MOOD DISORDERS

Ellen Gluzman, MD
DEPRESSIVE SPECTRUM
DISORDERS
MAJOR DEPRESSIVE DISORDER
Major Depressive Episode DSM-IV TR
Criteria
A. Five (or more) of the following symptoms have been present
during the same 2-week period and represent a change from
previous functioning; at least one of the symptoms is either (1)
depressed mood or (2) loss of interest or pleasure. Note: Do not
include symptoms that are clearly due to a general medical
condItion, or mood-incongruent delusions or hallucinations.
1. depressed mood most of the day, near!y every day, as
indicated by either subjective report (e.g., feels sad or
empty) or observation made by others (e.g., appears
tearful). Note: In children and adolescents, can be irritable
mood.
2. markedly diminished interest or pleasure in all, or almost all,
activities most of the day, nearly every day (as indicated by
either subjective account or observation made by others)
3. significant weight loss when not dieting or weight gain (e.g.,
a change of more than 5% of body weight in a month), or
decrease or increase in appetite nearly every day. Note: In
children, consider failure to make expected weight gains.
4. insomnia or hypersomnia nearly every day

Major Depressive Episode DSM-IV
TR Criteria
5. psychomotor agitation or retardation nearly every day
(observable by others, not merely subjective feelings of
restlessness or being slowed down)
6. fatigue or loss of energy nearly every day
7. feelings of worthlessness or excessive or inappropriate guilt
(which may be delusional) nearly every day (not merely
self-reproach or guilt about being sick)
8. diminished ability to think or concentrate, or indecisiveness,
nearly every day (either by subjective account or as
observed by others)
9. recurrent thoughts of death (not just fear of dying),
recurrent suicidal ideation. without a specific plan, or a
suicide attempt or a specific plan for committing suicide

Clinical Features
Children
School Phobia and excessive clinging
Somatic Complaints
Adolescents
Irritable mood
Poor academic performance
Substance abuse, antisocial behavior, sexual promiscuity, truancy, running away
Elderly
Prevalence 25-50%
Can be correlated with low socioeconomic status, loss of a spouse, concurrent physical
illness, social isolation
Characterized more by somatic complaints
Characteristic Findings
Mood and Affect
Speech latency and lowered intensity
Social withdrawal or isolation
Sexual Dysfunction
Reduced libido, erectile dysfunction, and delayed or impaired ability to
achieve orgasm
Ruminations
Anxiety (90% of all depressed patients)
Risk factors for recurrent MDD
Severe index episode
Longer duration of a prior episode of MDD
Incomplete recovery from a prior episode of
MDD
Increasing age
Specifiers
With Atypical Features
A. Mood reactivity (i.e., mood brightens in response
to actual or potential positive events)
B. Two (or more) of the following features:
significant weight gain or increase in appetite
hypersomnia
leaden paralysis (i.e., heavy, leaden feelings in arms or legs)
long-standing pattern of interpersonal rejection sensitivity (not
limited to episodes of mood disturbance) that results in significant
social or occupational impairment
C. Criteria are not met for With Melancholic
Features or With Catatonic Features during the
same episode.

Specifiers
Characteristics associated with atypical features
Early age onset
Chronic course
Higher frequency in females
Higher frequency in borderline personality disorder
Good response to SSRIs, bupropion, MAOIs but not to TCAs
Possible improvement of carbohydrate cravings and improved
depression with chromium picolinate 600 micrograms/day
Specifiers
With Seasonal Pattern
A. There has been a regular temporal relationship between the onset of Major
Depressive Episodes in Bipolar I or Bipolar II Disorder or Major Depressive
Disorder, Recurrent, and a particular time of the year
B. Full remissions (or a change from depression to mania or hypomania) also
occur at a characteristic time of the year
C. In the last 2 years, two Major Depressive Episodes have occurred that
demonstrate the temporal seasonal relationships defined in Criteria A and B,
and no nonseasonal Major Depressive Episodes have occurred during that
same period.
D. Seasonal Major Depressive Episodes substantially outnumber the
nonseasonal Major Depressive Episodes that may have occurred over the
individual's lifetime.

