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Mood Disorders
•! Definitions:
o! Mood disorders: emotional disturbance involving episodes of depression, mania, or both.
o! Depressive disorders: Sadness severe enough or prolonged enough to impair function.
o! Bipolar disorders: Episodes of mania and depression, which may alternate, although many
patients have a predominance of one or the other.
!! Mania is abnormal periods (≥1 week) of great excitement, euphoria, delusions, and
overactivity.
!! Hypomania a mild form of mania thar does not cause functional impairment.
!! Mixed episode is having both a manic episode and a major depressive episode nearly every day
for ≥ 1 week.
o! Dysthymia: mild depressive symptoms lasting for ≥ 2 years without remission.
o! Cyclothymic disorder: hypomania and dysthymia (≥ than half the days of ≥ 2 years).
•! Etiology:
Depressive Disorders Bipolar disorders
•! Genetics (40–50%, gene–environment interactions). •! Genetics (Gene–environment interactions).
•! Early life experience: Parental separation, neglect, •! Environment: High risk of mania post partum
physical or sexual abuse, and maternal postpartum in those with untreated bipolar affective
depression. disorder.
•! Personality traits and disorders: e.g. borderline and •! Neurobiology: Structural & functional
OCD. abnormalities (in hippocampus and amygdala).
•! Acute stress: Loss or humiliation events. Neurotransmitters: levels of monoamines "
•! Chronic stress: Chronic pain and any other chronic mania.
illness ( in heart disease and stroke).
•! Neurobiology Abnormal regulation of cholinergic,
noradrenergic, dopaminergic & serotonergic (5-HT)
neurotransmission + Neuroendocrine dysregulation.
•! Types:
o! Depressive disorders:
Major depression disorder (MDD).
Persistent depressive disorder (dysthymia).

Seasonal affective disorder (SAD) Associated with winter season.

Psychotic depression MDD accompanied by psychotic symptoms.

Postpartum depression Depression affects women after childbirth (within

4 weeks).
Premenstrual dysphoric Disorder (PMDD) Severe form of PMS.

'Situational' (Adjustment) depression Associated with stressors.

Atypical depression •! Hypersomnia, # appetite, leaden paralysis, mood

reactivity.
•! Most common subtype. Treatment of choice is
MAOi, SSRI.
o! Bipolar disorder:
!! Bipolar I: manic or mixed episodes.
!! Bipolar II: depressive episode with at least one episode of hypomania.
!! Bipolar III*: depressive episodes with hypomania only when on antidepressant.

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Conditions Core symptoms Biologic (Somatic) Cognitive Psychotic

symptoms symptoms symptoms
Depressive •! Depressed •! Early morning awakening, •! Guilt. •! Abnormal
episode mood. initial insomnia, and •! Hopelessness. beliefs
•! Anhedonia. frequent waking. •! Suicide or self- (delusions,
•! Anergia. %Slow-wave sleep harm. overvalued
ideas).
%REM latency •! Reduced
concentration & •! Perceptual
#REM early in sleep cycle memory disturbance
(common among (hallucination
#Total REM sleep s).
elderlies)
•! Psychomotor retardation or
•! Poor self-esteem.
agitation.
•! Loss of libido.
•! Depression worse in the
morning.
•! Marked change of appetite
& weight change.
Manic •! Elevated, •! Decreased need for sleep. •! High self-esteem •! Abnormal beliefs.
episode expansive, or •! Increased energy. or grandiosity. •! Perceptual
irritable mood. •! Poor disturbance.
•! Increased goal- concentration. •! Circumstantiality
directed •! Accelerated and tangentiality.
activity or thinking. •! Disordered
energy. •! Impaired thought form.
judgment and •! Flight of ideas.
insight (risk
taking).

•! Diagnosis:
o! Major depressive disorder (Clinical criteria (DSM-V):
!! Symptoms (≥ 2 weeks):
1.! At least one of: depressed mood and/or anhedonia.
2.! And some of these to total 5 symptoms or more:
•! Changes in appetite/weight. •! Agitation.
•! Altered sleep pattern •! Reduced self-esteem.
(increase or decrease). •! Suicidal thoughts.
•! Lack of energy.
•! Difficulty concentrating.
a)! Impairment in social, occupational or other important areas of functioning.
b)! Exclusion of medical conditions, medication, or drug abuse.
c)! CBC, electrolytes, and TSH, vitamin B12, and folate levels to rule out physical disorders.

o! Bipolar disorders (Clinical criteria (DSM-V):

!! Bipolar-I:
$! Current or recent major depressive episode.
$! At least one previous manic episode or mixed episode.
$! Exclusion of psychotic disorder.
!! Bipolar-II:
$! Current or recent major depressive episode.
$! At least one previous hypomanic episode.
$! No history of manic or mixed episode.
$! Exclusion of psychotic disorder.
$! Impairment in social, occupational or other important areas of functioning.
$! Current episode meets criteria for hypomania or depression.
o! CBC, electrolytes, and TSH, vitamin B12, and folate levels to rule out physical disorders.
o! Exclusion of stimulant drug abuse clinically or by urine testing.

