Mood disorders: Pathology review

Definitions & Key takeaways

Mood stabilizers are a class of medications used to treat mood disorders, such as bipolar disorder and persistent depressive disorder. There are several different types of mood stabilizers, including lithium, valproate, and carbamazepine.

Nursing considerations for patients taking mood stabilizers include monitoring for side effects, dosing, educating patients about medication, and adherence. It is also crucial that nurses know any potential drug interactions and carefully monitor patients for any changes in their mood or behavior.

Chapters:

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Case study0:00–1:31

54 year old Liam presents to the clinic because of a persistent feeling of sadness, ever since he got divorced and his former wife moved out with their son, five months ago.
Liam mentions that he doesn’t enjoy anything anymore, not even listening to his favorite songs. However, he does briefly cheer up every time his son visits him.
Upon further questioning, Liam admits to gaining a lot of weight recently, and feels like he can’t stop eating. When you ask Liam about his sleep habits, he tells you that he often sleeps more than 13 hours a night, but still feels tired when waking up.
Next to him, 25 year old Elfie is brought to the clinic by her father, who is worried that Elfie has not slept much for the past 5 days, but still seems overly energetic.
Her father is also furious because two days ago Elfie maxed out her credit cards shopping for clothes.Elfie interrupts him to say that nobody understands her, because she’s more intelligent than everyone on this planet!
Then, Elfie starts pacing around the room as she continues to speak rapidly and jumps from one topic to another. She denies experiencing any psychotic symptoms, like hearing or seeing things that others don't.
Finally, Elfie also mentions that she hasn't stopped going to work or interacting with her colleagues these past five days.

Pathology1:31–2:30

Okay, based on the initial presentation, both Liam and Elfie seem to have some form of mood disorder. Many of us can have days when we feel sad or overly happy.
But with mood disorders, these emotional variations can become impossible to control, sometimes even to the point where they interfere with day-to-day activities like working, studying, eating, and sleeping.
Now, the main risk factors seem to include having a family history or experiencing a personal trauma. However, the underlying cause is poorly understood; for your exams, what you need to remember is that there’s usually an imbalance of the neurotransmitters serotonin, norepinephrine, and dopamine, which normally help regulate mood, reward-motivated behavior, appetite, and sleep.
Mood disorders can be seen as a spectrum of emotional states that range from depression or extreme sadness to mania or excessive excitement.

Depressive disorders2:30–4:09

So at one end of the spectrum, we have depressive disorders, which are characterized by depressive episodes that consist of nine key symptoms.
First, a person feels depressed or sad, hopeless, and may lack a sense of purpose most of the day, every day. Remember that in children, this can manifest as irritability.
Second, there’s anhedonia, which means a diminished interest in everyday activities that used to be really pleasurable, like no longer enjoying hobbies like cooking or gardening.
Third is either an increase or decrease in appetite, which can eventually lead to weight gain or loss. Fourth is sleeping too much or too little compared to what used to be normal for that person.
Fifth, the affected person may lack energy and feel extremely tired or chronically fatigued. Sixth is difficulty concentrating, while seventh can be psychomotor retardation or slowing down of a person’s thought, emotional reactions, and movements.
Eight involves having persistent feelings of worthlessness and excessive guilt. And finally, ninth, a person might have recurrent thoughts of death or suicidal ideation with or without a specific plan.Okay, now, the most high yield depressive disorder is major depressive disorder.

Major depressive disorder4:09–4:56

This is characterized by depressive episodes that last for at least two weeks and include five of these nine key symptoms, with at least one of them being the depressed mood or anhedonia.
Now, major depressive disorder has a few subtypes, which include depression with atypical features; major depressive disorder with seasonal pattern; major depressive disorder with psychotic features; and major depressive disorder with peripartum onset.
For your exams, remember that they all share the same symptoms of depressive episodes, but are distinguished by having unique features or a specific trigger.Depression with atypical features, sometimes referred to as atypical depression, is the most common subtype.

Depression with atypical features4:56–5:55

Now, in addition to depressive episodes, this type of depression is mainly characterized by two unique features. One is mood reactivity, which is when individuals transiently have an improved mood in response to pleasurable or positive events.
And the other is rejection sensitivity, which is when individuals feel anxious and overreact at the slightest evidence of rejection.
Other key clues include hyperphagia or increased appetite, and hypersomnia or excessive sleepiness. Additionally, a very unique feature is leaden paralysis, which is an unusual heavy feeling in the arms and legs, and is often associated with a feeling of fatigue.Next up is major depressive disorder with seasonal pattern, previously called seasonal affective disorder.

