Depressive Disorders - New York Medical College
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Transcript Depressive Disorders - New York Medical College
Mood Disorders
Bruce Shapiro, M.D.
April 6, 2001
Do psychiatrists have mood swings?
What Determines Mood?
Harlow and Spitz
Gross Anatomy
Neuroimaging
Regionalization questions
Synapse
Intracellular activities
Brain mediated
environment
Mood Disorders
History...
History
The Bible (King Saul, Job)
Hippocrates - Humoral theory
Arateus - Psychological theory
1800’s - Physical diagnosis
1900’s - Psychological diagnosis
1930’s - Somatic interventions
1940’s - Psychoanalysis
1950’s - Psychopharmacology
1980’s - Biological markers
1990’s - Neuroimaging
2000’s - Herbals and magnetism ...
Hippocrates
Mood Disorders
Famous Sufferers ...
Abraham Lincoln
Winston Churchill
Churchill's Black Dog
"Black Dog”: Churchill's name for his
depression
Lord Moran: inborn melancholia
Periods of solitude
Periods of high energy
Highly functional
Ernest Hemingway
Suicide - Familial Aspects
A Quote
“In my last severe depression,
I took coca again and a small
dose lifted me to the heights
in a wonderful fashion”
Sigmund Freud
Freud and Mom or Mom and Freud?
Famous Living Bipolars
Robert Boorstin, writer, special assistant to
President Clinton
Rosemary Clooney, singer
Dick Cavett, writer, media personality
Kitty Dukakis, former First Lady of Massachusetts
Patty Duke (Anna Pearce), actor, writer
Connie Francis, actor, musician
Shecky Greene, comedian
Kristy McNichols, actress
Kate Millett, writer
Charley Pride, musician
Axl Rose, musician
Ted Turner, entrepreneur, media giant
Jonathon Winters, comedian, actor, writer, artist
Famous Living Unipolars
Buzz Aldrin, astronaut
Rona Barrett, entertainment reporter, author
Art Buchwald, writer
Barbara Bush, former U.S. First Lady
Ray Charles, musician
Eric Clapton, musician
Dick Clark, television personality
Leonard Cohen, musician, writer
Francis Ford Coppola, director
Michael Crichton, writer
Kathy Conkrite, writer
Sheryl Crow, musician
Mike Douglas, media personality
Tony Dow, actor, director
Famous Living Unipolars
James Farmer, civil rights activist
John Kenneth Galbraith, economist, educator, author
Mariette Hartley, actor
Anthony Hopkins, actor
Robert McFarlane, former US National Security Advisor
Joan Rivers, comedienne, talk show host
Roseanne, actor, writer, comedienne
Rod Steiger, actor
William Styron, writer
James Taylor, musician
Livingston Taylor, musician
Mike Wallace, news anchor
Marie Osmond, entertainer
Mood Disorders
Classification and
Demographics ...
Mood Disorders (DSM-IV)
Depressive Disorders
– Major Depressive Disorder (single/recurrent)
– Dythymic Disorder
– Depressive Disorder, NOS
Bipolar Disorders
–
–
–
–
Bipolar I
Bipolar II
Cyclothymic Disorder
Bipolar Disorder, NOS
Mood Disorder due to:
– Medical condition
– Substance induced
Mood Disorders - DSM IV
Unipolar vs Bipolar
Unipolar
Prev
Gender
Onset
Suicide
Sleep
Rx
Genetics
5%
F>M
30’s
15%
insom
unipolar
lower
Bipolar
1%
F=M
20’s
20%
hyper
bipolar III
higher
Epidemiology
Lifetime risks:
– Major Depression: 6 %
– All mood disorders: 8 %
Prevalence
– Major Depression: (point prevalence approx 5 -6 %)
• Males: 2.6 - 5.5%
• Females: 6.0 - 11.8 %
– Dysthymia: 3 - 4 %
– In primary care practice:
• Major Depression: 4.8 - 9.2 %
• All depressive disorders: 9 - 20 %
Bipolar Disorder: 1.0 - 2.5 %
5 - 15 % of adult depressions are bipolar
Prevalence of Mood Disorders
20% of the U.S. population reports at least one
depressive symptom in a given month
12% report two or more depressive symptoms in
a year
Major Depression: 5% in the previous 30 days,
