Mood Disorders, Types and Complete Treatment

depressed-young-girl

Mood disorders re characterized by mania and depression. They may either be seen as separate entities or in combination called as bipolar disorder. Severely elated mood is called as mania and severely sad or dejected mood is termed as depression. Bipolar disorder or manic-depressive psychosis is characterized by repealed bouts of mania and depression either within short or long depression of times.

MANIA

The cardinal feature of mania is highly elated mood. There is a flight of ideas and psychomotor acceleration. When the mood is high but may not be significantly disturbing it is termed as hypomania. It is called mania only when it reaches its acme.

Distinctions like the above are very confusing and depend on the clinical acumen of the clinician that is always open to error. These patients are also known to lose contact with reality and then behavior may not be in total control.

 Extreme restlessness, talking incessantly and interrupting others repeatedly is also noted. These patients make a nuisance of themselves thought at times they manage to control their behavior and protest that nothing is wrong with them.

 Activity at times is so great that there may be a refusal to eat, relax and sleep. Ambitious plans of business, travel and living well are made but at closer scrutiny it can be envisaged that these plans are mere castles built in the air.

Other features include a pressure of speech, jumping from one topic to the other and a flight of ideas. There is accelerated thinking, clang association and rhyming of words seen. There may be punning and playing with the words.

Distractibility, incoherence, grandiose ideas and even delusions of grandeur or expensive thinking may be seen. It is often hard to control these individuals and make them relax.

Insomnia, indefatigability, increased libido and restlessness are always present.

DEPRESSION

The cardinal features of depression are persistent pervasive depressed mood, poverty of ideas and psychomotor retardation.

The depth of depression varies at all times and is easily affected by the surroundings and situations. Suicide and suicidal attempts are also known to occur. Guilt and self blame underlie these suicidal attempts with a need of self punishment and the suicide may be an escape from misery.

Self pity, feeling of hopelessness and helplessness are common. Loss of energy, easy fatigue, loss of libido, insomnia along with loss of weight and appetite are commonly seen.

Sometimes there may be hypochondriacal symptoms related to a particular organ or organ system seen.

BIPOLAR DISORDERS

                Patients from bipolar disorder suffer from swings of both mania depressions. Some patients suffer only from depression that usually precedes the mania and thus episodes of mania do not occur on their own although depression can occur alone. There are two types of bipolar disorder viz. Bipolar I where there is full blown mania and depression that occurs in phases and Bipolar II where there is a depression predominantly with a few spells of hypomania. There is a type of bipolar disorder called as rapid cycling bipolar with changes from mania to depression and vice-versa occurring in days or weeks and more than 4 such cycles occur in a year.

ENDOGENOUS DEPRESSION

It is a variety of depression where there are internal biological factors as a cause and these are unaffected by the environment. The main features are-

 Early morning insomnia.

Loss of appetite and at times hyperhagia.

Loss of weight or weight gain.

Diurnal mood variation – feels worse in the morning and better as the day progresses.

Loss of libido or sometimes hyper sexuality.

These patients generally respond well to ECT.

REACTIVE DEPRESSION

In contrast to endogenous depression, reactive depression is due to an external environmental cause, psychosocial stressors and the patient’s ability to cope with them. The patient and his personality traits are important in the causation.

GRIEF OR BEREAVEMENT

After the loss of a loved one, object or position there is a period of depression that occurs called as grief. This occurs in every individual the period of which it lasts is called as bereavement. In addition to depression, feelings of anger, guilt, irritability and somatic symptoms are common. The condition is self limiting and usually reduces in a mouth and tends to be better in three months. At times the condition may prolong in a minor or major form till the first anniversary and may then disappear. At times it may resurface at the first anniversary called as an anniversary reaction.

AGITATED DEPRESSION

This is characterized by restlessness, together with grumbling and mumbling. The patient cannot be made to sit still. The patients keep pacing the floor and if prevented tend to get violent.

MASKED DEPRESSION

                These patients present with predominantly body symptoms and most commonly pain in the face, neck, head and abdomen. The characteristic feature is the patient vehemently denies the depression and only discusses the offending symptom. As a result a general deterioration occurs in social, occupational and emotional interaction and functioning in adults. Sleep, appetite and bowel habits may be disturbed. There may be lost of interest in all activities and studies. Malnutrition and failure to thrive are also been seen. In infants this may be seen due to deprivation of maternal love and has been termed as Analytical Depression. Delinquent behavior in adolescence with a tendency to abuse alcohol and drugs along with antisocial activities and sexual promiscuity has also been noted in masked depression.

