Mood episodes

Schizoaffective and mood disorder exclusion Schizoaffective disorder and mood disorder with psychotic features have been ruled out because either (1) no major depressive, manic, or mixed episodes have occurred concurrently with the active-phase symptoms or (2) if mood episodes have occurred during active-phase symptoms, their total duration has been brief relative to the duration of the active and residual periods. 

Bipolar disorder is a mood disorder characterized by one or more episodes of mania or hypomania, often with a history of one or more major depressive episodes.1 It is a chronic illness with a course characterized by relapses and improvements or remissions. Mood episodes can be manic, depressed, or mixed. They can be separated by long periods of stability or can cycle... 

The mean age of onset of bipolar disorder is 20, although onset may occur in early childhood to the mid-40s.1 If the onset of symptoms occurs after 60 years of age, the condition is probably secondary to medical causes. Early onset of bipolar disorder is associated with greater comorbidities, more mood episodes, a greater proportion of days depressed, and greater lifetime risk of suicide attempts, compared to bipolar disorder with a later onset. Substance abuse and anxiety disorders are more common in patients with an early onset. Patients with bipolar disorder also have higher rates of suicidal thinking, suicidal attempts, and completed suicides. 

Bipolar disorders have been categorized into bipolar I disorder, bipolar II disorder, and bipolar disorder, not otherwise specified (NOS). Bipolar I disorder is characterized by one or more manic or mixed mood episodes. Bipolar II disorder is characterized by one or more major depressive episodes and at least one hypomanic episode. Hypomania is an abnormally and persistently elevated, expansive, or irritable mood, but not of sufficient severity to cause significant impairment in social or occupational function and does not require hospitalization. Most epidemiologic studies have looked at bipolar disorder of all types (bipolar I and bipolar II), or the bipolar spectrum, which includes all clinical conditions thought to be closely related to bipolar disorder. The lifetime prevalence of bipolar I disorder is estimated to be between 0.3% and 2.4%. The lifetime prevalence of bipolar II disorder ranges from 0.2% to 5%. When including the bipolar spectrum, the lifetime prevalence is between 3% and 6.5%.1... 

Schizophrenia and bipolar disorder often share certain symptoms, including psychosis in some patients. The prominence of mood symptoms and the history of mood episodes distinguish bipolar disorder and schizophrenia. In addition, the psychosis of schizophrenia occurs in the absence of prominent mood symptoms. 

TABLE 36-1. Evaluation and Diagnostic Criteria of Mood Episodes... 

TABLE 36-2. Algorithm and Guidelines for the Acute Treatment of Mood Episodes in Patients with Bipolar I Disorder... 

Conventional antipsychotic drugs such as chlorpromazine and haloperidol have long been used in the treatment of acute mania. More recently, atypical antipsychotic drugs including aripiprazole, olanzapine, quetiapine, risperidone, and ziprasi-done have been approved for the treatment of bipolar mania or mixed mood episodes as monotherapy or in combination with mood-stabilizing drugs.25 Aripiprazole and olanzapine are also approved for maintenance therapy. The combination of olanzapine and fluoxetine is approved for treatment of bipolar depression. Quetiapine is approved for treatment of... 

Obtain an initial medical evaluation to rule out other causes of mood episodes. 

Mixed mood episodes Symptoms of mania and depression occurring simultaneously or in close juxtaposition. 

Desynchronization of circadian or seasonal rhythms cause diurnal variations in mood and sleep patterns and can result in seasonal recurrences of mood episodes. 

Stressful life events often precede mood episodes and can increase recurrence rates and prolong time to recovery from mood episodes. 

Recurrences of mood episodes causes behavioral sensitivity and electrophysiologic kindling (similar to the amygdala-kindling models for seizures in animals) and can result in rapid or continuous mood cycling. 

The length and severity of a mood episode and the interval between episodes vary from patient to patient. Manic episodes are usually briefer and end more abruptly than major depressive episodes. The average length of untreated manic episodes ranges from 4 to 13 months. Episodes can occur regularly (at the same time or season of theyear) and often cluster at 12-month intervals. Women have more depressive episodes than manic episodes, whereas men have a more even distribution of episodes. 

Eliminate mood episode with complete remission of symptoms (i.e, acute treatment)... 

Prevent recurrences or relapses of mood episodes (i.e., continuation phase treatment)... 

Mood episodes document symptoms on a daily mood chart (document life stressors, type of episode, length of episode, and treatment outcome) monthly and yearly life charts are valuable for documenting... 

Patients should be encouraged to call their clinician if any problems or adverse events occur or if mood episodes occur between scheduled appointments rapidly identifying and correcting potential problems or making dosage adjustments is essential in achieving mood stabilization... 

