Mood disorder - Differential Diagnosis & Management

Differential Diagnosis

Step 1 - exclude a disorder with known organic cause. e.g. mood disorder, dementia etc.

Step 2 - rule out possibility of acute & transient psychotic disorders, schizophrenia, schizo-affective disorder

Step 3 - exclude possibility of other non-organic psychoses like delusional disorder

Step 4 - exclude the possibility of adjustment disorder with depressed mood, generalised anxiety disorder, normal grief reaction, ocd.

look for co-morbid medical and/or psychiatric disorders

Management

Somatic Treatment

Psychosocial treatment

Antidepressants

treatment of choice for vast majority of depressive episodes

e.g. Agomelatin, Amitriptyline, Amoxapine, Bupropion,Citalopram, Clomipramine etc.

can take 3 weeks before any appreciable response can be noticed. Before stopping/changing the drug it should be given in a therapeutically adequate dose for atleast 6 weeks

TCAs ( Tricyclic antidepressants) - Imipramine, amitriptyline & other related drugs come under this

SSRI (Selective serotonin reuptake inhibitors)- fluoetine, sertraline, citalopram, mirtazapine
SNRI ( serotonin norepinephrine reuptake inhibitors) - venlafaxine, duloxetine have little anticholinergic side effects and are safer to user in elderly patients

Electroconvulsive therapy (ECT)

3 main phases of treatment

Acute - till remission occurs

Continuation treatment - from remission till end of treatment

Maintenance - to prevent further recurrences

may be indicated in following patients

Partial response to acute treatment

poor symptom control during continuation treatment

more than 3 episodes

more than 2 episodes with early age of onset/recurrence within 2 yrs of stopping antidepressants

chronic depression (>2 yrs)/double depression

indications

severe depression with suicidal risk

severe depression with stupor, sever psychomotor retardation/somatic syndrome

severe treatment refractory depression

delusional depression

presence of significant antidepressant side effects/intolerance to drugs

can be used for acute manic excitement

antidepressants are also required alongwith ECT

Lithium

traditional drug of choice for treatment of manic episode (acute phase)/prevent bipolar mood disorder

common chronic side effects are nephorlogical and endocrinal

Antipsychotics

commonly used drugs - ROTOR

Risperidone

Olanzapine

queTiapine

halOperidol

aRipiprazole

customary to use atypical antipsychotics

indications

Acute manic episode

delusional depression

alongwith mood stabilisers, before the effect of mood stabilisers become apparent

where mood stabilisers are not effective or have significant side-effects

given parenterally for emergency treatment of mania

atypical antipsychotics might have some mood stabilising properties

customary to user atypical antipsychotics - LESS (oLanzapine quEtiapine riSperidone zipraSidone)

Other mood stabilisers

sodium valproate

carbamazepine & oxcarbazepine

Benzodiazepines

Lamotrigine

T3 and T4

GABRIEL (Group psychoAnalytic cognitiveBehaviouR Interpersonal bEhaviour famiLy) Therapy

Interpersonal Therapy

Psychoanalytic Psychotherapy

Behaviour Therapy

Group Therapy

Family and Marital Therapy

Cognitive Behaviour Therapy

aims at correcting depressive negative cognitions like hopelessness, worthlessness etc. useful in mild to moderate, non-nipolar depression. can be used with/without somatic treatment

attempts to recognise & explore interpersonal stressors, role disputes & transitions. useful in treatment of mild to moderate unipolar depression with/without antidepressants

this is short-term and aim at changing the personality itself. usefulness is uncertain

includes the various short term modalities such as social skills training, problem solving training and so on. useful in mild cases of depressions

useful in mild cases of depression.

main use is for family to be educated. However they are of little use in treatment of mood disorders