Specifiers
Common reported symptoms
increased appetite with carbohydrate craving,
increased weight, increased sleep, daytime drowsiness
Higher in females (4:1)
Higher in Northern regions
Related to decreased availability of sunlight in winter
Dysregulation of melatonin
Light therapy is an effective treatment
Specifiers
With psychotic features
Related to severe disease and poor prognosis
More common with bipolar disorder family history
Often require antipsychotics in addition to
antidepressants, and may need ECT
Can be applied to depressive or bipolar episodes
With melancholic features
Severe anhedonia, early morning awakening, weight loss,
feelings of guilt
Endogenous depression changes in autonomic system
Can be applied to depressive or bipolar episodes
Specifiers
Postpartum onset
Within 4 weeks postpartum
Often associated with psychotifc features
Can be applied to both depressive and bipolar
episodes
Chronic
Depressive disorder criteria met for 2 years
Can be applied to all depressive episodes

Clinical features of MDD
Produces more impairment of physical functioning, role
functioning, social functioning, and perceived current health
Associated with more bodily pain
Causes patients to spend more days in bed because of poor
health than do hypertension, diabetes, arthritis, and chronic
pulmonary disease

Clinical features: Suicide
45 to 77% of people who complete suicide
had a mood disorder.
10-15% of patients with mood disorder will go
on to commit suicide.
3% of the treated population will attempt over
10 years

Clinical features
Factors that increase risk of suicide
Demographic factors
Male sex
Recent loss
Never married
Older age
Symptoms
Severe depression
Anxiety
Hopelessness
Psychosis, especially with command hallucinations


Clinical features
Factors that increase risk of suicide
History of suicide attempts, especially if multiple or severe
attempts
Family history of suicide
Active substance abuse
Suicidal thinking
Presence of a specific plan
Means available to carry out the plan
Absence of factors that would keep the patient from
completing the plan
Rehearsal of the plan

Cost of Depression
The total cost in the United States is generally
estimated at $44 billion.
The direct costs of treating depression are about $12
billion, only $890 million of which is accounted for by the
price of antidepressants
The morbidity cost is around $24 billion
The mortality costs are $8 billion
Due to increased accident rates, substance abuse,
development of somatic illness such as coronary heart
disease, and increased use of medical hospitalization
and outpatient treatment

Course of illness
Onset
50% of patients had significant depressive symptoms before diagnosis
Before age 40 (mid-20s DSM) in about 50% of patients
Later onset associated with family history of mood disorders, antisocial
personality disorder, and alcohol abuse.
Duration
Untreated episodes last 6 to 13 months; most treated episodes last about 3
months
Withdrawal from antidepressants 3 months before completion results in
recurrence of symptoms
As the course progresses symptoms last longer.
DSM statistics
60% of patients will have a 2
nd
episode
70% chance of 3
rd
90% chance of a 4
th

Course of Illness
Development of Manic Episodes:
5 to 10 percent develop a manic episode 6 to 10 years after their 1
st

episode.
Mean age of switch is 32 years after 2 to 4 depressive episodes
Prognosis
Chronic condition, and patients symptoms recur
Patients who have been hospitalized for a 1
st
episode have 50% chance
of recovering in the 1
st
year
25% experience a recurrence in the 1
st
6 months after release from a
hospital, 30 to 50% in the 1
st
2 years, and about 50 to 75% in 5 years.
Generally the more episodes, the time in between episodes lessens
and severity worsens.
Prognostic Indicators
Good indicators
Mild episodes
No psychosis
Short hospital stay
Solid friendships during
adolescence
Stable family functioning
Sound social functioning
for 5 years preceding the
illness
No comorbid psychiatric
illnesses
No more than one
inpatient
Advanced age of onset

