Mood disorders
This chapter discusses disorders characterized by abnormalities of mood: namely, depression,
mania, or both. Included here are descriptions of a wide variety of mood disorders that occur over a
broad clinical spectrum. Also included in this chapter is an analysis of how monoamine
neurotransmitter systems are hypothetically linked to the biological basis of mood disorders. The
three principal monoamine neurotransmitters are norepinephrine (NE; also called noradrenaline or
NA), discussed in this chapter, dopamine (DA), discussed in , and serotonin (also calledChapter 4
5-hydroxytryptamine or 5HT), discussed in .Chapter 5
The approach taken here is to deconstruct each mood disorder into its component symptoms,
followed by matching each symptom to hypothetically malfunctioning brain circuits, each regulated by
one or more of the monoamine neurotransmitters. Genetic regulation and neuroimaging of these
hypothetically malfunctioning brain circuits are also discussed. Coverage of symptoms and circuits of
mood disorders in this chapter is intended to set the stage for understanding the pharmacological
concepts underlying the mechanisms of action and use of antidepressants and mood stabilizing
drugs, which will be reviewed in the following two chapters ( and ).Chapters 7 8
Clinical descriptions and criteria for how to diagnose disorders of mood will only be mentioned in
passing. The reader should consult standard reference sources for this material.
Description of mood disorders
Disorders of mood are often called affective disorders, since affect is the external display of mood,
an emotion that is felt internally. Depression and mania are often seen as opposite ends of an
affective or mood spectrum. Classically, mania and depression are "poles" apart, thus generating the
terms depression (i.e., patients who just experience the or depressed pole) and unipolar down
(i.e., patients who at different times experience either the [i.e., manic] pole or the bipolar up down
[i.e., depressed] pole). Depression and mania may even occur simultaneously, which is called a
mood state. Mania may also occur in lesser degrees, known as , or switch somixed hypomania
Figure 6-1. . Bipolar disorder is generally characterized by four types of illness episodes: manic,Mood episodes
major depressive, hypomanic, and mixed. A patient may have any combination of these episodes over the
course of illness; subsyndromal manic or depressive episodes also occur during the course of illness, in which
case there are not enough symptoms or the symptoms are not severe enough to meet the diagnostic criteria for
one of these episodes. Thus the presentation of mood disorders can vary widely.
fast between mania and depression that it is called .rapid cycling
Mood disorders can be usefully visualized not only to contrast different mood disorders from one
another, but also to summarize the course of illness for individual patients by showing them mapped
onto a mo.
1. Mood disorders
This chapter discusses disorders characterized by abnormalities
of mood: namely, depression,
mania, or both. Included here are descriptions of a wide variety
of mood disorders that occur over a
broad clinical spectrum. Also included in this chapter is an
analysis of how monoamine
neurotransmitter systems are hypothetically linked to the
biological basis of mood disorders. The
three principal monoamine neurotransmitters are norepinephrine
(NE; also called noradrenaline or
NA), discussed in this chapter, dopamine (DA), discussed in ,
and serotonin (also calledChapter 4
5-hydroxytryptamine or 5HT), discussed in .Chapter 5
The approach taken here is to deconstruct each mood disorder
into its component symptoms,
followed by matching each symptom to hypothetically
malfunctioning brain circuits, each regulated by
one or more of the monoamine neurotransmitters. Genetic
regulation and neuroimaging of these
hypothetically malfunctioning brain circuits are also discussed.
Coverage of symptoms and circuits of
mood disorders in this chapter is intended to set the stage for
understanding the pharmacological
concepts underlying the mechanisms of action and use of
antidepressants and mood stabilizing
drugs, which will be reviewed in the following two chapters (
and ).Chapters 7 8
Clinical descriptions and criteria for how to diagnose disorders
2. of mood will only be mentioned in
passing. The reader should consult standard reference sources
for this material.
Description of mood disorders
Disorders of mood are often called affective disorders, since
affect is the external display of mood,
an emotion that is felt internally. Depression and mania are
often seen as opposite ends of an
affective or mood spectrum. Classically, mania and depression
are "poles" apart, thus generating the
terms depression (i.e., patients who just experience the or
depressed pole) and unipolar down
(i.e., patients who at different times experience either the [i.e.,
manic] pole or the bipolar up down
[i.e., depressed] pole). Depression and mania may even occur
simultaneously, which is called a
mood state. Mania may also occur in lesser degrees, known as ,
or switch somixed hypomania
Figure 6-1. . Bipolar disorder is generally characterized by four
types of illness episodes: manic,Mood episodes
major depressive, hypomanic, and mixed. A patient may have
any combination of these episodes over the
course of illness; subsyndromal manic or depressive episodes
also occur during the course of illness, in which
case there are not enough symptoms or the symptoms are not
severe enough to meet the diagnostic criteria for
one of these episodes. Thus the presentation of mood disorders
can vary widely.
fast between mania and depression that it is called .rapid
cycling
8. issues relevant to theGuide
prescribing of these drugs in clinical practice.
Definition of a mood stabilizer: a labile label
"There is no such thing as a mood stabilizer" - FDA
"Long live the mood stabilizers" - prescribers
What is a mood stabilizer? Originally, a mood stabilizer was a
drug that treated mania and prevented
recurrence of mania, thus "stabilizing" the manic pole of bipolar
disorder. More recently, the concept
of mood stabilizer has been defined in a wide-ranging manner,
from "something that acts like
lithium," to "an anticonvulsant used to treat bipolar disorder,"
to "an atypical antipsychotic used to
treat bipolar disorder," with antidepressants considered as
"mood de-stabilizers." With all this
competing terminology, and with the number of drugs for the
treatment of bipolar disorder exploding,
the term has become so confusing that regulatory authorities
and some experts nowmood stabilizer
suggest that it is best to use other terms for agents that treat
bipolar disorder.
Rather than the term , some would argue that there are drugs
that can treat any ormood stabilizers
all of four distinct phases of the illness ( and ). Thus, a drug
can be "mania-minded"Figures 8-1 8-2
and "treat from above" to reduce symptoms of mania, and/or
"stabilize from above" to prevent
relapse and recurrence of mania ( ). Furthermore, drugs can be
"depression-minded" andFigure 8-1
"treat from
Figure 8-1. . Although the ideal "mood stabilizer" would treat
11. Genetic testing reveals that she is positive for CYP2D6*10
allele.
Patient confesses that she stopped taking her lithium (which was
prescribed in the hospital) since she was discharged two weeks
ago.
MENTAL STATUS EXAM
The patient is alert, oriented to person, place, time, and event.
She is dressed quite oddly- wearing what appears to be an
evening gown to her appointment. Speech is rapid, pressured,
tangential. Self-reported mood is euthymic. Affect broad.
Patient denies visual or auditory hallucinations, no overt
delusional or paranoid thought processes readily apparent.
Judgment is grossly intact, but insight is clearly impaired. She
is currently denying suicidal or homicidal ideation.
The Young Mania Rating Scale (YMRS) score is 22
RESOURCES
§ Chen, R., Wang, H., Shi, J., Shen, K., & Hu, P. (2015).
Cytochrome P450 2D6 genotype affects the pharmacokinetics of
controlled-release paroxetine in healthy Chinese subjects:
comparison of traditional phenotype and activity score systems.
European Journal of Clinical Pharmacology, 71(7), 835-841.
doi:10.1007/s00228-015-1855-6
Select what the PMHNP should do:
Begin Lithium 300 mg orally BID
Begin Risperdal 1 mg orally BID
Begin Seroquel XR 100 mg orally at HS