MOOD DISORDERS

Mood disorders are characterized by a disturbance of mood, accompanied by a full or partial manic or
depressive syndrome, which is not due to any other physical or mental disorder.

Broadly speaking, the emotions can be described as two main types:

1. Mood is a pervasive and sustained emotion that may have a major influence on a person’s perception of the world.
Examples of mood include depression, joy, elation, anger, and anxiety.
2. Affect is described as the emotional reaction associated with an experience and is short-lived.
So according to these definitions, depression and mania are mood disorders and not ‘ affective disorders’
as they have been called so frequently in the past.

CLASSIFICATION
The classification of mood disorders is an area which is fraught with multiple controversies. According to the
ICD-10, the mood disorders are classified as follows:
1. Manic episode
2. Depressive episode
3. Bipolar mood (affective) disorder
4. Recurrent depressive disorder
5. Persistent mood disorder
6. Other mood disorders

Manic Episode
Definition: Mania refers to a syndrome in which the central features are over-activity, mood change (which may be
towards elation or irritability) and self-important ideas.
OR
An alteration in mood that is expressed by feelings of elation, inflated self-esteem, grandiosity, hyperactivity,
agitation, and accelerated thinking and speaking. Mania can occur as a biological (organic) or psychological disorder, or as a
response to substance use or a general medical condition.
Classification of Mania (ICD 10)
• Hypomania
• Mania without psychotic symptoms
• Mania with psychotic symptoms
• Manic episode unspecified

Incidence: The life-time risk of manic episode is about 0.8- 1%. This disorder tends to occur in episodes lasting
usually 3-4 months, followed by complete clinical recovery. The future episodes can be manic, depressive or mixed.

CLINICAL FEATURES:
A manic episode is typically characterised by the following features (which should last for at least one week and
cause disruption in occupational and social activities).

Elevated, Expansive or Irritable Mood

The elevated mood can pass through following four stages, depending on the severity of manic episode:
a. Euphoria (mild elevation of mood): An increased sense of psychological well-being and happiness,
not in keeping with ongoing events. This is usually seen in hypomania (Stage I).
b. Elation (moderate elevation of mood): A feeling of confidence and enjoyment, along with an increased
psychomotor activity. Elation is classically seen in mania (Stage II).
c. Exaltation (severe elevation of mood): Intense elation with delusions of grandeur; seen in severe mania (Stage III).
d. Ecstasy (very severe elevation of mood): Intense sense of rapture or blissfulness; typically seen in delirious or
stuporous mania (Stage IV).

 Along with these variations in elevation of mood, expansive mood may also be present, which is an
 unceasing and unselective enthusiasm for interacting with people and surrounding environment.
 At times, elevated mood may not be apparent and instead an irritable mood may be predominant, especially when the
person is stopped from doing what he wants. There may be rapid, short lasting shifts from euphoria to depression or
irritability.

Psychomotor Activity
 There is an increased psychomotor activity, ranging from overactiveness and restlessness, to manic excitement
where the person is ‘on-the-toe-on-the-go’, (i.e. involved in ceaseless activity).
 The activity is usually goal-oriented and is based on external environmental cues. Rarely, a manic patient can go in
to a stuporous state (manic stupor).

Speech and Thought

 The person is more talkative than usual; describes thoughts racing in his mind; develops pressure of speech; uses
playful language with punning, rhyming, joking and teasing; and speaks loudly.
 Later, there is ‘ flight of ideas’ (rapidly produced speech with abrupt shifts from topic to topic, using external
environmental cues. Typically the connections between the shifts are apparent). When the ‘flight’ becomes severe,
incoherence may occur. A less severe and a more ordered ‘flight’, in the absence of pressure of speech, is called
‘prolixity’.
 There can be delusions (or ideas) of grandeur (grandiosity), with markedly inflated self-esteem.
 Delusions of persecution may sometimes develop secondary to the delusions of grandeur (e.g. I am so great that
people are against me).
 Hallucinations (both auditory and visual), often with religious content, can occur (e.g. God appeared before me and
spoke to me). Since these psychotic symptoms are in keeping with the elevated mood state, these are called mood
congruent psychotic features.
 Distractibility is a common feature and results in rapid changes in speech and activity, in response to
even irrelevant external stimuli.

Goal-directed Activity
 The person is unusually alert, trying to do many things at one time.
 In hypomania, the ability to function becomes much better and there is a marked increase in productivity and
creativity.
 In mania, there is marked increase in activity with excessive planning and, at times, execution of multiple activities.
 Due to being involved in so many activities and distractibility, there is often a decrease in the functioning ability in
later stage.
 There is marked increase in sociability even with previously unknown people. Gradually this sociability leads to an
interfering behaviour though the person does not recognise it as abnormal at that time.
 The person becomes impulsive and disinhibited, with sexual indiscretions, and can later become hypersexual and
promiscuous.
 Due to grandiose ideation, increased sociability, overactivity and poor judgement, the manic person is often involved
in the high-risk activities such as buying sprees, reckless driving, foolish business investments, and distributing
money and/or personal articles to unknown persons. He is usually dressed up in gaudy and flamboyant clothes,
although in severe mania there may be poor self-care.

