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Mood (affective) disorders
PSYCHIATRIC DISORDERS
What’s new ?
Mood (affective) disorders
• Bipolar disorders, particularly bipolar II disorders (hypomania/depression, often mistaken for unipolar depression) are now recognized to be more common than previously thought
Iain Macmillan A H Young I Nicol Ferrier
ICD-10 classification of mood disorders ICD-10 recognizes seven main groups of mood (affective) disorders.2 Subtypes are defined by severity and the presence or absence of psychotic symptoms, as follows.
Mood disorders (including unipolar and bipolar disorders) are common. They are characterized by persistent states of abnormal mood, which may be elevated, depressed or both alternately. • Depression is characterized by low mood, often with suicidal ideation and somatic symptoms such as sleep disturbance. Its severity varies from normal sadness to a severe, life-threatening illness. • Mania, and its milder variant hypomania, are characterized by abnormally elevated mood, often with physical over-activity, which may be extreme and life-threatening. Both depression and mania can be accompanied by psychotic symptoms, hallucinations (abnormal perceptual experiences) and/or delusions (abnormal beliefs), which are associated with a worse prognosis. Mood disorders carry a high morbidity and mortality. According to the Global Burden of Disease Study (Figure 1), unipolar depression is second only to ischaemic heart disease in terms of disability-adjusted life-years. Mood disorders account for 8.5% of the total disease burden in established market economies and more than 55% of the total disability caused by all psychiatric disorders (Figure 2).1 They are associated with increased risk of premature death from all causes and particularly with increased risk of death from suicide. Current classifications of mood disorders recognize that the presence of periods of elevation of mood is crucial in distinguishing bipolar from unipolar disorder. Previous distinctions between, for example, endogenous, reactive and neurotic depression have largely been abandoned. The main distinctions between different types of affective disorders are based on the pattern of recurrence and the presence or absence of manic or hypomanic episodes. The presence and severity of psychosis are used to subclassify episodes of mood disorders. Individuals who experience episodes of mania or hypomania in addition to episodes of depression are said to suffer from bipolar disorder; those who experience only episodes of depression have unipolar disorder. It is important to ask patients about previous episodes of mood disorder, and particularly about their history of hypomanic episodes, because this has implications for treatment.
Principal sources of disease burden in established market economies, 1990
1 2 3 4 5 6 7 8 9 10
% of total
9.0 6.8 5.0 4.7 4.4 3.0 2.9 2.7 2.4 2.3
1
Mental illness as a source of disease burden in established market economies, 1990
All causes Unipolar major depression Schizophrenia Bipolar disorder Obsessive–compulsive disorder Panic disorder Post-traumatic stress disorder Self-inflicted injuries (suicide) All mental disorders
Iain Macmillan is Consultant Psychiatrist in the Early Intervention Service of Norfolk Mental Health Care NHS Trust, Norwich, UK. A H Young is Professor of Psychiatry at the University of Newcastle upon Tyne, UK. I Nicol Ferrierr is Professor of Psychiatry at the University of Newcastle upon Tyne, UK
MEDICINE
Total disabilityadjusted lifeyears (millions) All causes 98.7 Ischaemic heart disease 8.9 Unipolar major depression 6.7 Cardiovascular disease 5.0 Alcohol use 4.7 Road traffic accidents 4.3 Lung and upper respiratory 3.0 tract cancers Dementia and degenerative 2.9 CNS diseases Osteoarthritis 2.7 Diabetes 2.4 Chronic obstructive 2.3 pulmonary disease
Total disabilityadjusted lifeyears (millions) 98.7 6.7 2.3 1.7 1.5 0.7 0.3 2.2 15.3
% of total
6.8 2.3 1.7 1.5 0.7 0.3 2.2 15.4
2
14
© 2004 The Medicine Publishing Company Ltd
PSYCHIATRIC DISORDERS
Manic episode (F30) – hypomania often starts with increased productivity and a sense of well-being. It is characterized by elevated mood, increased activity and energy (often unproductive), and reduced need for sleep. Mania disrupts social and occupational functioning and is often associated with reckless behaviour, which may have severe consequences. Few individuals experience a single episode of mania; almost all develop later episodes of depression, and often further manic episodes. Cases in which further episodes occur should be reclassified as bipolar. Bipolar affective disorder (F31) – a distinction has been made between: • type I bipolar disorder, in which patients experience at least one episode of mania in addition to depressive episodes • type II bipolar disorder, in which hypomanic and frequent depressive episodes occur. Mixed affective states, in which both manic and depressive symptoms occur at the same time, are increasingly recognized. Depressive episode (F32) – single episodes of depression are uncommon. Recurrent depressive disorder (F33) Persistent mood (affective) disorders (F34) include cyclothymia and dysthymia. • Cyclothymia can be viewed as a mild variant of bipolar disorder in which patients experience mild, recurrent episodes of low mood and mild hypomanic episodes. • Dysthymia is chronic low-grade depression. Individuals with dysthymia may also experience episodes of major depression; this combination is sometimes termed ‘double depression’. Other mood (affective) disorders (F38) include isolated mixed affective states and recurrent brief depression, in which depressive symptoms last for less than 2 weeks (2–3 days is most common). Unspecified mood (affective) disorders (F39) are a diagnosis of last resort.
