What is Mood Disorder?
Mood, as we define it, is a sustained emotional state that a person experiences internally. It significantly influences practically every aspect of the person’s behavior in their daily life. Mood disorders, also known as affective disorders, are mental health issues that cause severe emotional changes, like extreme sadness (depression) or extreme happiness (hypomania or mania). These disorders are common and can increase the risk of other health problems.
The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), categorizes mood disorders into two types: bipolar disorders and depressive disorders. Bipolar disorders are divided into various types, including bipolar I and II, cyclothymic disorder, and others that are related to medical conditions or induced by substances or medication.
Bipolar I disorder involves periods of intense elevated mood, known as mania, that lasts for at least a week or requires hospitalization. During these phases, people may exhibit several symptoms including increased activity, inflated self-esteem, less need for sleep, distraction, fast thoughts, rapid speech, and impulsive behaviors. If the mood is more irritable than elevated, at least four of these symptoms are required for a diagnosis.
Bipolar II disorder involves the presence of major depressive episodes and less severe manic periods, known as hypomania, that last at least four days.
Cyclothymia is a milder form of bipolar disorder characterized by slight mood swings between sub-threshold depression and mild hypomania. To be diagnosed with cyclothymia, an adult must experience these mood swings for at least 2 years without fitting the criteria for manic, hypomania, or major depression. In children or adolescents, these mood swings must last at least 1 year.
Hypomania is a less severe type of mania that lasts for at least four consecutive days and doesn’t severely disrupt one’s social or occupational functioning. Symptoms of hypomania include elevated mood, increased activity, inflated self-esteem, less need for sleep, distraction, fast thoughts, rapid speech, and impulsive behavior.
Major depressive disorder is diagnosed based on the presence of five of nine indicators. These include persistent sadness, difficulty sleeping, feelings of guilt, low energy, decreased concentration, loss of appetite, reduced interest in enjoyable activities, changes in physical movements, and frequent thoughts of suicide over a span of two weeks.
The DSM-5 also recognizes three additional types of depressive disorders. These are: disruptive mood dysregulation disorder, seen in children and adolescents who show anger and irritability beyond what is normal for the situation; persistent depressive disorder, a long-term mild depression lasting at least two years in adults and one year in children and adolescents; and premenstrual dysphoric disorder, characterized by irritability, anxiety, depression, and mood swings that occur during the week before menstruation and resolve afterwards.
Major depressive episodes can occur before or alongside persistent depressive disorder, a situation referred to as double depression.
Other types of depressive disorders include those linked to another medical condition, induced by substances or medication, and depressive disorders specified and unspecified types.
What Causes Mood Disorder?
The amygdala and the orbitofrontal cortex are parts of our brain which control our emotions. Studies with patients who have mood disorders, like depression or bipolar disorder, have shown that their amygdala is often larger than normal. This supports the idea that changes in these areas can cause mood disorders. Mood disorders can also lead to the enlargement of brain cavities called ventricles.
Biologically, there are neurotransmitters or brain chemicals which are vital in regulating our mood. Two examples are serotonin and norepinephrine which are typically reduced during depression. Serotonin is the most commonly linked neurotransmitter with depression. Meanwhile, dopamine, another neurotransmitter, can be decreased in depression or increased during mania, the high-energy phase of bipolar disorder.
Certain health conditions such as brain tumors, syphilis, confusion (delirium), encephalitis, flu, hemodialysis (a procedure to clean the blood), multiple sclerosis, Q fever, cancer, AIDS, and hypothyroidism (low thyroid hormone levels) can cause mood disorders. Additionally, the use of certain substances like amphetamines, cocaine, procarbazine, and steroids can generate symptoms similar to mood disorders.
Research has shown that genetics play a role in mood disorders. Studies indicate that mood disorders are more likely to develop in people who have a family history of these conditions. A parent with a mood disorder is continually a high-risk factor for their children developing one as well.