Bad Indicators
Coexisting dysthymic
disorder
D&A abuse
Anxiety disorder
symptoms
More than one
depressive episode
Being a men
predisposes a longer,
chronic course

MOOD DISORDER
SECONDARY TO
GENERAL MEDICAL
CONDITION
Mood Disorder Due to GMC DSM-IV
TR Criteria
A. A prominent and persistent disturbance in mood
predominates in the clinical picture and is characterized by
either (or both) of the following:
Depressed mood or markedly diminished interest or pleasure in all, or
almost all, activities
elevated, expansive, or irritable mood
B. There is evidence from the history, physical examination, or
laboratory findings that the disturbance is the direct
physiological consequence of a general medical condition.
Mood Disorder Due to GMC
Hypothyroidism
Leads to depression in 40% of individuals
Manifest with vegetative symptoms before mood or cognitive changes
appear
Treat with thyroid hormone and if indicated use an antidepressant also
Cushings disease
Most associated with depression (60-80%)
More frequent in women
Mood Disorder Due to GMC
Diabetes
Autoimmune disorders
SLE, MS, RA
Nutritional deficiencies
Deficiencies of B Vitamins (folic acid, B6, B12)
Deficiencies in B6 and B12 can reduce the
effectiveness of antidepressant treatment
Mood Disorder Due to GMC
Myocardial infarction and cardiovascular disease
15-22% of persons become depressed
If depression is untreated morbidity and mortality
increases
Statins increased depression and suicide risk (?)
TCAs contraindicated 6 months after MI and poor choice
CBT effective
SSRIs better choice
Sertraline is best studied
Mood Disorder Due to GMC
Neurological conditions
Cerebrovascular diseases
27-40%
anterior than in the posterior
more left than right
May present with a poststroke emotional lability not coducive to
depression
Parkinsons disease
50 to 75 %
Dementias
11% in Alzheimers disease
Worsens condition and deterioration
Mood Disorder Due to GMC
Neurological conditions
Epilepsy
20-60%
temporal lope epilepsy
especially if focus is on the left side
Cancer
20% of patients
Pancreatic carcinoma more common
Tumors in the diencephalic and temporal regions
HIV/AIDS
Pain syndromes

SUBSTANCE-INDUCED MOOD
DISORDER
Substance-Induced Mood Disorder
DSM IV-TR criteria
A. A prominent and persistent disturbance in mood predominates
in the clinical picture and is characterized by either (or both)
of the following:
depressed mood or markedly diminished interest or
pleasure in all, or almost all, activities
elevated, expansive, or irritable mood
B. There is evidence from the history, physical examination, or
laboratory findings of either:
the symptoms in Criterion A developed during, or within a
month of, substance Intoxication or withdrawal
medication use is etiologically related to the disturbance
Substance-Induced Mood Disorder
DSM IV-TR criteria
C. The disturbance is not better accounted for by a Mood
Disorder that is not substance induced. Evidence that the
symptoms are better accounted for by a Mood Disorder that
is not substance induced might include the following:
the symptoms precede the onset of the substance use
the symptoms persist for a substantial period of time (e.g., about a
month) after the cessation of acute withdrawal or severe intoxication
substantially in excess of what would be expected given the type or
amount of the substance used or the duration of use
there is other evidence that suggests the existence of an independent
non-substance-induced Mood Disorder (e.g., a history of recurrent
Major Depressive Episodes)

Substance-Induced Mood Disorder
DSM IV-TR criteria
D. The disturbance does not occur exclusively
during the course of a delirium.
E. The symptoms cause clinically significant
distress or impairment in social, occupational,
or other important areas of functioning.

