MANAGEMENT OF

MOOD DISORDERS

1
Introduction
 Overall, the treatment of mood disorders is rewarding .
 Specific treatments are now available for both manic
and depressive episodes.
 Data indicate that prophylactic treatment is also
effective.
 Because the prognosis for each episode is good,
optimism is always warranted and is welcomed by
both the patient and the patient's family.
2
Cont’d…
 Treatment of patients with mood disorders
should be directed toward several goals.
First, the patient's safety must be guaranteed.

Second, a complete diagnostic evaluation of the

patient is necessary.
Third, a treatment plan that addresses not only the

immediate symptoms but also the patient's

prospective well-being should be initiated.
3
Cont’d…
 General clinical management includes
Explanation of the diagnosis

Treatment plan and objectives

Anticipated treatment period

Counselling and management of adherence and side

effects
Regular assessment of whether the treatment

objectives are being met.

4
MANAGMENT OF
DEPRESSION

5
Principles of Treatment and Management
of depression
 Treatment is divided into three phases
Acute phase
Continuation phase
Maintenance phase

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Acute phase
Goal
 To reach full symptom remission and restoration of full
function
 Full remission is associated with lower relapse rate .
To increase the chances of reaching remission

○ Patient adherence is essential and can be enhanced

by patient education and shared decision-making.

○ The routine use of symptom and side-effect rating

scales with a systematic plan to change doses.

7
 When initiating acute treatment, clinicians must elect the
best setting( e.g., inpatient or outpatient) guided by
1) An estimate of imminent suicidal risk
2) The capacity of patients to recognize and adhere to
recommendations.
3) The level of psychosocial support
4) Psychosocial stress and functional impairment.

8
Cont’d…
Type of treatment (the strategy)
 Type of treatment based on acceptability, severity,
acuity, seasonal pattern, and chronicity.
 Medication

 Psychotherapy

 Combination

 Electroconvulsive therapy (ECT)

 light therapy alone or in combination with medication or

therapy. 9
Cont’d…
Duration
 At least a 6-week trial is often useful, especially for those
with more severe, chronic, or complicated depressions.
 To ensure that the treatment has sufficient time to work.

 A suggested rule of thumb is that the treatment should

continue if at least a 25% reduction in initial symptom
severity is found at 4 to 6 weeks.

10
Continuation phase
 Aims to sustain those gains, thereby preventing the return of
the index episode.
 Patients who have the best prognosis in the continuation
phase have had the best acute phase outcome.

Type of treatment
 The same types and doses of medication are recommended.
 Early medication discontinuation is associated with higher
relapse rates than later medication discontinuation.

11
ont’d…
 Patients with chronic depression may continue to
improve during the medication continuation phase.
 Continuation phase medication treatment may end with
a gradual taper.
 Careful symptom assessment during and for several
months after discontinuation or entry into maintenance
phase treatment.
 For psychotherapy, the visits may be reduced in
frequency.
12
Cont’d…
 For ECT, medication monotherapy or combinations
are recommended for continuation phase treatment.
Overall its efficacy is about the same as lithium

combined with nortriptyline in a recent multisite study.

Duration of treatment
 Continuation treatment typically lasts 4 to 9 months.

13
Maintenance treatment
 Aims at preventing new episodes (recurrences).
 Maintenance medication has prophylactic efficacy.
 Typically, maintenance phase treatment is
indicated if there have been
At least two and certainly three or more

episodes, or if the index episode has been

chronic (>2 years).
14
Cont’d…
 If only two episodes, the following, point toward a higher
likelihood recurrence.
Poor interepisode recovery between the two episodes.

The presence of two episodes within the last 3 years.

Positive family history for recurrent major depressive

or bipolar disorder.
• Maintenance treatment for at least 5 years for those with

highly recurrent depressions

 Early intervention shortens the length of the new
15
Choosing among Medications

 The available antidepressants differ in

Their pharmacology

Drug–drug interactions

Short- and long-term side effects

likelihood of discontinuation symptoms

Ease of dose adjustment.

 They do not differ in overall efficacy, speed of

response, or long-term effectiveness. 16
Antidepressant Medications

5-HT Reuptake Inhibitors Common Side Effects

Fluoxetine ( 10–40mg) All SSRIs may cause

insomnia, agitation, sedation,
Sertraline ( 50–150mg) GI distress, and sexual
dysfunction

• Many SSRIs inhibit various cytochrome P450 isoenzymes.