Other Features: (ADD SREEVANI’s OTHER FEATURES)

 Sleep is usually reduced with a decreased need for sleep. Appetite may be increased but later there is usually
decreased food intake, due to marked overactivity.
 Insight into the illness is absent, especially in severe mania.

Stages of mania:
Symptoms of manic states can be described according to three stages: hypomania, acute mania, and delirious mania.
Symptoms of mood, cognition and perception, and activity and behavior are presented for each stage.
Stage I: Hypomania
  At this stage the disturbance is not sufficiently severe to cause marked impairment in social or occupational
functioning or to require hospitalization.
Mood: The mood of a hypomanic person is cheerful and expansive.
There is an underlying irritability that surfaces rapidly when the person’s wishes and desires go unfulfilled, however.
Cognition and Perception:
 Perceptions of the self are exalted—ideas of great worth and ability.
 Thinking is flighty, with a rapid flow of ideas.
 Perception of the environment is heightened, but the individual is so easily distracted by irrelevant stimuli that goal-
directed activities are difficult.
Activity and Behavior
 Hypomanic individuals exhibit increased motor activity.
 They are perceived as being very extroverted and sociable, and because of this they attract numerous acquaintances.
 Some individuals experience anorexia and weight loss.
Stage II: Acute Mania
Symptoms of acute mania may be a progression in intensification of those experienced in hypomania, or they may be
manifested directly. Most individuals experience marked impairment in functioning and require hospitalization.
Mood:
 Acute mania is characterized by euphoria and elation. The person appears to be on a continuous
“high.”
 However, the mood is always subject to frequent variation, easily changing to irritability and anger or even to sadness
and crying.
Cognition and Perception:
 Cognition and perception become fragmented and often psychotic in acute mania.
 Rapid thinking proceeds to racing and disjointed thinking (flight of ideas) and may be manifested by a continuous
flow of accelerated, pressured speech, with abrupt changes from topic to topic.
 When flight of ideas is severe, speech may be disorganized and incoherent.
 Attention can be diverted by even the smallest of stimuli. Hallucinations and delusions (usually paranoid and
grandiose) are common.
Activity and Behavior.
 Psychomotor activity is excessive.
 Sexual interest is increased.
 There is poor impulse control, and the individual who is normally discreet may become socially and sexually
uninhibited.
 Excessive spending is common.
 Energy seems inexhaustible, and the need for sleep is diminished. They may go for many days without sleep and still
not feel tired.
 Hygiene and grooming may be neglected.
 Dress may be disorganized, flamboyant, or bizarre, and the use of excessive make-up or jewelry is common.
Stage III: Delirious Mania
Delirious mania is a grave form of the disorder characterized by severe clouding of consciousness and an
intensification of the symptoms associated with acute mania.
This condition has become relatively rare since the availability of antipsychotic medication.
Mood.
 The mood of the delirious person is very labile.
 He or she may exhibit feelings of despair, quickly converting to unrestrained merriment and ecstasy or becoming
irritable or totally indifferent to the environment. Panic anxiety may be evident.
Cognition and Perception.
 Cognition and perception are characterized by a clouding of consciousness, with accompanying confusion,
disorientation, and sometimes stupor. Other common manifestations include religiosity.

Treatment
Pharmacotherapy
• Lithium: 900-2100 mg/ day.
• Carbamazepine: 600-1800 mg/day.
• Sodium valproate: 600-2600 mg/ day.
 • Other drugs: Clonazepam, calcium channel blockers, etc.
Electroconvu/sive Therapy (ECT)
ECT can also be used for acute manic excitement if not adequately responding to antipsychotics and lithium.
Psychosocial Treatment
Family and marital therapy is used to decrease intra-familial and interpersonal difficulties and to reduce or modify
stressors. The main purpose is to ensure continuity of treatment and adequate drug compliance.

Write nsg mng from sreevani………………….

Depression:
Depression
An alteration in mood that is expressed by feelings of sadness, despair, and pessimism. There is a loss of interest in usual
activities, and somatic symptoms may be evident. Changes in appetite and sleep patterns are common.

