Depressive Illness,

Unipolar and Bipolar

Affective Disorder
AP HAITHAM
PH.D (Psychiatry)
ASSOCIATED PROFESSOR
IMS, MSU

Objectives
To acquire knowledge about various Mood/ Affective
Disorders
To know conceptualization of Bipolar Disorders and
Major Depressive Disorder
To identify clinical features (signs/symptoms) of
mood disorders
To know management of mood disorders

Introduction
Mood is a pervasive and sustained feeling tone that is experienced
internally and that influences a person's behavior and perception of the
world
Affect is the external expression of mood
Mood can be normal, elevated, or depressed
Healthy persons experience a wide range of moods and have an equally
large repertoire of affective expressions; they feel in control of their
moods and affects
Mood disorders are a group of clinical conditions characterized by a
loss of that sense of control and a subjective experience of great distress
These disorders are associated with impaired interpersonal, social, and
occupational functioning

Contd.

Patients afflicted with only major depressive episodes are said to

have major depressive disorder or unipolar depression
Patients with both manic and depressive episodes or patients with
manic episodes alone are said to have bipolar disorder
The terms unipolar mania and pure mania are sometimes
used for patients who are bipolar, but who do not have depressive
episodes
Hypomania is an episode of manic symptoms that does not meet
the full (DSM-IV-TR) criteria for manic episode.
Cyclothymia and dysthymia are defined by DSM-IV-TR as
disorders that represent less severe forms of bipolar disorder and
major depression, respectively.

History
Hippocrates used the terms mania and melancholia to describe
mental disturbances
Emil Kraepelin, described manic-depressive psychosis using
most of the criteria that psychiatrists now use to establish a
diagnosis of bipolar I disorder

Epidemiology
Mood disorders are common
Major depressive disorder has the highest lifetime prevalence
(almost 17 percent) of any psychiatric disorder
lifetime prevalence for bipolar disorder is 0 to 2.4%
Major depressive disorder is two times more common in females
bipolar I disorder has an equal prevalence among men and
women
Women have a higher rate of being rapid cyclers, defined as
having four or more manic episodes in a 1-year period
Mean age of onset for bipolar disorder 30 years
Mean age of onset for major depressive disorder 40 years

Etiology
Biological Factors:
Neurotransmitter: (Monoamine hypothesis)norepinephrine
and serotonin are most implicated in the pathophysiology of
mood disorders
Neuroanatomy: the prefrontal cortex (PFC), the anterior
cingulate, the hippocampus, and the amygdala
Genetic factors: if one parent has a mood disorder, a child will
have a risk of between 10 and 25 percent for mood disorder. If
both parents are affected, this risk roughly doubles

Etiology
Psychosocial factors:
Life Events and Environmental Stress
Personality Factors: Persons with certain personality
disorders histrionic, and borderline may be at greater risk for
depression
Psychodynamic Factors in Depression: disturbances in the
infant mother relationship during the oral phase
Psychodynamic Factors in Mania: Klein viewed mania as a
defensive reaction to depression, using manic defenses such as
omnipotence, in which the person develops delusions of
grandeur

Depressive Disorders in DSM-V

Major depressive disorder
--Prominent depressive symptoms meeting criteria for major depressive episode

Dysthymic disorder
--Prominent depressed mood lasting for 2 years

Substance induced mood disorder with depressive features

--Prominent depressive symptoms during/within 1 month of substance use

Mood disorder due to a general medical condition with depressive

features
--Symptoms as direct physiologic consequence of GMC

Adjustment disorder with depressed mood

--Symptoms arise in response to identifiable stressor(s)

Depressive disorder NOS

Prominent depressive symptoms not meeting other criteria

Contd.
Major Depressive episode:
A major depressive episode must last at least 2 weeks.
At least one of the symptoms is either (1) depressed mood or (2) loss of
interest or pleasure
There should be least four symptoms from the following: changes in appetite
and weight, changes in sleep and activity, psychomotor
agitation/retardation,lack of energy, feelings of worthlessness/guilt, problems
thinking/concentrating and making decisions, and recurring thoughts of death
or suicide.
Mild
Moderate
Severe without psychotic features
Severe with psychotic features: mood congruent/ mood incongruent
In Full remission

Contd.

