1
|
- Department of Psychiatry
- 1st Faculty of Medicine
- Charles University, Prague
- Head: Prof. MUDr. Jiří Raboch, DrSc.
|
2
|
- 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 imm=
ense
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 situati=
ons.
- The mood disorders may be subdivided into unipolar and bipolar type=
s:
- those that are characterized by depression only
- those that are characterized by manic episode either alone or in
combination with depression
|
3
|
- International Classification of Diseases (ICD-10) came into use in =
WHO
Member States as from 1994
- F30 Manic episo=
de
- F31 Bipolar aff=
ective
disorder
- F32 Depressive =
episode
- F33 Recurrent
depressive disorder
- F34 Persistent =
mood
(affective) disorders
- F38 Other mood
(affective) disorders
- F39 Unspecified=
mood
(affective) disorder
|
4
|
- 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)
|
5
|
- 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
|
6
|
- 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 unus=
ually
severe and of rapid onset.
- The lifetime prevalence: 17%; risk of recurrence >50%.
|
7
|
- The lowered mood varies little from day to day, is unresponsive to
circumstances and may be accompanied by so-called „somatic=
220;
symptoms:
- loss of interest or pleasure in activities that are normally enjoy=
able
(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 agitatio=
n
- loss of appetite
- weight loss
- loss of libido
|
8
|
- 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
|
9
|
- Two or three of the above symptoms are usually present.
- For mild depressive episode are typical depressed mood, anhedonia a=
nd
increased fatigability. The afflicted person is usually distressed =
by
the symptoms and has some difficulty in continuing with ordinary wo=
rk
and social activities, but will probably not cease to function comp=
letely.
|
10
|
- 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.
|
11
|
- In a severe depressive episode, the sufferer usually shows consider=
able
distress or agitation. Loss of self-esteem or feelings of uselessne=
ss or
guilt are likely to be prominent, and suicide is a distinct danger =
in
particularly severe cases. ; a number of "somatic" sympto=
ms
are usually present.
- Agitated depression
- Major depression
- Vital depression
|
12
|
- Psychotic symptoms may be present, such as
- delusions (ideas of sin, poverty or imminent disasters)
- hallucinations (defamatory or accusatory voices or of rotting filt=
h or
decomposing flesh)
- depressive stupor
- Severe ordinary social activities are impossible
- When the psychotic symptoms are consistent with the patient’s
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
|
13
|
- Recurrent depressive disorder is characterized by repeated episodes=
of
depression without any history of independent episodes of mood elev=
ation
and overactivity.
- Recovery is usually complete between episodes, but a substantial pa=
rt of
patients will have a recurrence and about 30% may develop a persist=
ent
depression.
- The lifetime prevalence - about 10—20 %; women:men 2:1.
- The risk of suicide (approximately 10—15%.
- Seasonal affective disorder - onset of mood symptoms is connected w=
ith
changes of seasons, with depression typically occurring during the
winter months and remissions or changes from depression to mania
occurring during the spring.
|
14
|
|
15
|
- 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
|
16
|
- F30 Manic epis=
ode
- 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
|
17
|
- 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 se=
xual
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 soc=
ial
rejection. There are no hallucinations or delusions
|
18
|
- Mania without psychotic symptoms:
- last for at least 1 weak
- mood is elevated out of keeping with individual’s circumstan=
ces
and may vary from carefree joviality to almost uncontrollable
excitement
- elation is accompanied by increased energy, resulting in overactiv=
ity,
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.
|
19
|
- Mania with psychotic symptoms represents a more severe form of mani=
a:
- inflated self-esteem and grandiose ideas may develop into delusion=
s,
and irritability and suspiciousness into delusions of persecution<=
/li>
- in severe cases, grandiose or religious delusions of identity or r=
ole
may be prominent, and flight of ideas and pressure of speech may r=
esult
in the individual becoming incomprehensible
- sustained physical activity and excitement may result in aggressio=
n 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
|
20
|
- Bipolar affective disorder is characterized by repeated, at least t=
wo
episodes in which the patient’s 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.=
li>
- The frequency of episodes and the pattern of remissions and relapse=
s 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.
|
21
|
- F31 Bipolar af=
fective
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 psycho=
tic
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
|
22
|
- 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 depress=
ive
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
|
23
|
- For cyclothymia persistent instability of mood, involving periods of
mild depression and mild elation is typical.
- This instability usua=
lly
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.
|
24
|
- Dysthymia represents a chronic, milder form of depression which doe=
s 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 depres=
sed.
- It usually begins in adult life and lasts for at least several year=
s,
sometimes indefinitely.
- The lifetime prevalence is approximately 3%, and it is more common =
in
women.
|
25
|
- dysthymie: mírná chronická deprese
- epidemiologie: celoživotní prevalence kolem 3%
- etiopatogeneze: faktory genetické i vnější<=
/li>
- léčba: jako u depresivní poruchy –
kognitivně-bahaviorální psychoterapie, antidepre=
siva
|
26
|
- Various antidepressants altering levels of central neurotransmitter=
s 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 wi=
th
atypical depression.
|
27
|
- Drug trials should last 4 to 8 weeks.
- No response within 4 weeks of treatment - the dose should be increa=
sed
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.
|
28
|
- First episode of depression - the drug should be continued for anot=
her
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 thera=
py to
prevent relapses.
- Electroconvulsive therapy (ECT) is the treatment of choice for some
patients with very severe depression, with high potential for suici=
de or
other selfdestroying behaviour and for pregnant women.
- Other biological methods:
- phototherapy (seasonal affective disorder)
- sleep deprivation
- repetitive transcranial magnetic stimulation (rTMS).
|
29
|
- Mood stabilizers:
- lithium (0.6—1.2 mEq/L)
- carbamazepine (6—12 mg/L)
- valproate (50—125 mg/L)
- Anticonvulsants:
- gabapentine
- topiramate
- lamotrigine
- Agitated or psychotic patient – coadministartion of
- antipsychotics of second generation (olanzapine, risperidone)
- benzodiazepines (lorazepam, clonazepam)
- ECT
|