trying to stop his
progress.
 The parents are very proud of their son’s interest in science
but admit that he has been more difficult to manage lately. He
can’t stop talking about his project, and others cannot get a
word in edgewise. His enthusiasm is now palpable. For the
past few weeks, he reads late into the night and gets minimal
sleep. Despite this, he seems to have plenty of energy and
amazes his parents’ friends with detailed plans of how he is
going to save the world. His friends have not been able to
tolerate his increased interest in his project. His train of
thought is difficult to follow. He paces around the examination
room saying, “I am anxious to get back to my project before it
is too late.” Although he has no suspects in mind, he is
concerned that his life may be in danger because of the
importance of his work.

 What is the most likely diagnosis and how to manage?

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