EPIDEMIOLOGY: The lifetime risk of depression in males is 8 to 12%and in females it is 20 to

26%.Depression occurs twice as frequently in women as in men.
Gender
Studies indicate that the incidence of depressive disorder is higher in women than it is in men by about 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. This occurrence may be related to gender differences in social roles and economic and social
opportunities and the shifts that occur with age. The construction of gender stereotypes, or gender socialization,
promotes typical female characteristics, such as helplessness, passivity, and emotionality, which are associated with
depression. In contrast, some studies have suggested that “masculine” characteristics are associated with higher self-
esteem and less depression.
 Studies have also shown that widowhood has a stronger effect on depression for men than for women. Possible
causes include the fact that widowhood is a more usual component of the life cycle for women.
Social Class
 Results of studies have indicated an inverse relationship between social class and report of depressive symptoms.
Race and Culture
 Studies have shown no consistent relationship between race and affective disorder.
 One problem encountered in reviewing racial comparisons has to do with the socioeconomic class of the race being
investigated. Sample populations of non-white clients are many times predominantly from a lower socioeconomic
class and are often compared with white populations from middle and upper social classes.
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.
Seasonality
 A number of studies have examined seasonal patterns associated with mood disorders. These studies have revealed
two prevalent periods of seasonal involvement: one in the spring (March, April, and May) and one in the fall
(September, October, and November). This pattern tends to parallel the seasonal pattern for suicide, which shows a
large peak in the spring and a smaller one in October.
A number of etiologies associated with this trend have been postulated. Some of these include the following:
 Meteorological factor: It is associated with drastic temperature and barometric pressure changes to human mental
instability.
● Sociodemographic variables: such as the seasonal increase in social intercourse (e.g., increased social activity
with the commencement of an academic year)
● Biochemical variables: There may be seasonal variations in various peripheral and central aspects of serotonergic
function involved in depression and suicide.

Classification of depression:
F32 Depressive episode
 F32.0 Mild depressive episode
F32.1 Moderate depressive episode
F32.2 Severe depressive episode without psychotic symptoms
F32.3 Severe depressive episode with psychotic symptoms
F32.8 Other depressive episodes
F32.9 Depressive episode, unspecified
F33 Recurrent depressive disorder
F34 Persistent mood [affective] disorders
F38 Other mood [affective] disorders

Clinical Features
A typical depressive episode is characterized by the following features, which should last for at least two weeks in
order to make a diagnosis:
Depressed mood: Sadness of mood or loss of interest and loss of pleasure in almost all activities (pervasive sadness),
present throughout the day (persistent sadness).
 The loss of interest in daily activities results in social withdrawal, decreased ability to function in occupational and
interpersonal areas.
 Decreased involvement in previously pleasurable activities. In severe depression, there may be complete anhedonia
(inability to experience pleasure).
Depressive cognitions/ ideation:
 Hopelessness (a feeling of 'no hope in future' due to pessimism),
 Helplessness (the patient feels that no help is possible),
 Worthlessness (a feeling of inadequacy and inferiority), unreasonable guilt and self-blame over trivial matters in the
past.
--The ideas of worthlessness can lead to self-reproach and guilt-feelings. The other features are difficulty in thinking,
difficulty in concentration, indecisiveness, slowed thinking, subjective poor memory, lack of initiative and energy.
--Often there are ruminations (repetitive, intrusive thoughts) with pessimistic ideas. Thoughts of death and
preoccupation with death are common.
Suicidal thoughts: Ideas of hopelessness are often accompanied by the thought that life is no longer worth living and
that death had come as a welcome release. These gloomy preoccupations may progress to thoughts of and plans for
suicide.
Psychomotor activity: Psychomotor retardation is frequent. The retarded patient thinks, walks and acts slowly.

 Slowing of thought is reflected in the patient's speech; questions are often answered after a long delay and in a
monotonous voice. In older patients agitation is common with marked anxiety, restlessness and feelings of
uneasiness.
 In a severe form, the patient can become stuporous ( depressive stupor).
Psychotic features:
 About 15-20% of depressed patients have psychotic symptoms such as delusions, hallucinations, grossly
inappropriate behaviour or stupor.
 Some patients have delusions and hallucinations (the disorder may then be termed as psychotic depression); these are
often mood congruent, i.e. they are related to depressive themes and reflect the patient's dysphoric mood. For
example, nihilistic delusions (beliefs about the non-existence of some person or thing), delusions of guilt, delusions
of poverty, etc. may be present.
Some patients experience delusions and hallucinations that are not clearly related to depressive themes (mood
incongruent), for example, delusion of control. The prognosis then appears to be much worse.
Somatic symptoms of depression, : according to ICD l0
• Significant decrease in appetite or weight.
• Early morning awakening, at least 2 or more hours before the usual time of waking up.
• Diurnal variation, with depression being worst in the morning.
• Pervasive lack of interest and lack of reactivity to pleasurable stimuli.
• Psychomotor agitation or retardation.
Other Features
• Difficulties in thinking and concentration.
 • Subjective poor memory.
• Menstrual or sexual disturbances.
• Vague physical symptoms such as fatigue, aching discomfort, constipation, etc.