Predictors of bipolarity Variable • • • • • •
Specificity (%) 100 98 88 85 84 68
3
disorder characterized by recurrent episodes over the individual’s lifetime.6 About 50% of patients diagnosed with unipolar depression have some features of bipolar disorder on careful examination. This gives rise to the concept of a ‘bipolar spectrum’ with no clear boundaries that merges into unipolar illness. Predictors of bipolarity in depression are summarized in Figure 3.7 Bipolar disorder The estimated annual incidence of bipolar disorder is 0.016–0.021% of individuals aged over 15 years of age seeking treatment.8 The estimated lifetime prevalence of bipolar I and II disorder is 1.2%.9 Wider definitions of ‘bipolar spectrum disorders’ have led to even higher estimates of the prevalence (up to 6%). The incidence of suicide in those with bipolar I disorder is 20–30 times that in the general population.10,11 Bipolar II disorders are also associated with a high risk of suicide.12 The lifetime risk of bipolar disorder is about 1% and the annual inception rate about 10/100,000 in men and 15/100,000 in women. Bipolar disorder is an important cause of disability in 15–44-yearolds.13 In the UK, the annual cost attributable to bipolar disorder was estimated at £200 million at 1999/2000 prices (estimated 297,000 affected individuals); hospital care accounts for 35% of the total cost.14 • Bipolar I disorder is generally recognized as mania, leads to severe occupational or social disturbance, and often requires inpatient psychiatric care. • Bipolar II disorders, in which the periods of elevated mood are of mild-to-moderate severity, are under-diagnosed. The symptoms of hypomania are easily missed; careful examination and historytaking are required, particularly regarding previous episodes of elevated mood, overactivity, reduced need for sleep and increased risk-taking or recklessness.
Types of mood disorder Depression Depression is a major public health problem. At any time, 6% of the population meet the criteria for depression or dysthymia, and in 20% of those with major depressive disorder, symptoms persist for more than 2 years.3 Relapse occurs within 3 months of recovery in 30% of individuals, and 50% experience a further episode within 2 years in the absence of continuation or maintenance treatment.4 Depression is recurrent in about 80% of those who receive psychiatric care for an episode of major depression; the median lifetime number of episodes is four. In the UK, the estimated annual and weekly prevalences of depression are 3–10% and 2.3% respectively.5 In the average general practice, up to 20% of patients are experiencing a major or less severe depressive state. There is substantial co-morbidity with other conditions, including substance abuse, anxiety disorders, obsessive–compulsive disorder and eating disorders. Any co-morbid disorder requires thorough assessment and treatment. Mood disorders, particularly depression, are common in patients who are physically ill. It has been suggested that the current clinical focus on management of discrete episodes of major depressive disorder is outdated and that there is a need to treat depression as a chronic
MEDICINE
Sensitivity (%) Pharmacological hypomania 32 Family history of bipolar episodes 56 Hypersomnia/retardation 59 Psychotic depression 42 Post-partum onset 58 Onset of depression < age 26 years 71
Puerperal mood disorders Puerperal psychoses occur in women within the first month postpartum following 0.5/1000 deliveries and within the first year in 1/1000 deliveries. They appear to be closely related to bipolar disorders.15,16 Long-term follow-up of index cases demonstrated that 80% of episodes were bipolar and there were no schizophrenic cases; 60% of these patients suffered recurrent episodes of psychosis.17
15
© 2004 The Medicine Publishing Company Ltd
PSYCHIATRIC DISORDERS
• Bibliotherapy (use of self-help guides) may be helpful. • ECT is indicated in patients with severe or psychotic depressive states and may be life-saving.
