Chapter 5 — Mood Disorders

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Chapter 5 — Mood Disorders Definitions and Diagnoses The term mood describes a pervasive and sustained emotional state that may affect all aspects of an individual’s life and perceptions. Mood disorders are pathologically elevated or depressed disturbances of mood, and include full or partial episodes of depression or mania. A mood episode (for example, major depression) is a cluster of symptoms that occur together for a discrete period of time. A major depressive episode involves a depression in mood with an accompanying loss of pleasure or indifference to most activities, most of the time for at least 2 weeks. These deviations from normal mood may include significant changes in energy, sleep patterns, concentration, and weight. Symptoms may include psychomotor agitation or retardation, persistent feelings of worthlessness or inappropriate guilt, or recurrent thoughts of death or suicide. The diagnosis of major depression requires evidence of one or more major depressive episodes occurring without clearly being related to another psychiatric, AOD use, or medical disorder. Major depression is subclassified as major depressive disorder, single episode and recurrent. There are nine symptoms of a major depressive episode listed in the DSM-IV draft, and diagnosis of this disorder requires at least five of them to be present for 2 weeks.

Dysthymia is a chronic mood disturbance characterized by a loss of interest or pleasure in most activities of daily life but not meeting the full criteria for a major depressive episode. The diagnosis of dysthymia requires mild to moderate mood depression most of the time for a duration of at least 2 years.

manic episode is a discrete period (at least 1 week) of persistently elevated, euphoric, irritable, or expansive mood. Symptoms may include hyperactivity, grandiosity, flight of ideas, talkativeness, a decreased need for sleep, and distractibility. Manic episodes, often having a rapid onset and symptom progression over a few days, generally impair occupational or social functioning, and may require hospitalization to prevent harm to self or others. In an extreme form, people with mania frequently have psychotic hallucinations or delusions. This form of mania may be difficult to differentiate from schizophrenia or stimulant intoxication.

hypomanic episode is a period (weeks or months) of pathologically elevated mood that resembles but is less severe than a manic episode. Hypomanic episodes are not severe enough to cause marked impairment in social or occupational functioning or to require hospitalization.

bipolar disorder is diagnosed upon evidence of one or more manic episodes, often in an individual with a history of one or more major depressive episodes. Bipolar disorder is subclassified as manic, depressed, or mixed, depending upon the clinical features of the current or most recent episodes. Major depressive or manic episodes may be followed by a brief episode of the other.

Cyclothymia can be described as a mild form of bipolar disorder, but with more frequent and chronic mood variability. Cyclothymia includes multiple hypomanic episodes and periods of depressed mood insufficient to meet the criteria for either a manic or a major depressive episode. The revised third edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-III-R) states that for a diagnosis of cyclothymia to be made, there must be a 2-year period during which the patient is never without hypomanic or dysthymic symptoms for more than 2 months.

Substance-induced mood disorder is described in the DSM-IV draft according to the following criteria:

  1. A prominent and persistent disturbance in mood characterized by either (or both) of the following:
  2. 1) depressed mood or markedly diminished interest or pleasure in all, or almost all, activities,
  3. 2) elevated, expansive, or irritable mood.
  4. There is evidence from the history, physical examination, or laboratory findings of substance intoxication or withdrawal, and the symptoms in criterion A developed during, or within a month of, significant substance intoxication or withdrawal.
  5. The disturbance is not better accounted for by a mood disorder that is not substance induced. Evidence that the symptoms are better accounted for by a mood disorder that is not substance induced might include: the symptoms precede the onset of the substance abuse or dependence; they persist for a substantial period of time (e.g., about a month) after the cessation of acute withdrawal or severe intoxication; they are substantially in excess of what would be expected given the character, duration, or amount of the substance used; or there is other evidence suggesting the existence of an independent non-substance-induced mood disorder (e.g., a history of recurrent non-substance-related major depressive episodes) .
  6. The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.
  7. The disturbance does not occur exclusively during the course of delirium.

