Affective disordersAffective disorders

Shaul Lev-Ran, MDShaul Lev-Ran, MD

Shalvata Mental Health CenterShalvata Mental Health Center

Major Depressive disorder Major Depressive disorder Dysthymic disorderDysthymic disorderCyclothymiaCyclothymiaBipolar II disorderBipolar II disorderBipolar I disorderBipolar I disorder

Major depressive disorderMajor depressive disorder

Prevalence=15%Prevalence=15%

F>MF>M

Mean age of onset=40Mean age of onset=40

GeneticGenetic 11stst degree relative of MDD – 2-3 times the degree relative of MDD – 2-3 times the

chance of suffering from MDDchance of suffering from MDD

Depression is 2nd only to IHD as major cause of disability and early death in

industrialized countries

Major Depressive EpisodeMajor Depressive Episode

5 of the following for at least 2 wks:5 of the following for at least 2 wks:1. depressed mood1. depressed mood2. markedly diminished interest or pleasure2. markedly diminished interest or pleasure 3. psychomotor disturbances 3. psychomotor disturbances 4. fatigue/loss of energy 4. fatigue/loss of energy 5. feelings of worthlessness or guilt 5. feelings of worthlessness or guilt 6. suicidal thoughts or attempt 6. suicidal thoughts or attempt 7. weight loss7. weight loss8. sleep disturbances8. sleep disturbances9. difficulty concentrating, thinking, or deciding9. difficulty concentrating, thinking, or deciding

ConsequencesConsequences

Functional impairment Functional impairment selfself familyfamily occupationaloccupational financialfinancial

Morbidity and mortality Morbidity and mortality Worse outcome of disease than control Worse outcome of disease than control Cardiac – independent prognostic factorCardiac – independent prognostic factor Sudden deathSudden death suicidesuicide

Specifiers describing depressive Specifiers describing depressive episodeepisode

With psychotic featuresWith psychotic features

With melancholic featuresWith melancholic features

With atypical featuresWith atypical features

With catatonic featuresWith catatonic features

Postpartum onsetPostpartum onset

Treatment - goalsTreatment - goals

5 X R5 X R ((achieveachieve) Response) Response ((achieveachieve) Remission) Remission ((achieveachieve) Recovery) Recovery ((preventprevent) Relapse) Relapse ((preventprevent) Recurrence) Recurrence

Treatment-strategiesTreatment-strategies

What, where & how?What, where & how?

(focus, locus, modus):(focus, locus, modus):

What – major concerns, type of depressionWhat – major concerns, type of depression

Where?Where? Suicidal riskSuicidal risk Support systemSupport system ComplianceCompliance Psychosocial stressorsPsychosocial stressors Level of functional impairmentLevel of functional impairment

What= Biopsychosocial approach:What= Biopsychosocial approach: Bio=medication, others (ECT, TMS, VNS…)Bio=medication, others (ECT, TMS, VNS…) Psycho=Psycho=

Explaining the diagnosisExplaining the diagnosisTreatment plan and objectivesTreatment plan and objectivesAssessmentAssessmentAdvantages: deals with secondary consequences Advantages: deals with secondary consequences (marital discord, occupational difficulties), (marital discord, occupational difficulties), adherence to medicationadherence to medication

Social=couples, family, occupational, etc. Social=couples, family, occupational, etc.

PrognosisPrognosis

Untreated episode – 6-13 monthsUntreated episode – 6-13 months

Treated episode – 3 monthsTreated episode – 3 months

Tends to be chronic – Tends to be chronic – 25% recurrence in 6 m. after discharge25% recurrence in 6 m. after discharge 50% recurrence in 2 yrs. 50% recurrence in 2 yrs. 75%recurrence in 5 yrs.75%recurrence in 5 yrs.