Detection and referral Mood disorders can be treated effectively once diagnosed, but the rate of detection in primary care is low. Detection of depression can be improved by use of standardized diagnostic criteria and screening questionnaires such as the Hospital Anxiety and Depression Scale (HADS).18 Psychiatric referral is recommended when: • the patient fails to respond to treatment • the treating physician lacks the expertise required to manage the condition • the patient is at risk of suicide • psychotic symptoms are present • the patient has bipolar disorder.
REFERENCES 1 Murray C J L, Lopez A D, eds. The global burden of disease and injury series, volume 1: a comprehensive assessment of mortality and disability from diseases, injuries, and risk factors in 1990 and projected to 2020. Cambridge: Harvard University Press, 1996. 2 WHO. ICD-10: classification of mental and behavioural disorders. Geneva: WHO, 1992. 3 Keller M B, Lavoir P W, Mueller T I et al. Time to recovery, chronicity and levels of psychopathology in major depression: a 5-year prospective follow up of 431 subjects. Arch Gen Psychiatryy 1992; 49: 809–16. 4 Scott J, Dickey B. Global burden of depression: the intersection of culture and medicine. Br J Psychiatryy 2003; 183: 92–4. 5 Jenkins R, Lewis G, Bebbington P et al. The National Psychiatric Morbidity Surveys of Great Britain – initial findings from the household surveys. Psychol Med d 1997; 27: 775–89. 6 Scott J, Thorne A, Horn P. Effect of a chronic disease management approach to detection and treatment of depression in primary care. BMJJ 2002; 325: 951–4. 7 Akiskal H S, Walker P, Puzantian V R et al. Bipolar outcome in the course of depressive illness: phenomenologic, familial and pharmacologic predictors. J Affect Disord d 1983; 5: 115–28. 8 Goodwin F K, Jamison K R. Manic-depressive illness. Oxford: Oxford University Press, 1990. 9 Weissman M M, Myers J K. Affective disorders in a US urban community: the use of research diagnostic criteria in an epidemiological survey. Arch Gen Psychiatryy 1978; 35: 1304–11. 10 Osby U, Brandt L, Correia N et al. Excess mortality in bipolar and unipolar disorder in Sweden. Arch Gen Psychiatryy 2001; 58: 844–50. 11 Guze S B, Robins E. Suicide and primary affective disorders 1970. Br J Psychiatryy 1970; 117: 437–8. 12 Rhimer Z, Pestality P. Bipolar II disorder and suicidal behaviour. Psychiatr Clin North Am 1999; 22: 667–73. 13 Murray C J, Lopez A D. Global mortality, disability and the contribution of risk factors: global burden of disease study. Lancett 1997; 349: 1436–42. 14 Das Gupta R, Guest J F. Annual cost of bipolar disorder to UK society. Br J Psychiatryy 2002; 180: 227–33. 15 Jones I, Craddock N. Do puerperal psychotic episodes identify a more familial subtype of bipolar disorder? Results of a family history study. Psychiatr Genett 2002; 12: 177–80. 16 Brockington I F, Cernik K F, Schofield E M et al. Puerperal psychosis. Phenomena and diagnosis. Arch Gen Psychiatryy 1981; 38: 829–33. 17 Videbech P, Gouliaev G. First admission with puerperal psychosis: 7–14 years of follow up. Acta Psychiatr Scand d 1995; 91: 167–73. 18 Zigmond A S, Snaith R D. The Hospital Anxiety and Depression Scale. Acta Psychiatr Scand d 1983; 67: 361–70. 19 Anderson I M, Nutt D J, Deakin J F. Evidence-based guidelines for treating depressive disorders with antidepressants: a revision of the 1993 British Association for Psychopharmacology guidelines. J Psychopharmacol 2001; 14: 3. 20 Goodwin G M. Evidence-based guidelines for treating bipolar disorder: recommendations from the British Association for Psychopharmacology. J Psychopharmacol 2001; 17: 149–73.