Substance-induced mood disorder can be specified as having 1) manic features, 2) depressive features, or 3) mixed features. Also, it can be described as having an onset during intoxication or withdrawal. For most of the major mental illnesses, the DSM-IV draft includes the alternative of a substance-induced disorder within that diagnosis.

Prevalence

Using structured interviews, the Epidemiologic Catchment Area (ECA) studies found that nearly 40 percent of people with an alcohol disorder also fulfilled criteria for a psychiatric disorder. Among people with other drug disorders, more than half reported symptoms of a psychiatric disorder (Regier et al., 1990).

The most common psychiatric diagnoses among patients with an AOD disorder are anxiety and mood disorders. Among those with a mood disorder, a significant proportion has major depression. Mood disorders may be more prevalent among patients using methadone and heroin than among other drug users. In an addiction treatment setting, the proportion of patients diagnosed with major depression is lower than in a mental health setting.

The prevalence rates of mood disorders in the general population can be estimated from the results of the ECA studies (Regier et al., 1988; Robins et al., 1988). These studies indicate that:

  • The lifetime prevalence rates for any mood disorder ranged from 6.1 to 9.5 percent in the ECA study of New Haven, Baltimore, and St. Louis.
  • The lifetime prevalence rates for major depressive episode ranged from 3.7 to 6.7 percent.
  • The lifetime prevalence rates for dysthymia ranged from 2.1 to 3.8 percent.
  • The lifetime prevalence rates for manic episode ranged from 0.6 to 1.1 percent.

Some studies demonstrate that the prevalence of mood and anxiety disorders is no greater among AOD abusers than in the general population. Other studies show elevated rates of these disorders among people with AOD disorders. Many patients receiving treatment for addiction appear depressed, but only a small percent receive a formal diagnosis of major depression as a concurrent illness.

During the first months of sobriety, many AOD abusers may exhibit symptoms of depression that fade over time and that are related to acute withdrawal. Thus, depressive symptoms during withdrawal and early recovery may result from AOD disorders, not an underlying depression. A period of time should elapse before depression is diagnosed.

Among women with an AOD disorder, the prevalence of mood disorders may be high. The prevalence rate for depression among alcoholic women is greater than the rate among men. Counselors should be reminded that women in both addiction and nonaddiction treatment settings are more likely than men to be clinically depressed.

In addition to women, other populations require special consideration. Native Americans, patients with HIV, patients maintained on methadone, and elderly people may all have a higher risk for depression. The elderly may be the group at highest risk for combined mood disorder and AOD problems. Episodes of mood disturbance generally increase in frequency with age. Elderly people with concurrent mood and AOD disorders tend to have more mood episodes as they get older even when their AOD use is controlled.

Differential Diagnosis

Diagnostic Process

Diagnoses of psychiatric disorders should be provisional and constantly reevaluated. In addiction treatment populations, many psychiatric disorders are substance-induced disorders that are caused by AOD use. Treatment of the AOD disorder and an abstinent period of weeks or months may be required for a definitive diagnosis of an independent psychiatric disorder. Unfortunately, the severely depressed person may drop out of treatment or even commit suicide while the clinician is trying to sort things out (see section on “Assessing Danger to Self or Others.”)

Acute manic symptoms may be induced or mimicked by intoxication with stimulants, steroids, hallucinogens, or polydrug combinations. They may also be caused by withdrawal from depressants such as alcohol and by medical disorders such as AIDS and thyroid problems. Acute mania with its hyperactivity, psychosis, and often aggressive and impulsive behavior is an emergency and should be referred to emergency mental health professionals. This is true whatever the causes may appear to be.

Other psychiatric conditions can mimic mood disorders. The predominant condition that mimics a mood disorder is addiction, which is frequently undiagnosed or misdiagnosed. Disorders that can complicate diagnosis include schizophrenia, brief reactive psychosis, and anxiety disorders.

Patients with personality disorders, especially of the borderline, narcissistic, and antisocial types, frequently manifest symptoms of mood disorders. These symptoms are often fluid and may not meet the diagnostic criterion of persistence over time. In addition, all of the psychiatric disorders noted here can coexist with AOD and mood disorders.

