Mood Disorders

What are mood disorders?

mental health problems that affect a person’s emotional state

Major Depressive Disorder (MDD) is also known as

Depression

Definition of Major Depressive Disorder (MDD)

A mental health condition characterized by at least $2\,\text{weeks}$ of pervasive low mood, low self-esteem, and anhedonia causing significant distress or impairment.

Accidental discovery that led to monoamine biological theories of depression

The mood-altering effects observed during treatment with isoniazid (INH).

Cortisol abnormalities associated with the Hypothalamic-Pituitary-Adrenal (HPA) axis in MDD

Approximately $50\%$ of MDD patients exhibit increased cortisol secretion, which typically normalizes once depression is cured.

Role of the Hypothalamic-Pituitary-Thyroid (HPT) axis in depression treatment

Small doses of replacement thyroid hormone ($T_3$) can accelerate the therapeutic response to antidepressants.

Diagnostic criteria requirement for symptom count in a Major Depressive Episode

Must exhibit depressed mood or anhedonia plus at least $4$ additional symptoms for at least $2\,\text{weeks}$.

Term for depression in patients who present with somatic complaints rather than reporting depressed mood

Masked depression.

Psychomotor activity changes observable in depressed patients

Psychomotor retardation (slowness in thinking, speaking, or body movements) or psychomotor agitation (pacing, hand wringing).

Differences in guilt and self-esteem manifestations across cultures in MDD

European cultures often feature guilt and delusions of poverty or unpardonable sin, whereas other cultures more commonly manifest shame or humiliation.

Reversible cognitive impairment resembling dementia in elderly depressed patients

Pseudodementia.

Diagnostic criteria for Atypical Depression subtype

Mood reactivity (mood brightens in response to positive events) plus at least $2$ of: weight gain/increased appetite, hypersomnia, leaden paralysis, or interpersonal rejection sensitivity.

Diagnostic criteria for Melancholic Subtype of MDD

Loss of pleasure in all/almost all activities plus at least $3$ of: distinct quality of mood, depression worse in the morning, early morning awakening ($\ge 2\,\text{hours}$ early), psychomotor agitation/slowing, anorexia/weight loss, or excessive guilt.

Timeframe criteria for diagnosing MDD with peripartum onset

Depressive symptom onset occurring during pregnancy (50%) or within $4\,\text{weeks}$ after delivery.

Diagnostic criteria timing for Premenstrual Dysphoric Disorder (PMDD)

At least $5$ total symptoms present in the final week before menses onset, improving within a few days post-menses, across most cycles in the preceding year.

Exclusion criteria required before diagnosing Major Depressive Disorder

Symptoms must not be due to a substance or medical condition, not part of a mixed bipolar episode, and not better accounted for by bereavement.

Recommended evaluation schedule and continuation duration for antidepressant therapy

Evaluate response every $3-4\,\text{weeks}$, and continue treatment for at least $6\,\text{months}$ during the high-risk relapse period.

First-line SSRI medications listed for MDD

Fluoxetine, Paroxetine, Sertraline, Citalopram, Escitalopram, and Fluvoxamine.

Key clinical advantage and contraindications for Bupropion (NDRI)

Advantage: avoids sexual dysfunction and sedation. Contraindications: history of seizures or bulimia (due to lowering the seizure threshold).

Key characteristics and side effect profile of Mirtazapine

Alpha-2 antagonist that is sedating and appetite-stimulating, commonly causing drowsiness, weight gain, xerostomia, and elevated cholesterol.

Antimuscarinic side effects associated with Tricyclic Antidepressants (TCAs)

Blurry vision, lowered GI motility, constipation, and urinary retention.

Mechanism behind acute hypertensive crisis caused by MAOIs

Inhibition of tyramine metabolism leads to excess neurotransmitter release; treated urgently with the alpha-blocker phentolamine.

Required washout period between MAOIs and SSRIs or TCAs

At least $2\,\text{weeks}$ to avoid provoking serotonin syndrome or delirium with severe hypertension.

Newer and specialized pharmacological agents for treatment-resistant MDD

Glutamatergic agents (intranasal esketamine, IV ketamine), 5-HT1A partial agonist (gepirone), and neuroactive steroids/GABA-A modulators (brexanolone, zuranolone).

Standard treatment parameters and post-remission duration for Electroconvulsive Therapy (ECT)

Typically $6-12$ sessions given $3\times/\text{week}$; continued for $6-12\,\text{months}$ following remission.

Core focus of Interpersonal Psychotherapy vs Cognitive Behavioral Therapy (CBT)

Interpersonal Psychotherapy focuses on current interpersonal disputes, losses, and social isolation; CBT focuses on recognizing and correcting erroneous beliefs and maladaptive behaviors.

Positive vs poor prognostic indicators in Major Depressive Disorder

Positive: absence of psychotic symptoms, short hospitalization/duration, good family functioning. Poor: comorbid psychiatric/substance disorders, early onset, long first episode, inpatient hospitalization.