Hormones are also involved in mood disorders. An overactive HPA (a part of the brain that responds to stress) is linked with stress and depression. Increased TSH (a hormone that controls the thyroid) is associated with depression.
Life stressors like the death of a loved one, traumatic events, or childhood abuse can significantly impact the development of mood disorders later in life. Certain personality traits or disorders like borderline and obsessive-compulsive disorder (OCD) are more often associated with depression. Problems with forming secure relationships and adverse experiences in early childhood have also been linked with depression.
The immune system appears to play a role in mood disorders as well, as it can affect certain substances in the brain such as IL-1beta, IL-6, and TNF-alpha. New studies have identified that nitric oxide, a molecule involved in inflammation, contributes to mood disorder symptoms. Changes in nitric oxide levels have been found in patients with mood disorders too.
Lastly, people with depression or bipolar disorder often have an increased amount of unusually intense spots (hyperintensities) in certain areas beneath the cortex, the outer layer of the brain.
Risk Factors and Frequency for Mood Disorder
Major depression is more common than you might think, impacting around 5% to 17% of people at some point in their lives. Women are nearly twice as likely to experience depression as men. Annually, 7.1% of adults in the U.S. experience depression, while 2.8% grapple with bipolar disorder. On average, most people first experience major depression at the age of 32.
Mood disorders aren’t just an adult problem; they also affect children and teenagers. It’s estimated that 15% of young people experience a mood disorder, with 12% of those cases being severe. Depression, specifically, is significant among young people, with rates of 18% to 22% in girls and 7% to 10% in boys by age 17. There is also a condition called disruptive mood dysregulation disorder, affecting between 0.8% to 4.3% of children.
- The lifetime prevalence rate for different types of bipolar disorder are:
- 0.6% for bipolar I
- 0.4% for bipolar II
- 2.4% for bipolar spectrum disorder (BPS)
Signs and Symptoms of Mood Disorder
Diagnosing mood disorders like bipolar disorder involves taking a detailed account from the patient about their behaviors and feelings. If someone’s experiencing a manic episode, they could display behavior such as heightened self-confidence, irritability, restlessness, delusions, or hallucinations. On the other hand, depressive episodes might be signalled by feelings of sadness, guilt, a decreased interest in enjoyable activities, or even thoughts of self-harm and suicide.
Distinguishing between unipolar (only depressive episodes) and bipolar (both depressive and manic episodes) depression is crucial too. Clues that it might be bipolar depression include an early start to the symptoms, sudden onset, multiple episodes of depression, a family history of bipolar disorder, experiencing hypomania triggered by antidepressants, and exhibiting psychotic symptoms before the age of 25. Past episodes of high mood with little need for sleep and lots of energy could also be indicators of bipolar disorder, but these are often overlooked by patients during their discussions with the medical team. Evaluating the risk of suicide and homicide is another essential part of the process.
During a formal interview and assessment, people with depression may avoid eye contact, show minimal emotion, speak and react slowly, and appear untidy and neglectful of their hygiene. They usually exhibit significantly decreased physical activity. In contrast, those experiencing a manic episode would show a lot of restless behaviour, seem agitated and irritable, talk rapidly, react quickly, and be hard to interrupt. They may also hallucinate or exhibit paranoid behaviour, or in some cases, have deluded beliefs. It’s also worth noting that major depression can sometimes also present with psychotic symptoms.
Testing for Mood Disorder
To diagnose mood disorders early, it’s crucial to have a comprehensive understanding of the individual’s personal and family histories, as well as a thorough mental status exam. Substance-related mood disorders may require a urine drug test for confirmation. There are specific assessment tools, or rating scales, that help measure the severity or progress of mood disorders.
The Hamilton Rating Scale for Depression (HAM-D) is one such tool used by health professionals. This 17-point checklist assesses symptoms like low mood, trouble sleeping, concentration issues, guilt feelings, suicidal thoughts, anxiety symptoms, and physical discomfort. The scoring is either on a 3 or 5 point scale. If one scores between 0 to 7, they are considered normal, and a score above 20 typically requires intervention.