Management The principal treatments for mood disorders are psychological, psychopharmacological and physical. Psychological treatments include cognitive and cognitive behavioural therapies, which aim to alter dysfunctional thought patterns and negative automatic thoughts and modulate the patient’s response to stressful events. Interpersonal psychotherapies aim to modify existing patterns of relating to others, and problem-solving therapy may be useful. These psychological therapies are particularly useful in mild-to-moderate depression and may be combined with antidepressant drug treatment in more severe disorders. Drug treatments: a comprehensive review of drug treatments for mood disorders is beyond the scope of this contribution. Useful guidelines for both depression (unipolar) and the various phases of bipolar disorders have been prepared by the British Association for Psychopharmacology.19,20 Antidepressant agents, mood-stabilizing agents and antipsychotics are used, often in combination. Drug treatment may be divided into two principal categories – acute and maintenance. Use of appropriate medications to treat different phases of the illness is important. • Acute depression may require antidepressant drugs that augment serotonergic or noradrenergic neurotransmission. The main classes of antidepressants are the selective serotonin re-uptake inhibitors, the tricyclics, serotonin and noradrenaline re-uptake inhibitors, and monoamine oxidase inhibitors. Adequate doses of antidepressants are recommended for at least 2 years in unipolar patients with frequent recurrences. • Drugs to prevent recurrence are central to the management of bipolar disorders and include lithium salts, carbamazepine, valproic acid formations and lamotrigine. • Antipsychotic agents, particularly atypical antipsychotics (e.g. risperidone, olanzapine, quetiapine) are useful in the management of any affective disorder accompanied by psychotic symptoms. They may also be useful in prophylaxis of bipolar disorders, because they may have mood-stabilizing properties. Physical treatment • Phototherapy may be an effective treatment for depression, particularly in those with seasonal affective disorder. • Exercise can improve mood symptoms in milder depressive disorders.
MEDICINE
16
© 2004 The Medicine Publishing Company Ltd
What’s new ?
Mood (affective) disorders
• Bipolar disorders, particularly bipolar II disorders (hypomania/depression, often mistaken for unipolar depression) are now recognized to be more common than previously thought
Iain Macmillan A H Young I Nicol Ferrier
ICD-10 classification of mood disorders ICD-10 recognizes seven main groups of mood (affective) disorders.2 Subtypes are defined by severity and the presence or absence of psychotic symptoms, as follows.
Mood disorders (including unipolar and bipolar disorders) are common. They are characterized by persistent states of abnormal mood, which may be elevated, depressed or both alternately. • Depression is characterized by low mood, often with suicidal ideation and somatic symptoms such as sleep disturbance. Its severity varies from normal sadness to a severe, life-threatening illness. • Mania, and its milder variant hypomania, are characterized by abnormally elevated mood, often with physical over-activity, which may be extreme and life-threatening. Both depression and mania can be accompanied by psychotic symptoms, hallucinations (abnormal perceptual experiences) and/or delusions (abnormal beliefs), which are associated with a worse prognosis. Mood disorders carry a high morbidity and mortality. According to the Global Burden of Disease Study (Figure 1), unipolar depression is second only to ischaemic heart disease in terms of disability-adjusted life-years. Mood disorders account for 8.5% of the total disease burden in established market economies and more than 55% of the total disability caused by all psychiatric disorders (Figure 2).1 They are associated with increased risk of premature death from all causes and particularly with increased risk of death from suicide. Current classifications of mood disorders recognize that the presence of periods of elevation of mood is crucial in distinguishing bipolar from unipolar disorder. Previous distinctions between, for example, endogenous, reactive and neurotic depression have largely been abandoned. The main distinctions between different types of affective disorders are based on the pattern of recurrence and the presence or absence of manic or hypomanic episodes. The presence and severity of psychosis are used to subclassify episodes of mood disorders. Individuals who experience episodes of mania or hypomania in addition to episodes of depression are said to suffer from bipolar disorder; those who experience only episodes of depression have unipolar disorder. It is important to ask patients about previous episodes of mood disorder, and particularly about their history of hypomanic episodes, because this has implications for treatment.
