Mood Disorders Treatments – Quick Reference

Tricyclic Antidepressants (TCAs)

  • First drugs shown to reliably relieve depression; now used less due to numerous side effects.
  • Major side effects: anticholinergic effects, drop in blood pressure, cardiac arrhythmia.
  • Overdose risk: potentially fatal; overdose amount about 3\text{ to }4\times the average daily dose.

Monoamine Oxidase Inhibitors (MAOIs)

  • Increase monoamine neurotransmitter levels by inhibiting MAO enzyme.
  • Efficacy comparable to TCAs, but safety concerns are high.
  • Dangerous interactions: aged cheese, red wine, beer can cause fatal hypertensive crisis.
  • Interacts with many drugs (e.g., antihypertensives, OTCs like antihistamines).
  • Potential liver damage, weight gain, severe blood pressure drops, and similar side effects to TCAs.

Mood Stabilizers

  • Bipolar disorder treatment often includes mood stabilizers; may also use atypical antipsychotics.
  • Lithium
    • Most effective agent for preventing both manic and depressive episodes; reduces suicidal thoughts.
    • Narrow therapeutic window; requires close medical monitoring.
    • Side effects range from nausea/vomiting/diarrhea, blurred vision, tremors, toxicity, organ damage.
    • Long-term risks: diabetes, hypothyroidism, kidney dysfunction; birth defects if used in first trimester.
    • Many patients stay on lithium even when asymptomatic to prevent relapses.
    • Mechanism: alters neurotransmitter metabolism (catecholamines, serotonin); exact mechanism unknown.
    • Benefits must be balanced with significant drawbacks.
  • Anticonvulsants and Atypical Antipsychotics
    • Valproate (Depakote): mood stabilization; often preferred due to tolerability; can cause blurred vision, fatigue, vertigo, rash, liver disease; birth defects risk if pregnant; not the best for suicide prevention.
    • Carbamazepine (Tegretol, Equetro): side effects include dizziness, drowsiness, rash, liver effects; significant drug interactions.
    • Lamotrigine (Lamictal): good for maintenance therapy and preventing recurrence; risk of rash; pregnancy considerations.
    • Atypical antipsychotics (e.g., olanzapine, aripiprazole, quetiapine, risperidone): help control mood swings and severe manic symptoms; side effects include weight gain and metabolic changes (diabetes risk, lipid changes).

Electroconvulsive Therapy (ECT)

  • Indicated for severe/persistent mood disorders, especially treatment-resistant depression and during psychotic episodes.
  • Efficacy: remission \text{rate} \approx 50\%\text{ to }80\%; often superior to antidepressants for certain cases.
  • Procedure: series of seizures induced by electrical current; anesthesia and muscle relaxants used; electrodes placed on the head.
  • Typical course: 6\text{ to }12\text{ sessions}; current practice often uses unilateral (right-sided) ECT to reduce memory impairment, though bilateral ECT is still used.
  • Side effects: memory loss and learning difficulties, more prominent with bilateral ECT; unilateral tends to reduce this risk.
  • Relapse: relapse rates up to 85\%; >30\% relapse in first 6 months after ECT.
  • Continuation/maintenance ECT is controversial with no universal guidelines.
  • Mechanism: not fully understood; may involve neural network changes, neurotransmitter effects, and neurogenesis.
  • Access issues: stigma and rights concerns persist; many patients face barriers to long-term access.

Newer Methods of Brain Stimulation

  • Repetitive Transcranial Magnetic Stimulation (rTMS)
    • Noninvasive; outpatient; targeted to left prefrontal cortex (often hypoactive in depression).
    • Few side effects (usually mild headaches); effective for treatment-resistant depression.
  • Vagus Nerve Stimulation (VNS)
    • Invasive; electrodes on the vagus nerve with implanted pulse generator.
    • Some long-term studies show superior outcomes for chronic, severe, treatment-resistant depression; insurance coverage often limited.
  • Deep Brain Stimulation (DBS)
    • Invasive; electrodes implanted in specific brain regions; early trials show promise for intractable depression.

Light Therapy

  • SAD (seasonal affective disorder) is a specifier of MDD; symptoms worsen in winter due to reduced daylight.
  • Light therapy can significantly reduce symptoms by bright-light exposure for several hours daily.
  • Remission rates: 57\% with light therapy alone; 79\% with light therapy plus cognitive therapy; control group 23\% remission.
  • Theories:
    • Reset circadian rhythms to normalize hormone/neurotransmitter production.
    • Decrease melatonin production, increasing norepinephrine and serotonin.
    • Bright light may directly increase serotonin.

Psychological Treatments for Mood Disorders

  • Behavioral Therapy
    • Focus: increase positive reinforcers, reduce aversive experiences; short-term (about 12\text{ weeks}).
    • Approach: functional analysis to link circumstances with symptoms; modify environment to reduce isolation; teach relaxation and social skills.
  • CASE STUDY: Mark
    • Mark worked constantly, lacked vacations, avoided social activities; therapy encouraged scheduling social/relaxing activities and learning new social/recreation skills.
    • Outcome: improved mood and sense of control; depression lifted after adopting new behaviors.