Major Depressive Disorder:

Presence of one or more major depressive episode(s).
The major depressive episode(s) not better accounted for by schizoaffective
disorder/ schizophrenia/ delusional disorder or other psychotic disorders.
There has never been a manic episode/ hypomanic episode or mixed episode

Chronic Major depressive Disorder: for past 2 years

MDD with catatonic features specifier: atleast two of the following are
present: motoric immobility/ stupor. Excessive motor activity. Extreme
negativism. Peculiar movements. Echolalia/ echopraxia
MDD with postpartum onset specifier: Onset within 4 weeks of postpartum
MDD with seasonal pattern specifier

Melancholic Depression
Melancholia is one of the oldest terms used in psychiatry
It is used to refer to a depression characterized by:
-severe anhedonia
-early morning awakening
-weight loss
-profound feelings of guilt (often over trivial events)

It is not uncommon for patients who are melancholic to have

suicidal ideation
Also called as endogenous depression

Atypical depression
Mood reactivity (i.e., mood brightens in response to actual or
potential positive events)
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
Reversed vegetative symptoms
Younger age of onset

Contd.

Dysthymic disorder:
A. Depressed mood for most of the day, for at least 2 years.
B. Presence, while depressed, of two (or more) of the following:

poor appetite or overeating

insomnia or hypersomnia
low energy or fatigue
low self-esteem
poor concentration or difficulty making decisions
feelings of hopelessness

C. The person has never been asymptomatic during this period

D. No major depressive episode has been present during the first 2
years of the disturbance
E. There has never been a manic/hypomanic or mixed episode

Bipolar Disorders in DSM-IV-TR

Bipolar I disorder
Bipolar II disorder
Cyclothymia
Substance induced mood disorder with manic/ mixed
features
Mood disorder due to a general medical condition
with manic/ mixed features
Bipolar disorder NOS

Contd.

A manic episode is a distinct period of an abnormally and persistently

elevated, expansive, or irritable mood lasting for at least 1 week, or
less if a patient must be hospitalized.
During the period of mood disturbance, three (or more) of the
following symptoms have persisted (four if the mood is only irritable)
and have been present to a significant degree:

inflated self-esteem or grandiosity

decreased need for sleep (e.g., feels rested after only 3 hours of sleep)
more talkative than usual or pressure to keep talking
flight of ideas or subjective experience that thoughts are racing
distractibility (i.e., attention too easily drawn to unimportant or irrelevant external stimuli)
increase in goal-directed activity
excessive involvement in pleasurable activities that may have painful consequences
(sexual indiscretions, or foolish business investments)

Contd.

Psychotic symptoms in mania: in its most severe form, mania may be

associated with psychotic symptoms

A hypomanic episode lasts at least 4 days and is similar to a manic

episode except that it is not sufficiently severe to cause
impairment in social or occupational functioning, and no
psychotic features are present.
Both mania and hypomania are associated with inflated selfesteem, decreased need for sleep, distractibility, great physical and
mental activity, and overinvolvement in pleasurable behavior
A mixed episode is a period of at least 1 week in which both a
manic episode and a major depressive episode occur almost daily.

Contd.

bipolar I disorder is defined as having a clinical course of one

or more manic episodes and, sometimes, major depressive
episodes.
A variant of bipolar disorder characterized by episodes of
major depression and hypomania rather than mania is known
as bipolar II disorder.
Cyclothymic disorder is characterized by at least 2 years of
frequently occurring hypomanic symptoms that cannot fit the
diagnosis of manic episode and of depressive symptoms that
cannot fit the diagnosis of major depressive episode.

Rapid cycling bipolar I/II disorder

More common in females
external factor such as stress or drug treatment may be
involved in the pathogenesis
At least four episodes of a mood disturbance in the previous
12 months that meet criteria for a major depressive, manic,
mixed, or hypomanic episode
Episodes are demarcated either by partial or full remission for
at least 2 months

Differential Diagnosis
Mood disorders due to general medical conditions

Endocrine disorders
Mania: Hyperthyroidism; Depression: Hypothyroidism, Cushing syndrome

Substance induced Mood disorders

Other Psychiatric Disorders

Schizophrenia
Schizoaffective disorders
Acute/ transient psychotic disorders
Adjustment disorders with depressed mood
Generalized anxiety disorders/ Obsessive compulsive disorder