Principal sources of disease burden in established market economies, 1990
1 2 3 4 5 6 7 8 9 10
% of total
9.0 6.8 5.0 4.7 4.4 3.0 2.9 2.7 2.4 2.3
1
Mental illness as a source of disease burden in established market economies, 1990
All causes Unipolar major depression Schizophrenia Bipolar disorder Obsessive–compulsive disorder Panic disorder Post-traumatic stress disorder Self-inflicted injuries (suicide) All mental disorders
Iain Macmillan is Consultant Psychiatrist in the Early Intervention Service of Norfolk Mental Health Care NHS Trust, Norwich, UK. A H Young is Professor of Psychiatry at the University of Newcastle upon Tyne, UK. I Nicol Ferrierr is Professor of Psychiatry at the University of Newcastle upon Tyne, UK
MEDICINE
Total disabilityadjusted lifeyears (millions) All causes 98.7 Ischaemic heart disease 8.9 Unipolar major depression 6.7 Cardiovascular disease 5.0 Alcohol use 4.7 Road traffic accidents 4.3 Lung and upper respiratory 3.0 tract cancers Dementia and degenerative 2.9 CNS diseases Osteoarthritis 2.7 Diabetes 2.4 Chronic obstructive 2.3 pulmonary disease
Total disabilityadjusted lifeyears (millions) 98.7 6.7 2.3 1.7 1.5 0.7 0.3 2.2 15.3
% of total
6.8 2.3 1.7 1.5 0.7 0.3 2.2 15.4
2
14
© 2004 The Medicine Publishing Company Ltd
PSYCHIATRIC DISORDERS
Manic episode (F30) – hypomania often starts with increased productivity and a sense of well-being. It is characterized by elevated mood, increased activity and energy (often unproductive), and reduced need for sleep. Mania disrupts social and occupational functioning and is often associated with reckless behaviour, which may have severe consequences. Few individuals experience a single episode of mania; almost all develop later episodes of depression, and often further manic episodes. Cases in which further episodes occur should be reclassified as bipolar. Bipolar affective disorder (F31) – a distinction has been made between: • type I bipolar disorder, in which patients experience at least one episode of mania in addition to depressive episodes • type II bipolar disorder, in which hypomanic and frequent depressive episodes occur. Mixed affective states, in which both manic and depressive symptoms occur at the same time, are increasingly recognized. Depressive episode (F32) – single episodes of depression are uncommon. Recurrent depressive disorder (F33) Persistent mood (affective) disorders (F34) include cyclothymia and dysthymia. • Cyclothymia can be viewed as a mild variant of bipolar disorder in which patients experience mild, recurrent episodes of low mood and mild hypomanic episodes. • Dysthymia is chronic low-grade depression. Individuals with dysthymia may also experience episodes of major depression; this combination is sometimes termed ‘double depression’. Other mood (affective) disorders (F38) include isolated mixed affective states and recurrent brief depression, in which depressive symptoms last for less than 2 weeks (2–3 days is most common). Unspecified mood (affective) disorders (F39) are a diagnosis of last resort.
Predictors of bipolarity Variable • • • • • •
Specificity (%) 100 98 88 85 84 68
3
disorder characterized by recurrent episodes over the individual’s lifetime.6 About 50% of patients diagnosed with unipolar depression have some features of bipolar disorder on careful examination. This gives rise to the concept of a ‘bipolar spectrum’ with no clear boundaries that merges into unipolar illness. Predictors of bipolarity in depression are summarized in Figure 3.7 Bipolar disorder The estimated annual incidence of bipolar disorder is 0.016–0.021% of individuals aged over 15 years of age seeking treatment.8 The estimated lifetime prevalence of bipolar I and II disorder is 1.2%.9 Wider definitions of ‘bipolar spectrum disorders’ have led to even higher estimates of the prevalence (up to 6%). The incidence of suicide in those with bipolar I disorder is 20–30 times that in the general population.10,11 Bipolar II disorders are also associated with a high risk of suicide.12 The lifetime risk of bipolar disorder is about 1% and the annual inception rate about 10/100,000 in men and 15/100,000 in women. Bipolar disorder is an important cause of disability in 15–44-yearolds.13 In the UK, the annual cost attributable to bipolar disorder was estimated at £200 million at 1999/2000 prices (estimated 297,000 affected individuals); hospital care accounts for 35% of the total cost.14 • Bipolar I disorder is generally recognized as mania, leads to severe occupational or social disturbance, and often requires inpatient psychiatric care. • Bipolar II disorders, in which the periods of elevated mood are of mild-to-moderate severity, are under-diagnosed. The symptoms of hypomania are easily missed; careful examination and historytaking are required, particularly regarding previous episodes of elevated mood, overactivity, reduced need for sleep and increased risk-taking or recklessness.