Bipolar Disorder - approximately 1 % of the
population
Increase in cohort post 1940
Younger age of onset
Genetics
Unipolar
– Dizygotic: 30%
– Monozygotic: 50%
– Family history: 25%
Bipolar
– Dizygotic: 30%
– Monozygotic: 80%
– Family history: 50%
Gender differences
Bipolar - no difference
Unipolar - Female > Male
– ?genetic
– sociocultural
– alcoholism/substance abuse
Mood Disorders: Across the Lifespan
Infancy - Spitz and Harlow
Childhood - depressive equivalents
Adolescence - major onset;
substance abuse
Adulthood - major onset
Geriatric - multiple symptoms;
pseudodementia; differential
medical diagnoses
Predisposing factors
Prior mood disorder or moodswings
Positive family history
Female gender
Severe prolonged stress
Recent loss
Postpartum period
Medical co-morbidity
Current alcohol/substance abuse
Prognosis
Major Depression recurrence rates:
1 episode:
50 - 60%
2 episodes:
70%
3 episodes:
90%
Untreated episode: 6-12 months
20-30 % chronicity
Episode length and frequency: shorter
episodes with increasing frequency
Treatment yields good results
Mood Disorders
Clinical Syndromes ...
Hypomania:
What does it feel like?
“At first when I'm high, it's tremendous...ideas are
fast...like shooting stars you follow until brighter
ones appear...all shyness disappears, the right
words and gestures are suddenly
there...uninteresting people, things, become
intensely interesting. Sensuality is pervasive, the
desire to seduce and be seduced is irresistible.
Your marrow is infused with unbelievable
feelings of ease, power, well-being,
omnipotence, euphoria...you can do
anything...but, somewhere this changes”.
Mania:
What does it feel like?
“The fast ideas become too fast and there
are far too many...overwhelming
confusion replaces clarity...you stop
keeping up with it--memory goes.
Infectious humor ceases to amuse. Your
friends become frightened...everything is
now against the grain...you are irritable,
angry, frightened, uncontrollable, and
trapped”.
Clinical Mania
A sustained period of behavior that is different
from usual
Increased energy, activity, restlessness,
Racing thoughts and rapid talking
Excessive "high" or euphoric feelings
Extreme irritability and distractibility
Decreased need for sleep
Unrealistic beliefs in one's abilities and powers
Uncharacteristically poor judgment
>>
Clinical Mania
Reckless behavior
Increased suspiciousness/paranoid ideation
Increased sexual drive
Abuse of drugs, particularly cocaine, alcohol,
and sleeping medications
Flight of ideas
Provocative, intrusive, or aggressive behavior
Possibly delusions
(paranoid/grandiose/religious)
Possibly hallucinations
Denial that anything is wrong
Cycle Length
Bipolar: Frequency of Recurrence
Hypomania
Inflated self-esteem
Decreased need for sleep
More talkative than usual
Excessive involvement in pleasurable activities that have a high
potential for painful consequences (e.g., the person engages in
unrestrained buying sprees, sexual indiscretions, or foolish
business investments)
Increased activity
No major life disruption
No need for hospitalization
No psychotic symptoms
Cyclothymia
Alternating hypomania and
non-major depression
At least 2 years in duration
Depression:
What does it feel like?
“I doubt completely my ability to do
anything well. It seems as though my mind
has slowed down and burned out to the
point of being virtually useless....[I am]
haunt[ed]...with the total, the desperate
hopelessness of it all... Others say, "It's
only temporary, it will pass, you will get
over it," but of course they haven't any
idea of how I feel, although they are
certain they do. If I can't feel, move, think,
or care, then what on earth is the point?”
