Mood Disorders Part 1

What are mood disorders?

Mental health problems that affect a person's emotional state.

What are some examples of mood disorders?

Major depression; dysthymia; bipolar disorder; cyclothymic disorder; and mood disorder due to a general medical condition.

What is major depressive disorder (MDD) also called, and what core pattern defines it?

It is also called depression. It involves 2 weeks of pervasive low mood, low self-esteem, and anhedonia.

When was the MDD symptom cluster adopted by the APA?

In the 1980 version of the DSM (DSM-III).

How does the epidemiology of depression differ by sex and age?

It is 2-3 times more common in adolescent and adult females than males; prepubertal children are affected equally.

When does depression most commonly begin?

It peaks in the second and third decades of life; median onset is around age 25; about 40% experience their first episode before age 20.

What is known about the precise cause of MDD?

The precise cause is unknown despite intensive attempts to establish a pathophysiologic basis.

What is the current consensus about the etiology of MDD?

Multiple factors, including genetics, biochemical factors, psychodynamic factors, and socioenvironmental factors, may interact in complex ways.

How can crucial life events relate to depression?

Events such as the death of a loved one can precipitate depression, but such loss precedes only a small but substantial number of cases.

What does depression with little or no apparent provocation suggest?

A predisposing factor, such as a genetic, developmental, or temperamental factor.

How were associations between mood and monoamines discovered?

They were discovered accidentally through the mood-altering effects of INH.

Which monoamines are associated with mood in the biological theory of depression?

Norepinephrine, serotonin, and dopamine.

How do clinically effective antidepressants relate to monoamine signaling?

All clinically effective antidepressants affect postsynaptic signaling of serotonin, norepinephrine, or both.

What is the neurotransmitter-deficiency hypothesis of depression?

Depression is caused by a neurotransmitter deficiency, and antidepressants work by treating this imbalance.

How may emotional trauma relate to depression and endocrine disorders?

Emotional trauma sometimes precedes depression and may also precede endocrine disorders such as hypothyroidism and Cushing disease; when endocrine changes accompany psychological disturbance, their relationship can be unclear.

What HPA-axis finding occurs in approximately half of patients with MDD?

Increased cortisol secretion that returns to normal when the depression is cured.

What hormone sequence and feedback pattern are shown for the HPA axis?

The hypothalamus releases CRH (corticotropin-releasing hormone), which stimulates the anterior pituitary to release ACTH (adrenocorticotropic hormone), which stimulates the adrenal cortex to release cortisol; cortisol provides negative feedback.

Does every depressed patient have significant hypercortisolism?

No.

What possible antidepressant effect is associated with antiglucocorticoid drugs?

Drugs with an antiglucocorticoid effect, such as ketoconazole, may have an antidepressant effect in depressed patients.

What effects do thyroid hormones have on the brain?

They have profound effects on brain development, maturation, and connectivity.

What psychiatric manifestations may occur with hypothyroidism?

Depression and cognitive decline.

How may T3 be used with antidepressant therapy?

Small doses of replacement thyroid hormone (T3) may accelerate the therapeutic effect of antidepressants.

What early-life experiences have been studied as contributors to depression risk?

Physical or emotional abuse, neglect, and parental loss.

What lasting effects may early childhood trauma produce?

Long-lasting effects on neuroendocrine, psychophysiological, and neurochemical systems, potentially increasing the risk of psychopathology including depression.

What is the genetic relationship of depressive disorders compared with other disorders?

Depressive disorders appear familial to some extent, but genetic determination is not as strong as in bipolar disorder, schizophrenia, or alcohol use disorder; the exact mode of transmission is unclear.

What family-history findings are MDD risk factors?

High risk in families with a history of depression (7%) or alcoholism (8%).

What racial pattern in MDD risk is noted?

MDD may be less common in African Americans.

What life-event pattern is an MDD risk factor?

Recent negative life events may precede an episode.

Which personality traits are listed as MDD risk factors?

Insecure, worried, introverted, stress-sensitive, obsessive, unassertive, and dependent.

What childhood experiences are listed as MDD risk factors?

Early childhood trauma, such as significant loss or a disruptive, hostile, negative environment.

What postpartum and menopause relationships are listed among MDD risk factors?

Postpartum depressive episodes are common; menopause has no relationship.

What social-network factor increases MDD risk?

A relative lack of interpersonal relationships.

What is the cardinal feature of a major depressive episode?

Depressed mood or anhedonia.

How long must the cardinal feature of a major depressive episode predominate, and what impact must it have?