Substance induced mood disorder
Intoxication with these classes of substances can cause mood
disorders:
Alcohol, amphetamine and related substances, cocaine, hallucinogens,
inhalants, opioids, phencyclidine and related substances, sedatives,
hypnotics, and anxiolytics
Withdrawal from the following substances can induce mood
symptoms
Alcohol, amphetamine and related substances, cocaine, sedatives,
hypnotics, and anxiolytics


Substance induced mood disorder
Medications that may mood symptoms:
anesthetics, analgesics, anticholinergics, anticonvulsants,
antihypertensives, antiparkinsonian medications, antiulcer
medications, cardiac medications, oral contraceptives,
psychotropic medications (e.g., antidepressants,
benzodiazepines, antipsychotics, disulfiram), muscle
relaxants, steroids, and sulfonamides.
Higher likelihood of producing depressive features
high doses of reserpine, corticosteroids, anabolic steroids
Substance induced mood disorder
Heavy metals and toxins
gasoline and paint
organophosphate insecticides
nerve gases
carbon monoxide and carbon dioxide

BEREAVEMENT
Depression in Bereavement
Duration and expression of "normal" bereavement varies
considerably among different cultural groups
Diagnosis of depression not given unless the symptoms are
still present 2 months after the loss
Symptoms that are not characteristic of a "normal" grief reaction:
guilt about things other than actions taken or not taken by the
survivor at the time of the death
thoughts of death other than the survivor feeling that he or she would
be better off dead or should have died with the deceased person



Depression in Bereavement
morbid preoccupation with worthlessness
marked psychomotor retardation
prolonged and marked functional impairment
hallucinatory experiences other than thinking that
he or she hears the voice of or transiently sees the
image of the deceased person.

MANAGEMENT OF DEPRESSION
Management of Depression
1. Perform a diagnostic evaluation
2. Evaluate the safety of the patient and others
3. Evaluate and address functional impairments
4. Determine the treatment setting
5. Establish and maintain a therapeutic alliance
6. Monitor psychiatric status and safety
7. Provide education to the patient and, when appropriate, to his or her family
8. Enhance medication adherence
9. Address early signs of relapse

Management of Depression
Mild to Moderate
Can use solo treatment if patient prefers
Indications for therapy
Presence of significant psychosocial stressors
Intrapsychic conflict, Interpersonal difficulties
Comorbid personality disorder
Pregnancy, lactation, or wish to become pregnant
Patient preference



Management of Depression
Indications for Combined Pharmacotherapy and
Psychotherapy:
Clinically significant psychosocial issues
Interpersonal problems
Comorbid personality disorder
History of only partial response to single treatment modalities
Poor adherence to treatments (combine medication with a
psychotherapeutic approach that focuses on treatment adherence)

Basis for Selection of Antidepressant
Effectiveness and side effects
Patients preference or prior positive response
Prior positive response by a close family
member
Age and medical status of the patient
Presence of a prior history of substance abuse
Basis for Selection of Antidepressant
Depression symptoms
Insomnia, anger, worry, fear, or restlessness
More focus on 5HT based
SSRI, tertiary-amine TCA, venlafaxine, duloxetine, MAOI,
mirtazapine
Bupropion alone can increase anxiety
Anergia, lack of focus, difficulty with concentration or inattentiveness
More focus on NE based
TCA (tertiary or secondary), higher dose of venlafaxine, higher
dose of paroxetine, duloxetine, mirtazapine, MAOI, bupropion
Anhedonia, low energy, concerns about sexual dysfunction
More a DA based
Bupropion, high dose sertaline
Basis for Selection of Antidepressant
APA guidelines (2000)
Depression and anxiety: SSRI, avoid bupropion
Depression and OCD: SSRI or clomipramine
Severe Depression: TCAs
Melancholic Depression: TCAs preferred to SSRIs
Atypical depression: SSRIs and MAOIs avoid TCAs
Basis for Selection of Antidepressant
Depression types
Atypical depression: MAOIs
Depression with seasonal features: light therapy
Depression with postpartum onset: estrogen after delivery, antidepressants,
ECT
Depression with psychosis: Antidepressant plus antipsychotic, ECT, amoxapine
Depression with melancholia responds better to 5-HT/NE based and ECT than
to SSRIs.