Bipolar I disorderBipolar I disorder

Prevalence=1%Prevalence=1%M=FM=FMean age of onset=30 Mean age of onset=30 At least 1 manic episodeAt least 1 manic episodeMost often starts with depressive episodeMost often starts with depressive episode10-20% - only manic episodes10-20% - only manic episodesGeneticGenetic 11stst degree relative with BP – 8-18 times the chance for degree relative with BP – 8-18 times the chance for

BPBP 1 parent with BP – 25% chance of affective dis.1 parent with BP – 25% chance of affective dis. 2 parents with BP – 50-75% chance of affective dis.2 parents with BP – 50-75% chance of affective dis.

Manic episodeManic episode

Abnormally elevated, expansive or irritable mood Abnormally elevated, expansive or irritable mood lasting 1 wk. or requiring hospitalization.lasting 1 wk. or requiring hospitalization.

At least 3 of the following:At least 3 of the following: Inflated self esteem or grandiosityInflated self esteem or grandiosity More talkative/pressure to keep on talkingMore talkative/pressure to keep on talking Flight of ideas (including subjective feeling)Flight of ideas (including subjective feeling) DistractabilityDistractability Increase in goal directed activityIncrease in goal directed activity Excessive involvement in pleasurable activity with Excessive involvement in pleasurable activity with

high potential for painful consequencehigh potential for painful consequence

Mixed episodeMixed episode

The criteria for both manic episode and The criteria for both manic episode and MD episode are met nearly every day for MD episode are met nearly every day for at least one weekat least one week

Specifiers describing recurrent Specifiers describing recurrent episodesepisodes

Rapid cycling -4 or more episodes in 1 yr.Rapid cycling -4 or more episodes in 1 yr.

With seasonal patternWith seasonal pattern

Affective disordersAffective disorders

Major Depressive disorder (unipolar)Major Depressive disorder (unipolar) Major depressive episodesMajor depressive episodes

Dysthymic disorderDysthymic disorder Milder & more chronic depressionMilder & more chronic depression

CyclothymiaCyclothymia Hypomanic episodes and milder depressionHypomanic episodes and milder depression

Bipolar II disorderBipolar II disorder Hypomanic episodes and major depressive episodesHypomanic episodes and major depressive episodes

Bipolar I disorderBipolar I disorder Manic episodes and major depressive episodesManic episodes and major depressive episodes

Bipolar II disorderBipolar II disorder

Includes at least one hypomanic episode:Includes at least one hypomanic episode: Lasting at least 4 daysLasting at least 4 days Criteria similar to manic episodeCriteria similar to manic episode The episode is The episode is notnot severe enough to cause severe enough to cause

marked impairment in functioning and there marked impairment in functioning and there are are nono psychotic features psychotic features

Dysthymic disorderDysthymic disorder

At least 2 years At least 2 years

No major depressive episode for first two yearsNo major depressive episode for first two years

2 of the following2 of the following Eating disturbancesEating disturbances Sleeping disturbancesSleeping disturbances Fatigue/low energyFatigue/low energy Low self esteemLow self esteem Poor concentration or difficulty making decisionsPoor concentration or difficulty making decisions Feelings of hopelessnessFeelings of hopelessness

CyclothymiaCyclothymia

At least two years of hypomanic and minor At least two years of hypomanic and minor depressive episodesdepressive episodes

No major depressive, manic or mixed No major depressive, manic or mixed episode for first two yearsepisode for first two years

Treatment-strategiesTreatment-strategies

Where, what & how?Where, what & how?(focus, locus, modus):(focus, locus, modus):

Where?Where? Danger to self and othersDanger to self and others Significant harm to self or othersSignificant harm to self or others Support systemSupport system ComplianceCompliance Psychosocial stressorsPsychosocial stressors Level of functional impairmentLevel of functional impairment

What= Biopsychosocial approach:What= Biopsychosocial approach: Bio=medication, others (ECT, TMS, VNS…)Bio=medication, others (ECT, TMS, VNS…) Psycho=Psycho=

Explaining the diagnosisExplaining the diagnosisTreatment plan and objectivesTreatment plan and objectivesAssessmentAssessmentAdvantages: deals with secondary consequences Advantages: deals with secondary consequences (marital discord, occupational difficulties), (marital discord, occupational difficulties), adherence to medicationadherence to medication

Social=couples, family, occupational, etc. Social=couples, family, occupational, etc.