• Dosing is less complicated
• Better tolerated than TCAs
• Have high safety in overdose.
• Shorter half-life SSRIs may be associated with
discontinuation
symptoms when abruptly stopped. 17
t’d…
Amitriptyline (75–300mg) Drowsiness, OSH, CA,
weight ↑, anticholinergic
Imipramine (75–300mg ) Drowsiness, insomnia and
agitation, OSH, CA, GI
distress, weight ↑,
anticholinergic
• Overdose may be fatal.
• Dose titration is needed
• TCAs account for a greater percent of completed suicides
than the newer agents.
• TCAs typically are started at lower doses

18
Selecting Initial Treatments
 About 45 to 60% of outpatients respond to medication or
psychotherapy or a combination of the two.
 i.e., achieve at least a 50% reduction in baseline

symptoms
 At least 1/2 of patients should anticipate a second
treatment trial
i.e., if the initial treatment is poorly tolerated or

ineffective.
19
d…

 Selecting among the initial treatments (medication,

psychotherapy, the combination, or ECT) depends on
Prior course of illness and treatment response

Family history of illness and treatment response

Symptom severity

The presence of concurrent general medical or other

psychiatric conditions
Potential drug–drug interactions

Patient preference
20
Selecting Second Treatment Options
 For those initially receiving medication, common options
are .
Adjusting the dose

Extending the period of the trial

Switching to an alternative treatment (either

medication or psychotherapy)
Augmenting the current treatment with another

 Factors recommending dose escalations are

21
ont’d…
2) A prior history that is consistent with rapid drug metabolism

3) Low therapeutic blood levels

4) Partial benefit at lower doses

 Extending the initial trial further is indicated if

1) The initial trial is less than 6 weeks

2) There is a partial response (≥25 % reduction in

pretreatment depressive symptom severity) by 6 weeks

3) Prior medication trials have been unsuccessful and shorter

than 6 weeks.
22
Cont’d…
 Augmenting – lithium and thyroid hormone
For those who have not benefited sufficiently from
several single treatment trials.
Response occurs in 2-4 week.
How long to continue augmentation is not clear
Preferred with patients who have gained some benefit
with the initial treatment
• Switching
For those with only one or two prior treatment attempts
No meaningful benefit from the initial treatment, or
cannot be tolerated

23
Timely Declaration of Treatment Failures
 If less than a 20 % to 25% symptom reduction has occurred at 6
weeks, then a treatment change is likely needed.
 Slow metabolizers encounter side effects earlier in treatment or at
lower doses.
 Patients may not respond to a medication, because

1) They cannot tolerate the side effects even in the face of

good response

2) An idiosyncratic adverse event may occur

3) The clinical response is not adequate

24
’d…
 Some side effects are dose dependent (e.g., sedation) and
can be reduced by decreasing the dose or slowing the rate
of dose escalation.
 Some side effects are less dose dependent, and tolerance
to them is less likely (e.g., orthostatic hypotension)
A change in treatment is often indicated.

 Moderate side effects, when encountered

Argue for withholding further dose escalations and

allowing time for physiological adaptation, which often

results in fewer side effects.
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 MANAGMENT OF
BIPOLAR DISORDERS

26
History
 The treatment of bipolar disorder has changed markedly from
that of the middle and late 1990s and is still rapidly evolving.
 Lithium and its augmentation by antidepressants,
antipsychotics, and benzodiazepines had been the major
approach to the illness.
 Now, three anticonvulsant mood stabilizers,
carbamazepine , valproate , and lamotrigine , have been
added, as well as a series of atypical antipsychotics.

27
Acute treatment
1. Manic or mixed episodes
 The primary goal
Control of symptoms to allow a return to normal

levels of psychosocial functioning.

The rapid control of agitation, aggression, and

impulsivity is particularly important to ensure the

safety of patients and those around them.

28
Cont’d…
Indication for hospitalization
 Suicidal or homicidal risk
 Severely ill without social support
 Significantly impaired judgment
 Medical complications
 Who not respond for out patient treatment

29
nt’d…

First-line pharmacological treatment

 Initiation of either lithium or valproate plus an antipsychotic.
 Severely ill or agitated patients may require short-term
adjunctive treatment with a benzodiazepine
 For less ill patients
 Monotherapy with lithium, valproate, or an antipsychotic

such as olanzapine may be sufficient.

