MOOD DISORDERS

Dr. Ida Ayu Kusuma Wardani, SpKJ, MARS

Bag/ SMF Psikiatri RSUP Sanglah
Denpasar

Major Depression and Bipolar Disorder

A group of disorders in which the clinical
picture is dominated by the pathological mood
and related disorders ( Affective Disorders)
Other signs and symptoms of mood disorders
include change in activity level, cognitive
abilities, speech, and vegetative function
(sleep, appetite, sexual activity, and other
biological rhythms) periodic weeks-months

History

Hippocrates: mania and melancholia

Celsus: melancholia
1854, Jules Falret : folie circulaire
1882, Karl Kahlbaum : cyclothymia
1889, Emil Kraepelin : manic-depressive
psychosis (non dementing &deteriorating DD
dg Schizophrenia), involutional melancholia

EPIDEMIOLOGY
Sex
-Bipolar I, prevalence = .
-Manic episode > , depresssion
episode >
-Manic episode > with mixed
features, > rapid cycling
-Episode bipolar I > like picture
manic episode
but > like picture MDD

 Age
Onset bipolar I disorders > earlier
than MDD (as early age 5 or 6 years
until 50 years, with means age of 30
years)
Related to be increased use of
alcohol and drugs of abuse in this
age group

 Marital Status
Bipolar I disorder is more common in divorced
and single person than among married person,
but this differences may reflect the early onset
and the resulting marital discord characteristic
of the disorder
Social economic and cultural factor
No correlation MDD
Bipolar I disorder not graduate , Bipolar II
disorder in college graduate

Classification DSM-5
Major Depressive Disorder (MDD) / unipolar
depression :
No history of manic episodes manic/ hypomanic/
mixed
2 weeks
4 symptoms : changes in appetite and weight,
changes in sleep and activity, loss energy, guilty
feeling, problem in thinking and decision,
ercurrent thoughts of death/ suicide

 Manic episode
A distinct period of an abnormally & persistently
elevated, expansive, or irritable mood
1 weeks (or less if a patient must be hospitalized)
Hypomanic episode :
4 consecutive days
= manic episode, No occupational functioning
No psychotic features
Manic & hypomanic: inflated self-esteem,
decreased need for sleep, more talkative than usual,
over involvement in activities that have a high
potential in unrestrained buying
Bipolar I : 1/> manic episode depression

 Mixed episode: 1 weeks manic

episodes + MDD usually every day
Bipolar II : hypomanic + MDD
Dysthymia : 2 years, depressed
mood < MDD
Cyclothymia: 2 years, frequently
occurring hypomanic symptoms (<
manic episode) & depressive
symptoms (< MDD)

ETIOLOGI
Biological Factors (monoamine neurotransmitters:
norepinephrine, dopamine, serotonin)
Biogenic amines:
Activation receptor adrenergic 2 pre-sinaptic
norepinefrin decrease & serotonine release depresi
Depletion serotonin may precipitate depression and suicidal
impulses low CSF concentration of serotonin metabolites
and uptake sites on platelets
Dopamin : decreased activity (disfungsi mesolimbic
dopamin pathway & D1 Rec hipoactive ) reduced in
depression & increased in mania

Faktor Genetik
Significant (but the pattern of genetic inheritance
is complex ) particularly in bipolar I
- Family studies : likelihood of having a mood
disorder as the degree of relationship widened
- Adoption studies : biological relatives of bipolar
probands
- Twin studies : monozygotic concordance rate
bipolar I : 33-90 %, MDD : 50 %
- Linkage studies no genetic association has
been consistently replicated

Psychosocial Factors
Live events & Environmental stress
Stress accompanying the first episode results in longlasting changes in the brains biology a high risk of
undergoing subsequent episodes of mood disorder,
even without an external stressor
Examples: losing a parent before age 11 years, loss of
a spouse, unemployment
Personality Factors:
- No single personality trait predisposes depression
- Personality disorders: OCD, histrionic and bordeline
greater risk depression than antisocial and paranoid
because can use projection & eksternalizing defense
mechanism
- Dysthymia & Cyclothima risk factor MDD/ bipolar I

DIAGNOSIS
MDD = Unipolar = Single episode
Single / recurent
Differentiation between these patients and
those who have two or more episodes of MDD
is justified because of the uncertain course of
the former patients disorder

Bipolar I
Abnormal mood lasting at least 1 week
Include separate bipolar I disorders (single
manic episode and a recurrent episode based
on the symptoms of the most recent episode)
Manic episodes clearly precipitated by
antidepressant treatment
Bipolar I disorders, single manic episode :
episode manik I
Bipolar I disorders,recurent : at least 2
months without significant symptoms mania
or hypomania

BIPOLAR II
Specify the particular severity, frequency
and duration of the hypomanic symptoms
Sometime to overdiagnosis of hypomanic
episodes and the incorrect classification of
patients with MDD
Bipolar II with psychotic features
Bipolar II no psychotic features

Clinical Pictures Disordersipolar (GB)

Mania Subsyndromal
Mania
(Hypomania)

Mania

Maintenance

bsyndromal Depression
Depression
ysthymia)

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Rekomendasi Farmakoterapi Untuk GB

Pilihan

Jenis Obat

Lini I

Litium, divalproat, olanzapin, risperidon, quetiapin, quetiapin XR,

aripiprazol, ziprasidon, litium atau divalproat + risperidon, litium atau
divalproat + quetiapin, litium atau divalproat + olanzapin, litium atau
divalproat + aripiprazol

Lini II

Karbamazepin, ECT, litium + divalproat, Asenapin, litium atau

divalproat + Asenepin, paliperidon monoterapi

Lini III

Haloperidol, klorpromazin, litium atau divalproat + haloperidol, litium +

karbamazepin, klozapin, oksakarbazepin, tamoksifen

Monoterapi gabapentin, topiramat, lamotrigin, verapamil, tiagabin,

Tidak
direkomendasi risperidon + karbamazepin, olanzapin + karbamazepin
kan

9/27/16

Diagnosis GB

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o Tuntunan/panduan disesuaikan secara

individual
o Gunakan obat yang sudah terbukti efektif
selama ini
o Pilih obat terbaik, misalnya:
Aman dan ditoleransi dengan baik
Penggunaan paling mudah (untuk
pasien)
Pengelolaan paling mudah (untuk
dokter)
o Tujuan remisi simtom, bukan hanya
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o Tidak satu pun obat yang benar-benar mujarab untuk

menyembuhkan sehingga pengobatan ditujukan
untuk mengurangi/menghilangkan tanda dan gejala
yang mengganggu.
o Jangan menyerah.
o Restorasi psikososial.
o Gunakan keluarga, edukasi, psikoterapi.
o Semakin kronik penyakit respons terapi semakin
lambat.

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Terima Kasih