Phases of Treatment
Acute Phase (0-16 weeks)
Start antidepressant
Expect a response 1-3 weeks after starting medication
Maintain therapeutic dose for 3-12 week
Continuation Phase (begins after the acute phase and last an additional 6-
9 months)
Maintenance phase (begins after recovery)
Continue same dose that got the patient well
Goal is to prevent new mood episodes in patients who are known to have
recurrent or chronic depression
Management of Depression
Indications for ECT
Major depressive episode with a high degree of symptom severity and
functional impairment
Psychotic symptoms or catatonia
Urgent need for response (e.g., suicidality or nutritional compromise in a
patient refusing food)
May be the preferred treatment when:
the presence of comorbid medical conditions precludes the use of
antidepressant medications
there is a prior history of positive response to ECT
the patient expresses a preference for ECT.

BIPOLAR DISORDER
What is the difference between the Bipolar Disorders?
Bipolar I disorder: Mixed or Mania
No depression required for diagnosis
Bipolar disorder, single (mixed/manic) episode
If there is a history of depression, specify in diagnosis,
i.e.:
Bipolar disorder, most recent episode _____
Bipolar II disorder: No Mixed or Manic episodes
Hypomania and at least one major depressive episode
Causes significant distress or impairment in social,
occupational, or other areas of functioning.

MANIC EPISODE
Criteria for Manic Episode
A. A distinct period of abnormally and persistently elevated,
expansive, or irritable mood, lasting at least 1 week (or any duration
if hospitalization is necessary).
B. During the period of mood disturbance, three (or more) of the
following symptom have persisted (four if the mood is only irritable)
and have been present to a significant degree:
(1) inflated self-esteem or grandiosity
(2) decreased need for sleep (e.g., feels rested after only 3 hours
of sleep)
(3) more talkative than usual or pressure to keep talking
(4) flight of ideas or subjective experience that thoughts are
racing
(5) distractibility (i.e., attention too easily drawn to unimportant
or irrelevant external stimuli)
(6) increase in goal-directed activity (either socially, at work or
school, or sexually) or psychomotor agitation
(7) excessive involvement in pleasurable activities that have a
high potential for painful consequences (e.g., engaging in
unrestrained buying sprees, sexual indiscretions, or foolish
business investments)
More Mania
Mood and Affect can be euphoric or expansive
but can quickly become labile
High potential for assault or violence
Caution is advised
75% have psychotic features, grandiose
delusions
Very poor insight




More on Mania
Excessive ETOH intake
Disinhibited nature
Pathological gambling
Wearing clothing and jewelry of bright colors
in unusual or outlandish combinations and
inattention to small details
Preoccupied with religious, political, financial,
sexual, or persecutory ideas that can evolve
into complex delusions

More on Mania
Mania in Adolescents
Misdiagnosed as Antisocial PD or Schizophrenia
Psychosis
Substance Abuse
Suicide Attempts
OCD
Multiple somatic complaints
Marked Irritability
Specifiers
With Rapid Cycling
At least four episodes of a mood disturbance in the previous 12 months that
meet criteria for major depressive, mania, or hypomania.
Episodes are demarcated either by partial or full remission for at least 2
months or a switch to an episode of opposite polarity.
Risk factors
Bipolar II disorder
Being a woman
Hypothyroidism
Right cerebral hemisphere disease
Mental retardation
Use of alcohol and stimulants
Features
Found 5-15% of all Bipolars
less response to Lithium


