Mood Disorders

Introduction Mood disorders sometimes known as affective disorders are a major public health problem in the United States. Data indicate that mood disorders are leading cause of disease burden, morbidty and mortality worldwide. Theses illnesses involve changes in all areas including physiology, cognition and behavior. In addition to the effects of mood disorders have on individual and family suffering, interpersonal relationships, career and work productivity, and societal and health system costs, these illnesses are also sometimes fatal: 15% of those afflicted commit suicide. Depression is also linked to morbidity and mortality when it is associated with other illnesses such as cardiovascular disease. As a result of these serious consequences, there has been ongoing research about the etiology, clinical course and outcomes and treatment modalities for mood disorders. HISTORICAL PERSPECTIVES

Many ancient cultures (e.g. Babylonian, Egyptian, and Hebrew) believed in the supernatural or divine origin of depression and mania. The Old Testaments states in the Book of Samuel that King Saul's depression was inflicted by an evil spirit sent from the God to torment him. Greek medical community form the 5th century B.C. thorough 3rd century AD had nondivine point of view regarding depressive and manic states. This represented the thinking of Hippocrates, Celsus and Galen and among others. They strongly rejected the idea of divine origin and considered the brain as the seat of all emotional states. Hippocrates believed that melancholia was caused by an excess of black bile, a heavily toxic substance produced in the spleen or intestine, which affected the brain. During the Renaissance, several new theories evolved. Depression was viewed by some as being the result of obstruction of vital air circulation, excessive brooding or helpless situations beyond the individual's control. These strong emotions of depression and mania were reflected in major literary works of the time, including Shakespeare's King Lear, Macbeth and Hamlet. In the 4th and 5th centuries BC ,the term melancholia was used by ancient Greeks to describe the dark mood of depression. Hippocrates used the term melancholia to describe depression and, mania to describe the mental disturbances in clients. During the second century AD, Arteaeus of Cappadocia described cyclothymia as a form of mental with alternating periods of depression and mania. For centuries ,melancholia and cyclothymia were regarded to be separate disease entities rather than diverse expression of mood disorders. In 1854 ,Jules Faret described a condition called folie circulaire, in which patients experience alternating moods of depression and mania. By 1880, four categories of mood disorders existed: mania, melancholia, monomania, and dipsomania. In 1882 ,a German psychiatrist, Karl Kahlbaum described melancholia and mania as a continuum of the same illness.

In 1889, Emil Kraepelin, reinforced Kahlbaum's theory about the continuum of depression. He introduced the category of manic depressive psychosis, citing the most of the criteria now used to establish the diagnosis of bipolar I disorder. He also introduced the category of involutional melancholia, now viewed as a mood disorder that that occurs in late adulthood. In the 19th century ,the definition of mania was narrowed down from the concept of total madness to that of a disorder of affect and action. The old notion of melancholia was refurnished with meaning and emphasis was placed on the primary affective nature of the disorder. Events Early chronicles describe Nebuchadnezzar as suffering from wild erratic mood (probably mania) followed by profound depression. Hippocrates related depression to the humidity of the brain. His theory of body substances ,called humors determined physical and mental health. Depression was blamed on a surplus of melancholy (black bile) Attitude about hope changed with the spread of Christianity when St.Paul declared that hope stands with love. During the Elizabethan period ,people prided themselves on being melancholic and and came to view it as a superior malady and mark of refinement among those deeply touched by the paths in life. The writings of Shakespeare and Robert Burton included depressive themes. Dostoyevsky ,Poe and Hawthorne expressed inner anguish despair in the writings. Later poets such as Shelley accepted the fatalistic cynical view of the Greeks. Nietzsche wrote ,Hope is the worst of evils ,for it prolongs the torment of man. Winston Churchill, by frequent referral to his " black dog " of depression ,suggested how familiar a companion his despair was. ECT was introduced in Rome by two physicians who observed that epileptic client showed no evidence of schizophrenia. Thinking that seizures prevented schizophrenia, they promoted the use of artificially induced seizures to treat schizophrenia and depression. Introduction of the first clinically effective antidepressant ,imipramine and MAOIs An age of depression exists ,generated by the rising expectations for standards of living after world war II, coming up against the harsh realities of the population explosion, limited resources, inflation, unemployment and the possibility of nuclear warfare. The anxieties of the mid 1960s have given way to despair as a dominant mood. Suicide is a major health problem in U.S. The antidepressant Prozac shows promise in treating depression without having the side effects associated with other antidepressants. The decade of the brain emerges with an emphasis on biological causes of depression such as disruption in the circadian rhythm, brain dysfunction and the role of genetics.