Major depressive disorder with seasonal pattern5:55–6:32

Here, symptoms appear during cold seasons due to a decreased exposure to sunlight. In fact, sunlight seems to be associated with boosting mood and improving symptoms of depressive episodes.
For your test, remember that diagnosis requires at least two depressive episodes to have occurred during cold months for the past two years, with no history of depressive episodes during warmer seasons.There’s also major depressive disorder with psychotic features, previously known as psychotic depression.

Major depressive disorder with psychotic features6:32–7:25

This is when depression is accompanied by psychotic features, including illusions or misperception of sensory stimuli, as well as hallucinations or perceiving something that’s not real.
It’s important to remember that these features are mood-congruent, meaning that their content is usually aligned with the person’s low mood, and may often center around guilt, punishment, inadequacy, illness, or death.
Another key fact here is that the psychotic features occur only during episodes of major depression. This is a key difference with schizoaffective disorder, which involves the presence of psychotic symptoms for at least two weeks but without having a depressed mood.
Next is major depressive disorder with peripartum onset, previously known as postpartum depression, which has an incidence rate of 10 to 15%.

Major depressive disorder with peripartum onset7:25–8:08

Peripartum onset means that it most often happens during pregnancy or four to six weeks following parturition or delivery, but keep in mind that it can occur anytime within and no later than the first year after delivery.
And that’s a high yield fact! Now, the exact cause isn’t understood, but it’s likely related to hormonal changes, along with the emotional and physical stress that can accompany the birth of a child.
For your exams, you should be able to differentiate major depressive disorder with peripartum onset from postpartum blues, which is way more common!

Postpartum blues8:08–8:42

In fact, the incidence rate goes from 50 to 85%, and symptoms may include depressed mood, crying outbursts, and lethargy or fatigue.
But the most important clue is that postpartum blues usually start 2 to 3 days after delivery, and typically resolve within 10 days.Another high yield mood disturbance that can occur during the peripartum period is postpartum psychosis, which instead is way less frequent, with an incidence rate of about 0,1%.

Postpartum psychosis8:42–9:24

Symptoms of postpartum psychosis include illusions, hallucinations, as well as suicidal ideation, or thoughts of harming their baby.
For your exams, remember that postpartum psychosis is often associated with an underlying psychotic or bipolar disorder, or a recent medication change, and occurs more commonly in first-time pregnancies and those with a family history.

Persistent depressive disorder9:24–10:25

All right, back to depressive disorders, another high yield one is persistent depressive disorder, previously known as dysthymia.
What you need to remember here is that it is milder, and must include at least two of the following: a change in appetite, a change in sleep, fatigue or low energy, reduced self-esteem, decreased concentration or difficulty making decisions, and a feeling of hopelessness or pessimism.
Now, the key to diagnose persistent depressive disorder is that these symptoms need to persist over longer periods of time, specifically two or more years in adults and one or more years in children or adolescents.
And remember that individuals with persistent depressive disorder may have remission periods where they have no depressive episodes.
However, what’s characteristic is that these remission periods never last for more than 2 months. Now, before diagnosing a depressive disorder, it is essential to differentiate it from grief, which is a feeling of deep sorrow in response to physical or emotional loss.

Grief10:25–12:30

For instance, grief can be experienced when losing a loved one, as well as when a person learns that they have a terminal illness, and this is completely normal..
Now, according to the Kübler-Ross model, grief can be divided into five stages, which include denial, anger, bargaining, depression, and acceptance.
Keep in mind that these can happen in any order. During denial, the person may deny or reject the reality of their loss or illness.
During anger, they might become angry with themselves or others, such as a caregiver, for no reason. Bargaining is when the person tries to make a promise or deal, usually with a higher power like their God, in return for relief from their pain or to prolong their life.
Depression is when the person realizes the full impact of their loss or illness, and that might make them cry, refuse meals, become withdrawn, or stop sleeping.
Finally, acceptance is when the person makes peace and comes to terms with the reality of their situation. Other high yield symptoms that can be normally experienced by a grieving individual are intense sadness and yearning for their loved one, as well as feeling guilt, anxiety, and sometimes somatic symptoms, such as headaches or chest pain.
Some individuals may even experience auditory or visual hallucinations of the deceased person, as well as thoughts of dying that are limited to joining the deceased one.
And that’s a high yield fact! Now, the duration of grief can vary widely, but normally resolves within 6 to 12 months, as the individual progressively starts feeling better.

Persistent complex bereavement disorder12:30–13:03

On the other hand, when grief becomes extreme, it’s called persistent complex bereavement disorder. This means that there’s obsessive preoccupation or yearning for a deceased one, which significantly impairs daily functioning.
And this needs to persist for at least 12 months for adults or 6 months for children. For your exams, note that during the course of persistent complex bereavement disorder, criteria for a major depressive episode can also be met.Now let’s totally switch gears and look at the other end of the spectrum, which is mania.