HYPOMANIC EPISODE
Criteria for Hypomanic Episode
A. A distinct period of persistently elevated, expansive, or irritable
mood, lasting throughout at least 4 days, that is clearly different from the
usual nondepressed mood.
B. During the period of mood disturbance, three (or more) of the
following symptom have persisted (four if the mood is only irritable) and
have been present to a significant degree.
(1) inflated self-esteem or grandiosity
(2) Decreased need for sleep (e.g., feels rested after only 3 hours of sleep)
(3) more talkative than usual or pressure to keep talking
(4) Flight of ideas or subjective experience that thoughts are racing
(5) Distractibility (i.e., attention too easily drawn to unimportant or irrelevant
external stimuli)
(6) Increase in goal-directed activity (either socially, at work or school, or
sexual or psychomotor agitation
(7) Excessive involvement in pleasurable activities that have a high potential
for painful consequences (e.g., the person engages in unrestrained buying
spree sexual indiscretions, or foolish business investments)
BIPOLAR DEPRESSION
Depression
Unipolar vs. Bipolar
Later onset, fewer episodes,
More gradual onset
Female > male
More psychomotor agitation,
typical symptoms, insomnia
Lower risk of suicide
Less frequently accompanied by
psychotic symptoms in younger
patients
Antidepressants more effective,
Lithium less effective
Family history of depression
Normal [Ca2+]

Earlier onset, More episodes,
Acute onset
Female = male
More psychomotor retardation
and lethargy
Atypical symptoms
Hypersomnia
Greater risk of suicide
Greater likelihood of psychotic
symptoms in younger patients
Antidepressants less effective,
Lithium more effective
Family history of mania and
depression
Increased [Ca2+]

MIXED EPISODES
Criteria for Mixed Episode

A. The criteria are met both for a Manic Episode and for a
Major Depressive Episode (except for duration) nearly
every day during at least a 1-week period.
B. The mood disturbance is sufficiently severe to cause
marked impairment in occupational functioning or in usual
social activities or relationships with others, or to
necessitate hospitalization to prevent harm to self or
others, or there are psychotic features.
C. The symptoms are not due to the direct physiological
effects of a substance or a general medical condition
Note: Mixed-like episodes that are clearly caused by somatic
antidepressant treatment (e.g., medication, electroconvulsive
therapy, light therapy) should not count toward a diagnosis of
Bipolar I Disorder.



Other Features of Mixed Episode
Severe, impairing, and more treatment
resistant
Psychosis and suicide are more common
40% of manic episodes present with mixed
features
Usually followed by a depressive episode
Bipolar Disorder and Suicide
Patients with mixed bipolar states may be more
likely to involve others in a suicide attempt
As many as 4% of the people who commit suicide
murder someone else first.
High levels of distress and hopelessness increase
the risk of suicide attempts in adolescents
Bipolar II are at higher risk of attempting and
completing suicide

Rules of 3
Will help uncover a bipolar episode
3 marriages before age 30
Failure of 3 antidepressants
3 different careers by age 30
3 first degree relatives with a mood disorder
3 consecutive generations with a mood disorder
Course for Bipolar Disorder
Average age at first onset usually by the
second or third decade of life.
The median duration of:
Manic episode is 510 weeks
Bipolar depressive episode is 19 weeks
Mixed bipolar episodes have a median duration of
36 weeks
Less than one-third remain euthymic for a
year
Course for Bipolar I

Most often starts with Depression
75 percent of women, 67 percent of the men
Experience both symptoms
Untreated mania last about 3 months
90% of patients who have had a manic episode are likely to
have another
As the disorder progresses, the time between episodes
decreases
After about 5 episodes, interepisode interval stabilizes for 6 to
9 months

Course Bipolar I
Incidence in Children and Adolescents is 1%.
Onset can be 8 years old.
Early onset associated with poor prognosis
Onset in older persons is uncommon

Prognosis
Poor vs Good
Premorbid poor
occupational status
Substance Abuse
Psychotic features
Rapid cycling pattern
and mixed episodes
Interepisode
depressive features
Male gender
Younger age at initial
onset
Increasing frequency
of bipolar episodes
Short duration of
manic episodes
Advanced age of onset
Few suicidal thoughts
Few coexisting
psychiatric or medical
problems
Prognosis for Bipolar I
Poorer prognosis when compared to MDD
40 to 50 percent will have a manic episode within 2 years of
the 1
st
episode
Only 50 to 60 percent of patients achieve control with Lithium
7% have no recurrence of symptoms
45% have more than one episode
Patients can have 2 to 30 manic episodes, mean number is 9
More than 40 percent have more than 10 episodes
Long term follow up
15% are well