Types of mood disorder Depression Depression is a major public health problem. At any time, 6% of the population meet the criteria for depression or dysthymia, and in 20% of those with major depressive disorder, symptoms persist for more than 2 years.3 Relapse occurs within 3 months of recovery in 30% of individuals, and 50% experience a further episode within 2 years in the absence of continuation or maintenance treatment.4 Depression is recurrent in about 80% of those who receive psychiatric care for an episode of major depression; the median lifetime number of episodes is four. In the UK, the estimated annual and weekly prevalences of depression are 3–10% and 2.3% respectively.5 In the average general practice, up to 20% of patients are experiencing a major or less severe depressive state. There is substantial co-morbidity with other conditions, including substance abuse, anxiety disorders, obsessive–compulsive disorder and eating disorders. Any co-morbid disorder requires thorough assessment and treatment. Mood disorders, particularly depression, are common in patients who are physically ill. It has been suggested that the current clinical focus on management of discrete episodes of major depressive disorder is outdated and that there is a need to treat depression as a chronic
MEDICINE
Sensitivity (%) Pharmacological hypomania 32 Family history of bipolar episodes 56 Hypersomnia/retardation 59 Psychotic depression 42 Post-partum onset 58 Onset of depression < age 26 years 71
Puerperal mood disorders Puerperal psychoses occur in women within the first month postpartum following 0.5/1000 deliveries and within the first year in 1/1000 deliveries. They appear to be closely related to bipolar disorders.15,16 Long-term follow-up of index cases demonstrated that 80% of episodes were bipolar and there were no schizophrenic cases; 60% of these patients suffered recurrent episodes of psychosis.17
15
© 2004 The Medicine Publishing Company Ltd
PSYCHIATRIC DISORDERS
• Bibliotherapy (use of self-help guides) may be helpful. • ECT is indicated in patients with severe or psychotic depressive states and may be life-saving.
Detection and referral Mood disorders can be treated effectively once diagnosed, but the rate of detection in primary care is low. Detection of depression can be improved by use of standardized diagnostic criteria and screening questionnaires such as the Hospital Anxiety and Depression Scale (HADS).18 Psychiatric referral is recommended when: • the patient fails to respond to treatment • the treating physician lacks the expertise required to manage the condition • the patient is at risk of suicide • psychotic symptoms are present • the patient has bipolar disorder.