MDD etiology

Major Depressive Disorder (MDD) etiology is unknown however the current consensus is there are multiple factors that include a combination of genetic, biological, environmental, and psychological factors influencing the onset and course of the disorder.

All clinically effective antidepressants affect

postsynaptic signaling of serotonin, norepi, or both

Hypothesis for depression causation and antidepressant effect

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

Cardinal Feature of a MDD episode

Depressed mood or anhedonia

Anhedonia

• Inability to enjoy usual activities nearly universal among depressed patients

• patient of family may report diminished interest in all or nearly all previsouly enjoyed activities

Three classifications of insomnia seen in depressed patients

Initial (trouble falling asleep), middle (trouble staying asleep or night awakenings), and late (early morning awakening).

Sleep disturbance complaint opposite to insomnia seen in some depressed patients

Hypersomnia.

Observed features of psychomotor retardation in depressed patients

Slowness in thinking, speaking, or body movements, decrease in speech volume or content, and long pauses before answering.

Manifestations of psychomotor agitation expressing anxiety in depressed patients

Pacing, inability to sit still, and hand wringing.

Term for the significant loss of energy reported by almost all depressed patients

Anergia.

Clinical manifestations of anergia in Major Depressive Disorder

Unusual fatigue, tiredness, and lack of efficiency in small tasks.

Performance pattern on formal psychological testing in depressed patients

Accuracy is retained, but speed and performance are slowed.

Reversible cognitive impairment resembling dementia in elderly depressed patients

Pseudodementia.

U.S. mortality rank and approximate annual death count for suicide

$8\text{th}$ leading cause of death in the U.S., with over $30{,}000$ deaths per year.

High-risk demographic factors for suicide in MDD

White, male, and older than $45\text{ years}$ of age.

Symptom count requirement and timing for diagnosing Major Depressive Disorder with Anxious Distress

At least $2$ characteristic symptoms present during the majority of days of the current or most recent Major Depressive Episode.

Five diagnostic symptoms defining Major Depressive Disorder with Anxious Distress

Feeling "keyed-up" or tense, feeling unusually restless, difficulty concentrating due to worry, fear that something awful may happen, and feeling that one might lose control of oneself.

Required core affective symptoms for Premenstrual Dysphoric Disorder (PMDD)

Must include at least 1 of the following core symptoms: marked affective lability, marked irritability or anger, marked depressed mood, or marked anxiety/tension.

Secondary or additional symptoms contributing to the 5-symptom threshold for Premenstrual Dysphoric Disorder (PMDD)

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

Specific physical symptoms listed in the diagnostic criteria for Premenstrual Dysphoric Disorder (PMDD)

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

Typical seasonal pattern for onset and remission of Seasonal Affective Disorder (SAD)

Episodes most commonly begin in fall or winter and remit in spring (though summer episodes occasionally occur).

Three factors that influence the prevalence of Seasonal Affective Disorder (SAD)

Latitude, age, and sex.

Diagnostic significance of laboratory findings in a Major Depressive Episode

No lab findings are diagnostic of a major depressive episode, although several lab findings may be abnormal in some patients with MD compared to the general population.

Occurrence pattern of laboratory abnormalities in Major Depressive Disorder

Most lab abnormalities are state dependent (i.e., they occur while patients are depressed).

Disorder that may precede Major Depressive Disorder

Dysthymic disorder.

Average age range at onset for Major Depressive Disorder

Mid-teens to late $20\text{s}$ (though it can begin at any age).

Timeframe over which MDD symptoms typically develop and common pre-existing conditions

Symptoms develop over days to weeks; prodromal symptoms and pre-existing conditions such as generalized anxiety disorder (GAD), panic attacks, and phobias are common.

Possible outcomes regarding the remission of depressive episodes

Depressive episodes may remit completely, partially, or not at all.

What is the difference between PPD and Baby Blues

Postpartum Depression (PPD) is a more severe and lasting form of depression that occurs after childbirth, whereas Baby Blues refers to the mild emotional fluctuations that typically resolve within two weeks.

Number of exclusion criteria required to diagnose Major Depressive Disorder

$3$ exclusion criteria.

Common presentation pattern of depressed patients seeing a primary care physician

Presenting with somatic complaints (e.g., "I can't sleep" or "I have no energy") rather than psychiatric complaints.

Non-psychiatric etiologies that can produce symptoms of depression

Medical disorders and various medications.

Clinical features and diagnostic status of uncomplicated bereavement

Grief symptoms experienced after the loss of a loved one; it is not classified as a mental disorder, even though it may present with symptoms of a major depressive episode (e.g., sadness, insomnia, decreased appetite, weight loss, hopelessness).

Indications for initiating antidepressant therapy in a grieving patient experiencing bereavement

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