Sadness vs Clinical Depression
Intensity
Duration
Neurovegetative changes
Self esteem changes
Normal Grief vs. Depressive Illness
Depressive Disorders - DSM - IV
Major Depressive Disorder (296.xx)
Dysthymic Disorder (300.4)
Depressive Disorder NOS (311)
Mood Disorder due to general
medical condition (293.83)
Substance-Induced mood disorder
(293.83)
Clinical Depression
Loss of the ability to experience
pleasure
Unexplained or prolonged sadness or
crying spells
Significant changes in appetite and
sleep patterns
Diurnal variation of mood
Irritability, anger, worry, agitation,
anxiety
Pessimism, indifference
A sense of hoplessness/helplessness
Clinical Depression
Loss of energy, persistent lethargy,
pathological fatigue
Feelings of guilt, worthlessness
Inability to concentrate, indecisiveness
Social withdrawal
Difficulty with personal hygiene
Unexplained aches and pains
May have delusions or hallucinations
Recurring thoughts of death or suicide
Other Specifiers
Catatonic Features
With Melancholic Features
With Atypical Features
With Postpartum Onset
Physical Symptom
Indicators
Fatigue
Pain
Sleep disturbances
GI disorders (IBS)
– unexplained by medical testing
Atypical Presentations
Anxiety/panic symptoms
Irritability
Hysterical symptoms
Hypochondriacal symptoms
Unexplained pain syndromes
Substance abuse presentations
“Personality disorder”
Dysthymia
This disorder is characterized by a
chronic state of depression,
exhibited by a depressed mood on
most days for at least 2 years. (1
year in children and adolescents).
There are no psychotic symptoms
.
Dysthymia: symptoms and
duration
poor appetite or overeating
insomnia or hypersomnia
low energy or fatigue
low self-esteem
poor concentration or difficulty making
decisions
feelings of hopelessness
Dysthymic individuals must not have gone for more than 2 months
without experiencing two or more of these symptoms
Mood Disorders
Suicide ...
Suicide Rates in Mood Disorders
Unipolar: 15 %
Bipolar: 20 %
Suicide Risk Factors
Clinical depression
Suicidal ideation
Self oriented (non-manipulative)
Available lethal method
Male>Female
White>black
Elderly
Loss with alcohol/substance abuse
Suicide Rates
Suicide - Clusters
Mood Disorders
Causes
and
Treatments ...
Psychological Models
Psychoanalytic
Interpersonal
Cognitive
Behavioral/learned helplessness
Treatment: Psychological
Individual Psychotherapy
– Psychodynamic/Psychoanalytic
– Cognitive
– Interpersonal
– Supportive
Group Therapy
Couples Therapy
Family Therapy
Biological Models
Genetic
Neurotransmitter dysfunction
Neuroendocrine dysfunction
Chronobiological
Sensitization/Kindling
Serotonergic pathways
Neurotransmission
Neurons
Basic Synapse
Serotonin Synapse
Reuptake pump
Synaptic Interactions
Synaptic Transmission
Biological Markers in Major
Depression
DST
TRH/TSH
Shortened REM latency
Treatment: Biological
Antidepressants
Antipsychotics (typical, atypical)
Mood stabilizers (thymoleptics)
Augmentation strategies
Herbal
Phototherapy
ECT
rTMS
Mood Stabilizing Medications
Lithium carbonate/citrate
Tegretol (carbamazepine)
Depakote (valproic acid)
Neurontin (gabapentin)
Lamictal (lamotrigine)
Klonopin (clonazepam)
Zyprexa (olanzapine)
Antidepressant Medication
Antidepressant medications are non-
addictive.
Another antidepressant can be tried
should the first have unacceptable sideeffects.
Antidepressants take time to work
Physical symptoms are more likely to
respond before psychological symptoms
Undulating improvement
Antidepressant
medications
TCA’s (imipramine, nortriptyline, desopramine)
MAOI’s (phenelzine, tranylcypromine, meclobemide)
SSRI’s (fluoxetine, sertraline, paroxetine, fluvoxamine,
citalopram)
SNRI’s (venlafaxine)
CRI’s (buprorion)
Alpha2 adrenergic antagonists (mirtazapine)
Serotonin2A antagonists and serotonin reuptake inhibitors
(trazodone, nefazodone)
Modified amino acids (SAMe)
Psychostimulants
Augmentation strategies (Li, T3, buspirone, anxiolytics )
Electroconvulsive Therapy
(ECT)
History
Indications
Efficacy
Adverse effects
Safety
rTMS
Integrative Treatments
Nature AND Nurture
In major syndromes: combinations
of medication and psychotherapy
Treat the individual
Never give up