Psychiatry

Medical Knowledge
What are the types of mood disorder??
Medical Knowledge

Mood Disorders
DEPRESSION BIPOLAR ANXIETY
 1- Depressive disorder
DSM 5 definition;
• Major Depressive Disorder (MDD) is a medical illness that affects how you feel, think and behave
causing persistent feelings of sadness and loss of interest in previously enjoyed activities.
• Depression can lead to a variety of emotional and physical problems.
• It is a chronic illness that usually requires long-term treatment.

Prevalence
• Lifetime prevalence for adolescents: 15% to 20%.
• 2:1 ratio of girls to boys in adolescence.
 Etiology of Depression
– Genetic factors (Family history)

– Biochemical factors
Neurotransmitters in the brain — specifically serotonin, dopamine, or norepinephrine — affect feelings
of happiness and pleasure and may be out of balance in people with depression.

– Hormonal factors
Changes in hormone production or functioning could also lead to the onset of depressive states. Any
changes in hormone states — including menopause, childbirth, thyroid problems, or other disorders —
could cause depression.
 Etiology of Depression (Cont.)
– Seasonal factors
As the daylight hours get shorter in the winter, many people develop feelings of lethargy, tiredness, and a
loss of interest in everyday tasks.
It is called seasonal affective disorder, or SAD, this condition usually goes away once the days get longer.

– Situational factors
Any time of trauma, big change, or struggle in life can trigger a case of depression. Losing a loved one,
being fired, having financial troubles, or undergoing a serious change can have a big impact on people.
How can you diagnose depression??
 Diagnosis of Depression
DSM-5 sets 5 criteria:

A. 5+ symptoms present in same 2-week period, where at least one symptom is… depressed mood or loss of interest or pleasure.

The rest of the symptoms may include:

– Depressed mood most of the day nearly every day.
– Diminished interest/pleasure in all or almost all activities most of the day nearly every day.
– Weight loss, weight gain, decrease/increase in appetite.
– Insomnia/hypersomnia.
– Psychomotor agitation/retardation.
– Fatigue or loss of energy.
– Feelings of worthlessness or excessive or inappropriate guilt.
– Diminished ability to think or concentrate, or indecisiveness.
– Recurrent thoughts of death, recurrent suicidal ideation, suicide attempts, or suicide plans.
 Diagnosis of Depression (Cont.)
B. Symptoms cause clinically significant distress or impairment in social, occupational, or other important areas
of functioning

C. The episode is not due to the effects of a substance or to a medical condition

D. The occurrence is not better explained by schizoaffective disorder, schizophrenia, schizophreniform disorder,
delusional disorder, or other specified and unspecified schizophrenia spectrum and other psychotic disorders

E. There has never been a manic episode or a hypomanic episode

What are the types of depression??
 Classification of Depression
1- Major depressive disorder (MDD) commonly called major depression, unipolar depression, or clinical depression,
wherein a person has one or more MDD episodes.
After a single episode, Major Depressive Disorder (single episode) would be diagnosed.
After more than one episode, the diagnosis becomes Major Depressive Disorder (Recurrent). 

2- Melancholic depression is characterized by…

a loss of pleasure (anhedonia) in most or all activities,
a failure of reactivity to pleasurable stimuli,
a quality of depressed mood more pronounced than that of grief or loss,
a worsening of symptoms in the morning hours, early-morning waking, 
Psychomotor retardation,
excessive weight loss, or
excessive guilt.
 Classification of Depression (Cont.)
3- Psychotic major depression (PMD), or simply psychotic depression, is the term for…
a major depressive episode, in particular of melancholic nature, wherein the patient experiences psychotic symptoms such
as delusions or hallucinations.

4- Catatonic depression is a rare and severe form of major depression involving disturbances of motor behavior and other
symptoms.
Here, the person is mute, and either is immobile or exhibits purposeless or even bizarre movements.

5- Postpartum depression (PPD), it refers to the intense, sustained and sometimes disabling depression experienced by
women after giving birth.
It affects 10–15% of women, typically sets in within three months of labor, and lasts as long as three months.
In the treatment of postpartum major depressive disorders and other unipolar depressions in women who are breastfeeding, 
nortriptyline, paroxetine (Paxil), and sertraline (Zoloft) are in general considered to be the preferred medications.
 Classification of Depression (Cont.)
6- Seasonal affective disorder (SAD), also known as "winter depression" or "winter blues", is a specifier.
Some people have a seasonal pattern, with depressive episodes coming on in the autumn or winter, and resolving in spring. 