Another tool for depression diagnosis is the Montgomery-Asberg Depression Rating Scale (MADRS). It evaluates symptoms like feelings of sadness, inner stress, appetite, sleep issues, self-harming thoughts, and suicidal tendencies on a 0 to 60 point scale. A score from 0 to 6 is normal, 7 to 19 shows mild depression, 20 to 34 shows moderate depression, and a score above 34 suggests severe depression.
When evaluating mania, clinicians use the Young Mania Rating Scale (YMRS). This 11-point scale measures symptoms such as irritability, speech patterns, thought content, disruptive behavior, elevated mood, increase in activity, sexual desire, sleep patterns, appearance and insight. Some items are scored from 0 to 8, while others are scored from 0 to 4. Scores under 12 indicate remission, 13 to 25 suggest moderate mania, and 38 to 60 indicate severe mania.
Treatment Options for Mood Disorder
Recognising and appropriately treating mood disorders early can reduce associated health risks and complications. A careful evaluation of a patient’s safety and functioning level is essential before choosing treatment options. Mental health care involves building a strong therapeutic relationship, teaching the patient about signs and symptoms of mood disorders, reinforcing the importance of taking medication as prescribed, highlighting the significance of regular sleep and a balanced diet, anticipating stress triggers, recognizing mood disorder relapses, and minimizing social and functional difficulties.
When treating Bipolar Disorder, the choice of medication depends on the severity of symptoms. If symptoms are severe or mixed, a patient might be started on a mood stabilizer like lithium or valproic acid, and an antipsychotic such as risperidone, olanzapine, quetiapine, ziprasidone, or aripiprazole. For less severe episodes, a single drug may be sufficient: lithium, an anticonvulsant, or an antipsychotic. If a patient is experiencing a depressive episode, quetiapine, lurasidone, lamotrigine, or a combination of olanzapine and fluoxetine may be prescribed.
Lithium, a first-choice mood stabilizer, slows down the activities of overactive nerve cells involved in manic states. It also reduces the supply of a certain chemical that is needed to regenerate membrane components. Adults usually begin with a 300 milligram dose, whereas older people with kidney problems start with a lower dose. Possible side effects include stomach upset, tremors, excessive thirst and urination, hormone imbalances, and cognitive impairment. Sodium valproate, another popular mood stabilizer, enhances the action of a calming neurotransmitter and can rapidly stabilize patients who are behaving aggressively.
The treatment for Unipolar depression or prolonged low mood involves a different set of medications. Selective serotonin reuptake inhibitors (SSRIs) reduce depression by boosting the level of the neurotransmitter serotonin in the brain, but they can cause stomach upset, reduced sex drive, sleep disturbances, etc. Antipsychotics like aripiprazole are also used in combination with other drugs for treating depression.
In addition to medication, psychotherapy, including mindfulness-based cognitive therapy (MBCT), acceptance and commitment therapy (ACT), interpersonal psychotherapy, cognitive-behavioral therapy (CBT), dialectical behavioral therapy, are beneficial in improving mood symptoms and preventing relapses. Moreover, ‘brain stimulation’ therapy like repetitive transcranial magnetic stimulation (rTMS) has shown promising results in treating mood disorders. Electroconvulsive therapy (ECT), another brain stimulation therapy, is used in severe, treatment-resistant depression.
Lastly, lifestyle modifications such as adopting a healthy diet, consistent exercise and yoga, smoking cessation, and incorporating omega-3 fatty acids into the diet can play a critical role in managing mood disorders.
What else can Mood Disorder be?
Diagnosing mood disorders isn’t always straightforward. According to the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), doctors should keep these other conditions in mind when figuring out what might be causing a patient’s symptoms:
- Generalized anxiety disorder, panic disorder, posttraumatic stress disorder (PTSD), or other anxiety disorders: These conditions can sometimes look like mood disorders, as they can have similar symptoms such as racing thoughts and aggressive behavior. Careful evaluation of a patient’s history is necessary to tell anxiety disorders and mood disorders apart.
