Mood Disorders

Mood Disorders

Licínia Ganança

Alejandro S. Cazzulino

Maria A. Oquendo


Mood disorders are defined by the presence of a distinct period of persistently altered disposition, specifically, depressed, manic, or hypomanic states. These states are categorized as depressive or bipolar disorders depending on the presenting symptoms and the longitudinal course of the illness. Comorbidity between mood and neurologic disorders occurs frequently. Furthermore, not only may mood, especially depressive, symptoms be part or precede the clinical presentation of some neurologic disorders (e.g., Huntington disease [HD]) but they may also increase the risk for cerebrovascular disorders, and possibly some dementias, and therefore have a considerable impact in the prognosis and quality of life of primary neurologic disorders.


Major depression is one of the leading causes of disability in the United States and worldwide. It ranked 11th in terms of disabilityadjusted life years (DALYs) in a study of 291 diseases and injuries conducted in 21 regions. Moreover, according to the National Mental Health Association, depression affects 1 in every 33 children and 1 in every 8 adolescents. In any given year, about 21 million people in the United States will suffer from major depression (

The incidence of depression is nearly twice as high in women as it is in men, and suicide attempts are more numerous in women. However, death from suicide is far more common in men. Additionally, postpartum depression occurs after as many as 10% of all deliveries. The 12-month prevalence of depression in the U.S. population is estimated to be around 8.1% for women and 4.6% for men.

Bipolar disorder has a lifetime risk of 0.3% to 1.5%, with equal prevalence among men and women. It is estimated that around 10% of depressed patients may in fact be bipolar but have yet to be diagnosed.



A depressive episode is distinct from the normal emotional feelings of sadness or loss or a passing state of these emotions. Functional impairment and significant distress are key criteria and indeed, depression encompasses dysfunction in affective, cognitive, behavioral, and psychomotor domains.

In order to make the diagnosis, at least one of two gateway symptoms must be present for a minimum of 2 weeks: depressed mood and/or substantial decrease in interest or pleasure. Interestingly, depressed mood can manifest in a variety of ways and patients may report feeling down, sad, depressed, anxious, angry, or irritable. Of note, males may be more likely to present with irritability or anger, sometimes making the diagnosis more challenging to identify. Women more often present with “classic” sadness or depression. Anhedonia, or inability to feel pleasure, manifests as a reduction or loss of interest in things, people, or activities. As “gateway symptoms,” the diagnosis of depression cannot be made in the absence of at least one of them.

Cognitively, patients may experience difficulty concentrating or making decisions, a decrease in productivity, forgetfulness, and slowed thoughts. In addition, patients often report distorted thoughts that are negative and pessimistic, including feelings of worthlessness, loss of self-esteem, and unreasonable self-blame or guilt. The future is regarded with a sense of doom or dread and hopelessness. Moreover, negative memories from the past may be preferentially recalled. At times, such cognitive distortions may be of delusional intensity. For example, patients may become convinced they are gravely ill or impoverished and unable to process or “believe” results from medical tests or bank reports. Other delusions typical of depression with psychotic features focus on pessimism or deserved punishment. Auditory hallucinations that are usually simple and mood congruent may be present as well.

The behavioral symptoms of depression include changes in appetite and weight and disruptions of sleep patterns. Sleep disturbances include difficulty falling asleep (early insomnia), waking up in the middle of the night (middle insomnia), and waking up earlier than usual (terminal insomnia). Middle and terminal insomnias are more specific to depression than early insomnia, which is more common in the absence of a mood disorder. However, some patients experience hypersomnia rather than insomnia. Similarly, patients often report poor appetite and weight loss, although increased appetite and weight are sometimes observed, too. Other behavioral symptoms include loss of libido.

Psychomotor activity is usually diminished in depression and low energy and physical fatigue are often present. Patients may experience difficulty completing day-to-day activities and self-care or find that these activities require greater effort. In extreme cases, patients may become virtually immobile and mute, and this condition combined with loss of appetite and overall self-neglect can result in a medical emergency due to dehydration or poor nutrition. In contrast, some patients exhibit psychomotor agitation, which is often accompanied by intense anxiety. Agitation can often be seen in depressed patients but may also result from the side effects of antidepressant medications.

Perhaps, the most worrisome symptom of depression is suicidal thinking or behavior. Suicidal ideation may range from passing thoughts that life is not worth living to well-defined plans with intent to kill oneself. About 15% of patients with depression acknowledge a suicide attempt at some point in their lives and between 2% and 12% of patients with depression commit suicide. This is another way in which depression can lead to morbidity and mortality.

On examination, depressed patients characteristically exhibit a dejected posture, with bent shoulders, frowning, and a downcast gaze. Gestural movements and facial expressions are reduced, and grooming may be neglected. Patients usually take more time to start answering questions and speak slowly and softly.


The distinguishing feature of bipolar disorder is the presence of a manic or hypomanic state that lasts a week or longer (can be less for
hypomania). As with depressive disorders, there are impairments in affective, cognitive, psychomotor, and behavioral domains.

Mania, lasting a minimum of 1 week, is characterized by abnormally elevated or euphoric feelings. As with depression, there can be significant irritability and anger, especially when the patient is frustrated. Patients often appear exaggeratedly cheerful and happy.

Cognitive abnormalities include rapid or even racing thoughts, which may translate into rapid, pressured speech that can, as the severity of mania progresses, become increasingly disorganized. As thoughts become disorganized, speech can exhibit flight of ideas or loosening of associations. In addition, patients are easily distracted and have difficulty focusing on tasks that require concentration. Patients also frequently exhibit impaired judgment and engage in activities they would normally eschew if well. Patients may go on spending sprees, engage in promiscuous sexual behaviors, or make risky business decisions. Cognitive distortions in mania often include inflated self-esteem and grandiose ideas such as a sense of being special, capable of anything, or possessing special powers. As in depression, the cognitive distortions can cross the line into delusional or psychotic thinking. Grandiose delusions are a common psychotic feature in mania.

Behaviorally, manic patients are usually overactive with increased energy levels and engage in multiple activities. Typically, the number of hours of sleep is reduced, without the sensation of fatigue or sleepiness. In fact, insomnia is often the first recognizable symptom of a manic episode. Appetite is usually reduced and combined with increased activity can lead to significant weight loss. Manic patients classically dress with bright colors, use excess make up, or wear extravagant clothing. Movements are exaggerated or theatrical, and patients may express excessive familiarity toward strangers.

From a psychomotor vantage, manic patients frequently have increased psychomotor activity. They may engage in both goaloriented activities at an accelerated pace or be overactive in a general way, with pacing or fidgeting.

Interviewing can be very difficult, as manic psychopathology tends to block communication. It is usually counterproductive for the physician to spend time arguing with or countering the illogical thinking of the patient. Insight is absent in virtually all cases and, therefore, patients typically object to treatment.

Hypomania has a similar clinical presentation but may be briefer, cause less functional impairment, and has no psychotic symptoms.

Although the presence of manic or hypomanic episodes differentiates bipolar from depressive disorders, depression is prominent in bipolar disorder. In fact, over the course of the disorder, most bipolar patients spend significantly more time depressed than manic or hypomanic. Bipolar depression usually has an earlier onset, greater risk of suicidal behavior, likely linked to the greater time spent depressed, and more episodes of illness.

Jul 27, 2016 | Posted by in NEUROLOGY | Comments Off on Mood Disorders
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