7- Dysthymia is a condition related to unipolar depression, where the same physical and cognitive problems are evident,
but they are not as severe and tend to last longer (usually at least 2 years).

8- Depressive Disorder Not Otherwise Specified (DD-NOS) According to the DSM-IV, DD-NOS

encompasses "any depressive disorder that does not meet the criteria for a specific disorder.

9- Depressive personality disorder (DPD) is a controversial psychiatric diagnosis that denotes a personality

disorder with depressive features.
 Classification of Depression (Cont.)
10- Recurrent brief depression (RBD), distinguished from major depressive disorder primarily by differences in
duration.
People with RBD have depressive episodes about once per month, with individual episodes lasting less than two
weeks and typically less than 2–3 days. 

11- Minor depressive disorder or simply minor depression, which refers to a depression that does not meet full
criteria for major depression but in which at least two symptoms are present for two weeks.
Terminology Depression course

• Patient Response 50% Improvement

4 – 9 months
• Patient remission 100% Improvement
> 12 months
• Patient recovery 100% Improvement
4 – 9 months
• Patient Relapse Depression
> 12 months
• Patients Recurrence Depression

• Untreated patients recover after 6 – 24 months.

Illustrate the depression five Rs??
How can you rate Depression ?????
 Depression rating scales
– MADRs scale, Montgomery–Åsberg Depression Rating Scale
– HAM-D scale , Hamilton Rating Scale for Depression
– HARSD-17, Hamilton Rating Scale for Depression (17 item)
– SDS, Shehaan Disability Scale
 3- Anxiety disorder
‒ It is a group of mental disorders characterized by feelings of anxiety and fear.
‒ Anxiety is a worry about future events and fear is a reaction to current events.
‒ These feelings may cause physical symptoms, such as a fast heart rate and shakiness.
‒ There are a number of anxiety disorders: including…
generalized anxiety disorder, specific phobia, social anxiety disorder,  agoraphobia and panic
disorder.
People often have more than one anxiety disorder.
 Etiology of Anxiety
– Genetic factors (Family history)

– Environmental factors
Poverty,
Child abuse or
Life stresses such as financial worries or chronic physical illness.

– Medical conditions
Occasionally, an anxiety disorder may be a side-effect of an underlying endocrine disease that causes
nervous system hyperactivity, such as hyperthyroidism.
Etiology of Anxiety (Cont.)
– Drugs
Anxiety and depression can be caused by alcohol abuse, which in most cases improves with prolonged abstinence.
Even moderate, sustained alcohol use may increase anxiety levels in some individuals.
Caffeine and benzodiazepines dependence can worsen or cause anxiety and panic attacks.

– Anxiety disorders often occur with other mental disorders (comorbidity),

particularly major depressive disorder, personality disorder, and substance use disorder.

Anxiety disorders often occur along with other mental disorders, in particular depression, which may occur in as
many as 60% of people with anxiety disorders.
The fact that there is considerable overlap between symptoms of anxiety and depression, and that the same
environmental triggers can provoke symptoms in either condition, may help to explain this high rate of comorbidity.
What are the types of anxiety??
 Classification of Anxiety
1- Generalized anxiety disorder
(GAD) is a common disorder, characterized by long-lasting anxiety that is not focused on any one object or situation.
Those suffering from generalized anxiety disorder experience non-specific persistent fear and worry, and become
overly concerned with everyday matters.
Generalized anxiety disorder is "characterized by chronic excessive worry accompanied by three or more of the
following symptoms: restlessness, fatigue, concentration problems, irritability, muscle tension, and sleep
disturbance".