Psychiatric Management
1. Perform a diagnostic evaluation
2. Evaluate the safety of the patient and others and determine
a treatment setting
3. Establish and maintain a therapeutic alliance
4. Monitor treatment response
5. Provide education to the patient and to the family
6. Enhance treatment compliance
7. Promote awareness of stressors and regular patterns of
activity and sleep
8. Work with the patient to anticipate and address early signs of
relapse
9. Evaluate and manage functional impairments
MANAGEMENT OF BIPOLAR
DISORDER
FDA approved treatment for mania
Lithium
Depakote, Depakene, Carbamazepine
Zyprexa, Seroquel, Geodon, Abilify, Risperdal
Thorazine
Medications not approved at all for Bipolar (and actually
found in some studies to be ineffective)
Tiagabine
Topiramate
Gabapentin
Management of Acute Episodes
Mania or mixed episodes
Severe episodes: initiate of either lithium plus an antipsychotic or valproate
plus an antipsychotic
For less ill patients, monotherapy with lithium, valproate, or an antipsychotic
such as olanzapine may be sufficient
Short-term adjunctive treatment with a benzodiazepine may also be helpful
For mixed episodes, valproate may be preferred over lithium
Atypical antipsychotics are preferred over typical antipsychotics because of
their more benign side effect profile
Alternatives include carbamazepine or oxcarbazepine in lieu of lithium or
valproate
Antidepressants should be tapered and discontinued if possible
If psychosocial therapy approaches are used, they should be combined with
pharmacotherapy
Management of Acute Episodes
Presence of a manic or mixed episode despite medicine
compliance
the first-line intervention should be to optimize the
medication dose
Introduction or resumption of an antipsychotic is
sometimes necessary
Severely ill or agitated patients may also require short-
term adjunctive treatment with a benzodiazepine


Management of Acute Episodes
If first-line medications at optimal doses fails to control
symptoms
Addition of another first-line medication
Alternative treatment: carbamazepine or oxcarbazepine
Adding an antipsychotic if not already prescribed
Changing from one antipsychotic to another
Clozapine effective in refractory illness

Management of Acute Episodes
Electroconvulsive therapy (ECT) for:
Patients with severe or treatment-resistant mania
If preferred by the patient in consultation with the
psychiatrist
For patients experiencing mixed episodes
For patients experiencing severe mania during
pregnancy

Treatment of Hypomanic Episodes
No drug is approved for hypomanic episodes
DSM-IV TR indicates that hypomania does not
have a dysfunctional course
Aggressive treatment only indicated if
escalating into mania or rapid cycling
Otherwise no treatment is warranted
FDA approved for Bipolar Depression
Symbyax
Seroquel
Lamictal is not yet approved
Management of Bipolar Depression
First-line is lithium or lamotrigine
Antidepressant monotherapy is not recommended
As an alternative, initiate simultaneous treatment with lithium
and an antidepressant
* Can also use Symbiax as it has FDA approval
In patients with life-threatening inanition, suicidality, or
psychosis, ECT also represents a reasonable alternative
ECT is also a potential treatment for severe depression during
pregnancy
Interpersonal therapy and cognitive behavior therapy may be
useful when added to pharmacotherapy. Psychodynamic also
effective