ATYPICAL DEPRESSION

The symptoms usually seen in depression here are not seen though from the history it is clear that the patient in the case of depression. Physical symptoms like an inability to use the lower limbs and the feeling of being paralyzed or leaden are seen. The symptoms are bodily like masked depression though her patient agrees that he is depressed. Hyperhagia and weight gain are common.

EPIDEMIOLOGY

The prevalence of depression is 5-10% with women affected more than men.

The prevalence of bipolar disorder is 1-3%.

 Genetic studies have revealed the concordance rate of 79% for monozygotic and 19% in dizygotic twins in bipolar while the figures for depression are 54% and 24% respectively.

An autosomal dominant inheritance has been proposed though the case may be polygenic.

ETIOLOGY

Biological factors- dysregulation of the serotonergic and adrenergic neurons are seen in depression. The structures implicated are the locus ceruleus, basal ganglia, temporal lobe and the limbic structures. Increased intracellular sodium in both in mania and depression are noted. Deficiency of both indolamines and catecholamines has been proposed as a cause for depression.

Endocrinal factors- decreased TSH and growth hormone along with a hyper secretion of cortisol is seen. A positive Dexamathasone suppression test has been reported to have an association with depression.

Organic factors- depression has been closely linked to medical conditions like hypothyroidism, anemias, viral infections, disseminated sclerosis, Parkinsonism, cerebral tumors and neurosphilis. Drugs like reserpine, methyl dopa, levodopa and steroids may also caused depression.

Psychological factors- internalization of a lost object and feeling of guilt and ambivalence has been proposed as the main cause of depression by Sigmund Freud. Maternal deprivation and loss of parental care and nurture is also a leading cause of depression. Repeated loses and a tendency of learned helplessness is another cause. Loss of self esteem and a failure to achieve goals set in life play a role. Socio-economics handicaps along with stressful events without dreams of better days ahead have been blamed as major factor.

MANAGEMENT

PHARMACOTHERAPY FOR DEPRESSION

Tricyclic antidepressants are the older drugs and are still used frequently in the treatment of depression. A combination of imipramine 10-25 mg TDS along with Amitryptiline 25-75 mg HS serves as good combination. Nortryptiline or trimipramine may be tried if the above combination does not give a response in full course of 6 weeks. The disadvantage of this therapy is that the takes around 3 weeks and there are a lot of anticholinergic side effects of these antidepressants like dry mouth and constipation that shape up in this period.

Tetracyclic antidepressants like Meanserin may be used in mild depression as they cause fewer side effects but have a less therapeutic value.

Trazadone, Doxepin, Dotheipin are the other drugs belonging to the first generation or the older group. They have their role to play and are more useful in neurotic depression and also have a strong anxiolytic effect.

Selective Serotonin Reuptake Inhibitors (SSRIs) have been used widely are now becoming the first line drugs for depression. Sertraline in doses of 50-100 mg TDS and Flouxetine 20-60 mg OD are used. Tianeptine which has a similar method of action is also used in doses of 12.5 mg TDS.

PHARMACOTHERAPY OF BIPOLAR DISORDERS

Lithium is the main stay of treatment with bipolar disorders. Starting with doses of 150 mg TDS and gradually increasing in the rule. The serum Lithium levels must be done ideally twice a month initially and once a month to make sure that the therapeutic levels of 0.8-1.2 meq/L are reached. Lithium is the ideal drug though in acute mania tranquillizers may be preferred.

 In case of intolerance of Lithium, Carbamezapine 200-400 mg TDS and Sodium Valporate may be used as alternatives. There a nowadays sustained released preparation of the all the above three drugs that can be tried for better results.

 Chloropromazine may be tried for management of the excitement mania in doses of 50-200 mg a day. Haloperidol 5-10 mg given IM at regular intervals may serve to curb the excitement along with Promethazine 50 mg IM.

 Newer antiepileptic and the newer atypical antipsychotics have been implicated in the treatment of bipolar disorders. These are the latest drugs like Lamotrigine, Gabapentin, Topiramate, Olanzapine and Respiridone.

Dietary alteration to increase inositol and Choline are also being tried.

OTHER THERAPIES FOR MOOD DISORDERS

 Sleep Derivation- is being tried for depression.

Electroconvulsive Therapy- must be used in depressives who are suicidal and refuses to eat. It also has a role in mania especially if the excitements not coming under control. Around 8-10 treatments may be given.

Psychotherapy- supportive and insight oriented psychotherapy along with interpersonal psychotherapy is useful.

Cognitive Therapy- restructuring the way of thinking and perception of others, the self and the environment plays a vital role in cure. A form of therapy called rational emotive therapies useful here.

Family therapy.

Trancranial Magnetic stimulation along with Vagus nerve stimulation is being tried for depression.

Credits for photograph flickr

This article has been written by Dr. Md Ali Rabbani