Mood Disorders | Medical Science Optional Notes for UPSC PDF Download

Mood Disorders

Mood disorders are categorized into:

1. Depressive disorders
2. Bipolar disorders
3. Depression associated with medical conditions such as alcohol and substance abuse or medical illness.
   a) Medications - Including antihypertensives, hypolipidemic drugs, and antiarrhythmic agents.
   b) Among cardiac patients.
   c) In cases of cancer.
   d) Associated with neurological disorders.
   e) Related to diabetes.
   f) Linked to hypothyroidism.

Major Depressive Disorders

Criteria for Major depressive disorder (DSM-V)

A. To diagnose unipolar depression, five or more of the following symptoms must be present during the same two-week period, reflecting a change from the individual's previous functioning. At least one of the symptoms must be either (1) depressed mood or (2) loss of interest or pleasure:

1. Persistent depressed mood for most of the day, nearly every day, evidenced by subjective feelings (e.g., sadness, emptiness, hopelessness) or observations made by others (e.g., appearing tearful).
2. Marked reduction in interest or pleasure in almost all activities throughout most of the day, nearly every day, as reported subjectively or observed.
3. Significant weight loss or weight gain (e.g., >5% change in body weight within a month) or changes in appetite nearly every day.
4. Insomnia or hypersomnia nearly every day.
5. Psychomotor agitation or retardation nearly every day, observable by others, not just subjective restlessness or slowed down feelings.
6. Fatigue or loss of energy nearly every day.
7. Persistent feelings of worthlessness or excessive/inappropriate guilt, occurring nearly every day (may be delusional, not just self-reproach or guilt about illness).
8. Diminished ability to think, concentrate, or make decisions, occurring nearly every day (subjectively or observed by others).
9. Recurrent thoughts of death, suicidal ideation without a specific plan, suicide attempt, or a specific plan for suicide.

B. These symptoms must cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.
C. The episode cannot be attributed to the physiologic effects of a substance or another medical condition.
D. The major depressive episode's occurrence is not better explained by seasonal affective disorder, schizophrenia, schizophreniform disorder, delusional disorder, or other specified and unspecified schizophrenia spectrum and other psychotic disorders.
E. There has never been a manic or hypomanic episode, indicating unipolar depression.

Mnemonic for Major Depressive Disorder Presentation: 

"SIG E CAPS"
Sleep (insomnia or hypersomnia)
Interest loss (anhedonia)
Guilt (low self-esteem)
Energy (low energy or fatigue)
Concentration (poor concentration or difficulty making decisions)
Appetite (decreased appetite or overeating)
Psychomotor agitation or retardation
Suicidality

Etiopathogenesis

• While the evidence for the genetic transmission of unipolar depression is not as robust as in bipolar disorder, monozygotic twins exhibit a higher concordance rate (46%) compared to dizygotic siblings (20%).
• Neuroendocrine abnormalities reflecting the neurovegetative signs and symptoms of depression include elevated cortisol and corticotropin-releasing hormone (CRH) secretion, reduced inhibitory response of glucocorticoids to dexamethasone, and a diminished thyroid-stimulating hormone (TSH) level response to thyroid-releasing hormone (TRH) infusion.
• Antidepressant treatment results in the normalization of these abnormalities.
• Diurnal variations in symptom severity and disruptions in the circadian rhythmicity of several neurochemical and neurohumoral factors suggest that biological differences may stem from a primary defect in the regulation of biological rhythms.
• Individuals with major depression consistently display findings such as a decrease in rapid eye movement (REM) sleep onset (REM latency), an increase in REM density, and, in some cases, a reduction in stage IV delta slow-wave sleep.

Depression is roughly twice as prevalent in women compared to men, and its frequency tends to rise with age in both genders. When a physician suspects the presence of a major depressive episode, the initial challenge is to determine whether it represents unipolar or bipolar depression or falls within the 10-15% of cases linked to general medical illness or substance abuse.

Physicians should also evaluate the risk of suicide through direct questioning, as patients may be hesitant to express such thoughts without prompting. If specific plans are revealed or significant risk factors are identified (such as a history of suicide attempts, profound hopelessness, concurrent medical conditions, substance abuse, or social isolation), immediate referral to a mental health specialist is crucial.

Approximately 4-5% of all depressed patients ultimately commit suicide, with many having sought assistance from physicians within one month of their deaths.

Dysthymic disorder

Persistent Depressive Disorder, also known as dysthymic disorder, encompasses a pattern of chronic (lasting at least 2 years) and continuous depressive symptoms. These symptoms are typically less severe or less numerous than those observed in major depression. However, the functional consequences may be equivalent to or even more significant. Distinguishing between the two conditions can be challenging, and they may co-occur, a phenomenon referred to as "double depression."

Subtypes

Depression with seasonal pattern (seasonal affective disorder, winter depression):
Manifests annually during the fall and winter seasons, individuals experiencing this condition endure the typical symptoms of Major Depressive Disorder (MDD), coupled with atypical manifestations like weight gain and an increased need for sleep. Research has indicated that light therapy can effectively alleviate these symptoms.