At least 2 weeks, causing significant distress or impairment in social, occupational, or other important areas of functioning.

How many additional symptoms are required beyond diminished mood and anhedonia?

At least 4 additional symptoms.

What is the most characteristic symptom of depression, and how common is it?

Depressed mood; it occurs in more than 90% of patients.

How may patients describe depressed mood?

Sad, low, empty, hopeless, gloomy, or down in the dumps; its quality is different from normal sadness or grief.

What is masked depression?

Depression in a patient who does not report depressed mood.

What is anhedonia, and how common is it among depressed patients?

The inability to enjoy usual activities; it is nearly universal among depressed patients.

How may anhedonia be reported?

The patient or family may report diminished interest in all or nearly all previously enjoyed activities, such as sex, hobbies, and daily routines.

What appetite and weight pattern occurs in about 70% of depressed patients?

Diminished appetite with accompanying weight loss.

What appetite pattern occurs in a small percentage of depressed patients?

Increased appetite, usually with craving for sweets.

How common are sleep disturbances in depression, and which is most common?

About 80% report some sleep disturbance; insomnia is most common.

How are the types of insomnia in depression defined?

Initial insomnia is trouble falling asleep; middle insomnia is trouble staying asleep or night awakenings; late insomnia is early-morning awakening.

What sleep change can occur instead of insomnia in depression?

Hypersomnia.

What psychomotor slowing occurs in about half of depressed patients?

Slowing of the normal activity level, including thinking, speaking, and body movements.

How may psychomotor slowing affect speech?

Decreased volume or content of speech with long pauses before answering.

How may anxiety appear as psychomotor agitation?

Pacing, inability to sit still, or hand wringing.

What is required for psychomotor agitation or slowing to count as a symptom?

It must be observable by others.

What energy symptom occurs in almost all depressed patients?

Significant loss of energy (anergia), including unusual fatigue, tiredness, and lack of efficiency in small tasks.

How may worthlessness or guilt appear in depression?

A marked and unrealistic decrease in self-esteem.

How may cultural context influence worthlessness or guilt symptoms?

European cultures may show guilt, delusions of poverty, or unpardonable sin; other cultures may show shame or humiliation.

How common is slowing of thought in depression, and how does it affect decisions?

About 50% complain of slowed thought; they doubt their judgment and may be unable to make even small decisions.

What happens during formal psychological testing in depressed patients with indecisiveness?

Accuracy is retained, but speed and performance are slow.

What is depressive pseudodementia?

A dementia-like presentation that may occur, especially in older adults, and is usually reversible with treatment of the underlying depression.

What range of suicidal thinking may occur in depression?

Recurrent thoughts of death ranging from transient feelings that others would be better off without the person to actual planning and implementation.

Which demographic factors are associated with suicide?

Age older than 45 years, male sex, and white race; risk is greater in males, especially white males, and appears to increase with age.

Which personal and family history factors are associated with suicide?

Prior suicide attempt or other self-injury; family history of suicide or psychiatric illness; recent severe loss; and present or anticipated poor health.

Which planning, support, and psychiatric factors are associated with suicide?

A detailed plan; inability to accept help; lack of available societal support such as living alone or unemployment; psychotic symptoms; and comorbid alcoholism or drug abuse.

What proportion of suicides is associated with alcohol and drug dependence?

About 25%.

How often is psychosis present in suicides?

10%.

What proportion of completed suicides occurs in patients with a history of suicide attempts?

50%.

What is required for MDD with atypical features?

Mood reactivity, meaning mood brightens in response to a positive event, plus at least 2 of the following: significant weight gain or increased appetite, hypersomnia, leaden paralysis, or sensitivity to real or perceived interpersonal rejection.

What is leaden paralysis in atypical depression?

A heavy feeling in the arms or legs.

What is required for MDD with anxious distress?

At least 2 specified symptoms during the majority of days of the current or most recent major depressive episode.

Which symptoms qualify for the anxious-distress specifier?

Feeling keyed-up or tense; feeling unusually restless; difficulty concentrating because of worry; fear that something awful may happen; or feeling that the individual might lose control of themself.

What is required for major depression with melancholic features?

Loss of pleasure in all or almost all activities plus at least 3 specified features.

Which features qualify for the melancholic subtype?

A distinct quality of depressed mood unlike that after a relative's death; depression regularly worse in the morning; awakening at least 2 hours before the usual time; marked psychomotor agitation or slowing; significant anorexia or weight loss; or excessive or inappropriate guilt.

When do about 50% of postpartum major depressive episodes begin?

Before delivery.