– Diagnosis of GAD…
When a person has been excessively worried about an everyday problem for six months or more.
Appearance looks strained, with increased sweating from the hands, feet, and axillae,
and they may be tearful, which can suggest depression.
Obsessive Compulsive Disorder OCD

O.C.D is recurrent and persistent ideas, thoughts, impulses or images

(obsessive) that are repetitive, purposed and intentional behavior
(compulsive) that are recognized by the person as excessive or unreasonable.
Panic
Disorder

Panic disorder is an anxiety disorder. When panic attacks occur repeatedly,

without warning. These attacks can happen many times every day or every
week. People with this disorder mighty worry about having these attacks
throughout the day. It can interfere with work and personal life.
Panic attack is defined as a discrete period of intense fear or discomfort
accompanied by somatic and psychic symptoms. The attack has a sudden onset
and rapidly builds to a peak (usually in 10 minutes or less). It is accompanied by
a sense of imminent danger or impending doom and an urge to escape.
 Social Anxiety Disorders (SAD)

Excessive inappropriate fears connected with social or performances in

front of other people.
Excessive distressing
Avoidance of social situations
Palpitation
Sweating
Blushing

The anxiety of exposure

Agoraphobia: multiple intense fear of crowds, public places and other
situations that require separation from a source of security.
 post-traumatic stress disorder
Post-traumatic stress disorder (PTSD) is NO longer an anxiety disorder.

– Post-traumatic stress can result from an extreme situation, such as combat,

natural disaster, rape, hostage situations, child abuse, bullying, or even a serious
accident.
– It can also result from long-term (chronic) exposure to a severe stressor, for
example…
soldiers who endure individual battles but cannot cope with continuous battle.

– Common symptoms include…

hypervigilance, flashbacks, avoidant behaviors, anxiety, anger and depression. 
Charlie Chaplin workshop
Comorbidity of anxiety disorders
Comorbidity of depression & anxiety

48% of patients with PTSD1 Up to 65% of patients with Panic Disorder2

Post-Traumatic
Panic
Stress Disorder
Disorder

DEPRESSION
Social
Anxiety GAD
Disorder OCD

Up to 70% of patients with 67% of patients with 42% of patients with

Social Anxiety Disorder5 Obsessive-Compulsive Generalised Anxiety
Disorder4 Disorder3

1
Kessler et al, Arch Gen Psychiatry 1995; 2 DSM-IV-TR™ 2000; 3 Brawman-Mintzer et al, Am J Psychiatry 1993;
4
Rasmussen et al, J Clin Psychiatry 1992 ; 5Dunner, Depression and Anxiety 2001
What is the goal of depression
treatment??
 Treatment of depression

Goal of MDD treatment:

– Remission is the main goal of depression treatment.
If a depression treatment completely relieves patient’s depressive symptoms it will be
less likely to have a depression relapse in the future.
– Treatment should restore the pre-depression functioning.
Depression pharmacological and non pharmacological
treatment??
 Non-pharmacological treatment
1- Psychotherapy (known as talk therapy or psychological therapy)
‒ Different types of psychotherapy can be effective for depression.
Examples: Cognitive-behavioral therapy (CBT) & Interpersonal therapy (IPT)

2- Electroconvulsive therapy (ECT) 

‒ Electrical currents are passed through the brain.
‒ It is performed under anesthesia, this procedure is thought to impact the function and effect of
neurotransmitters in your brain and typically offers immediate relief of even severe depression.

3- Trans-cranial magnetic stimulation (TMS) 

‒ A coil sends brief magnetic pulses to stimulate nerve cells in the brain that are involved in
mood regulation and depression.
 Pharmacological treatment
Most antidepressants have similar rates of efficacy overall and time to onset of effectiveness (eg, they
all require 4-6 weeks to achieve maximum therapeutic benefit), but differ in terms of side-effect
profiles.

1- Tricyclic antidepressants (TCAs)

The first generation of antidepressants
Examples: imipramine (Tofranil), amitriptyline, clomipramine (Anafranil), doxepin, nortriptyline, and
desipramine.
• Common side effects include…blurred vision, dry mouth, constipation, difficulty urinating,
drowsiness, weight gain (exceeding 13 lbs. on average), and sexual dysfunction.
• If taken in excess can cause death.
• Side-effect profile is difficult to handle.
2- Monoamine oxidase inhibitors (MAOIs)

 
Examples: phenelzine (Nardil) and tranylcypromine
• The class is used infrequently due to its potential for severe, often life-threatening interaction with
other substances.
• MAO are responsible for breaking down tyramine, foods that contain this amine must be
avoided or the patient risks a life-threatening hypertensive crisis "cheese effect."
• MAOIs interact negatively with many common over-the-counter medications.
• Other common side effects of MAOIs include…sedation, weight gain, and orthostatic hypotension.
 3- SSRIs
Selective serotonin reuptake inhibitors
The main benefit of SSRIs when compared with the TCAs is that the side-effect profile is often milder.
Common side effects include…
decrease in appetite, nausea, sexual side effects, and headaches.

