Mood (Affective) Disorders

Department of Psychiatry
1
st
Faculty of Medicine
Charles University, Prague
Head: Prof. MUDr. Ji Raboch, DrSc.
Mood (Affective) Disorders
Mood disorders are very common, their life
prevalence is up to 20 %, and they have a high
level of morbidity and mortality as well as an
immense impact on disabilities worldwide.
The fundamental disturbance is a change in mood
or affect, usually to depression (with or without
associated anxiety) or to elation. The mood change
is usually accompanied by a change in the overall
level of activity.
Most of these disorders tend to be recurrent, and
the onset of individual episodes is often related to
stressful events or situations.
The mood disorders may be subdivided into
unipolar and bipolar types:
1. those that are characterized by depression only
2. those that are characterized by manic episode either
alone or in combination with depression
Classification of Mood Disorders
International Classification of Diseases (ICD-
10) came into use in WHO Member States as
from 1994

F30 Manic episode
F31 Bipolar affective disorder
F32 Depressive episode
F33 Recurrent depressive disorder
F34 Persistent mood (affective) disorders
F38 Other mood (affective) disorders
F39 Unspecified mood (affective) disorder

Test Methods
Self-reported scales:
Young Mania Rating Scale (YMRS)
Beck scale (depression)
Zung scale (depression)

Interview with physician:
Hamilton scale (HAMD)
Montgomery and Asberg scale (MADRS)
F32 Depressive Episode
Pathological sadness

Depressive episode:
depressed mood
loss of interest and enjoyment
reduced energy leading to increased fatigability
and diminished activity
marked tiredness after only slight effort
reduced concentration and attention
reduced self-esteem and self-confidence
ideas of guilt and unworthiness
bleak and pessimistic views of the future
ideas or acts of self-harm or suicide,
disturbed sleep and diminished appetite
F32 Depressive Episode
Clinical presentation shows marked individual
variations
in some cases, anxiety, distress, and motor agitation
may be more prominent at times than the depression
the mood change may also be masked (masked
depression) by added features such as irritability,
excessive consumption of alcohol, histrionic behaviour,
and exacerbation of pre-existing phobic or obsessional
symptoms, or by hypochondriacal preoccupations.

Depressive episode should last at least 2 weeks
(typically several months), but shorter periods
may be reasonable if symptoms are unusually
severe and of rapid onset.
The lifetime prevalence: 17%; risk of recurrence
>50%.
F32 Depressive Episode
The lowered mood varies little from day to day, is
unresponsive to circumstances and may be
accompanied by so-called somatic symptoms:
loss of interest or pleasure in activities that are normally
enjoyable (anhedonia)
lack of emotional reactivity to normally pleasurable
surroundings and events
waking in the morning 2 hours or more before the usual time
depression worse in the morning
objective evidence of definite psychomotor retardation or
agitation
loss of appetite
weight loss
loss of libido
F32 Depressive Episode
F32 Depressive episode
F32.0 Mild depressive episode
F32.1 Moderate depressive episode
F32.2 Severe depressive episode without
psychotic symptoms
F32.3 Severe depressive episode with
psychotic symptoms
F32.8 Other depressive episodes
F32.9 Depressive episode, unspecified
F32.0 Mild Depressive Episode
Two or three of the above symptoms are
usually present.
For mild depressive episode are typical
depressed mood, anhedonia and increased
fatigability. The afflicted person is usually
distressed by the symptoms and has some
difficulty in continuing with ordinary work
and social activities, but will probably not
cease to function completely.
F32.1 Moderate Depressive
Episode
An individual with moderate depressive
episode suffers from more symptoms
(four or more of the above symptoms are
usually present) of greater severity and
will usually have considerable difficulty in
continuing with social, work or domestic
activities.
F32.2 Severe Depressive Episode
without Psychotic Symptoms
In a severe depressive episode, the
sufferer usually shows considerable distress
or agitation. Loss of self-esteem or feelings
of uselessness or guilt are likely to be
prominent, and suicide is a distinct danger
in particularly severe cases. ; a number of
"somatic" symptoms are usually present.
Agitated depression
Major depression
Vital depression
F32.3 Severe Depressive Episode
with Psychotic Symptoms
Psychotic symptoms may be present, such as
delusions (ideas of sin, poverty or imminent disasters)
hallucinations (defamatory or accusatory voices or of
rotting filth or decomposing flesh)
depressive stupor
Severe ordinary social activities are impossible
When the psychotic symptoms are consistent
with the patients mood, they are referred to as
mood congruent, when they are inconsistent,
they are referred as mood incongruent.