REFERENCES 1 Murray C J L, Lopez A D, eds. The global burden of disease and injury series, volume 1: a comprehensive assessment of mortality and disability from diseases, injuries, and risk factors in 1990 and projected to 2020. Cambridge: Harvard University Press, 1996. 2 WHO. ICD-10: classification of mental and behavioural disorders. Geneva: WHO, 1992. 3 Keller M B, Lavoir P W, Mueller T I et al. Time to recovery, chronicity and levels of psychopathology in major depression: a 5-year prospective follow up of 431 subjects. Arch Gen Psychiatryy 1992; 49: 809–16. 4 Scott J, Dickey B. Global burden of depression: the intersection of culture and medicine. Br J Psychiatryy 2003; 183: 92–4. 5 Jenkins R, Lewis G, Bebbington P et al. The National Psychiatric Morbidity Surveys of Great Britain – initial findings from the household surveys. Psychol Med d 1997; 27: 775–89. 6 Scott J, Thorne A, Horn P. Effect of a chronic disease management approach to detection and treatment of depression in primary care. BMJJ 2002; 325: 951–4. 7 Akiskal H S, Walker P, Puzantian V R et al. Bipolar outcome in the course of depressive illness: phenomenologic, familial and pharmacologic predictors. J Affect Disord d 1983; 5: 115–28. 8 Goodwin F K, Jamison K R. Manic-depressive illness. Oxford: Oxford University Press, 1990. 9 Weissman M M, Myers J K. Affective disorders in a US urban community: the use of research diagnostic criteria in an epidemiological survey. Arch Gen Psychiatryy 1978; 35: 1304–11. 10 Osby U, Brandt L, Correia N et al. Excess mortality in bipolar and unipolar disorder in Sweden. Arch Gen Psychiatryy 2001; 58: 844–50. 11 Guze S B, Robins E. Suicide and primary affective disorders 1970. Br J Psychiatryy 1970; 117: 437–8. 12 Rhimer Z, Pestality P. Bipolar II disorder and suicidal behaviour. Psychiatr Clin North Am 1999; 22: 667–73. 13 Murray C J, Lopez A D. Global mortality, disability and the contribution of risk factors: global burden of disease study. Lancett 1997; 349: 1436–42. 14 Das Gupta R, Guest J F. Annual cost of bipolar disorder to UK society. Br J Psychiatryy 2002; 180: 227–33. 15 Jones I, Craddock N. Do puerperal psychotic episodes identify a more familial subtype of bipolar disorder? Results of a family history study. Psychiatr Genett 2002; 12: 177–80. 16 Brockington I F, Cernik K F, Schofield E M et al. Puerperal psychosis. Phenomena and diagnosis. Arch Gen Psychiatryy 1981; 38: 829–33. 17 Videbech P, Gouliaev G. First admission with puerperal psychosis: 7–14 years of follow up. Acta Psychiatr Scand d 1995; 91: 167–73. 18 Zigmond A S, Snaith R D. The Hospital Anxiety and Depression Scale. Acta Psychiatr Scand d 1983; 67: 361–70. 19 Anderson I M, Nutt D J, Deakin J F. Evidence-based guidelines for treating depressive disorders with antidepressants: a revision of the 1993 British Association for Psychopharmacology guidelines. J Psychopharmacol 2001; 14: 3. 20 Goodwin G M. Evidence-based guidelines for treating bipolar disorder: recommendations from the British Association for Psychopharmacology. J Psychopharmacol 2001; 17: 149–73.
Management The principal treatments for mood disorders are psychological, psychopharmacological and physical. Psychological treatments include cognitive and cognitive behavioural therapies, which aim to alter dysfunctional thought patterns and negative automatic thoughts and modulate the patient’s response to stressful events. Interpersonal psychotherapies aim to modify existing patterns of relating to others, and problem-solving therapy may be useful. These psychological therapies are particularly useful in mild-to-moderate depression and may be combined with antidepressant drug treatment in more severe disorders. Drug treatments: a comprehensive review of drug treatments for mood disorders is beyond the scope of this contribution. Useful guidelines for both depression (unipolar) and the various phases of bipolar disorders have been prepared by the British Association for Psychopharmacology.19,20 Antidepressant agents, mood-stabilizing agents and antipsychotics are used, often in combination. Drug treatment may be divided into two principal categories – acute and maintenance. Use of appropriate medications to treat different phases of the illness is important. • Acute depression may require antidepressant drugs that augment serotonergic or noradrenergic neurotransmission. The main classes of antidepressants are the selective serotonin re-uptake inhibitors, the tricyclics, serotonin and noradrenaline re-uptake inhibitors, and monoamine oxidase inhibitors. Adequate doses of antidepressants are recommended for at least 2 years in unipolar patients with frequent recurrences. • Drugs to prevent recurrence are central to the management of bipolar disorders and include lithium salts, carbamazepine, valproic acid formations and lamotrigine. • Antipsychotic agents, particularly atypical antipsychotics (e.g. risperidone, olanzapine, quetiapine) are useful in the management of any affective disorder accompanied by psychotic symptoms. They may also be useful in prophylaxis of bipolar disorders, because they may have mood-stabilizing properties. Physical treatment • Phototherapy may be an effective treatment for depression, particularly in those with seasonal affective disorder. • Exercise can improve mood symptoms in milder depressive disorders.
MEDICINE
16
© 2004 The Medicine Publishing Company Ltd