Course and Prognosis

Major depressive disorder is not a benign disorder
It tends to be chronic, and patients tend to relapse
Mild episodes, the absence of psychotic symptoms, short
hospital stay, stable family functioning, and generally sound
social functioning are good prognostic indicators
Patients with bipolar I disorder have a poorer prognosis than
do patients with major depressive disorder
Bipolar I disorder with an early onset, premorbid poor
occupational status, alcohol dependence, psychotic features,
interepisode depressive features, and male gender is associated
with a poor prognosis

Management
Hospitalization:
Indications: risk of harm to self/others/ property, severe
depressive/psychotic symptoms, history of rapidly progressing
symptoms, patient's grossly reduced ability to get food and
shelter, and the need for diagnostic procedures, rupture of a
patient's usual support systems, initiation of ECT, treatment
resistant depression
Manic patients often have a complete lack of insight into their
disorder that hospitalization seems absolutely absurd to them

Pharmacological Treatment
Treatment of Major Depressive Disorder:
Antidepressants:

Tricyclic antidepressants
Selective serotonine reuptake inhibitors
Serotonine norepinephrine reuptake inhibitors(venlafaxine)
Dopamine reuptake inhibitor(bupropion,naltrexone,wellbutrin)

Antidepressant treatment should be maintained for at least 6

months or the length of a previous episode, whichever is
greater.

Contd.

Treatment of Bipolar Mood Disorder:

Treatment of Acute Manic Episode:
Mood stabilizers: Sodium Valproate, Lithium Carbonate,
Carbamazepine, Oxcarbazepine etc.
Atypical Antipsychotics
Benzodiazepines (Clonazepam and Lorazepam)

Treatment of Acute Depressive Episode:

Antidepressants are recommended to be used only in combination
with mood stabilizers
Lamotrigine
Atypical antipsychotics

Contd.

Maintenance Treatment of Bipolar Disorder

Aim: Prevention of recurrent episodes (mania or depression)
Mood stabilizers (Sodium Valproate, Lithium, carbamazepine)
alone or in combination, are the most widely used agents in
the long-term treatment of patients who are bipolar.
Lamotrigine has prophylactic antidepressant and, potentially,
mood-stabilizing properties.
Atypical antipsychotics

Suicide prevention: Lithium

Treatment Resistant Depression

Failure to respond to adequate trials of two to four different
antidepressants (plus or minus ECT)
Seek answers to these questions:
Is the diagnosis correct?
Are the doses & duration appropriate?
Is patient compliant to medications?
Are there any maintaining factors?

Treatment options:
Continue monotherapy at maximum tolerable doses
Add psychotherapy
Change antidepressant
Consider augmentation: lithium/atypical antipsychotic/thyroid hormone/lamotrigine
Combine antidepressant from different classes
Electro-convulsive therapy

Non pharmacologic treatment

Although most studies indicate and most clinicians and
researchers believe that a combination of psychotherapy and
pharmacotherapy is the most effective treatment for major
depressive disorder
Interpersonal therapy (Gerald Klerman)
Cognitive therapy (Aaron Beck)
Family therapy

Non pharmacologic treatment: Bipolar Disorder

Interpersonal & social rhythm therapy:
To reduce mood lability maintain regular pattern of daily activities
Evidence suggest improved long term outcome

Cognitive behavior therapy:

Educate about bipolar disorder & treatment
Teach skills: cope with stressors
Facilitate compliance with treatment

Family therapy
Psycho-education of patient & family members: accepting reality of illness, identifying
precipitating stresses

Support Groups
Patient may benefit from hearing the experiences of others, struggling with similar issues

Changes in DSM-V
Among Bipolar Disorder the diagnosis of Mixed episode
is replaced by a new specifier with mixed features.
A new diagnosis of Disruptive Mood Dysregulation
Disorder has been added in DSM-V to avoid
overdiagnosis and overtreatment of bipolar disorder in
children. These children present with persistent
irritability.
Major depressive episode presenting with additional
manic symptoms (which dont fulfill the criteria of manic
episode) is represented with a specifier with mixed
features

Take Home Message

Types of Mood disorders
Approach to a patient with mood disorders
History/ MSE; signs/symptoms (Diagnosis)

Differential diagnoses
Management of Mood disorders
Investigations
Hospitalization
Pharmacologic treatment
Non pharmacologic treatment