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Lecturer on Psychiatry, Harvard Medical School Associate Professor Psychiatry, Boston University The pervasive feeling, tone, and internal emotional state of a person that, when impaired, can markedly influence virtually all aspects of the person's behavior or his or her perception of external events.
EUTHYMIC
DEPRESSION
 Sadness is a “normal” human condition Rapid Cycling
Unlikely to
consult MD
Hypomania
Euthymia
Dysthymia
 Fundamental difference is impairment in Likely to
consult MD
Unipolar
A one week period of abnormal and persistent Two weeks of five or more of the following and represent a change from previous functioning. At least one symptom is During this period of mood disturbance, three or either depressed mood or loss of interest or pleasure Depressed mood most of the day -- in older adults or children can be irritability Diminished ability to think or concentrate Recurrent thoughts of death or suicidal ideation These symptoms cause significant impairment in social, occupational or other important areas of function 20.9 million or 9.5% of the US population 18  14.8 million or 6.7% have MDD: F>M  5.7million or 2.6% have bipolar disorder  90% had a diagnosable mental disorder  Highest suicide rate in white men over age 85  Almost complete absence of residual symptoms  Return to a pre morbid level of function Patients with residual symptoms relapsed 3 times Relapse rates were 76 % in patients with residual symptoms as compared to 25% in patients with no 1: Judd et al J Affect Disord 1998: 50(2-3) 97-1082: Paykel et al: Psychological Medicine 1995 (25) 1171-80  Attributed to other psychiatric condition  Premature discontinuation of treatment  Psychosocial treatment not emphasized Psychiatrists focus on emotional and social May deny mood change, unless asked specifically Symptoms overlap those of medical illness Misunderstanding of regulatory guidelines Cultural factors often influence presentation  Recognizing mood disorder in non verbal Considerable overlap with medical comorbidity Non adherence with treatment is a major problem Treatment must continue for about nine months after remission Do some patients need “life time treatment”  Lack of faith in or understanding of treatment Severe, sudden, life-threatening episodes in past 3 yr.
Treatment must not be discontinued abruptly  Over thirty drugs available in the USA MOOD DISTURBANCE
 Minimal cardiac, cognitive or anticnolonergic All are well tolerated and safe in overdose  Fluoxetine can produce EPS when combined  Paroxetine must not be withdrawn abtuptly  Agitation, tremor, Hypertension, Seizures  Sertraline associated with diarrhea and rarely, titration,somnolence, dizziness, elevation of BP -- must monitor Balanced dual action (SER and NE) reuptake T1/2 12 hours: Metabolized by 2D6 1A2 Moderate inhibition 2D6 Disappointing results for severe depression MOOD DISTURBANCE
lithium carbonate
T 1/2 24 - 36 hours increased in renal disease First generation
Second generation
 Most antihypertensives (diuretics, ACE FIRST GENERATION: Major tranquilizers
 Decrease hyperarousal and impulsivity  Impair motor control (EPS, akinesia, rigidity) SECOND GENERATION: Atypical antipsychotics
 Decrease hyperarousal and impulsivity  Improve cognition (Increase PFC dopamine)  Minimal effect on extrapyramidal system  Minimal impact on tubero-infundibular system Known to occur with almost all antipsychotic drugs Possibly 5HT2c and H1 receptor antagonism At present ALL antipsychotic drugs have a potential Increased appetite within 3 wks of starting treatmentBaseline BMI (Lower BMI=Higher gain) All patients started on an antipsychotic drug should have Most evident in the young - little evidence of  Recheck at one month and once every three  Monitor at all times for S/S diabetes Increased risk of CVAE’s reported in elderly patients treated with some antipsychotics Glucose dysregulation and increased rates of insulin resistance noted in psychiatric patients Initially reported with risperidone but now also long before the introduction of antipsychotics1-4
Issue remains controversial -- numbers small Effects of antipsychotics on glucose metabolism known even before introduction of atypical Risk factors include diabetes, alcoholism, antipsychotics5
obesity, cardiac irregularities, prior CVA and concomitant use of benzodiazepines 1.Braceland RJ, et al. Am J Psychiatry. 1945;102:108-110. 2.Freeman H. Arch Neurol Psychiatry. 1946;56:74-78.
3.Langfeldt G. Acta Psychiatr Scand. 1952;80(suppl):189-200.
4.Lorenz WF. Arch Neurol Psychiatry. 1922;8:184-196.
5.Erle G, et al. Eur J Clin Pharmacol. 1977;11(1):15-18.
HYPO MANIA -- MANIA
DEPRESSION
ANTICONVULSANT
MOOD STABILIZER
ANTIPSYCHOTIC
MOOD STABILIZER

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