• Citalopram, Cipram “Depram”

• Escitaolpram, Cipralex, xygarot
• Paroxetine, Seroxate CR
• Fluoxetine, Prozac
• Sertraline, Lustral “Moodapex”
• Fluvoxamine, Faverin
SSRIs mode of action
 4- SNRIs
Serotonin-norepinephrine reuptake inhibitors
It used to treat major depressive disorder, anxiety, and panic disorder.

Side Effects:
Nausea, drowsiness, dizziness, dry mouth, constipation, loss of appetite, blurred vision,
nervousness, trouble sleeping & unusual sweating.

• Venlafaxine, Efexor XR
• Des-venlafaxine, Pristiq
• Duloxetine, Cymbalta
SNRIs mode of action
 5- NASSA
Noradrenergic & specific serotonergic antidepressants

It has faster onset of antidepressant action when compared to SSRIs.

Side effects:
decreased appetite, weight loss, insomnia, nausea and vomiting, diarrhea, urinary
retention, increased body temperature, excessive sweating, pupil dilation and sexual
dysfunction.
It may cause a withdrawal syndrome upon discontinuation.

• Mirtazapine, Remeron
NASSA mode of action
 6- NDRIs
Norepinephrine-dopamine reuptake inhibitors

• Used for depression, seasonal affective disorder (SAD) and also smoking cessation.
• It's one of the few antidepressants not frequently associated with sexual side effects.
Examples include Bupropion, Wellbutrin
Newer antidepressants:
Include vortioxetine (Brintellix) and vilazodone (Viibryd).
Vilazodone is thought to have a low risk of sexual side effects.
vortioxetine blocks SERT (serotonin transporter), 5-HT3, 5-HT1D and 5-
HT7 receptors, stimulates 5-HT1A receptor, and partially stimulates the
5-HT1B receptor.
it increases serotonin concentrations in the brain by inhibiting its
reuptake in the synapse, and by modulating (activating certain
receptors while blocking, or antagonizing, others) certain
serotonin receptors.
 Introduction
•Depram: Citalopram
on the SSRI class of antidepressants.
Forms: Depram 20mg, 40mg
Indications:
Depression
Anxiety
Somatization
Premature Ejaculation.
 Pharmacokinetics
Absorption is rapid following oral administration
( t max= 2-4 hr) peak plasma conc. after 2-4 hrs post-dose.


Steady-state plasma levels are achieved after 1 week with linear pharmacokinetics …. No Dose titration.

 Plasma levels are independent of age (18-65) … High Safety for elderly patients.

 Food has no effect on absorption High Compliance.

 T ½ =35 hours ….. Once Daily Dosing.

Limited hepatic first-pass metabolism.

80% bioavailability
 Depram pharmacokinetics

Depram (40 mg citalopram) pharmacokinetics

is virtually the same as a 20 mg dose of
escitalopram .

 No risk of accumulation.

 No risk of withdrawal symptoms.

STEPS: Factors to Consider in SSRI Selection

Safety
Drug-drug interaction potential-Selectivity

Tolerability
Acute and long term

Efficacy
Onset of action
Treatment and prophylaxis
Activity in subpopulations
Payment
Cost effective
Simplicity
Dosing
No need for titration
 Depram is the Most Selective Among SSRIs:

5H
T
2C
NRI

SSRI SRI SSRI SRI  SSRI SRI

CY
P
1A

CY
6

CY
2

2D
Citalopram

P
P
P

3A
3A
CY

4
4
m-A NRI
Fluoxetine Fluvoxamine
C h
DRI
SSRI SRI
S
NO
 SSRI SRI
D6
P2
CY

Paroxetine Sertraline
Adapted from Stahl, July 1998 59
 Selectivity of Antidepressants

3500

(IC50 NA Uptake/ (IC50 5-HT Uptake)

3000
Serotonin (5-HT) Selectivity

2500

2000

1500

1000

500

0
Citalopram Sertraline Paroxetine Fluvoxamine Fluoxetine

Adapted from Hyttel et al., 1995 60

Depram safety:

