Mood+Disorders

=**Mood Disorders**=


 * 1. Define the epidemiological profiles for major depressive disorder and bipolar I disorder. Include prevalence, incidence, gender, age, social class, race, family history, childhood experiences, and marital status.**


 * || **Major Depressive Disorder** || **Bipolar I Disorder** ||
 * **Incidence** || 440 / 100,000 for women, 150 / 100,000 for men || 20 / 100,000 for women, 12 / 100,000 for men ||
 * **Prevalence** || 16-25% for women, 5-12% for men || 0.4-1.6% for women and men (combined) ||
 * **Gender** || Women > Men || Women = Men ||
 * **Age** || Mean 40 || Mean 30 ||
 * **Race** || No Difference || No Difference ||
 * **Social Class** || No Pattern || More frequent in upper socioeconomic groups ||
 * **Family History** || Increased risk with family Hx of depression/EtOH dependence || Increased risk with family Hx of bipolar disorder ||
 * **Marital Status** || More frequent in individuals with no close interpersonal relationships || More frequent in divorced and single individuals ||
 * **Childhood Experiences** || Increased risk with parental loss before age 11 || Inconclusive ||


 * 2. Describe the neurochemical basis of major depressive disorder and bipolar I disorder.**

The neurochemical basis of major depressive disorder and bipolar I disorder is a depletion of neurotransmitters, particularly excitatory NE, 5-HT, and DA receptors. Disregulation of other neurotransmitters such as GABA may be involved. This may be due to faulty regulation of endocrine systems (thyroid axis and adrenal axis) resulting in altered release of brain-derived neurotrophic factor (BDNF). Depletion of excitatory neurotransmitters such as 5-HT may not only have a direct effect on synaptic chemical transmission, but also have transcription level effects.

Brain morphology changes such as global atrophy, hippocampal atrophy, increased white matter and periventricular hyperintensities, larger third ventrical, and smaller frontal lobe, cerebellum, caudate, and putamen can also be detected.

Genetic factors also play a role, with more influence in bipolar I disorder than major depressive disorder. Psychosocial factors also have an effect.


 * 3. Discuss the differential diagnosis for mood disorders.**

Major depressive disorder and bipolar I disorder differential diagnoses may include a general medical condition, neurological conditions, and other mental or psychiatric conditions.

It is necessary to rule out symptoms that are clearly due to general medical conditions, mood-incongruent delusions or hallucinations, direct physiological effects of a substance, or not better accounted for by recent bereavement.


 * 4. Explain the common symptoms associated with major depressive episodes.**

__SIGECAMPS__ Common symptoms associated with major depressive episodes are changes in sleep pattern, lost of interest (anhedonia), feelings of guilt, loss of energy, decreased concentration, changes in appetite, psychomotor agitation/retardation, and thoughts of death (not always suicide).


 * 5. Explain the common symptoms associated with manic and hypomanic episodes and distinguish between the two.**

Patients experiencing manic episodes often present with inflated self-esteem/grandiosity, decreased need for sleep, talkativity, distractability, increased goal-oriented activity, and excessive involvement in pleasurable, high-risk activities.

Patients experiencing hypomanic episodes experience same symptoms as patients experiencing a manic disorder but have episodes that are not severe enough to cause marked impairment in social or occupational functioning, necessitate hospitalization or present with psychotic features.


 * 6. Using the criteria for major depressive, manic, and hypomanic episodes, compare the diagnoses of major depressive disorder, bipolar I, and biopolar II disorder.**

__Major Depressive Episode__ Major depressive episode is defined as having //five or more// of the following symptoms presenting with in a //2 week period//, with //at least one of the symptoms being either depressed mood or loss of interest/pleasure//. Symptoms include (1) depressed mood most of the day, nearly every day, (2) markly diminished interest or pleasure, (3) significant non-intentional weight loss/gain or changes in appetite, (4) insomnia or hypersomnia, (5) psychomotor agitation or retardation, (6) fatigue, (7) feelings of worthlessness/inappropriate guilt, (8) diminished concentration, and (9) recurrent thoughts of death. Symptoms must not also meet criteria for a mixed episode, be explained by drug use or underlying medical condition, and must cause significant distress or impairment.

__Manic Episode__ Manic episode is defined as having //three or more// of the following symptoms (//four or more if mood is only irritable//) within a //one week// period. Symptoms include (1) inflated self-esteem/grandiosity, (2) decreased need to sleep, (3) talkativity, (4) distractibility, (5) increased goal-oriented activity, and (6) excessive involvement in pleasurable, high-risk behaviors. Symptoms must not also meet criteria for a mixed episode, be explained by drug use or underlying medical condition, and must cause significant distress or impairment.

