Mood Disorders: Identification and Management
Perry Dickinson, MD
University of Colorado
Department of Family Medicine
Copyright by The MacArthur Foundation

LECTURE OUTLINE
Background
Epidemiology, impact
Recognition
Risk factors
Types of mood disorders
Presentation and symptoms
Treatment

DEPRESSION IS COMMON
Major Depression (lifetime) - 10% of men; 20% of women
Most common mental disorder in primary care
Depressed patients visit primary care physicians 3 times more often than patients not depressed

DEPRESSION IS SIGNIFICANT
Associated with suicidality
Often recurs
Increased morbidity/mortality from medical conditions
Compounds disability and impaired function
Costs over $44 billion yearly

UNDER-RECOGNITION/
UNDERTREATMENT
50% of patients stop medication within first 3 months
30%-70% of depression is missed

BARRIERS TO RECOGNITION
Somatization - present with physical symptoms
Competing demands
Comorbidity - multiple problems
Stigma - social, insurance
Reimbursement; carve-outs
Discomfort with emotional issues
Insufficient training

RISK FACTORS FOR MOOD DISORDERS
First degree relatives with mood disorders (at least 3 times higher)
Gender - women twice as likely
Marital status - separated or divorced higher; married males lower; married females higher
Caretaking responsibilities
History of abuse, trauma
Economic hardship
Stressful events, loss

MAJOR TYPES OF MOOD DISORDERS
Major depression
Dysthymia
Minor depression
Bipolar disorder


MAJOR DEPRESSION
 Four Hallmarks:
Depressed mood
Anhedonia
Physical symptoms
Psychological symptoms

DEPRESSED MOOD
Hallmark 1
Neither necessary nor sufficient
Can be misleading
Beware of asking the question, “Are you depressed?”

ANHEDONIA
 Hallmark 2
Loss of interest or pleasure
May be most important and useful hallmark
“What do you enjoy doing?”

PHYSICAL SYMPTOMS
 Hallmark 3
Sleep disturbance
Appetite or weight change
Low energy or fatigue
Psychomotor retardation or agitation

PSYCHOLOGICAL SYMPTOMS
 Hallmark 4
Low self-esteem or guilt
Poor concentration
Suicidal ideation or persistent thoughts of death

DSM-IV CRITERIA FOR MAJOR DEPRESSION
Depressed mood or anhedonia
A total of 5 out of the 9 listed   symptoms
Symptoms that persist most of the day, nearly every day, for 2 weeks

DYSTHYMIA
Characterized by 2 years of depressed mood, occurring more days than not
Persists with at least 2 other symptoms of depression
Increases risk of major depression

MINOR DEPRESSION
Fewer symptoms than major depression
Shorter duration than chronic depression
Not well studied
However, significant disability
Treatment???

"Challenge to identify"
Challenge to identify
Presenting symptom usually depression
Characterized by episodes of mania or hypomania (pathologically elevated mood), along with depression
Depression in bipolar more recurrent & severe, more likely to have psychotic symptoms, increased suicide risk

"Potential risks from antidepressants"
Potential risks from antidepressants
May induce mania or hypomania
Can cause rapid cycling
Treated initially with lithium; antidepressant added cautiously later if depression continues
Generally need Psychiatry referral

MENTAL HEALTH REFERRAL
May be indicated when:
bipolar disorder
suicidality
questions about diagnosis
comorbid psychiatric conditions
lack of response to treatment
need for psychotherapy

TREATMENT
Pharmacotherapy
Psychotherapy
Psychosocial interventions

PHARMACOTHERAPY
Effective for major depression
Probably effective in dysthymia
Untested in minor depression

MEDICATION GUIDELINES
Titrate agent to achieve therapeutic dose or remission
Full effect may take 4-6 weeks
Treat for 4 to 9 months
Use maintenance medication for recurrent depressions

PROMOTING ADHERENCE
Inquire into prior use of antidepressants
Advise to take medication daily
Explain that it may take 2 to 4  weeks for therapeutic effects, longer for full effect
Advise patients to continue medication even if they feel better
Tell patients to call physician before stopping medication

ANTIDEPRESSANTS
 TRICYCLICS
  SSRIs
  citalopram (Celexa)
  fluoxetine (Prozac)
  paroxetine (Paxil)
  sertraline (Zoloft)

ANTIDEPRESSANTS
OTHER NEW AGENTS
 bupropion (Wellbutrin) - DA/NE
 mirtazapine (Remeron) -NE/5HT
 nefazodone (Serzone) - SRI/5HT
 venlafaxine (Effexor) - SRI/NRI

TRICYCLIC ANTIDEPRESSANTS
Equally effective as newer agents, at least for major depressive episodes
Side effects relatively common, bothersome
Adherence may be an issue
Certainly acceptable for use with selected patients
Start with low dosage and titrate q 3 - 7 days

ADVANTAGES OF SSRIs AND OTHER NEW AGENTS
Fewer side effects
Safety better
Increased patient satisfaction
Improved adherence to therapy
Adherence issues especially important in long term maintenance therapy

SUGGESTED MEDICATION ALGORITHM
Start with SSRI
Increase every 2 - 4 weeks prn
If no response, switch agents
If side effects, try to manage; switch agents if not improved
Continue treatment 4 - 9 months
If recurrent - may need maintenance
If elderly or comorbid panic or anxiety - start low, titrate slowly

MANAGING SSRI SIDE EFFECTS
Agitation/Insomnia
Use adjunctive sedating agent
Switch to mirtazapine, nefazodone
Sexual dysfunction
Switch to bupropion, mirtazapine, nefazadone
Add bupropion, sildenafil, yohimbe
Sedation - give medication at HS

SSRI SIDE EFFECTS
GI distress
Risk of peptic ulcer disease?
Give medication after meals
Consider peptic ulcer medication
Constipation - increase bulk in diet
Dry mouth - hard candy, liquids
Postural hypotension - hydration, change position slowly, support hose

SIDE EFFECTS 
(OTHER NEW AGENTS)
bupropion -   agitation, headache, lowered seizure threshold
mirtazepine - sedation, weight gain
nefazodone -  sedation
venlafaxine -  GI distress, elevated BP

PSYCHOTHERAPY
Effective for mild to moderate major depression
Useful adjunct to medication
Possibly effective in chronic and minor depression
Particularly useful when underlying psychosocial issues, abuse issues, family dysfunction, life transitions

PSYCHOSOCIAL INTERVENTIONS
(BY PRIMARY CARE PHYSICIAN)
Watchful waiting
Office counseling
Physician support

FOLLOW UP
Assess every 2 to 4 weeks
Use a severity tool to assess progress
Titrate dose for total remission
Maintain effective dose for 4 to 9 months (continuation phase)
Monitor for early signs of recurrence
Consider maintenance therapy

PARTIAL OR NO RESPONSE
Check for adherence
Re-evaluate diagnosis
Adjust dosage
Change medication
Add psychotherapy
Psychiatric consultation