Manic episodes13:03–15:17

For your exams, remember that a manic episode lasts for at least a week, but may often last longer, and is a state where at least three of the following seven symptoms should be present.
First, individuals might have a really high self-esteem of self-image, which is referred to as grandiosity. Second, they might be more talkative than usual or have pressured speech, meaning that they feel the need to keep talking constantly at a rapid-fire pace.
Third, they might have flight of ideas or racing thoughts, which may cause them to quickly jump from topic to topic. Fourth, they might feel easily distracted and unable to concentrate.
Fifth, they might feel the need to achieve certain things and engage in extreme goal-directed activities, for example, an individual might spend more than twenty hours a day on social media just to reach a certain number of followers.
Sixth, individuals might get involved in impulsive and reckless behaviors like sexual indiscretions or bad financial investments, without any regard for later consequences.
And seventh, they might feel ‘wired,’ as if they don’t need sleep. And this can often be associated with psychomotor agitation, which is when an individual feels restless and performs movements with no purpose, such as tapping their toes or pacing around the room.
For your test, remember that these symptoms need to be severe enough to cause significant impairment at school, work or social life, or be accompanied by psychotic features.
Keep in mind that these will typically be mood-congruent, meaning that they center around their elevated mood. For example, individuals might experience delusions of grandeur, where they believe that they are on a personal mission from God, or that they have supernatural powers.
And a very important thing to note is that manic episodes can be so severe that they require hospitalization.Now, on the same spectrum, some individuals may experience a hypomanic episode, which must also include at least three of the same seven symptoms, but they’re milder than a manic episode, meaning that they don’t lead to functional impairment, and should last at least four days.

Hypomanic episodes15:17–15:45

In addition, hypomanic episodes don’t present with psychotic features, and they don’t require hospitalization.Okay, now, manic and hypomanic episodes are characteristic for bipolar disorders, which can be classified into bipolar I disorder, bipolar II disorder, and cyclothymic disorder.

Bipolar I disorder15:45–16:21

Bipolar I disorder features at least one manic episode, which tends to last for several weeks. This might be preceded or followed by a hypomanic or depressive episode, and may have periods of remission and stable mood between each episode, but remember that it’s not required for diagnosis.
On the other hand, in bipolar II disorder, individuals have hypomanic and depressive episodes, but no manic episodes. Lastly, cyclothymic disorder or cyclothymia is the mildest form of bipolar disorder, where individuals have mild hypomanic and depressive episodes like you see in bipolar II.

Bipolar II disorder16:21–16:30

Cyclothymic disorder16:30–17:18

But what sets these two apart is that, in cyclothymic disorder, individuals fluctuate or cycle back and forth between these two moods more frequently than bipolar I and II disorders.
For example, they might feel ecstatic one moment, and soon after, they might get extremely sad, and then ecstatic again.
To diagnose cyclothymic disorder, these mood swings must occur over a time period of at least 2 years, with periods of remission lasting no longer than 2 months.Now, treating mood disorders can be very challenging and extremely rewarding.

Treatment of mood disorders17:18–22:20

Milder forms of depression and bipolar disorders usually do not require medication. Instead, they can be managed by psychotherapy, including cognitive-behavioral therapy.
These therapies primarily focus on teaching the individual strategies to better cope with stress and social pressures, as well as identify the patterns of thought that may be influencing their disorder.
In addition, lifestyle changes like physical activity, meditation, deep-breathing exercises, yoga, and acupuncture have also shown benefits.
For your test, remember that bright light therapy is also useful for major depressive disorder with a seasonal pattern.Now, for both depressive and bipolar disorders, there are also pharmacological options available.
For depressive disorders, remember that the first line treatment is selective serotonin reuptake inhibitors or SSRIs, such as fluoxetine, paroxetine, and sertraline.
Common side effects of SSRIs include anxiety, insomnia, gastrointestinal disturbances, and sexual dysfunction. The most dangerous side effect, however, is that they can potentially trigger suicidal ideations and manic episodes in individuals who are predisposed to them.
So, for your exams, keep in mind that it’s important to assess the risk for suicide and rule out a history of mania or hypomania, before starting an SSRI treatment.
Now, bear in mind that, if individuals treated with SSRIs, also take other antidepressants that increase serotonin level, such as monoamine oxidase inhibitors or MAOIs, they can develop serotonin syndrome.
This is a life threatening condition caused by serotonin accumulation, which ultimately leads to over stimulation of the central nervous system.
This syndrome is characterized by skin flushing, hyperthermia, agitation, muscle rigidity, seizures, and coma. And that’s a high yield fact!
Now, those who can’t tolerate the side effects of SSRIs may be treated with another antidepressant medication, such as serotonin and norepinephrine reuptake inhibitors or SNRIs, like venlafaxine, desvenlafaxine, and duloxetine.
Another option includes atypical antidepressants like mirtazapine or bupropion. An important thing to take into consideration is that bupropion may cause tachycardia, insomnia, and even seizures, which is why it’s contraindicated in people with a history of seizures or eating disorders.
Moving on, treatment of bipolar disorders includes mood stabilizers like lithium. What’s high yield to remember is that, before prescribing lithium, it’s necessary to check the renal function, as it should generally be avoided in individuals with renal dysfunction due to its nephrotoxic effects.
Other options to treat bipolar disorders include anticonvulsants like valproate or lamotrigine, as well as antipsychotics like quetiapine or lurasidone.
Lastly, both depressive and bipolar disorders can benefit from electroconvulsive therapy or ECT for short. This is when a small and controlled amount of electric current is passed through the brain while the individual is under general anesthesia and neuromuscular blockade, and this induces a brief seizure.
For your test, remember that electroconvulsive therapy is indicated especially for refractory cases, like severely depressed individuals experiencing life threatening symptoms, such as suicidality, refusing to eat or drink, and severe psychosis.
The exact mechanism for why ECT helps with mood disorders is unknown, and side effects might include anterograde and retrograde amnesia, usually lasting less than 6 months, headache, and disorientation.
And that’s a high yield fact!You also need to note that ECT is safe for pregnant and elderly individuals and there are no absolute contraindications.
All right, as a quick recap. Mood disorders can be seen as a spectrum of emotional states.