- Substance/medication-induced mood disorder: Sometimes, the use of certain substances or medications (like steroids or alpha-interferons) can cause symptoms similar to those in mood disorders, such as mania or depression. The key factor here is whether the symptoms stop when the patient stops using the substance or medication.
- Attention-deficit/hyperactivity disorder (ADHD): Particularly in children and teenagers, ADHD can often be confused with bipolar disorder because they share symptoms like hyperactivity and restlessness. However, the episodic (comes and goes) nature of bipolar disorder can help distinguish it from ADHD.
- Personality disorder: Some personality disorders, like borderline personality disorder, can mimic bipolar disorder due to overlapping symptoms like impulsive behavior and delusions. The difference lies in whether these symptoms occur episodically or are always present.
- Schizophrenia spectrum and other related psychotic disorders: It’s important to distinguish between bipolar disorder or severe depression with psychotic symptoms and disorders like schizophrenia. Symptoms like delusions typically occur without a mood disorder in conditions like schizophrenia.
- Delirium, catatonia, and acute anxiety: Mania can sometimes look like these conditions, making it crucial to tell them apart given the severe implications on treatment strategy.
What to expect with Mood Disorder
In the first year of monitoring, patients who had a mood disorder starting in childhood, a delayed diagnosis, and a longer duration of untreated illness experienced significant severity of the disorder. They went through more episodes, had additional depressed days and showed a limited number of “normal” days.
About one out of three mood disorders reoccur, a third of the patients develop psychotic disorders, and one more third end up with a lifelong anxiety disorder. It’s also common for patients to constantly think about dying (80.8%) and suicide (69.5%). Females frequently had more detailed suicidal plans during the follow-up.
These mood disorders often come with lifelong anxiety, substance abuse disorder, missing work, and family discord, which can lead to a poor quality of life. It also increases direct and indirect health care costs because of the extended duration of hospital stays.
Possible Complications When Diagnosed with Mood Disorder
Research seems to suggest that when a mood disorder, like depression or bipolar disorder, lasts a long time, it can lead to more serious outcomes like self-harm or suicide. In some cases, mood disorders, especially bipolar disorders, might not be instantly recognized and could go unnoticed or be wrongly diagnosed for up to 10 years. A late recognition of bipolar disorder can have serious effects, including substance misuse.
Furthermore, people with mood disorders often suffer from other concurrent mental health issues. Anxiety disorder is one of the most commonly associated ailments. Other frequently overlapping conditions include Attention Deficit Hyperactivity Disorder (ADHD), oppositional defiant disorder, and conduct disorders.
Mood disorders can also lead to significant issues in the individuals’ personal and professional lives, causing problems like inability to work and difficulties in maintaining healthy emotional relationships with family and friends.
Common Effects and Comorbidities of Mood Disorders:
- Increased risk of self-harm/suicide
- Misdiagnosis or late diagnosis
- Potential substance abuse
- Common co-occurring conditions: Anxiety disorder, ADHD, oppositional defiant disorder, conduct disorders
- Significant impact on personal and professional life (e.g., inability to work, challenges in sustaining emotional relationships)
Preventing Mood Disorder
Mood disorders, such as depression and bipolar disorder, are common mental health conditions that can seriously affect a person’s quality of life and even be life-threatening. It’s crucial that people who suffer from these conditions understand the symptoms and seek treatment promptly. Teaching them about their mental health condition can improve their cooperation with their treatment plan and reduce their chances of having a recurrent episode.
Before leaving a psychiatric facility, patients and their caregivers should be educated about the early warning signs of a mood disorder episode. If a patient starts to show signs such as not needing much sleep, being more talkative than usual, having racing thoughts, or feeling extremely energetic, it’s important to seek medical help right away for treatment adjustments.
Recovering from an episode of mania or depression is a crucial step, and sticking to the prescribed medication and therapy is the key to a successful recovery. Doctors should emphasize the importance of regular check-ups and adherence to the treatment plan at every appointment.