Psychiatry: A Course of Lectures - V. S. Bitensky 2004

Affective Disorders

In modern domestic Classification of mental illnesses, endogenous Affective Disorders are subdivided into affective psychoses and non-psychotic affective disorders (cyclothymia and dysthymia). METABOLISM/2.html">THE CONCEPT OF "affective psychosis" encompasses endogenous mental disorders characterized by the periodicity of well-defined affective (manic, depressive, mixed) states with complete reversibility, a return to symptom-free lucid intervals, and full restoration of pre-morbid mental traits. Affective psychosis is a non-progredient disorder, occurs in phases, and never leads to dementia. By definition, affective psychosis meets the criteria of an endogenous disease traditionally designated as manic-depressive psychosis (other names: circular insanity, cyclophrenia, circular psychosis, manic-depressive illness, phasic psychosis).

Affective disorders are somewhat akin to the natural emotional reactions experienced by humans during periods of misfortune or success. A depressed mood is frequently a component of many psychopathologic syndromes and usually accompanies physical malaise; an elevated mood is likewise a constituent element of certain mental disorders. This section describes mood disturbances as syndromes in which the mood disorder is primary. The central features of these syndromes are, on the one hand, a depressed (lowered) mood, pessimistic thoughts, anhedonia, decreased energy, and slowness; on the other hand, an elevated mood, hyperactivity, and grandiose ideas concerning oneself and environmental factors. The former disorder is termed depressive disorder, and the latter is termed manic (or, in milder presentations, hypomanic) state.

Depressive disorders are frequently encountered in the practice of physicians of any specialty, particularly general practitioners, yet they often go undetected. Undiagnosed depressive disorder is a common cause of protracted illness and delayed recovery from physical ailments. Therefore, it is essential that physicians across all specialties, especially general practitioners, be capable of identifying and assessing existing depressive disorders, managing less severe cases, and making timely referrals to a psychiatrist in more pronounced instances to prevent the risk of suicide or other adverse outcomes. Manic states are not diagnosed as frequently as depressive ones. Nevertheless, it is crucial that the symptoms of manic syndrome are recognized in their early stages, as patients become increasingly Treatment-resistant as the condition progresses.

Etiology AND Pathogenesis of Affective Disorders

Affective disorders comprise several links in their etiology and pathogenesis:

1. Some authors consider affective disorders to be Hereditary diseases and single out specific genes responsible for them. There are also theories regarding the genetic diversity of affective disorders, suggesting the existence of dominant, recessive, and polygenic modes of inheritance.

2. The biochemical cause involves impaired neurotransmitter turnover—their levels decrease in depression (serotonin) and increase in mania, alongside catecholamines, whose deficiency is noted in depression.

3. Neuroendocrine causes manifest as a disruption in the rhythmic functioning of the hypothalamo-pituitary system, the limbic system, and the Pineal Gland, which affects the pulsatile release of releasing Hormones and melatonin. This indirectly impacts the body's overall biorhythms, notably the Sleep-wake, sexual, and feeding cycles, which are systematically disrupted in affective disorders.

4. Theories of social loss encompass cognitive and psychoanalytical interpretations. The cognitive interpretation is based on The Study of the fixation of depressogenic schemas, such as: bad mood – I can do nothing – my energy is dropping – I am useless – mood deteriorates. This schema operates at both personal and social levels. The stylistics of depressive thinking presupposes a lack of future planning. According to S. Freud's structural theory, the ambivalent introjection of a lost object into the "Ego" leads to The Development of typical depressive symptoms, evaluated as a loss of energy belonging to the "Ego". The "Superego", unable to react appropriately to the loss of energy in external manifestation, strikes a blow at the mental representation of the lost object, which is now internalized into the "Ego" as an introject. When this overcomes or merges with the "Superego", the release of energy previously bound in depressive symptoms is observed, resulting in the development of mania with its characteristic symptoms of excess.

5. Negative (distress) and positive (eustress) stress can act as triggers for affective disorders. A series of stressors leads to overstrain and subsequently to exhaustion—the final phase of the General adaptation syndrome—and the development of depression in constitutionally predisposed individuals. The most significant stressors include the death of a spouse or child, marital conflicts, and the loss of socioeconomic status.

6. The psychobiological foundation of affective disorders lies in regulatory dysfunctions within THE SPECTRUM OF aggressive and auto-aggressive behavior. A selective factor for depression is The stimulation of altruism within a group and family, while hypomania is also characterized by a clear predominance in group and individual Selection. This determines a stable incidence rate of susceptibility to affective disorders within the population.