Predisposing Factors
The etiology of depression is unclear. No single theory or hypothesis has been postulated that gives a clear-cut
explanation for the disease. Evidence continues to mount in support of multiple causations, recognizing the combined
effects of genetic, biochemical, and psychosocial influences on an individual’s susceptibility to depression. A number
of theoretical postulates are:
Biological Theories
Genetics
A genetic link has been suggested in numerous studies; however, no definitive mode of genetic transmission has yet
to be demonstrated.
Twin Studies.: Twin studies suggest a strong genetic factor in the etiology of affective illness. Considering unipolar
and bipolar disorders together, the concordance rate for monozygotic twins is 70 to 90 percent, whereas that for
dizygotic twins is only 16 to 35 percent.
Family Studies:
 Most family studies have shown that major depression is 1.5 to 3 times more common among first-degree biological
relatives of people with the disorder than among the general population.
Indeed, the evidence to support an increased risk of depressive disorder in individuals with positive family history is
quite compelling. It is unlikely that random environmental factors could cause the concentration of illness that is seen
within families.
Adoption Studies:
Further support for heritability as an etiological influence in depression comes from studies of
the adopted offspring of affectively ill biological parents.
These studies have indicated that biological children of parents with mood disorders are at increased risk of
developing a mood disorder, even when they are reared by adoptive parents who do not have the disorder.
Biochemical Influences
Biogenic Amines: It has been hypothesized that depressive illness may be related to a deficiency of the
neurotransmitters norepinephrine, serotonin, and dopamine, at functionally important receptor sites in the brain.
--Neurons that contain serotonin are critically involved in the regulation of many psychobiological functions, such as
mood, anxiety, arousal, vigilance, irritability, thinking, cognition, appetite, aggression, and circadian rhythm
--Norepinephrine has been identified as a key component in the mobilization of the body to deal with stressful
situations.
--The level of dopamine in the mesolimbic system of the brain is thought to exert a strong influence over human
mood and behavior
 A diminished supply of these biogenic amines inhibits the transmission of impulses from one neuronal fiber to
another, causing a failure of the cells to fire or become charged.
 More recently, the biogenic amine hypothesis has been expanded to include another neurotransmitter, acetylcholine.
Cholinergic transmission is thought to be excessive in depression and inadequate in mania.

Neuroendocrine Disturbances
Neuroendocrine disturbances may play a role in the pathogenesis or persistence of depressive illness. This notion has
arisen in view of the marked disturbances in mood observed with the administration of certain hormones or in the
presence of spontaneously occurring endocrine disease.
Hypothalamic–Pituitary–Adrenocortical Axis. In clients who are depressed, the normal system of hormonal
inhibition fails, resulting in a hyper-secretion of cortisol.
Hypothalamic–Pituitary–Thyroid Axis
 Thyrotropin releasing factor (TRF) from the hypothalamus stimulates the release of thyroid-stimulating hormone
(TSH) from the anterior pituitary gland. In turn, TSH stimulates the thyroid gland.
 Diminished TSH response to administered TRF is observed in approximately 25 percent of depressed persons. This
laboratory test has future potential for identifying clients at high risk for affective illness.
Physiological Influences
 Depressive symptoms that occur as a consequence of a non-mood disorder or as an adverse effect of certain
medications are called a secondary depression. Secondary depression may be related to medication side effects,
neurological disorders, electrolyte or hormonal disturbances, nutritional deficiencies, and other physiological or
psychological conditions.
Medication Side Effects. A number of drugs, either alone or in combination with other medications, can
produce a depressive syndrome. Most common among these drugs are those that have a direct effect on the central
nervous system. Examples of these include the anxiolytics, antipsychotics, and sedative-hypnotics. Certain
antihypertensive medications, such as propranolol.
Neurological Disorders. An individual who has suffered a cardiovascular accident (CVA) may experience a
despondency unrelated to the severity of the CVA. These are true mood disorders, and antidepressant drug therapy
may be indicated.
 Brain tumors, particularly in the area of the temporal lobe, often cause symptoms of depression.
 Agitated depression may be part of the clinical picture associated with Alzheimer’s disease, Parkinson’s disease,
and Huntington’s disease. Agitation and restlessness may also represent an underlying depression in the individual
with multiple sclerosis.
Electrolyte Disturbances.
 Excessive levels of sodium bicarbonate or calcium can produce symptoms of depression, as can deficits in
magnesium and sodium.
 Potassium is also implicated in the syndrome of depression. Symptoms have been observed with excesses of
potassium in the body, as well as in instances of potassium depletion.
Hormonal Disturbances.
-Depression is associated with dysfunction of the adrenal cortex and is commonly observed
in both Addison’s disease and Cushing’s syndrome. Other endocrine conditions that may result in symptoms of
depression include hypoparathyroidism, hyperparathyroidism, hypothyroidism, and hyperthyroidism.
Nutritional Deficiencies. Deficiencies in vitamin B1 (thiamine), vitamin B6 (pyridoxine), vitamin B12, niacin, vitamin
C, iron, folic acid, zinc, calcium, and potassium may produce symptoms of depression.
Other Physiological Conditions. Other conditions that have been associated with secondary depression include
collagen disorders, such as systemic lupus erythematosus (SLE) and polyarteritis nodosa; cardiovascular disease,
such as cardiomyopathy, congestive heart failure, myocardial infarction, and cerebrovascular accident (stroke);
infections, such as encephalitis, hepatitis.
Psychosocial Theories
Psychoanalytical Theory
 Freud observed that melancholia occurs after the loss of a loved object, either actually by death or emotionally by
rejection, or the loss of some other abstraction of value to the individual. Freud indicated that in melancholic clients,
the depressed patient’s rage is internally directed because of identification with the lost object.
 Freud indicated that in melancholic clients, the depressed patient’s rage is internally directed because of
identification with the lost object.
Learning Theory
 The model of “learned helplessness” arises out of Seligman’s (1973) experiments with dogs. The animals were
exposed to electrical stimulation from which they could not escape. Later, when they were given the opportunity to
avoid the traumatic experience, they reacted with helplessness and made no attempt to escape. A similar state of
helplessness exists in humans who have experienced numerous failures (either real or perceived).
Seligman theorized that learned helplessness predisposes individuals to depression by imposing a feeling of lack of
control over their life situation.
Object Loss Theory
 The theory of object loss suggests that depressive illness occurs as a result of having been abandoned by or otherwise
separated from a significant other during the first six months of life. Because during this period the mother
represents the child’s main source of security, she is the “object.” The response occurs not only with a physical loss.
This absence of attachment, which may be either physical or emotional, leads to feelings of helplessness and despair
that contribute to lifelong patterns of depression in response to loss.