Psychosocial or physical stressors that may precipitate an episode and strategies for coping with stressful life events / Limiting substances and drugs that can trigger mood episodes / Development of a crisis intervention plan Other nonpharmacologic approaches include ... 

An example treatment algorithm for the acute treatment of mood episodes in patients with bipolar I disorder is shown in Table 69-6. 

Doses can be started at 400 mg to 600 mg/day in divided doses, and increased by 200 mg/day every 2 to 4 days up to 10 to 15 mg/kg/day. Outpatients should be titrated upward more slowly to avoid side effects. Many patients are able to tolerate once daily dosing once their mood episode has stabilized. 

Another BRAD diagnostic modifier is the frequency of mood episodes or cycling. Patients who experience four or more episodes (depressed, hypomanic, or manic) per year are said to have rapid cycling BRAD. Rapid cycling patients are more likely to be female and, like those with mixed episodes, respond preferentially to certain anticonvulsants and perhaps atypical antipsychotics than to lithium. 

If we dehne a mood stabilizer as a medication that is both an effective anti-manic and antidepressant, then lithium arguably remains to this day the prototypical mood stabilizer. Lithium not only reduces the symptoms of acute BPAD, it also prevents the recurrence of additional mood episodes. Despite the fact that lithium has revolutionized the treatment of BPAD and remains nearly 50 years after its introduction as the single best treatment for many patients with BPAD, there is still no consensus as to how it works. Lithium exerts effects on several neurotransmitter systems (e.g., serotonin, dopamine, norepinephrine, acetylcholine), on second messenger systems inside the nerve cell, and on nerve cell gene expression. Yet, precisely how these varied effects produce lithium s therapeutic benefit remains unclear. 

Lamotngine (Lamictal). Lamotrigine, another anticonvulsant used to treat BPAD, is currently FDA approved for the prevention of both depressive and manic episodes during BPAD maintenance therapy. This represents a shift in the paradigms for BPAD therapy, as medications used to treat acute episodes have also typically been used for antimanic prophylaxis. Lamotrigine is not effective in the acute treatment of mania but has become for many the drug of choice for bipolar depression as well as for prevention of subsequent mood episodes of either polarity. 

Bipolar disorder For the maintenance treatment of Bipolar I Disorder to delay the time to occurrence of mood episodes (eg, depression, mania, hypomania, mixed episodes) in patients treated for acute mood episodes with standard therapy. 

C. The mood episodes in criteria A and B are not better accounted for by schizoaffective disorder and are not superimposed on schizophrenia, schizophreniform disorder, delusional disorder, or psychotic disorder not otherwise specified. 

The most commonly used semi-structured diagnostic scale is the Structured Clinical Interview for DSM-IV Axis I Disorders (SCI I) First et al., 1997). A clinical version of the SCID (SCID-CV) is designed for use in clinical settings and covers the most commonly seen diagnoses according to DSM-IV. The research version of the SCID includes ratings for different subtypes, severity and course specifiers of mental disorders. The SCLD-CV contains six modules (A) Mood Episodes (B) Psychotic Symptoms (C) Psychotic Disorders (D) Mood Disorders (E) Substance Use Disorders fF) Anxiety and Other Disorders. 

Lithium Plus Thyroid Supplementation. Treatment-resistant and rapid-cycling bipolar patients may have an increased frequency of thyroid dysfunction. Further, some patients suffer from subclinical hypothyroidism and improve with the addition of thyroid supplementation. In this context, several case reports involving this population found that high doses of the thyroid hormone levothyroxine sodium (T ) were clinically beneficial (122,123 and 124). Kusalic (1.25) found that 6 of 10 rapid cyclers had hypothyroidism, based on their thyrotropin-releasing hormone stimulation tests. Further, the average number of mood episodes per year decreased by more than 75% (i.e., from 9.7 to 2.2) after thyroxine was added to the treatment regimen. 

Macritchie K, Geddes JR, Scott J, et al. Valproate for acute mood episodes in bipolar disorder. Cochrane Database Syst Rev. 2003 CD004052. 

Williams NM, Green EK, MacGregor, Dwyer, Norton N, et al. 2006. Variation at the DAOA/G30 locus influences susceptibility to major mood episodes but not psychosis in schizophrenia and bipolar disorder. Arch Gen Psychiatry... 

In a randomized, placebo-controlled, 12-month maintenance comparison of lithium and divalproex in 372 bipolar I outpatients, neither active drug was more effective than placebo on the primary outcome measure—the time to recurrence of any mood episode (79). While a history of intolerance to either lithium or divalproex was an exclusion criterion, it was not stated whether or not prior nonresponders were entered and, if so, how many. The following adverse effects were significantly more frequent ... 

A combined analysis of the data from these two studies, involving over 1300 bipolar I patients, showed that in the 638 randomized patients lamotrigine and lithium were superior to placebo regarding time to intervention to the next mood episode (96). 

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