Single episodes of:
major depression with psychotic symptoms
psychogenic depressive psychosis
psychotic depression
reactive depressive psychosis
F33 Recurrent Depressive Disorder
Recurrent depressive disorder is characterized by
repeated episodes of depression without any history
of independent episodes of mood elevation and
overactivity.
Recovery is usually complete between episodes, but
a substantial part of patients will have a recurrence
and about 30% may develop a persistent
depression.
The lifetime prevalence - about 1020 %;
women:men 2:1.
The risk of suicide (approximately 1015%.

Seasonal affective disorder - onset of mood
symptoms is connected with changes of seasons,
with depression typically occurring during the winter
months and remissions or changes from depression
to mania occurring during the spring.
F33 Recurrent Depressive Disorder
Kupfer 1991
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no depression
symptoms
syndrome
treatment stage
response
relapse
remission
relapse recurrence
recovery
F33 Recurrent Depressive Disorder
F33 Recurrent depressive disorder
F33.0 Recurrent depressive disorder, current episode
mild
F33.1 Recurrent depressive disorder, current episode
moderate
F33.2 Recurrent depressive disorder, current episode
severe without psychotic symptoms
F33.3 Recurrent depressive disorder, current episode
severe with psychotic symptoms
F33.4 Recurrent depressive disorder, currently in
remission
F33.8 Other recurrent depressive disorders
F33.9 Recurrent depressive disorder, unspecified
F30 Manic Episode
F30 Manic episode
F30.0 Hypomania
F30.1 Mania without psychotic symptoms
F30.2 Mania with psychotic symptoms
F30.8 Other manic episodes
F30.9 Manic episode, unspecified

F30.0 Hypomania
Hypomania is characterized by
persistent mild elevation of mood for at least
several days
increased energy and activity
usually marked feelings of well-being and both
physical and mental efficiency
Increased sociability, talkativeness,
overfamiliarity, increased sexual energy,
and a decreased need for sleep are often
present but not to the extent that they
lead to severe disruption of work or result
in social rejection. There are no
hallucinations or delusions
F30.1 Mania without Psychotic
Symptoms
Mania without psychotic symptoms:
last for at least 1 weak
mood is elevated out of keeping with individuals
circumstances and may vary from carefree joviality to
almost uncontrollable excitement
elation is accompanied by increased energy, resulting in
overactivity, pressure of speech, and a decreased need for
sleep
normal social inhibition are lost, attention cannot be
sustained, and there is often marked distractibility
self-esteem is inflated, and grandiose or over-optimistic
ideas are freely expressed
perceptual disorders may occur
the individual may embark on extravagant and impractical
schemes, spend money recklessly, or become aggressive,
amorous, or factious in inappropriate circumstances.
F30.2 Mania with Psychotic
Symptoms
Mania with psychotic symptoms represents a
more severe form of mania:
inflated self-esteem and grandiose ideas may develop into
delusions, and irritability and suspiciousness into delusions
of persecution
in severe cases, grandiose or religious delusions of identity
or role may be prominent, and flight of ideas and pressure of
speech may result in the individual becoming
incomprehensible
sustained physical activity and excitement may result in
aggression or violence, and neglect of eating, drinking, and
personal hygiene may result in dangerous states of
dehydration and self neglect