Cognitive Theory
Beck, Rush, Shaw, and Emery (1979) proposed a theory suggesting that the primary disturbance in depression is
cognitive rather than affective. The underlying cause of the depressive affect is seen as cognitive distortions that
 result in negative, defeated attitudes. Beck identifies three cognitive distortions that he believes serve as the basis for
depression:
1. Negative expectations of the environment
2. Negative expectations of the self
3. Negative expectations of the future
Cognitive theorists believe that depression is the product of negative thinking. This is in contrast to the
view of other theorists, who suggest that negative thinking occurs when an individual is depressed.

The Transactional Model

As is clearly evident, no single theory or hypothesis exists to substantiate a clear-cut explanation for depressive
disorder. Evidence continues to support of multiple causation. The transactional model recognizes the combined
effects of genetic, biochemical, and psychosocial influences on an individual’s susceptibility to depression.
The dynamics of depression using the Transactional Model of Stress/Adaptation are presented as:

TYPES OF Depressive Disorders

Depressive Disorders
1. Major Depressive Disorder
 This disorder is characterized by depressed mood or loss of interest or pleasure in usual activities.
 The impairment in social and occupational functioning that has existed for at least 2 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 Episode or Recurrent.
o 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 response 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 past 2 years.
7. With Seasonal Pattern.
This diagnosis indicates the presence of depressive symptoms during the fall or winter months. This diagnosis is
made when the number of seasonal depressive episodes is substantially higher than the number of non-seasonal
episodes that have occurred over the individual’s lifetime. This disorder has previously been identified in the
literature as seasonal affective disorder (SAD).

(SAD is thought to be related to the presence of the hormone melatonin, which is produced by the pineal
gland. Melatonin plays a role in the regulation of biological rhythms for sleep and activation. It is produced during
the cycle of darkness and shuts off in the light of day. During the months of longer darkness hours, there is
increased production of melatonin, which seems to trigger the symptoms of SAD in susceptible people. Light
therapy, or exposure to light, has been shown to be an effective treatment for SAD.)

A. Five (or more) of the following symptoms have been present during the same 2-week period and represent a
change from previous functioning; at least one of the symptoms is either (1) depressed mood, or (2) loss of
interest or pleasure.
1. Depressed mood most of the day, nearly every day, as indicated by either subjective report (e.g., feels sad or
 empty) or observation made by others (e.g., appears tearful).
NOTE: In children and adolescents, can be irritable mood.
2. Markedly diminished interest or pleasure in all, or almost all, activities most of the day, nearly every day
(as indicated either by subjective account or observation made by others).
3. Significant weight loss when not dieting or weight gain (e.g., a change of more than 5% of body weight
in a month), or a decrease or increase in appetite nearly every day.
NOTE: In children, consider failure to make expected weight gains.
4. Insomnia or hypersomnia nearly every day.
5. Psychomotor agitation or retardation nearly every day (observable by others, not merely subjective feelings
of restlessness or being slowed down).
6. Fatigue or loss of energy nearly every day.
7. Feelings of worthlessness or excessive or inappropriate guilt (which may be delusional) nearly every day
(not merely self-reproach or guilt about being sick).
8. Diminished ability to think or concentrate, or indecisiveness, nearly every day (either by subjective account or as observed by
others).
9. Recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation without a specific plan, or
a suicide attempt or a specific plan for committing suicide.
B. There has never been a manic episode, a mixed episode, or a hypomanic episode that was not substance or treatment induced or
due to the direct physiological effects of a general medical condition.
C. The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of
functioning.
D. The symptoms are not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication)
or a general medical condition (e.g., hypothyroidism).
E. The symptoms are not better accounted for by bereavement (i.e., after the loss of a loved one), the symptoms
persist for longer than 2 months or are characterized by marked functional impairment, morbid preoccupation
with worthlessness, suicidal ideation, psychotic symptoms, or psychomotor retardation. is

2. Dysthymic Disorder (also called neurotic/ reactive depression)

 It is a chronic, mild depressive state. The characteristics of this mood disturbance are somewhat milder than, those
of major depressive disorder. Individuals with dysthymic disorder describe their mood as sad or “down in the
dumps.”
 The essential feature is a chronically depressed mood (or possibly an irritable mood in children or adolescents) for
most of the day, more days than not, for at least 2 years (1 year for children and adolescents). It is more common in
females with an average age of onset in late third decade.

