Mood disorder substance-induced

The mood disorders were once called affective disorders and are grouped into two main categories unipolar and bipolar. The unipolar depressive disorders include major depressive disorder and dysthymic disorder the bipolar disorders include bipolar 1, bipolar II, bipolar not otherwise specified, and cyclothymic disorder. Other mood disorders are substance-induced mood disorders and mood disorders due to a general medical condition. In addition, mood disturbance commonly occurs as a symptom in other psychiatric disorders including dementia, post-traumatic stress disorder, substance abuse disorders, and schizophrenia. 

The unipolar mood disorders consist solely of episodes of depression. On the other hand, the bipolar mood disorders consist of episodes of both depressed and elevated mood. The periods of elevated mood are characterized by either euphoria or irritability and are called mania or hypomania depending on the level of severity. A schematic of the mood disorders is shown in Figure 3.1. Substance-induced mood disorders and mood disorders due to general medical conditions usually manifest depressed mood however, manic episodes are occasionally seen as well. 

The cause of most psychiatric disorders including depression remains unknown nevertheless, some diagnostic considerations are based on presumed causative factors. In these cases, the distinction from major depression is not based on the symptomatic presentation because there may be no symptomatic difference. The difference lies in the presence of an identifiable biological factor that is presumably causing the depressive syndrome. The causative differential of MDD includes a mood disorder due to a general medical condition in medically ill patients and a substance-induced mood disorder in patients using certain medications or substances of abuse. A comprehensive evaluation of depression must include consideration of potentially treatable causative factors. 

Substance-Induced Mood Disorder. Many prescription medications and abused substances cause depression (see Table 3.5). This idea is not new. In fact, recognizing that certain medications cause depression has helped us to understand the biology of depression better. 

Depression caused by a substance is usually indistinguishable from major depression. It s seldom that a substance-induced mood disorder can be diagnosed with absolute certainty. However, when your patient becomes depressed shortly after beginning to use a medication known to cause depression in others, it s reasonable to assume that the substance may be causing your patient s depression. 

To summarize, comorbidities on which a manic syndrome can be superimposed include ADHD, ODD, conduct or pervasive developmental disorders, Tour-ette s syndrome, or medical conditions such as brain tumors, multiple sclerosis, temporal lobe seizures, human immune-deficiency syndrome (HIV), and endocri-nopathies such as hyperthyroidism and Cushing s syndrome (James and Javaloyes, 2001). Organic affective syndrome, a condition given separate designation in DSM I-IIIR, is now subsumed under mood disorder due to a general medical condition in DSM IV. Substance induced mood disorder has a similar due to. . . designation. 

Some of the most tragic medical-legal cases I have evaluated began with the patient in effect telling the doctor shortly after starting the medication, I ve never felt better in my life. Too often this signals the start of a drug-induced manic reaction, technically called a substance-induced mood disorder with manic features. 

Mood disorder due to a general medical condition Substance-induced mood disorder... 

Substance-induced delirium Substance-induced psychotic disorder Substance-induced mood disorder Substance-induced persisting amnestic disorder Substance-induced anxiety disorder... 

Hypomania is a less severe form of mania, and by dehnition does not cause a marked impairment in social or occupational functioning, and no delusions or haUucinations are present. " Patients with hypomania often do not seek treatment imtil they have a depressive episode, thus hypomania may not be recognized or reported. Symptoms found in hypomanic episodes are similar to those of cocaine- or antidepressant-induced mood disorders thus the differential diagnosis should rule out any substance-induced or medical conditions that present with elevated mood. Hypomanic states should be closely monitored, because 5% to 15% of patients may rapidly switch to a manic episode." ... 

DSM-IV-TR (American Psychiatric Association 2000) recognizes inhalant-, anesthetic-, and solvent-related disorders (Table 13-8). Anesthetics are associated with substance-induced anxiety disorder. Inhalant-related disorders include intoxication, delirium, persisting dementia, psychotic disorders with delusions or hallucinations, mood or anxiety disorders, and disorders not otherwise specified. Diagnosis depends on history or laboratory studies described earlier in this chapter. Physical signs such as deposits from inhalants around the mouth or nose or on hands and clothing may indicate recent use (Westermeyer 1987). Nasal membranes may be inflamed (Wester-meyer 1987). 