 No anti cholinergic S.E ( blurred vision , urine

retention , constipation.
No adrenergic S.E (postural hypotension sedation
dizziness ).
No antihistaminic S.E (body weight , increase
appetite, drowsiness ).
No anti dopaminergic S.E ( sedation).
Challenges in Pharmacological
treatment of SSRIs

 GIT, CNS and sexual side effects

 Activation and sedation side effects

 Weight gain

 Drug-drug interactions

 Discontinuation syndrome
 *GI Side-Effects With Antidepressants

Citalopram

Fluoxetine
SSRIs

Fluvoxamine

Paroxetine

Sertraline

Bupropion
Others

Nefazodone

Venlafaxine
0
10 20 30 40 50 60
Total % Reporting Side-Effects
*Placebo - Adjusted Rates
Dewan & Anand. J Nerv Ment Dis 1999;187: 96-101. 63
 Spectrum of SSRI CNS Effects
Activation vs. Sedation

Sedating Activating
Paroxetine Sertraline

Fluvoxamine Citalopram Fluoxetine

Adapted from CANMAT1 and side effect incidence of each product as reported in
the Compendium of Pharmaceuticals and Specialties 2

1
CANMAT: Guidelines for the Diagnosis and Pharmacological Treatment of Depression, First Edition 1999.
2
Compendium of Pharmaceuticals and Specialties (CPS, 36th ed. Canadian Pharmacists Association, 2001).

Reesal R. Diagnosis 2001 64

SSRIs and Weight Gain ≥ 7% Weight Gain Over Six
Months
30
% Ppatients with  7% 25.5%
Weight Gain

20

10
6.8%
3.9% 4.2%

0
Citalopram Fluoxetine Paroxetine Sertraline

Fava M. Weight gain and antidepressants. J Clin Psychiatry 2000;61 Suppl 11:37-41
65
 Comparison of SSRIs’ Cytochrome P450
Inhibition in in-vitro and in-vivo Studies

Cytochrome P450 enzyme (in vitro and in vivo data)

Antidepressant 1A2 2C19 2D6 3A4
Citalopram 0 +° +° 0

Fluoxetine +0(+) ++ ++++ (++++) ++ (+++)

Fluvoxamine ++++ ++ 0 +++

Paroxetine 0 0 ++++ 0
Sertraline 0 ++ (++) + (++) ++ (++)

0 Unknown or insignificant effect +++ Moderate and usually significant

+ Mild and usually insignificant ++++ Potent (effect of a metabolite
++ Moderate and possibly significant is shown in parentheses)

 Adapted from DeVane 1998 66

 Common Drugs Affected by Inhibition
of the CYP450 System

1A2 2C19 2D6 3A4

Theophylline Phenytoin Codeine Calcium-channel
Warfarin Warfarin Venlafaxine blockers
Olanzapine Amitriptyline Trazodone Carbamazepine
Clozapine Clomipramine Risperidone Cisapride
Benzodiazepines Omeprazole Haloperidol Corticosteroids
Fluvoxamine ß-blockers
Caffeine Amitriptyline
Nortriptyline Protease inhibitors
Imipramine Statins
Desipramine Quetiapine
Sildenafil

Michalets, Pharmacotherapy. 1998, Cupp & Tracy. Am Fam Physician, 1998 67

 Antidepressant Risk of Discontinuation Syndrome

High Moderate Low

Paroxetine Fluvoxamine Citalopram
Fluoxetine
Sertraline

• Tricyclic antidepressants, MAOIs and venlafaxine:

 high risk for discontinuation syndrome

.Reesal R. The Canadian Journal of Diagnosis, Nov 1999

68
Depram psychiatry campaign
What is seasonal affective disorder (SAD)?
• Seasonal affective disorder (SAD) is a form of
depression that people experience at a particular time
of year or during a particular season. It is a recognized
mental health disorder.
What are the winter blues?
• seasonal symptoms are fairly mild and usually concentrated in the
middle of the winter – December, January and February. These
symptoms are often known as the ‘winter blues’, or sub-syndromal
SAD.
What are the
common
signs of
SAD?
What causes SAD?
What treatments are available for SAD?
How to beat
SAD?
Non psychiatry campaign
PSYCHOLOGICAL IMPACT AND
ATTITUDES (cont.)
PSYCHOLOGICAL IMPACT AND
ATTITUDES
THANK YOU