Dysthymic disorder may be further classified as:

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.

A. Depressed mood for most of the day, more days than not, as indicated either by subjective account or
observation by others, for at least 2 years. NOTE: In children and adolescents, mood can be irritable and
duration must be at least 1 year.
B. Presence, while depressed, of two (or more) of the following:
1. Poor appetite or overeating
2. Insomnia or hypersomnia
3. Low energy or fatigue
4. Low self-esteem
5. Poor concentration or difficulty making decisions
6. Feelings of hopelessness
C. During the 2-year period (1 year for children or adolescents) of the disturbance, the person has never
been without the symptoms in A or B for more than 2 months at a time.
D. No major depressive disorder has been present during the first 2 years of the disturbance (1 year for children
and adolescents).
E. There has never been a manic, mixed or hypomanic episode, and criteria have never been met for
cyclothymic disorder.
F. The disturbance does not occur exclusively during the course of a chronic psychotic disorder, such as
schizophrenia or delusional disorder.
G. The symptoms are not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a general
medical condition (e.g., hypothyroidism).
H. The symptoms cause clinically significant distress or impairment in social, occupational, or other important
 areas of functioning.

Differences between Major (somatic/ major/endogenous depression/ melancholia) and Dysthymic

(neurotic /depression /reactive)
Major depression Dysthymic depression.
(a) Caused by factors within the -Caused by stressful events.
individual.
(b) Premorbid personality: cyclothymic -Premorbid personality:
or dysthymic. anxious, or obsessive.

(c) Early morning awakening (late insomnia).
(d) Patient feels more sad in the morning.
(e) Feels better when alone.
(f) Psychotic features Iike psychomotor retardation, suicidal
tendencies, delusions etc are common.
(g) Relapses are common.
(h) ECT and antidepressants are used
for management.
-Difficulty in falling asleep (early insomnia).
-Patient feels more sad in the evening.
-Feels better when in a group.
-Usually psychomotor agitation and no other psychotic
features.
-Relapses are uncommon.
Psychotherapy and antidepressants are used
for management.

(i) Insight is absent. -Insight is present.

3. Premenstrual Dysphoric Disorder

 The DSM-IV-TR (APA, 2000) does not include premenstrual dysphoric disorder as an official diagnostic category.
 The essential features 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

Other type:
1. Recurrent Depressive Disorder
This disorder is characterised by recurrent (at least two) depressive episodes. The current episode in recurrent
depressive disorder is specified as one of the following:
i. mild,
ii. moderate,
iii. severe, without psychotic symptoms,
iv. severe, with psychotic symptoms,
v. in remission.

2. Involutional Melancholia
 Described by Kraepelin, this is a form of severe depression which occurs in the involutional period of
life (i.e. 40-65 years of age).
 It is typically characterised by marked agitation, presence of psychotic features (such as delusions of
persecution, tactile and auditory hallucinations) and multiple somatic symptoms (or hypochondriacal
delusions).
Presently, it is no longer thought of as an independent entity but the term is used to describe the
severity of a depressive episode

3. Mixed Anxiety Depressive Disorder

 This disorder is characterised by the presence of depressive and anxiety symptoms which result in significant distress
or disability in the person. The symptoms should not meet the criteria of either an anxiety disorder or a mood
disorder.
 This disorder is apparently seen more frequently in the medical outpatient departments and primarycare centres.
Several cases probably exist untreated in the general population, but rarely come to medical attention.
In clinical practice, it is important to consider a diagnosis of either a mood disorder or an anxiety disorder, before
attempting a diagnosis of mixed anxiety-depressive disorder.

4. Masked Depression
  In masked depression, the depressive mood is not easily apparent and is usually hidden behind the somatic
symptoms. This is especially common in the elderly, where the somatic symptoms range from chronic pain,
insomnia, atypical facial pain, and paraesthesias. The depressive symptoms can also be masked by drug and/
or alcohol misuse.
However, a more detailed examination will bring out the tell-tale symptomatology of depression.
The treatment is similar to a depressive episode
5. Double Depression
 This is a major depressive episode (usually acute), superimposed on an underlying dysthymia or neurotic
depression (usually chronic). The response to treatment is usually poor.
6. Agitated Depression
 This is a type of severe depression with marked motor restlessness or agitation. It is either seen alone or along
with involutional melancholia. It is more common after the age of 40 years.
 The treatment of agitated depression usually requires addition of antipsychotics or benzodiazepines to the
antidepressant therapy.
7. Secondary Depression Both depressive and manic episodes can occur secondary to certain physical
diseases and drugs.