Review22:20–26:12

At one end of the spectrum, depressive episodes consist of nine features including extreme sadness associated with anhedonia, significant appetite and weight changes, sleeping too much or too little, lack of energy, difficulty concentrating, psychomotor retardation, feelings of worthlessness and excessive guilt, and finally recurrent thoughts of death or suicidality.
The most high yield depressive disorder is major depressive disorder, where depressive episodes last for at least two weeks and include at least five of the key depressive symptoms.
The most common subtype of major depressive disorder is depression with atypical features, which is characterized by mood reactivity, rejection sensitivity, hyperphagia, hypersomnia, and leaden paralysis.
Then there’s major depressive disorder with seasonal pattern, which appears during cold seasons due to a decreased exposure to sunlight.
Next is major depressive disorder with psychotic features, which is characterized by illusions and hallucinations. Major depressive disorder with peripartum onset happens during pregnancy or up to one year following or delivery.
Finally, there’s also persistent depressive disorder, where symptoms of depression are milder and last for two or more years in adults and one or more years in children or adolescents.
Before diagnosing a depressive disorder, it’s important to rule out grief, which is a normal feeling of deep sorrow in response to physical or emotional loss, which shouldn’t last longer than 12 months.
That’s in contrast to persistent complex bereavement disorder, where there’s extreme preoccupation or yearning for a deceased one, and significant impairment of functioning, and lasts longer.
Now, at the other end of the spectrum, manic and hypomanic episodes feature seven symptoms including grandiosity, pressured speech, racing thoughts, inability to concentrate, impulsiveness and recklessness, increased goal-oriented activity, and finally a decreased need for sleep, which is often associated with psychomotor agitation.
The main difference is that manic episodes must last at least one week, while hypomanic episodes are milder and last at least 4 days.
Now, bipolar I disorder has at least one manic episode that can be preceded or followed by a hypomanic or depressive episode, whereas bipolar II disorder is characterized by hypomanic and depressive episodes, but no manic episodes, and finally cyclothymic disorder is a milder form of bipolar disorder, where individuals fluctuate between these two moods for at least two years.
Treatment of mood disorders includes cognitive behavioral therapy and lifestyle changes. Medications for depressive disorders may include SSRIs and SNRIs, as well as atypical antidepressants, while bipolar disorders can be treated with lithium, anticonvulsants, antipsychotics, and benzodiazepines.
Finally, refractory cases of both depressive and bipolar disorders can benefit from electroconvulsive therapy.Okay, back to our cases.

Summary26:12–27:32

Liam is a 54 year old man that comes in with a persistent feeling of sadness and anhedonia, which are characteristic for depressive disorder.
An important clue is that Liam briefly cheers up every time his son visits him, which means that he experiences mood reactivity.
And because he’s also experiencing hyperphagia and hypersomnia, we can conclude that Liam is suffering from depression with atypical features.
After Liam, you see Elfie, who presents with a grandiose self-image, as well as pressured speech, and racing thoughts, which combined are characteristic for manic episodes.
Two days ago, she also maxed out her credit cards shopping for clothes, which is a sign of reckless behavior. An important thing to consider though is the fact that she hasn’t experienced psychotic symptoms or functional impairment.
The final clue is that Elfie is pacing around the room, which is a sign of psychomotor agitation, and seems overly energetic, despite not sleeping much for the past 5 days.
So, because the episode lasts more than four days but less than one week, we can say that Elfie is experiencing a hypomanic episode.