MOOD DI S OR DERS - I

BY: NATNAEL HABTAMU, C 2 U N DE RGRA D

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Outline
Introduction
Epidemiology in Ethiopia
History
Etiology
Diagnosis
o Course Specifiers
o Differential Diagnosis
o Investigations
Prognostic Factors
Management Principles

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Classification of Mood Disorders
Depressive • Major Depressive Disorder
(Unipolar) • Dysthymic Disorder

• Bipolar I
Bipolar • Bipolar II
• Cyclothymic Disorder
• Substance Induced mood Disorder
Etiologic • Mood disorder due to general Medical
condition

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 Major Depressive Disorder
Lifetime prevalence 5-17% (~12%) vs 1% of Bipolar illness
Female to male ratio is 2:1
• Hormonal, childbirth, differing psychosocial stressors for
women and men…etc

The incidence rate is greatest between age 20-50 yrs

(mean – 40)
• Vs mean age 30 yrs of Bipolar I
• Suspected to be due to increased use of alcohol and drug abuse
in the young

Higher incidence in those

• W/out close interpersonal r/ships, divorced, separated
• From rural areas

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 Major Depressive Disorder
Lifetime prevalence 5-17% (~12%) vs 1% of Bipolar illness
Major cause of
Female to male ratio is 2:1 disability and suicide
• Hormonal, childbirth, differing psychosocial stressors for American Medical
women and men…etc Association
researchers found
The incidence rate is greatest between age 20-50 yrs that 27% of MEDICAL
(mean – 40) STUDENTS had
• Vs mean age 30 yrs of Bipolar I depression or
• Suspected to be due to increased use of alcohol and drug abuse symptoms of it, and
in the young 11% REPORTED
SUICIDAL thoughts
Higher incidence in those
during medical
• W/out close interpersonal r/ships, divorced, separated
school!
• From rural areas

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 MDD: Epidemiology in Ethiopia
Prevalence in Ethiopia
 9.1% (only 22% sought treatment) [Hailemariam, 2012]
 6.8% - 11% [Bitew, 2014]

Risk factors: [Bitew, 2014]

 Sociodemographic (highest among pregnant women &
college students in Hawasa)
 Intimate partner violence

Hamar Tribe young pregnant woman

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 MDD: Importance
It affects many people
It increases risk of premature death (twofold increase in suicide)
It’s costly due
◦ Lost productivity
◦ Family cost
◦ Expenses related to treatment

It interacts negatively with physical disease

◦ TB, HIV, CA, HTN, Diabetes, MI

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 MDD: History
Old Testament story of King Saul
Story of Ajax’s suicide in Homer’s Iliad (Greek Mythology)
Hippocrrates  Mania & Molancholia to describe mental
disturbances
Roman Physician Celsus  “De re medicina”
• Depression Caused by black bile

Robert Burton’s Anatomy of Melancholy

Kraepelin  described a depression that came to be known as
involutional melancholia

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 MDD: Etiology
1. Biological Factors
o Abnormalities in Amine Neurotransmitters
o Neuroendocrine abnormalities in hypothalamic
pituitary adrenal (HPA) axis.
o Genetic Factors:
• More common in monozygotic twins.
• Unipolar depressions in a parent

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 MDD: Etiology
2. Psychological Factors
o Major life events (Death of loved ones, repeatedly unemployed, Guilt)
o Interpersonal relations, absent or unsatisfactory significant special bonds have
negative effect on self regards
o Distorted thinking
• E.g. Tendency to experience the world as hostile and demanding, Expectation of suffering and
failure.

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 MDD: Diagnosis
Criteria For Major Depressive Episode : 5 or More Of The Following For At Least 2 Weeks

Depressed
1 Anhedonia 2 Guilt 3
Mood
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 MDD: Diagnosis
Criteria For Major Depressive Episode : 5 or More Of The Following For At Least 2 Weeks

Sleep Sleep
4 4 Energy 5
Disturbance Disturbance

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 MDD: Diagnosis
Criteria For Major Depressive Episode : 5 or More Of The Following For At Least 2 Weeks

Appetite 6 Appetite 6 Psychomotor 7

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 MDD: Diagnosis
Criteria For Major Depressive Episode : 5 or More Of The Following For At Least 2 Weeks

Concentration Suicidality
8 9

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 MDD: Diagnosis
Additional Components of the criteria
Atleast one of the symptoms is either “1” or “2”
The symptoms cause clinically significant distress or impairment in social, occupational, or other
important areas of functioning.
The episode is not attributable to the physiological effects of a substance or to another medical
condition.
The occurrence of the major depressive episode is not better explained by schizoaffective disorder,
schizophrenia, schizophreniform disorder, delusional disorder, or other specified and unspecified
schizophrenia spectrum and other psychotic disorders.
There has never been a manic episode or a hypomanic episode.

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MDD: Diagnosis  Course Specifiers

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MDD: Diagnosis  Course Specifiers
Other Specifiers
o With psychotic
features
o With melancholic
features
o With Atypical
Features
o With catatonia
o With Seasonal
pattern…..etc

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 MDD – Differential Diagnosis
1. Bio
o Endocrine Disorders: Addison’s Disease, Cushing’s disease, Hyper/Hypothroidism…
o Metabolic Disorders: Hypoglycemia, Hypercalcemia
o Infections: Syphilis, Lyme Disease, HIV encephalopathy
o Inflammatory Conditions: SLE
o Medication Related: Antihypertensives, Steroids
2. Psycho Social
o Bearevement
o Anxiety Disorder
o Schizophrenia and Schizoaffective disorder
o Sleep Disorders
o Substance Misuse

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 MDD - Investigations
There are No specific tests
Investigation – for exclusion of treatable causes
or other secondary problems Standard Tests Focused Tests
• CBC • Toxicology
• ESR • Blood/Breath
• LFT Alcohol
• RBS • Thyroid
• TFT Antibodies
• Ca level • Syphilis
Serology

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MDD: Prognostic factors

Mild episodes Moderate to severe Episodes

Short hospital stay Coexisting dysthymic disorder
No more than 1 previous Substance Abuse
hospitalization for MDD Anxiety disorder symptoms
History of solid friendship at Psychotic symptoms
adolescence
Men?
Stable family & social functioning
for 5 yrs preceding the illness
Advanced age of onset

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 Management
PRINCIPLES OF MANAGEMENT HOSPITALIZATION: IF THERE IS

• Guarantying patient’s safety • Serious risk of suicide

• Complete Diagnostic evaluation of the patient • Serious risk of harm to others
• Treatment plan for immediate (acute) symptoms • Significant self-neglect
and maintenance. • Severe:
• Pharmacotherapy • Depressive or Psychotic symptoms
• Psychotherapy
• Lack of breakdown of social supports
• Cognitive behavioral therapy
• Interpersonal Therapy
• Need for diagnostic procedures
• Other options: ECT • Need to address comorbid conditions
• Initiation of ECT
• Treatment resistant depression.

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References
Bitew T., Prevalence and Risk factors of depression in Ethiopia, 2014
Haileselase H. Impact o Major Depressive Disorder in Ethiopia, 2012
Kaplan Sadock’s Synopsis of Psychiatry: Behaviroal sciences/Clinical Psychiatry eleventh edition,
2015

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THANK YOU!!!

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