Management of Bipolar Depression
Breakthrough depressive episode despite compliance
First step is to optimize dose.
If there is no response to first-line medication treatment at
optimal doses add:
Lamotrigine
Bupropion
Paroxetine
Alternative next steps include adding other newer antidepressants or
a monoamine oxidase inhibitor (MAOI)
For patients with severe or treatment-resistant depression or
depression with psychotic or catatonic features, ECT should be
considered
Management of Rapid Cycling
Initial intervention
Identify possible contributors such as
hypothyroidism, or drug and alcohol use
If caused by an antidepressant should be tapered
if possible
Initial treatment
Lithium or valproate
An alternative treatment is lamotrigine
FDA approved for maintenance
treatment
Lithium
Zyprexa
Lamictal
Maintenance Treatment
The medications with the best empirical evidence to support
their use in maintenance treatment include lithium and
valproate
Possible alternatives include lamotrigine, carbamazepine, or
oxcarbazepine
Reassess ongoing antipsychotic treatment upon entering
maintenance treatment
Maintenance therapy with atypical antipsychotics may be
considered
Concomitant psychosocial intervention
DYSTHYMIC DISORDER
DSM-TR Criteria for Dysthymic
Disorder
A. Depressed mood for most of the day, for more days than
not, as indicated either by subjective account or
observation by others, for at least 2 years. Note: In children
and adolescents, mood can be irritable and duration must
be at least 1 year.
B. Presence, while depressed, of two (or more) of the
following:
1. poor appetite or overeating
2. insomnia or hypersomnia
3. low energy or fatigue
4. low self-esteem
5. poor concentration or difficulty making decisions
6. feelings of hopelessness
Possible presentations
Ive been depressed as long as I can
remember or Ive been depressed all my
life
Being sarcastic, nihilistic, brooding,
demanding, habitually gloomy, pessimistic,
humorless, anhedonic, or complaining
Being rigid or resistant to therapy
Dysthymic disorder vs. MDD
MDD has more severe symptoms in quantity than
DD.
Cognitive symptoms and social-motivational
symptoms are more frequent in DD
It is difficult to determine which one of the two
conditions impairs more functioning.
Risk of 75% that MDD will be developed within the
next 5 years

Course
Early and insidious onset as a chronic course
They come to treatment when they have a superimposed
major depression
Remission rate as low as 10% per year
Recovery rate 73.9%, with median

time of 52 months
Estimated risk of relapse into another period of chronic

depression was 71.4%
68% and 90% of dysthymic patients experience at least one
major depressive episode



Double Depression
Major depressive episode must appear 2 years or
more (1 year in children and adolescents) after the
onset of dysthymia for double depression to be
diagnosed
More severe depressive symptoms, more
psychosocial impairment, a greater risk of suicide
more treatment resistance and more comorbidity,
especially with avoidant and dependent personality
disorders, less likely to remit) and is more likely to
recur
Treatment
Antidepressant medications have been found to be effective
SSRIs are 1
st
line
Sertaline and imipramine improve social functioning as well as
depressive symptoms
MAO-I can be effective
Trifluoperazine has been shown effective in treatment resistant cases
Psychotherapy, including interpersonal therapy and cognitive
behavioral therapy
responses have been somewhat smaller when compared to major
depressive disorder.
CYCLOTHYMIA
DSM IV TR Criteria for Cyclothymia
A. For at least 2 years, the presence of numerous periods with
hypomanic symptoms and numerous periods with
depressive symptoms that do not meet criteria for a Major
Depressive Episode. In children and adolescents, the
duration must be at least 1 year.
B. During the above 2-year period (1 year in children and
adolescents), the person has not been without the
symptoms in Criterion A for more than 2 months at a time.
Clinical features
50% have depressive features as presentation
Experience mood states that alternate between
depression, irritability, cheerfulness, and relative
normality that last days, weeks, or months.
Complain of unpredictable changes in energy, vague
physical symptoms, and a seasonal pattern of mood
swings (e.g., depression in the winter)
44% of the cyclothymic patients developed
hypomania while taking antidepressants
Course
Insidious onset and a chronic course
15%50% risk that the person will
subsequently develop Bipolar I or II Disorder.
50% start out with depressive symptoms
Treatment of Cyclothymia
Mood Stabilizers are the first line of treatment
Use the same plasma concentrations that you would
use for Bipolar disorder
Be cautious when using antidepressants as there is a
40-50% of patients that will develop antidepressant
induced hypomania.
Psychotherapy should be geared towards helping
them become familiar with their condition and help
them with coping mechanisms to deal with their
mood swings.