Mania with:
mood-congruent psychotic symptoms
mood-incongruent psychotic symptoms
Manic stupor
F31 Bipolar Affective Disorder
Bipolar affective disorder is characterized by
repeated, at least two episodes in which the patients
mood and activity levels are significantly disturbed
(manic or depressive syndromes, patients who suffer
only from repeated episodes of mania are
comparatively rare).
The first episode may occur at any age from childhood
to old age.
The frequency of episodes and the pattern of
remissions and relapses are both very variable.
The lifetime prevalence is between 0,5 an 1 %.
Suicidality about 19%. Comorbidity with alcohol and
drug abuse
The rapid-cycling specifier identifies those patients
who have had at least four episodes of a major
depressive, manic, or mixed episode during the past
12 months.
F31 Bipolar Affective Disorder
F31 Bipolar affective disorder
F31.0 Bipolar affective disorder, current episode hypomanic
F31.1 Bipolar affective disorder, current episode manic without
psychotic symptoms
F31.2 Bipolar affective disorder, current episode manic with
psychotic symptoms
F31.3 Bipolar affective disorder, current episode mild or
moderate depression
F31.4 Bipolar affective disorder, current episode severe
depression without psychotic symptoms
F31.5 Bipolar affective disorder, current episode severe
depression with psychotic symptoms
F31.6 Bipolar affective disorder, current episode mixed
F31.7 Bipolar affective disorder, currently in remission
F31.8 Other bipolar affective disorders
F31.9 Bipolar affective disorder, unspecified
F34 Persistent Mood (Affective)
Disorders
Persistent mood disorders are persistent and
usually fluctuating disorders of mood in which
individual episodes are not sufficiently severe to
warrant being described as hypomanic or even mild
depressive episodes.
Lasting more than 2 years


F34 Persistent mood (affective) disorders
F34.0 Cyclothymia
F34.1 Dysthymia
F34.8 Other persistent mood (affective) disorders
F34.9 Persistent mood (affective) disorder, unspecified
F34.0 Cyclothymia
For cyclothymia persistent instability of
mood, involving periods of mild depression
and mild elation is typical.
This instability usually develops early in
adult life and pursues a chronic course,
although the mood may be normal and
stable for months at a time.
The mood swings are usually perceived by
the individual as being unrelated to life
events.
F34.1 Dysthymia
Dysthymia represents a chronic, milder
form of depression which does not fulfill
the criteria for recurrent depressive
disorder especially in terms of severity.
Sufferers usually have periods of days or
weeks when they describe themselves as
well, but most of the time they feel tired
and depressed.
It usually begins in adult life and lasts for
at least several years, sometimes
indefinitely.
The lifetime prevalence is approximately
3%, and it is more common in women.
F34.1 Dysthymie
dysthymie: mrn chronick deprese
epidemiologie: celoivotn prevalence
kolem 3%
etiopatogeneze: faktory genetick i vnj
lba: jako u depresivn poruchy
kognitivn-bahaviorln psychoterapie,
antidepresiva
Treatment of Depression
Various antidepressants altering levels of central
neurotransmitters are available to treat
depression.
Their overall effectiveness: 65-70%
Mild to moderate depressive episode: SSRIs.
Severe depression: antidepressants with broader
spectrum of effects, like SNRI or TCA.
Patients with insomnia or anorexia may do better
with more sedating medication (mirtazapine,
trazodon)
Patients with lethargy, hypersomnia, weight gain
and lower levels of tension and anxiety may
prefer the less sedating medications such as
bupropion, reboxetin or stimulating SSRIs.
IMAOs or RIMA should be tried in refractory
patients or patients with atypical depression.
Treatment of Depression
Drug trials should last 4 to 8 weeks.
No response within 4 weeks of treatment - the
dose should be increased or the patient should be
switched to another drug.
In partial responders - augmentation strategy;
coadministration of lithium carbonate or
trijodthyronine.
Psychotic patient - adding on neuroleptics.
Anxious or agitated patients (also to improve the
sleep quality) - benzodiazepine coadministration
for a short period of time.
Lithium prophylaxis is an option to
antidepressants.

Supportive psychotherapy.
Treatment of Depression
First episode of depression - the drug should be
continued for another 16-20 weeks after the patient
is thought to be well (continuation treatment to
prevent recurrence).
The medication should be tapered gradually because
many patients experience some mild withdrawal
effects.
Patients with recurrent depression need long-term
maintenance therapy to prevent relapses.
Electroconvulsive therapy (ECT) is the treatment of
choice for some patients with very severe
depression, with high potential for suicide or other
selfdestroying behaviour and for pregnant women.
Other biological methods:
phototherapy (seasonal affective disorder)
sleep deprivation
repetitive transcranial magnetic stimulation (rTMS).
Treatment of Mania
Mood stabilizers:
lithium (0.61.2 mEq/L)
carbamazepine (612 mg/L)
valproate (50125 mg/L)
Anticonvulsants:
gabapentine
topiramate
lamotrigine
Agitated or psychotic patient
coadministartion of
antipsychotics of second generation
(olanzapine, risperidone)
benzodiazepines (lorazepam, clonazepam)
ECT