CASE EXAMPLES: GEORGE AND MARY

George is a 37-year-old divorced male who was brought into the emergency room intoxicated. His blood alcohol level was 152, and the toxicology screen was positive for cocaine. He was also suicidal (“I’m going to do it right this time! I’ve got a gun.”). He has a history of three psychiatric hospitalizations and two inpatient AOD treatments. Each psychiatric admission was preceded by AOD use. George has never followed through with psychiatric treatment. He has intermittently attended AA, but not recently.

Mary is a 37-year-old divorced female who was brought into a detoxification unit with a blood alcohol level of 150 and was noted to be depressed and withdrawn. She has never used drugs (other than alcohol), and began drinking alcohol only 3 years ago. However, she has had several alcohol-related problems since then. She has a history of three psychiatric hospitalizations for depression, at ages 19, 23, and 32. She reports a positive response to antidepressants. She is currently not receiving AOD or psychiatric treatment.

Differential diagnostic issues for case examples.

Many factors must be examined when making initial diagnostic and treatment decisions. For example, what if George’s psychiatric admissions were 2 or 3 days long — usually with discharges related to leaving against medical advice? Decisions about diagnosis and treatment would be quite different if two of his psychiatric admissions were 4 to 6 weeks long with clearly defined manic and psychotic symptoms continuing throughout the course, despite aggressive use of psychiatric treatment and medication.

Similarly, what if Mary had abstained from alcohol for 6 months “on her own,” but over the past 3 months, she had become increasingly depressed, tired, and withdrawn, with disordered sleep and poor concentration, as well as suicidal thoughts? In addition, last night, while planning to kill herself, she relapsed. A different diagnostic picture would emerge in this case if Mary had been using antidepressants for the past year and, during the past month, she had experienced an increase in heavy drinking, losing her job yesterday because of alcohol use.

AOD-Induced Mood Disorders

It is important to distinguish between mood disorders and AOD intoxication, withdrawal, and/or chronic effects. These distinctions are especially important following the chronic use of drugs that cause physiologic dependence.

All psychoactive drugs cause alterations in normal mood. The severity and manner of these alterations are regulated by preexisting mood states, type and amount of drug used, chronicity of drug use, route of drug administration, current psychiatric status, and history of mood disorders.

AOD-induced mood alterations can result from acute and chronic drug use as well as from drug withdrawal. AOD-induced mood disorders, most notably acute depression lasting from hours to days, can result from sedative-hypnotic intoxication. Similarly, prolonged or subacute withdrawal, lasting from weeks to months, can cause episodes of depression, sometimes accompanied by suicidal ideation or attempts.

Also, stimulant withdrawal may provoke episodes of depression lasting from hours to days, especially following high-dose, chronic use. Stimulant-induced episodes of mania may include symptoms of paranoia lasting from hours to days. Overall, the process of addiction per se can result in biopsychosocial disintegration, leading to chronic dysthymia or depression often lasting from months to years.

Since symptoms of mood disorders that accompany acute withdrawal syndromes are often the result of the withdrawal, adequate time should elapse before a definitive diagnosis of an independent mood disorder is made.

Conditions that most frequently cause and mimic mood disorders and symptoms must be differentiated from AOD-induced conditions. When symptoms persist or intensify, they may represent AOD-induced mental disorders. Transient dysphoria following the cessation of stimulants can mimic a depressive episode. According to the DSM-IV draft, if symptoms are intense and persist for more than a month after acute withdrawal, a depressive episode can be diagnosed. Symptoms of shorter duration can be diagnosed as a substance-induced mood disorder.

It is difficult to generalize about specific drugs causing specific behavioral syndromes. There is tremendous variability, as demonstrated in Multiple drug use further complicates the differential diagnosis. Diagnostic procedures such as urinalysis and toxicology screens should be used if possible. It should also be emphasized that addicted patients may experience withdrawal from one drug despite using another drug.