 Anti depressant must be tapered and discontinued.

30
Cont’d…
 For patients who, despite receiving the aforementioned
medications, experience syptoms (i.e., a “breakthrough”
episode)
The first-line intervention should be to optimize the

medication dose.
Introduction or resumption of an antipsychotic is often

necessary.
Addition of another first-line medication.

Alternative treatment options include adding carbamazepine

or oxcarbazepine 31
Cont’d…

 ECT may also be considered

For patients with severe or treatment-resistant illness

is
 During pregnancy.

 Patients displaying psychotic features during a manic

episode
Require antipsychotic medication.

 Atypical antipsychotics are favoured because of their

more benign side effect profile. 32
Cont’d…

• With adequate dosing and serum levels, medications

for the treatment of mania generally exert some

appreciable clinical effect by the 10th to the 14th day of
treatment.

33
nt’d…

Mood stabilizers

Lithium
 Typical clinical features of manic patients responding to
lithium;
Classic euphoric mania than dysphoric

Fewer prior episodes & non-rapid cycling course

No co-morbid anxiety or substance abuse

Family history of affective illness , especially with good

34
 Lithium is usually started in low, divided doses to minimize
side effects
E.g., 300 mg t.i.d. or less, depending on the patient’s

weight and age, with the dose titrated upward .

 level of 0.9 mEq/l (minimum) to 1.4 mEq/l (limit above
which toxicity outweighs benefit)
 Its onset of action is relatively slow
Clinical improvement usually occurring over the first 1 to

3 weeks of treatment
35
ont’d….
Valporate
 Typical dose level 750-2500mg/day.
 Rapid oral loading with 15-20mg/kg was tolerated & associated with
rapid response.
 Blood level to be achieved is between 50-120ug/ml.
 Response has been shown in patients;
With dysphoric mania

With history of lithium non-response

Rapid cyclers , substance abusers and co morbid anxiety disorders.

36
Cont’d….

Carbamazipine
 Typical dose for mania is between 600-1800mg/day with blood
level ranging between 4-12 ug/ml.
 There is great individual variation with dose & side effect.
 Response to carbamazepine seen in;
Patients with a negative family history

Those with comorbid anxiety and substance abuse.

Schizoaffective presentations with mood-incongruent

delusions.
37
Cont’d…

Combination of a Mood Stabilizer and an

Atypical Antipsychotic
 This approach is associated with a more rapid onset
and higher remission rates and response rates (60 to
80 %)
Than with mood stabilizers alone ( 50 %) or with

the atypical antipsychotics alone (about 50 %).

38
nt’d…

2) Bipolar depression
 The first-line pharmacological treatment
Initiation of either lithium or Valporate.

• Alternative approaches if 1st line fails

1) Optimizing the dose of the current mood stabilizer

regimen.

2) Augmenting with triiodothyronine (T3), lithium, or

folate.

39
 3) Adding another mood stabilizer.

4) Using or adding an atypical antipsychotic.

5) ECT
 Antidepressant monotherapy is not recommended .

 Depressive episodes with psychotic features usually

Require adjunctive treatment with an antipsychotic

medication .
 ECT represents a reasonable alternative.
40
…

 Switching into a hypomanic episode with anti

depressant is probably lower in patients with bipolar
II depression.
Antidepressant treatment is recommended earlier

in patients with bipolar II disorder .

• Interpersonal therapy and cognitive behaviour therapy

may be useful.

41
Cont’d….

3) Rapid cycling
 The initial intervention
Identify and treat medical conditions, such as hypothyroidism

Drug or alcohol use.

Discontinue antidepressants.

 The initial pharmacotherapy

Valproate or lithium

 An alternative treatment is lamotrigine.

 For many patients, combinations of medications are required.