Most inhalants or volatile substances are solvents, but the DSM-IV-TR text attributes only five of the eight disorders associated with inhalants to solvents substance-induced psychotic disorder, anxiety disorder, delirium, persisting amnestic disorder, and symptoms of dementia. The association of solvents with dementia is more controversial than their association with mood disorders, but DSM-IV-TR does not recognize mood disorder resulting from solvent exposure. These inconsistencies probably reflect incomplete fidelity between the literature and the psychiatric nosology rather than current opinion. 

Glassification of Substance-Related Disorders. The DSM-IV classification system (1) divides substance-related disorders into two categories (/) substance use disorders, ie, abuse and dependence and (2) substance-induced disorders, intoxication, withdrawal, delirium, persisting dementia, persisting amnestic disorder, psychotic disorder, mood disorder, anxiety disorder, sexual dysfunction, and sleep disorder. The different classes of substances addressed herein are alcohol, amphetamines, caffeine, caimabis, cocaine, hallucinogens, inhalants, nicotine, opioids, phencyclidine, sedatives, hypnotics or anxiolytics, polysubstance, and others. On the basis of their significant socioeconomic impact, alcohol, nicotine, cocaine, and opioids have been selected for discussion herein. 

Alcohol Health Res World 22 122-123, 1998 Solhkhah R, Finkel J, Hird S Possible risperidone-induced visual hallucinations. J Am Acad Child Adolesc Psychiatry 39 1074-1073, 2000 Solhkhah R, Wilens TE, Prince JB, et al Bupropion sustained release for substance abuse, ADHD, and mood disorders in adolescents (NR31), in New Research Absrracts, Annual Meeting of the American Psychiatric Associarion. Washington, DC, American Psychiatric Associarion, 2001... 

Personality disorders can complicate management (e.g., borderline disorder with a superimposed MDD). Dual depression occurs in patients who have chronic dysthymic disorder and then experience a superimposed MDD. Substance abuse and dependence are frequently co-morbid with mood disorders and substantially increase depression-related morbidity and mortality rates (see Drug-Induced Syndromes ). 

The DSM-IV makes multiple references to the fact that antidepressants can cause mania or maniclike behavior. It states, for example, Symptoms like those seen in a Manic Episode may be due to the direct effects of antidepressant medication (p. 329). Similarly, it observes, Symptoms like those seen in a Manic Episode may also be precipitated by antidepressant treatment such as medication (p. 331). References to antidepressant-induced mania and mood disorder can also be found elsewhere in the manual as well (e.g., pp. 332 [note at bottom of table], 334, 336, 337, 351, 371, and 372). The DSM-IV-TR contains the same statements. It emphasizes that a diagnosis of mania or bipolar disorder should not be made when the symptoms hypomania or mania first appear while taking a medication that can cause them and usually disappear when the individual is no longer exposed to the substance. Of great clinical importance, it adds, but resolution of symptoms can take weeks or months and may require treatment (p. 191). 

DSM-IV-TR (American Psychiatric Association 2000) recognizes four disorders resulting from lead poisoning (Table 8-6). The lack of consistency between DSM-IV-TR disorders and the literature probably reflects a developing psychiatric nosology, not an absence of association. The literature supports inclusion of substance-induced psychotic and mood disorders and delirium in addition to the four already listed in DSM-IV-TR. 

I want to reemphasize that drug-induced disturbances in mood or in behavior should be viewed as genuine neurological disorders rather than as vague mental illnesses. The capacity of speculative biochemical imbalances or genetic factors to cause or contribute to mania or depression remains unproven. Nor do we know the specific biochemical or neurological mechanisms whereby psychoactive substances cause mental disturbances. But the capacity for psychoactive substances to disrupt brain function and hence mental function is beyond dispute. Furthermore, a great deal of empirical data confirm their capacity to cause disinhibition, mania, depression, and other mental phenomena associated with violence toward oneself and others, as well as other destructive behaviors. 

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