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The stigma of depression and mental illness may diminish as biological causes are emphasized and replace the psychological causes of depression. Nurses are challenged to contribute to the expanding knowledge of the biological aspects of the mental illness by the collaborative research with other discipline. EPIDEMIOLOGY Major depression is one of the leading causes of disability in the United States. It affects almost 10 percent of the population, or 19million Americans, in a given year. During their lifetimes ,10 to 25 percent of women and 5 to 12 percent of men will become clinically depressed. This preponderance has led to the consideration of depression by some researchers as "the common cold of psychiatric disorders" and this generation as an age of melancholia". Bipolar affective disorder affects approximately 2.3 million American adults, or about 1.2 percent of the U.S population age 18 and older in a given year (National Institute of Mental Health, 2001). Gender Data from the National Comorbidity Survey Replication suggest that the lifetime prevalence of developing major depressive disorder is 16.2%, with twice as many women developing the disorder. The lifetime prevalence of bipolar disorder is about equal for men and women, 1.4% and 1.3%, respectively. Women have a life time prevalence of 21.3% for major depression and 8% for dysthymia, whereas men have a prevalence of only 12.7% for major depression and 4.8% for dysthymia. The incidence of bipolar disorder is roughly equal, with a ratio of women to men of 1.2 to 1. Age Several studies have shown that the incidence of depression is higher in young women and has a tendency to decrease with age. The opposite has been found in men , with the prevalence of depressive symptoms being lower in younger men and increasing with age. The average age at onset for a for a first manic episode is the early twenties. The first episode of a mood disorder seems to be occurring at younger ages. The average age for onset of bipolar illness is the mid to late twenties although children and teenagers are now being diagnosed. Although the average age of onset for unipolar depression has been the middle 30s ,there is some evidence that onset is occurring in younger individuals. The most frequent age of onset for depression is between 25 to 44years.Data indicate that when the onset of depression is at an early age (teens or early 20s) or at 55years or over ,it is usually more prolonged and chronic. Persons presenting with depression that is diagnosed in their early 20s or 30s often report not having depression in their early years. Rates of depression do not significantly increase during menopause. The risk of developing depression and mania increases if there is positive family history for mood disorders. Sociocultural factors

Results of studies have indicated an inverse relationship between social class and report of depressive symptoms. Bipolar disorder appears to occur more frequently among the higher socioeconomic classes. Race and culture Depression seem to occur less frequently in African Americans than in either white or Hispanic groups in U.S. Although depression and mania occurs through out the world ,ethnicity and culture influences the expression of symptoms. For example , Asians describe more somatic symptoms of depression ,whereas people from Western cultures describe more mood and cognitive changes. In an increasingly stressful society characterized by mobility, family disruptions and economic stressors ,women and younger persons are manifesting depression more than in previous generations. Persons with depression often seeks help from their primary care providers for physical symptoms such as fatigue , insomnia, headache and loss of appetite. Research indicates that primary care providers do not always correctly diagnose depression or treat it appropriately. Marital status The highest incidence of depressive symptoms has been indicated in individuals without close interpersonal relationships and in persons who are divorced or separated. When gender and marital status are considered together, the differences reveal lowest rates of depressive symptoms among married men , and the highest among married women and single men. Seasonality Many studies revealed two prevalent periods of seasonal involvement: one in spring (March, April and May) and one in the fall(September, October and November). This pattern tends to parallel the seasonal patterns for suicide, which shows a large peak in the spring and a smaller one in October. TYPES OF MOOD DISORDERS The DSM IV TR Classification The DSM IV TR describes the essential features of theses disorders as a disturbance of mood, characterized by full or partial manic or depressive syndrome that cannot be attributed to another mental disorder. Mood disorders are classified into under two major categories :depressive disorder and bipolar disorders. DEPRESSIVE DISORDERS Major depressive disorder