STIMULANTS

Stimulants such as cocaine and the amphetamines cause potent psychomotor stimulation. Stimulant intoxication generally includes increased mental and physical energy, feelings of well-being and grandiosity, and rapid pressured speech. Chronic, high-dose stimulant intoxication, especially when combined with sleep deprivation, may prompt an episode of mania. Symptoms may include euphoric, expansive, or irritable mood, often with flight of ideas, severe impairment of social functioning, and insomnia.

Acute stimulant withdrawal generally lasts from several hours to 1 week and is characterized by depressed mood, agitation, fatigue, voracious appetite, and insomnia or hypersomnia. Depression resulting from stimulant withdrawal may be severe and can be worsened by the individual’s awareness of addiction-related adverse consequences. Symptoms of craving for stimulants are likely and suicide is possible.

Protracted stimulant withdrawal often includes sustained episodes of anhedonia and lethargy with frequent ruminations and dreams about stimulant use. There may be bursts of dysphoria, intense depression, insomnia, and agitation for several months following stimulant cessation. These symptoms may be either worsened or lessened by the quality of the patient’s recovery program.

DEPRESSANTS

The general effect of the central nervous system depressants such as alcohol, the benzodiazepines, and the opioids is a slowing down of an individual’s psychomotor processes. However, acute alcohol intoxication and opioid intoxication often include two phases: an initial period of euphoria followed by a longer period of relaxation, sedation, lethargy, apathy, and drowsiness.

Alcohol, barbiturates, and the benzodiazepines can cause sedative-hypnotic intoxication, especially when taken in high doses. Psychomotor symptoms include mood lability, mental impairment, impaired memory and attention, loss of coordination, unsteady gait, slurred speech, and confusion.

HALLUCINOGENS, MARIJUANA, AND PCP

The hallucinogens can cause a state of intoxication called hallucinosis, which has several features in common with psychotic disorders and a few in common with mood disorders. Hallucinogens such as LSD and drugs such as MDMA (methylenedioxy-methamphetamine, or Ecstasy) and MDA (methylenedioxyamphetamine) may precipitate intense emotional experiences that may be perceived as positive or negative mood states by the drug user.

These experiences are affected greatly by personality, preexisting mood state, personal expectations, drug dosage, and environmental surroundings. While many users will experience sensory and perceptual distortions, some will experience euphoric religious or spiritual experiences that may resemble aspects of a manic or psychotic episode. Others may have a deeply troubling introspective experience, causing symptoms of depression.

Marijuana, which has sedative and psychedelic properties, can cause a variety of mood-related effects. In the individual who has not developed tolerance for the drug’s effects, high doses of marijuana can cause acute marijuana intoxication with euphoria or agitation, grandiosity, and “profound thoughts.” Together, these symptoms can mimic mania. Because marijuana is only slowly eliminated from the body, chronic use results in relatively constant marijuana levels. Thus, daily marijuana use can be, in effect, a chronic marijuana intoxication. This state may include symptoms of chronic, low-grade lethargy and depression, perhaps accompanied by anxiety and memory loss. Phencyclidine (PCP) intoxication can include symptoms of euphoria, mania, or depression, in addition to sensory dissociation, hallucinations, delusions, psychotic thinking, altered body image, and disorientation.

Mood Disorders Due to A Medical Condition

The DSM-IV draft describes diagnostic criteria for mood disorder due to a general medical condition. The five criteria are:

  1. A prominent and persistent mood disturbance is characterized by either (or both) of the following:
  2. 1) depressed mood or markedly diminished interest or pleasure in all, or almost all, activities,
  3. 2) elevated, expansive, or irritable mood.
  4. There is evidence from the history, physical examination, or laboratory findings of a general medical condition judged to be etiologically related to the disturbance.
  5. The disturbance is not better accounted for by another mental disorder (e.g., adjustment disorder with depressed mood, in response to the stress of having a general medical condition).
  6. The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.
  7. The disturbance does not occur exclusively during the course of delirium or dementia.

Mood disorder due to a general medical condition can be described as having 1) manic features, 2) depressive features, or 3) mixed features in which symptoms of both mania and depression are present and neither predominates.