__Hypomanic Episode__ Hypomanic episode is defined as having //three or more// of the following symptoms (//four or more if mood is only irritable//) within a //four day// period. Symptoms include (1) inflated self-esteem/grandiosity, (2) decreased need to sleep, (3) talkativity, (4) distractibility, (5) increased goal-oriented activity, and (6) excessive involvement in pleasurable, high-risk behaviors. Symptoms must not also meet criteria for a mixed episode, be explained by drug use or underlying medical condition. However, the //hypomanic episode is not severe enough to cause significant distress or impairment//.

__Major Depressive Disorder__ Major depressive disorder is defined as one or more major depressive episodes and no history of manic episodes.

__Bipolar I Disorder__ Bipolar I disorder is defined as one or more manic or mixed episodes. It may or may not be accompanied by major depressive episodes. Manic episodes trump major depressive episodes so even if a patient has a history of major depressive episodes and only one manic episode, the patient will be automatically bumped into bipolar I disorder.

__Bipolar II Disorder__ Bipolar II disorder is defined as one or more major depressive episodes plus at least one hypomanic episode.


 * 7. Discuss the criteria for the two less severe, more chronic mood disorders: dysthymic disorder and cyclothymic disorder.**

__Dysthymic Disorder__ Dysthymic disorder is defined as //two or more// of the following symptoms over a //two year// period (//1 year for children/adolescence//). Symptoms include (1) poor appetite, (2) insomnia or hypersomnia, (3) fatigue, (4) low self-esteem, (5) poor concentration or indecisiveness, and (6) feelings of hopelessness. Criteria //cannot// be met for major depressive episodes, manic episodes, mixed episodes, hypomanic episodes or cyclothymic disorder during the 2 years of disturbance. During the 2 year duration, patient must not be symptom-free for more than 2 months at a time. Symptoms must not be explained by occurring during course of chronic psychotic disorder, drug use or underlying medical condition, and must cause significant distress or impairment.

__Cyclothymic Disorder__ Cyclothymic disorder is defined as //two or more// of the following symptoms over a //two year// period (//1 year for children/adolescence//). Symptoms include (1) inflated self-esteem/grandiosity, (2) decreased need to sleep, (3) talkativity, (4) distractibility, (5) increased goal-oriented activity, and (6) excessive involvement in pleasurable, high-risk behaviors. Criteria //cannot// be met for major depressive episodes, manic episodes, mixed episodes, hypomanic episodes or dysthymic disorder during the 2 years of disturbance. During the 2 year duration, patient must not be symptom-free for more than 2 months at a time. Symptoms must not be explained by occurring during course of chronic psychotic disorder, drug use or underlying medical condition, and must cause significant distress or impairment.


 * 8. Summarize major treatment modalities for the acute phase of depression: pharmacotherapy, psychotherapy, and ECT.**

During the acute phase of depression, pharmacotherapy, psychotherapy and ECT may all be employed in treatment. Treatment with antidepressant medications will take some time before patient feels benefit, but side effects will manifest immediately; therefore, it is important to make sure the patient understand that by taking the medication, they will initially feel worse before feeling better. Good formal psychotherapy can also help patient recovery since medication only has about a 70-75% response rate. In cases of psychotic or extremely severe symptoms with several failed courses of medications and need for rapid response, electroconvulsive therapy (ECT) may be warranted.

Treatment should continue not just until the response improves conditions so that the patient no longer meets disorder criteria, but instead keep going until no symptoms occur at all and complete recovery is reached. Remission is the goal of treatment in major depressive disorder.


 * 9. Diagram a typical major depressive episode in terms of symptom severity and time.**

In untreated major depressive disorder, episodes may last from 6-13 months. As the disorder progresses, the episodes become more frequent and last longer. Over a 20 year period, the mean number of episodes is 5-6 with periods in between episodes where individuals return to fully functional levels.


 * 10. Evaluate a clinical case presentation and diagnose the appropriate mood disorder.**

Determine episode types from symptoms and patient history. Any manic episodes will automatically bump patient into a diagnosis of bipolar I disorder, regardless of whether or not there is a history of major depressive episodes. If there are only major depressive episodes, then patient may be diagnosed with major depressive disorder. If the patient experienced major depressive disorder with at least one hypomanic episode, then the patient may be diagnosed with bipolar II disorder. Diagnoses for dysthymic and cyclothymic disorder would be similar to major depressive disorder and bipolar I disorder but less severe and more chronic.