Symptomatology of depression can be viewed on a continuum according to severity of the illness.

Transient Depression
Symptoms at this level of the continuum are not necessarily dysfunctional. Alterations include:
1. Affective: sadness, dejection, feeling downhearted, having the “blues”
2. Behavioral: some crying possible
3. Cognitive: some difficulty getting mind off of one’s disappointment
4. Physiological: feeling tired and listless
Mild Depression
Symptoms at the mild level of depression are identified by those associated with normal grieving. Alterations at the
mild level include:
1. Affective: denial of feelings, anger, anxiety, guilt, helplessness, hopelessness, sadness, despondency
2. Behavioral: tearfulness, regression, restlessness, agitation, withdrawal
3. Cognitive: preoccupation with the loss, self-blame, ambivalence, blaming others
4. Physiological: anorexia or overeating, insomnia or hypersomnia, headache, backache, chest pain, or other
symptoms associated with the loss of a significant other

Moderate Depression
This level of depression represents a more problematic disturbance. Symptoms associated with dysthymic disorder
include:
1. Affective:
 It includes- feelings of sadness, dejection, helplessness, powerlessness, hopelessness; gloomy and pessimistic
outlook; low self-esteem; difficulty experiencing pleasure in activities
2. Behavioral:
 Slowed physical movements (i.e., psychomotor retardation); slumped posture
 Slowed speech; limited verbalizations, possibly consisting of ruminations about life’s failures or regrets social
isolation with a focus on the self
 Increased use of substances possible;
 Self-destructive behavior possible;
 Decreased interest in personal hygiene and grooming
3. Cognitive:
 Retarded thinking processes; difficulty concentrating and directing attention; obsessive and
repetitive thoughts, generally portraying pessimism and negativism; verbalizations and behavior reflecting
suicidal ideation
4. Physiological:
 Anorexia or overeating; insomnia or hypersomnia; sleep disturbances; amenorrhea
 Decreased libido; headaches; backaches; chest pain; abdominal pain; low energy level; fatigue and
 listlessness; feeling best early in the morning and continually worse as the day progresses. (This may be
related to the diurnal variation in the level of neurotransmitters that affect mood and level of activity.)

Severe Depression
Severe depression is characterized by an intensification of the symptoms described for moderate depression.
Examples of severe depression include major depressive disorder. Symptoms at the severe level of depression
include:
1. Affective:
 feelings of total despair, hopelessness, and worthlessness; flat (unchanging) affect.
 appearing devoid of emotional tone; prevalent feelings of nothingness and emptiness; apathy; loneliness; sadness;
inability to feel pleasure
2. Behavioral:
 psychomotor retardation so severe that physical movement may literally come to a standstill, or
 psychomotor behavior manifested by rapid, agitated, purposeless movements; slumped posture;
 no personal hygiene and grooming; social isolation is common, with virtually no inclination toward
interaction with others
3. Cognitive:
 confusion, indecisiveness, and an inability to concentrate; hallucinations reflecting misinterpretations
of the environment; excessive self-deprecation, self-blame, and thoughts of suicide.

4. Physiological:
 Slowdown of the entire body, reflected in sluggish digestion, constipation, and urinary retention; amenorrhea;
impotence.
 Diminished libido; anorexia; weight loss; difficulty falling asleep and awakening very early in the morning;
feeling worse early in the morning and somewhat better as the day progresses.

Prognosis of Mood Disorders

PROGNOSIS
Classically, the prognosis in mood disorders is generally described as better than in schizophrenia. Some
of the good (and poor) prognostic factors in mood disorders are
Good Prognostic Factors
1. Acute or abrupt onset
2. Typical clinical features
3. Severe depression
4. Well-adjusted premorbid personality
5. Good response to treatment.
Poor Prognostic Factors
1. Co-morbid medical disorder, personality dis order or
alcohol dependence
2. Double depression (acute depressive episode superimposed on chronic depres sion or dysthymia)
3. Catastrophic stress or chronic ongoing stress
4. Unfavourable early environment
5. Marked hypochondriacal features.
 6. Poor drug compliance.

Diagnosis
Using information collected during the assessment, the nurse completes the client database, from which the selection
of appropriate nursing diagnoses is determined.

Treatment

Pharmacotherapy
Antidepressants are the treatment of choice for a vast majority of depressive episodes.

Electroconvulsive therapy (ECT)

Electroconvulsive therapy (ECT) is the induction of a grand mal (generalized) seizure through the application of electrical current
to the brain.
The indications for ECT in depression include:
i. Severe depression with suicidal risk.
ii. Severe depression with stupor, severe psychomotor retardation, or somatic syndrome.
iii. Severe treatment refractory depression.
iv. Delusional depression (psychotic features).
v. Presence of significant antidepressant side effects or intolerance to drugs.