Medical conditions that can either precipitate or mimic mood disorders include the following:

  • Malnutrition
  • Anemia
  • Hyper- and hypothyroidism
  • Dementia
  • Brain disease
  • Lupus
  • HIV/AIDS
  • Postcardiac condition
  • Stroke, especially among elderly people.

Medications, including reserpine and other medications that treat hypertension and hypotension, can cause conditions that may be confused with psychiatric or AOD disorders. Both prescribed and over-the-counter (OTC) medications can precipitate depression. Diet pills and other OTC medications can lead to mania. Patients treated with neuroleptic (antipsychotic) drugs may have a marked constriction of affect that can be misinterpreted as a symptom of depression.

Stages of Assessment

The patient with coexisting AOD and mood disorders requires a thorough assessment and treatment for both disorders. The assessment process can be divided into three clinical phases: acute, subacute, and long term.

Acute and subacute assessment may not be applicable to certain patients seen in some clinical settings. For instance, AOD treatment program staff in outpatient settings may see fewer patients with acute psychiatric symptoms than are seen in detoxification settings.

Acute Evaluation

ASSESSING DANGER TO SELF OR OTHERS

It is critical to assess whether patients are threats to themselves or others. This evaluation helps to determine if there is a duty to protect patients from self-harm, interrupt intentions of violence toward others, and/or warn intended victims of patients’ announced violent intent.

The responsibility to protect some patients from suicide or violence due to mental illness is not mitigated by confidentiality laws with respect to AOD addiction. Imminent risk, according to the laws of most States, justifies and requires commitment of patients or the warning of potential victims.

Generally, AOD confidentiality laws are very stringent. While some States protect against involuntary commitment for AOD abuse, they do not protect against commitment for AOD-induced psychiatric states which involve danger to oneself or others.

Screening personnel should assess whether suicidal feelings are transitory or reflect a chronic condition. Consider: Do patients have a suicide plan or serious intentions? Have they made past attempts? Whether the patients have had prior psychiatric hospitalization or are in current treatment should be determined. If patients are acutely dangerous to themselves or others, either voluntary or involuntary methods such as commitment should be pursued through local resources. AOD staff should have a thorough knowledge of local resources prior to and in anticipation of crises.

Placement in a safe holding environment can have a positive effect on patients with AOD problems and apparent suicidal intentions. If an intake facility cannot hold such patients, referral to an appropriate facility is recommended. For example, if someone walks into a program at 8:00 a.m. on Monday saying he wants to hurt himself, there should be time to talk the person down, assess treatment needs, and begin treatment or make assessment referrals. When necessary, an assessment should include a rapid triage. See the sections on the assessment of high-risk conditions in and Chapter 8 (Psychotic Disorders).

In virtually every recent study of successful or attempted suicide, AOD use and major depression are among the top associated conditions. Having both conditions simultaneously leads to even greater risk of suicide.

Patients with manic symptoms that approach psychotic proportions require thorough evaluation and require urgent care. Evaluation of mania should be done on a priority basis and should be monitored during subacute assessments.

Patients who have manic and hypomanic symptoms often minimize AOD and psychiatric disorders. Because of the symptom of grandiosity, manic patients may have poor insight into their AOD disorder, their mania, and their social situation. Manic patients may not see themselves as ill. They are usually hyperactive and irritable, and often become a danger to themselves or others through impulsivity, irritability, and poor judgment. When such people are also intoxicated, most will require involuntary commitment. See Chapter 8 for a discussion of assessment of patients with psychosis.

MEDICAL ASSESSMENT

Patients, particularly the elderly, with mood disorders may have life-threatening medical conditions, including hypoglycemia (insulin overdose), stroke, or infections. These conditions, as well as withdrawal and toxic drug reactions, must always be considered and require a thorough physical examination and laboratory assessment. Assessment personnel should make appropriate referrals for medical assessment and treatment. Facilities that have no medical component should train assessment staff in triage and referral.

A plan should be developed to assess and treat medical conditions that precipitate or complicate mood disturbances. Endocrine disorders (such as thyroid problems), neurological disorders (such as multiple sclerosis), and HIV infection should be considered. In addition to obvious medical problems, it can be assumed that basic medical needs of patients with dual disorders are not being met, and a plan should be developed to address these deficits.