42
 Maintenance treatment
 Following remission of an acute episode, patients may
remain at particularly high risk of relapse for a period of
up to 6 months.
This phase of treatment, sometimes referred to as

continuation treatment.
• If one of the medication used achieved remission from
most resent episode, it should be continued during
maintenance.
43
nt’d…
 Primary goal is :
Relapse prevention

Reduction suicide risk

Reduction of cycling frequency & mood instability

Improvement in over all function

 Drugs used for maintenance treatment are

Lithium or valproate

Alternatives like

○ Carbamazepine, lamotrigine, oxcarbamazepine

○ Atypical antipsychotics like : olanzapine , quantiapine.

44
Cont’d…

Lithium prohylaxisis
 Markedly decreases the frequency, the severity, and the duration of
manic and depressive episodes.
 Provides relatively more effective prophylaxis for mania than for
depression.
 Is almost always indicated
After the second episode of bipolar I disorder, depression or mania

After the first episode for adolescents

 For persons who have a family history of bipolar I disorder.

45
t’d…

 Others who benefit from lithium maintenance are those

who
Have poor support system, had no precipitating factors for

the first episode

Have a high suicide risk

Had a sudden onset of the first episode

had a first episode of mania

 Lithium is also effective treatment for persons with

severe cyclothymic disorder.
46
Cont’d…
• Blood level maintained b/n 0.5 – 0.8 meq/l ; in lower

levels greater relapse rate seen.

• Thyroid augmentation especially with T3 may improve

cognitive function.
 Laboratory monitoring
Serum lithium level: every 1- 2wks in the 1st 2 months,

then every 3 – 6 months

Thyroid function test and renal function tests every 6 –

12 months
47
Cont’d…

Valproate prophylaxis
• Alone or in addition to lithium.

• Is found effective in lithium or carbamazepine refractory

patients.
 Laboratory monitoring
Serum level every 1 – 2 wks & CBC & LFT monthly for

the first 2 months

Later serum level every 3 -6 months

CBC & LFT every 6 – 12 months

48
’d…

Carbamazepine
 Better response seen in bipolar II, rapid cycling,
dysphoria, substance abuse.
 Laboratory monitoring
Serum level every 1 – 2 wks & CBC, LFT monthly in the

1st 2 months of treatment

Later serum level every 3 – 6 months & CBC , LFT

every 6 – 12 months.

49
 Psychosocial treatment
• Concomitant psychosocial interventions addressing:
Adherence , life style changes , early detection of

prodromal symptoms and Interpersonal difficulties

 Psycho education to patients & family about the illness
has shown to be effective in medication compliance
 Family therapy ,Group psychotherapy
 CBT has shown in some to be effective in preventing
relapse.
50
 Special considerations
Pregnancy
 Many of the drugs are associated with birth defects
 lithium – CV defect, Ebstein anomaly

Valproate – NTD ,craniofacial & limb abnormality

Carbamazepine – craniofacial defects, NTD

 Options of treatment are

Continuing medication through out pregnancy

Discontinue medication before conception or only for the first

trimester 51
t’d…
 Risk benefit assessment should be made.
 Patient should be informed on both consequences of
continuing or discontinuing medications.
 ECT is a potential treatment during pregnancy.
 Prenatal monitoring : for those who choose to be on
treatment , check :
Alpha feto protein for NTD before 20 wks of gestation

High resolution U/S at 16 -18wk for cardiac defect

Serum levels of medications should be monitored

52
Cont’d…

Postpartum issues
 Discontinuing mood stabilizers is unwise due to increased
risk of mood episodes( 50%)
 Advice maintaining normal sleep pattern to avoid episodes.
 Studies suggest lithium / valproate prophylaxis may prevent
post partum episodes.
 All medications of bipolar disorder are secreted into the breast
milk but we should out weigh benefits of breast feeding.
 Not much studies showing specific S/E .
53
ont’d…

Geriatrics
 Similar Rx with young adults but lower doses because:
Decreased renal clearance & volume distribution

Concomitant medical condition & medications may

alter metabolism & excretion

May be sensitive to S/E.

May tolerate only low serum level of lithium ( 0.4-

0.6meq/l) & respond to this level

54
Reference
 Kaplan & Sadock's Comprehensive Textbook of
Psychiatry, 9th Edition.
 Kaplan & Sadock's Synopsis of Psychiatry: Behavioral
Sciences/Clinical Psychiatry, 10th Edition.
 The American Psychiatric Association (APA) Practice
Guidelines, Practice guideline for the treatment of
patients with bipolar disorder, second edition.

55
Thank you!!!

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