This disorder is characterized by depressed mood or loss of interest or pleasure in usual activities. Evidence will show impaired social and occupational functioning that has existed for at least two weeks ,no history of manic behavior ,and symptoms that cannot be attributed to use of substances or a general medical condition. Major depressive disorder may be further classified as follows : 1. Single episodic or recurrent : a single episode specifier is used for an individual's first diagnosis of depression. Recurrent is specified when the history reveals two or more episodes of depression. 2. Mild, moderate or severe: These categories are identified by the number and severity of symptoms. 3. With psychotic features : the impairment of reality testing is evident . the individual experiences delusions or hallucinations. 4. With catatonic features : this category identifies the presence of psychomotor disturbances such as severe psychomotor retardation ,with or without the presence of waxy flexibility or stupor or excessive motor activity. The individual may also manifest symptoms of negativism, mutism, echolalia or echopraxia. 5. With melancholic features : this is a typically severe form of major depressive episode. Symptoms are exaggerated. Even temporary reactivity to usually pleasurable stimuli is absent. History reveals a good respose to antidepressant or other somatic therapy. 6. Chronic: this classification applies when the current episode of depressed mood has been evident continuously for at least the pat two years. 7. With seasonal patterns: this diagnosis indicates the presence of depressive symptoms during the fall or winter month. This diagnosis is made when the number of seasonal depressive episode is substantially higher than the number of nonseasonal depressive episodes that have occurred over the individuals lifetime. 8. With postpartum onset : this specifier is used when symptoms of major depression occur within 4weeks of postpartum. DYSTHYMIC DISORDER: Individuals with dysthymic disorder describe the mood as sad or "down in the dumps". There is no evidence of psychotic symptoms. The essential feature is a chronically depressed mood for most of the day, more days than not ,for at least 2 years . It is classified into: 1. Early onset : identifies cases of dysthymic disorder when the onset occurs before age 21 years

2. Late onset : identifies cases of dysthymic disorder when the onset occurs at age 21 years or older. Premenstrual dysphoric disorder The DSM IV TR does not include premenstrual dysphoric disorder as an official diagnostic category ,but provides a set of research criteria to promote further study of the disorder. The essential feature include markedly depressed mood ,marked anxiety ,mood swings and decreased interest in activities during the week prior to menses and subsiding shortly after the onset of menstruation. BIPOLAR DISORDERS The bipolar disorder is characterized by mood swings from profound depression to extreme euphoria with intervening periods of normalcy. Delusions or hallucinations may or may not be part of the clinical picture and onset of symptoms may reflect a seasonal pattern. Bipolar I disorder it is diagnosis given to an individual who is experiencing or has experienced ,a full syndrome of manic and mixed symptoms. The client also may have experienced episodes of depression. Bipolar II disorders This diagnostic category is characterized by recurrent bouts of major depression with episodic occurrence of hypomania. The client has never experienced an episode that meets the full criteria for mania or mixed symptomatology. Cyclothymic disorder The essential feature of cyclothymic disorder is a chronic mood disorder is a chronic mood disturbance of at least 2years duration involving numerous episodes of hypomania and depressed mood of insufficient severity or duration to meet the criteria for either bipolar I or II disorder. OTHER MOOD DISORDERS Mood disorders due to a general medical condition This disorder is characterized by a prominent and persistent disturbance in mood that is judged to be the result of direct physiological effects of a general of a general medical condition. The mood disturbance may involve depression or elevated ,expansive or irritable mood and causes clinically significant distress or impairment in social ,occupational or other important areas of functioning. Substance induced mood disorders

The disturbance of mood associated with this disorder is considered to be the direct result of physiological effects of a substance. The mood disturbance may involve depression or elevated ,expansive or irritable mood and cause clinically significant distress or impairment in social ,occupational or other areas of functioning. ICD 10 classification of mood disorders The mood disorders are classified as follows : 1. manic episode 2. depressive episode 3. bipolar mood disorders 4. recurrent depressive disorders 5. persistent mood disorders( including cyclothymia and dysthymia). 6. other mood disorders (including mixed affective episode and recurrent brief depressive disorders ) Conclusion: Depression is also linked to morbidity and mortality when it is associated with other illnesses such as cardiovascular disease. As a result of these serious consequences, there has been ongoing research about the etiology, clinical course and outcomes and treatment modalities for mood disorders. References : 1. Carson V B. Mental Health Nursing :The Nurse Patient Journet.2nd ed.Philadelphia : W.B. Suanders Company;2000 2. Fortinash KM, Worret PA .Psychiatric Mental Health Nursing.4th ed. Philadelphia : W.B. Suanders Company;2008 3. Shives LR .Basic Concepts of Psychiatric -Mental Health Nursing.7th ed.Philadelphia : Lippincott publications; 2008 4. Sreevani R. A Guide to Mental Health and Psychiatric Nursing. New Delhi:Jaypee Medical Publications ;2004. 5. Mary TC. Psychiatric Mental Health Nursing -Concept of Care 3rd ed. Philadelphia :F.A. Davis Publishers ;2002 6. Ahuja N .A Short Text Book of Psychiatry 5th ed. New Delhi: Jayee Medical Brothers Publishers .2002. 7. Kaplan HI, Sadock BJ. Synopsis of Psychiatry , Behavioral Sciences/ Clinical Psychiatry .9th ed. Hong Kong :William and Wilkinson Publishers ;1998.

8. Sadock BJ ,Sadock VA. Synopsis of psychiatry :Behavioral Sciences/ Clinical Psychiatry.10th ed. Philadelphia :William and Wilkinson Publishers;2007.