Severe depression with suicidal risk is the first and foremost indication for use of ECT. The response is usually rapid,
resulting in a marked improvement.
 In most clinical situations, usually 6-8 ECTs are needed, given three times a week.
When six ECTs are administered, the usual pattern is three ECTs in the first week, two in the second week
and one in the third week.
 However, improvement is not sustained after stopping the ECTs. Therefore, antidepressants are often needed
along with ECTs, in order to maintain the improvement achieved.

Light Therapy
 People with recurrent depressive disorder exhibit a seasonal pattern whereby symptoms are exacerbated during the
winter months and subside during the spring and summer. It has commonly been
known as Seasonal Affective Disorder (SAD).
 The light therapy is administered by a 10,000-lux light box, which contains white fluorescent light tubes covered
with a plastic screen that blocks ultraviolet rays. The individual sits in front of the box with the eyes open (although
they should not look directly into the light). Therapy usually begins with 10- to 15-minute sessions, and gradually
progress to 30 to 45 minutes.

Transcranial Magnetic Stimulation

 Transcranial magnetic stimulation (TMS) is one of the newer technologies that is being used to treat depression.
 TMS involves the use of very short pulses of magnetic energy to stimulate nerve cells in the brain. The waves are
passed through a coil placed on the scalp to areas of the brain involved in mood regulation.

Psychosocial Treatment
• Cognitive therapy: It aims at correcting the depressive negative cognitions like hopelessness,
worthlessness, helplessness and pessimistic ideas, and replacing them with new cognitive and behavioral responses.
• Supportive psychotherapy:
Various techniques are employed to support the patient. They are reassurance, ventilation, occupational therapy,
relaxation and other activity therapies.
• Group therapy: Group therapy is useful for mild cases of depression. In group therapy
negative feelings such as anxiety anger, guilt, despair are recognized and emotional growth is improved through
expression of their feelings.
• Family therapy: Family therapy is used to decrease intra-familial and interpersonal difficulties
and to reduce or modify stressors, which may help in faster and more complete recovery.
 • Behavior therapy: It includes social skills training, problem solving techniques, assertiveness
training, self-control therapy, activity scheduling and decision making techniques.

Bipolar Disorders
 A bipolar disorder is characterized by mood swings from profound depression to mania, with intervening periods of
normalcy.
Or
 Bipolar affective disorder (BPAD) is characterized by recurrent episodes of mania and depression in the same patient
at different times.

Classification of Bipolar affective disorder (BPAD)

Bipolar mood disorder is further classified into bipolar I and bipolar II disorder (DSMIV).
Bipolar I disorder
 In this the individual experiences, or has experienced, a full syndrome of severe manic and severe depression.

Bipolar II disorder
This diagnostic category is characterized by recurrent bouts of major depression with episodic occurrence of
hypomania.
Cyclothymic Disorder
 The essential feature of cyclothymic disorder is a chronic mood disturbance of at least 2-year 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.
 Cyclothymia refers to a persistent instability in mood in which there are numerous periods of mild elation or mild
depression.
Predisposing Factors/ Etiology [Bipolar Disorder (Mania)]
Biological Theories
Genetics
Research suggests that bipolar disorder strongly reflects an underlying genetic vulnerability. Evidence
from family, twin, and adoption studies exists to support this observation.
 The lifetime risk for the first-degree relatives of patients with bipolar mood disorder is 25% and of
normal controls is 7%.
 The lifetime risk for the children of one parent with mood disorder is 27%
 Both parents with mood disorder is 74%

1. Twin Studies
 Twin studies have indicated a concordance rate for bipolar disorder among monozygotic twins at 60 to 80
percent compared to 10 to 20 percent in dizygotic twins. ( Because monozygotic twins have identical
genes and dizygotic twins share only approximately half their genes, this is strong evidence that genes
play a major role in the etiology.)

2. Family Studies
 Family studies have shown that if one parent has bipolar disorder, the risk that a child will have
the disorder is around 27 percent.
  If both parents have the disorder, the risk is two to three times (74%).

Biochemical Influences
1.Biogenic Amines
 Symptoms of mania is associated with a functional excess of the amines i.e., norepinephrine
and serotonin.
2. Electrolytes
 Possible alterations in normal electrolyte transfer across cell membranes in bipolar disorder resulting in
elevated levels of intracellular calcium.
Physiological Influences
1. Neuroanatomical Factors
 Right-sided lesions in the limbic system, temporo-basal areas, basal ganglia, and thalamus have been
shown to induce secondary mania.
 Enlarged third ventricles is also present in bipolar patients.
2. Medication Side Effects
The most common of these are the steroids. Amphetamines, antidepressants, and high doses of
anticonvulsants and narcotics also have the potential for initiating a manic episode

Psychosocial Theories
The etiology of this remains unclear, however, and it is possible that both biological and psychosocial
factors (such as environmental stressors) are influential.
Psychoanalytic theory:
In this model, mania is viewed as a denial of depression.