INITIAL ADDICTION ASSESSMENT USING THE CAGE QUESTIONS

Clinicians can easily use the CAGE questions for screening (see Chapter 3) as well as adapt them for use with patients who may have mood disorders. For example, consider the following questions adapted from the CAGE questionnaire. “Have you ever cut down or increased your AOD use related to being severely depressed (or manic, etc.)?” “Do you ever get more irritable, angry, depressed, or annoyed when using AODs?” “Do you drink or use other drugs to deal with guilt feelings?” “Do you feel more moody in the morning or evening?” “Have you ever been suicidal when intoxicated?”

Initial AOD assessment should focus on recent use of alcohol and other drugs and a behavioral history. The assessor needs to know what drug has been used, in what quantity, with what frequency, and how recently. Past treatments, past episodes of delirium tremens, hallucinosis, blackouts, and destructive behavior should be recorded.

SOCIAL ASSESSMENT

The social assessment should evaluate the patient’s social environment, especially in relation to AOD and psychiatric disorders. It is important to assess whether the patient experiences housing instability or homelessness. Where does the patient live? Does the patient live in a home? With whom does the patient live? With whom does the patient have regular social contact? Are the social and home environments stable?

In the patient’s social life, is there a precipitating crisis occurring? What is the patient’s existing support structure in the home and community? What role do others have? Is the home free of AODs? Are the home and social environments safe and free from violence? Do the home and social environments support an abstinent lifestyle? If not, it should be assessed whether the patient has the support necessary to overcome the adverse effect of home and social environments that do not support abstinence and recovery.

VIOLENCE BY OTHERS

During the screening interview, it is important to determine whether the patient’s family members are physically abusive. It should be determined whether the patient is in danger. Physical and behavioral observation can be an important aspect of evaluation. The best predictor of future violence is previous violence.

ASSESSING MOOD SYMPTOMATOLOGY

During AOD use history taking and psychiatric screening and assessment sessions, patients with AOD disorders may overemphasize or underemphasize their psychiatric symptoms. For instance, patients who feel depressed during the assessment may distort their past psychiatric experiences and unwittingly exaggerate the intensity or frequency of past depressive episodes.

In contrast, patients who are profoundly depressed during the assessment may minimize their depressive illness because they think it represents a normal state. Indeed, some patients may believe that they “deserve” to be depressed, rather than recognizing that depression is a deviation from normal mood states.

Some patients experience feelings of guilt that are excessive and inappropriate. Other patients do not accurately label their depression and fail to remember that they have experienced depression before. Since patients frequently confuse depression with sadness and other emotions, it is important during the assessment to ask such questions as: “Have you ever seen a psychiatrist or therapist?” (If yes: “Why?”) “Are you able to get out of bed in the morning or do you feel chronically tired?” “Have there been any recent changes in your sleeping patterns or in your appetite?”

Patients may select details from their psychiatric history consistent with their current mood. Those who are depressed may give a generally negative self-report. Addicted patients tend to emphasize psychiatric symptoms; psychiatric patients often underemphasize them. Unhappy addicted patients in a transient disturbance of mood will often rationalize their histories as lifelong depression. Thus, it is important to obtain collateral information from other people and from documents such as medical and psychiatric records. It is critical to continue the process of evaluation past the period of drug withdrawal.

Tips for Assessment

The following are sample questions to ask during the assessment process.

For depression:

  • “During the past month, has there been a period of time during which you felt depressed most of the day nearly every day?”
  • “During this period of time, did you gain or lose any weight?”
  • “Did you have trouble concentrating?”
  • “Did you have problems sleeping or did you sleep too much?”
  • “Did you try to hurt yourself?”

For mania:

  • “During the past month, have you experienced times during which you felt so hyperactive that you got into trouble or were told by others that your behavior was not normal for you?”
  • “Have you recently experienced bouts of irritability during which you would yell or fight with others?”
  • “During this period, did you feel more self-confident than usual?”
  • “Di
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