Major depressive disorder with peripartum onset:
Depression that occurs during pregnancy or within the initial four weeks after delivery is referred to as perinatal depression. Since most antidepressants can cross the placenta, their use is generally discouraged unless the patient is dealing with severe or recurrent depression.
A differential diagnosis involves considering postpartum blues, which involves mild depressive symptoms that typically resolve spontaneously within two weeks after delivery.

Principles of Management

• While most drugs demonstrate comparable efficacy, they vary in terms of their side effects.
• It takes more than four weeks for the effects of these drugs to become noticeable.
• Initiate treatment with the lowest dose and increment gradually.
• For a single episode, maintain medication for over six months.
• In the case of multiple episodes, continue medication for at least two years.
• If the patient is in remission, sustain antidepressant use for a minimum of 4-9 months.
• Gradual tapering of medication over 6-8 weeks is recommended to prevent depression relapse and mitigate antidepressant discontinuation syndrome, which includes flu-like symptoms, nausea, insomnia, hyperarousal, and sensory disturbances.

Pharmacotherapy

First-line: Selective Serotonin Reuptake Inhibitors (SSRIs)

Other options:

• Serotonin-Norepinephrine Reuptake Inhibitors (SNRIs)
• Atypical antidepressants
• Bupropion: reduces seizure threshold, exhibits less sexual dysfunction compared to SSRIs, and is effective in treating tobacco dependence
• Mirtazapine: associated with significant weight gain
• Tricyclic Antidepressants (TCA) and Monoamine Oxidase Inhibitors (MAOIs): pose greater risks in overdose and are associated with more side effects than SSRIs.

Medical Management of Major Depressive Disorder Algorithm

Treatment-Resistant Depression: Consider switching to a different drug within the same class or opting for a different drug from a distinct class.

For suicidal patients, Lithium can be combined with an antidepressant as prophylaxis to prevent recurrence.

Psychotherapy:
Cognitive-Behavioral Therapy

• Interpersonal Therapy
• Psychodynamic Psychotherapy
• Family and Couples Therapy

Other Measures:

• Implement lifestyle changes (aerobic exercise, nutrition, sleep hygiene, social support, stress reduction)
• Light therapy
• Transcranial Magnetic Stimulation (rTMS)
• Vagal Nerve Stimulation (VNS)
• Electroconvulsive Therapy: Reserved for severe or refractory depression or psychotic depression.

Bipolar Disorders

Bipolar disorder is marked by unpredictable shifts in mood, alternating between episodes of mania (or hypomania) and depression. The DSM-V characterizes episodes of mania as follows:
A. A distinct period characterized by abnormally and persistently elevated, expansive, or irritable mood, coupled with increased goal-directed activity or energy. This period lasts for at least 1 week and is present most of the day, nearly every day, or any duration if hospitalization is necessary.
B. During the mood disturbance and heightened energy or activity, three (or more) of the following symptoms (four if the mood is only irritable) are significantly present, representing a noticeable change from usual behavior:

1. Inflated self-esteem or grandiosity.
2. Reduced need for sleep (e.g., feeling rested after only 3 hours of sleep).
3. Increased talkativeness or pressure to keep talking.
4. Flight of ideas or a subjective experience that thoughts are racing.
5. Distractibility (attention easily drawn to unimportant or irrelevant external stimuli), as reported or observed.
6. Increase in goal-directed activity (socially, at work or school, or sexually) or psychomotor agitation (purposeless non-goal-directed activity).
7. Excessive involvement in activities with a high potential for painful consequences (e.g., unrestrained buying sprees, sexual indiscretions, or imprudent business investments).

C. The mood disturbance is severe enough to cause marked impairment in social or occupational functioning, necessitate hospitalization to prevent harm to self or others, or exhibit psychotic features.
D. The episode is not attributable to the physiological effects of a substance (e.g., drug abuse, medication, or other treatment) or another medical condition.

Family studies indicate a genetic predisposition to bipolar disorder, with an approximate 80% concordance rate for monozygotic twins.

Numerous risk genes identified so far overlap with those associated with other psychiatric disorders, such as schizophrenia and autism, suggesting shared pathophysiology.

Replicated loci include the alpha subunit of the L-type calcium channel (CACNA1C), teneurin transmembrane protein 4 (ODZ4), ankyrin 3 (ANK3), neurocan (NCAN), and tetratricopeptide repeat and ankyrin repeat-containing 1 (TRANK1).

Managed by Mood Stabilizers

Lithium carbonate stands as the cornerstone of bipolar disorder treatment. However, sodium valproate and carbamazepine, along with several second-generation antipsychotic agents (aripiprazole, asenapine, olanzapine, quetiapine, risperidone, ziprasidone), also have FDA approval for treating acute mania.

Depressive Disorders - Repeats

1. A 45-year-old lady, after death of her husband 2 months back, is feeling lonely and remains alone. Enumerate the likely conditions. How will you diagnose and manage a major depressive disorder? (2013) 
2. Describe the etiopathogenesis, clinical features and management of Bipolar Disorder. Enumerate the side effects of commonly used anti-psychotic drugs. (2018) 
3. A young 23-year-old lady had attempted suicide thrice in last one year. What is the cause of her condition? How do you diagnose and manage Major Depressive Disorder? (2017)