What timing defines MDD with peripartum onset?

Depressive symptoms begin during pregnancy or within 4 weeks after delivery.

What are the reported frequencies of major depressive episodes during and after pregnancy?

About 9% of pregnant women have an episode from conception to birth; about 7% have one between birth and 12 months after delivery.

Can postpartum depression include psychotic features?

Yes; it may present with or without psychotic features.

What timing pattern is required for PMDD symptoms?

In most menstrual cycles during the preceding year, at least 5 symptoms occur in the final week before menses, begin improving within a few days after menses starts, and become minimal or absent within 1 week after menses.

Which core PMDD symptoms require at least one to be present?

Marked affective lability; marked irritability or anger; marked depressed mood; or marked anxiety or tension.

Which additional PMDD symptoms may contribute to the required total of 5?

Anhedonia; difficulty concentrating; lack of energy; marked appetite change; insomnia or hypersomnia; feeling overwhelmed or out of control; or physical symptoms.

Which physical symptoms are listed for PMDD?

Breast tenderness or swelling, joint or muscle pain, bloating, or weight gain.

What seasonal pattern is typical of seasonal affective disorder?

Episodes usually begin in fall or winter and remit in spring, although they can occasionally occur in summer.

What factors affect the prevalence of seasonal affective disorder?

Latitude, age, and sex.

Are any laboratory findings diagnostic of a major depressive episode?

No.

How do laboratory abnormalities relate to major depression?

Several may be abnormal in some patients compared with the general population, but most are state-dependent and occur while the patient is depressed.

What may precede MDD?

Dysthymic disorder.

What is the age range and onset pattern for MDD?

It can begin at any age; average onset is from the mid-teens to late 20s; symptoms develop over days to weeks.

Which prodromal or pre-existing conditions are common before MDD?

Generalized anxiety disorder, panic attacks, and phobias.

What recurrence pattern occurs after a first depressive episode?

Some have a single episode with full return to premorbid functioning; about 50% have another episode and meet criteria for recurrent depression.

What are the possible remission outcomes of a depressive episode?

Complete remission, partial remission, or no remission.

What happens to functioning between depressive episodes?

It usually returns to the premorbid level, but 20%-35% have persistent residual symptoms and social impairment.

How common is early relapse after remission?

About 25% relapse within the first 6 months, especially if medications are discontinued.

Which three exclusion criteria must be met for a diagnosis of depression according to the source?

The illness is not due to a substance or general medical condition; it is not part of a mixed episode such as bipolar disorder; and symptoms are not better accounted for by bereavement.

How do many patients with depression present to primary care?

With somatic complaints, such as inability to sleep or lack of energy, rather than a psychiatric complaint.

What must be considered because it can produce depressive symptoms?

Many medications and medical disorders.

What is uncomplicated bereavement?

Grief symptoms after the loss of a loved one; it is not a mental disorder even though it can resemble a major depressive episode with sadness, insomnia, decreased appetite, weight loss, and hopelessness.

When is antidepressant treatment justified during bereavement?

When behavioral symptoms are prolonged or associated with continual functional impairment.

What education should the provider give the patient and family about depression?

Discuss the illness, symptoms, course, and recurrent nature; teach the patient and close family to recognize signs and symptoms of an impending episode, such as insomnia, loss of energy, and loss of appetite.

For which conditions are antidepressants used according to the source?

They are used for various psychiatric and other conditions; most widely for MDD, with reduced activity in treating dysthymic disorder and bipolar disorder.

What are the major clinical indications for antidepressants listed in the source?

Major depressive disorder, dysthymia, bipolar disorder of the depressed type, and panic disorder with or without agoraphobia.

What are the secondary clinical indications for antidepressants listed in the source?

Obsessive-compulsive disorder; generalized anxiety disorder; social phobia; bulimia nervosa; attention-deficit/hyperactivity disorder; diabetic polyneuropathy; chronic pain syndromes; sleep disorders; and enuresis.

Why is antidepressant efficacy in children and adolescents controversial?

Some clinical trials failed to show consistent benefit, and antidepressants may be associated with a transiently increased risk of self-injury.

What do the best data show about antidepressants and suicide risk in children and adolescents?

Overall suicide risk is reduced by antidepressant treatment.

How are antidepressants used differently in older depressed patients?

They are very useful, but daily dose requirements are usually reduced because of pharmacokinetic changes.

How are antidepressants generally initiated and monitored?

Start at a low dose, increase over 7-10 days to the initial target dose, increase further if needed, use caution in suicidal patients, and evaluate response every 3-4 weeks.