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•! Management:
o! Assess the risk of suicide, homicide, and drug and alcohol abuse. In-patient admission is advised
o! Depressive disorder: when:
! Highly distressing psychosis.
!! Psychological treatment: ! Active suicidal ideation or
$! Cognitive-behavioral therapy (CBT). planning, especially with
history of precious attemptes.
$! Interpersonal therapy (IPT). ! The patient is catatonic
(leading to extreme self-
neglecting).
!
!! Plus Antidepressants if the depression is moderate or severe.
!! Electroconvulsive therapy considered in pregnant women, refractory to other medications,
catatonic patients, strong suicidal ideations, psychotic features or stupor.
$! Produce painless seizure in anesthetized patients.
$! SE: headache, partial amnesia (resolves in 6 months).
o! Bipolar disorder:
!! Treatment of acute mania or hypomania:
•! Discontinuation of antidepressants.
•! Benzodiazepines for short term.
o! MOA: binds to a regulatory site on the GABA receptor to augment
A

the inhibitory effect of GABA " reducing anxiety, sedation, and

muscle relaxation.
o! SE: dependence & prolonged alcohol hangover.
$! Antipsychotic medication (2 generation). *Please refer to Schizophrenia file.
nd

!! Treatment of acute depression (moderate-severe):

$! SSRIs are first line.
$! Benzodiazepines for short term.
!! Maintenance treatment (for prevention of relapse):
$! Mood stabilizers (Lithium, Valproate, Carbamazepine, and lamotrigine).

Antidepressants
Drug Indications MOA Side Effects Notes
Tricyclic Major depression, Block the reuptake Dry mouth Sudden withdrawal
antidepressants Bedwetting of serotonin and Constipation leads to malaise,
E.g.: (Imipramine), NE. Urinary retention chills, coryza and
Amitriptyline, OCD Blurred vision muscle aches.
lofepramine, (Clomipramine), Sexual dysfunction
Clomipramine, Fibromyalgia. Postural
Imipramine. hypotension,
Weight gain,
Cardiotoxicity QT
prolongation
Sedation.
Monoamine oxidase Atypical Nonselective MAO Dizziness, !! Interaction with
inhibitors depression, inhibition Insomnia, dietary tyramine.
E.g.: Anxiety, increases levels of Headaches, !! Contraindicated
Tranylcypromine, Hypochondriasis. amine Sedation, with CVD and
Phenelzine, neurotransmitters Hepatotoxicity. hepatic
Isocarboxazid, (NE, serotonin, impairment.
Selegiline. dopamine).

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Selective serotonin Depression, Selective serotonin GI distress !! First-line therapy
reuptake inhibitors generalized reuptake inhibitor. Loss of appetite in MDD.
E.g.: anxiety disorder, Insomnia !! Their full effect is
Fluoxetine, panic disorder, Sexual dysfunction seen after 4
Paroxetine, OCD, bulimia, Postural weeks.
Sertraline, social phobias, hypotension. !! Should not be
Citalopram. PTSD. taken with MAO
inhibitors
(serotonin
syndrome).
Serotonin Depression. Inhibit serotonin Sustained Second-line
Norepinephrine Generalized and NE reuptake. hypertension, therapy in MDD.
reuptake inhibitors anxiety and panic Sedation,
E.g.: disorder Nausea,
Venlafaxine, (Venlafaxine).
Duloxetine. Diabetic
neuropathy or
neuropathic pain
(Duloxetine).
Serotonin syndrome (with any drug that increase serotonin levels): hyperthermia, confusion, myoclonus,
cardiovascular collapse, flushing diarrhea, and seizure.
Other medications: bupropion, trazodone, and mirtazapine.

•! Prognosis:
o! Depression is self-limiting disease, 1 episode remits without treatment typically in 6-12
st

months, and 80% will have a further episode, with the risk of future episodes.
o! Average length of untreated manic episode is 4 months (16 weeks).
o! 5% and 15% of patients will have rapid cycling (four or more mood episodes (depressive,
manic or mixed) within 1 year); rapid cycling is associated with a poor prognosis.
o! Completed suicide occurs in 10–15% of patients.
o! Elderly are more successful to commit suicide, however, adults and adolescence have more
attempts.
References:
1.! MARWICK K, BIRRELL S, BOURKE J. PSYCHIATRY. EDINBURGH: ELSEVIER; 2013.
2.! KUMAR P, CLARK M. KUMAR & CLARK'S CLINICAL MEDICINE. 8 ED. EDINBURGH: SAUNDERS ELSEVIER; 2012.
TH

3.! COLLEDGE N, WALKER B, RALSTON S. DAVIDSON'S PRINCIPLES AND PRACTICE OF MEDICINE. 21 ED. LONDON: ELSEVIER; 2010.
ST

4.! RANG H, DALE M. RANG AND DALE'S PHARMACOLOGY. 7TH ED. LONDON: ELSEVIER CHURCHILL LIVINGSTONE; 2012.
5.! MERCKMANUALS.COM. BIPOLAR DISORDERS: MOOD DISORDERS: MERCK MANUAL PROFESSIONAL [INTERNET]. 2014 [CITED 14
NOVEMBER 2014]. AVAILABLE FROM:
HTTP://WWW.MERCKMANUALS.COM/PROFESSIONAL/PSYCHIATRIC_DISORDERS/MOOD_DISORDERS/BIPOLAR_DISORDERS.HTML
6.! MERCKMANUALS.COM. DEPRESSIVE DISORDERS: MOOD DISORDERS: MERCK MANUAL PROFESSIONAL [INTERNET]. 2014 [CITED 14
NOVEMBER 2014]. AVAILABLE FROM:
HTTP://WWW.MERCKMANUALS.COM/PROFESSIONAL/PSYCHIATRIC_DISORDERS/MOOD_DISORDERS/DEPRESSIVE_DISORDERS.HTML
7.! LE T, BHUSHAN V, SOCHAT M, SYLVESTER P, MEHLMAN M, KALLIANOS K. FIRST AID FOR THE® USMLE.
8.! LE T. FIRST AID FOR THE USMLE STEP 2 CS. NEW YORK, NY: MCGRAW-HILL; 2010.

First Author: Lama AlLuhaidan. Reviewed by: Roaa Amer.

Second Author: Abdullah AlAsaad. Haifa Al Issa.

Format Editor: Adel Yasky.