Diagnosis of Affective Disorders

The primary features are alterations or affects of mood; other symptoms stem from these changes and are secondary.

According to ICD-10, affective disorders are classified as follows:

F30 Manic episode

F31 Bipolar affective disorder

F32 Depressive episode

F33 Recurrent depressive disorder

F34 Persistent affective mood disorders (cyclothymia, dysthymia)

F38 Other affective mood disorders

F39 Unspecified affective mood disorder

Clinical Features of Affective Disorders

Manic State

The core features of a manic state are an elevated mood verging on euphoria, heightened activity, and grandiose ideas. With an elevated mood, the patient appears cheerful and optimistic, sometimes displaying an infectious joviality. However, patients are often irritable rather than euphoric and can easily become angered. Mood frequently fluctuates throughout the day, albeit without the regular rhythm so characteristic of pronounced depressive disorders. The elevated mood in patients with a manic state is occasionally interrupted by brief episodes of depression.

The patient's appearance often reflects their prevailing mood. Clothing may be flamboyant and poorly matched. In more severe affective disturbances, the patient's physical appearance may be untidy and disheveled. Motor and emotional hyperactivity can be sustained and lead to physical exhaustion. Manic patients exhibit increased distractibility; they initiate numerous tasks but fail to complete them as they move on to new ones. Speech is rapid, words tumbling out as their thoughts shift swiftly in sequence ("flight of ideas"). In more pronounced disorders, a veritable "rush" of ideas is observed, changing so rapidly that it is difficult to keep pace. Sleep duration is frequently reduced. Patients awaken very early, feeling refreshed, energetic, and immediately plunging into vigorous activity. Appetite is increased, and food is consumed ravenously without regard for social etiquette. Libido is sharply increased, and patients become sexually uninhibited.

Clinical Features of Manic State

Hyperthymia or irritability Hyperactivity Increased distractibility Socially inappropriate behavior Reduced sleep Increased appetite

Flight of ideas

Delusions of overvaluation

Hallucinations

Impaired perception

Delusions of self-importance are common. Patients believe that their ideas are original, their opinions are extremely important, and their work is of outstanding quality. Many patients become extravagant, spending more money than they can afford on expensive cars or jewelry. Others make reckless decisions to quit good jobs or embark on risky business ventures.

Sometimes ideas of overvaluation are accompanied by delusions of grandeur. Patients may believe they are religious prophets or experts appointed to advise statesmen on critical issues. Delusions of persecution are observed from time to time. Patients believe that those around them are conspiring against them because of their special importance.

In one-fifth of patients with manic disorders, delusions of reference or other psychotic syndromes are diagnosed. However, these are short-lived: most disappear or resolve within a few days (if they persist longer, the diagnosis should be reconsidered, as Schizophrenia can frequently begin with affective disorders).

Hallucinations congruent with the prevailing mood are common, usually manifesting as a voice telling the patient about their special powers, or less frequently, as religious visions.

Rational thinking and critical faculties are consistently impaired. Patients cannot see any reason why their grandiose plans should be limited or their extravagant spending curtailed. Sufferers rarely recognize the presence of illness and therefore refuse treatment.

Most patients with manic syndrome can maintain some control over their symptoms for a short time. Some use this during examinations to dissimulate pathological disorders, which can often lead to underestimating the severity of the illness. Therefore, it is crucial to obtain information from people close to the patient. The following criteria help assess the severity of mania.

In mild manic syndrome, physical activity is increased, speech is accelerated, and mood is labile and predominantly hyperthymic, with periodically emerging irritability, ideas of overvaluation, and hypersexuality. In moderate severity, hyperactivity is noted with tension and disorganized speech; euphoric mood is increasingly interrupted by periods of irritability, hostility, and depression, and ideas of overvaluation may become delusional. In severe mania, there is hyperactivity, thought processes become incoherent, delusions grow increasingly bizarre and are accompanied by hallucinations. Very rarely, patients become immobile and mute—a state known as manic stupor. It must be emphasized that the aforementioned criteria are merely reference points; there is no rigid boundary when transitioning from one degree of severity to another.

Depressive Syndromes

For depressive episodes of all severity levels, the duration of the episode should be at least 2 weeks, although a diagnosis can also be made for shorter periods if the symptoms are unusually severe and onset is rapid.

Mild Depressive Disorder

Patients complain of depressed mood, lack of energy, anhedonia, and sleep disturbances. Mild depressive disorder is often accompanied by other symptoms that are rare in severe disorders. These symptoms can be broadly characterized as "neurotic" and include anxiety, phobias, obsessions, and sometimes conversion symptoms. Although anxiety can be a symptom of depressive disorder of any severity, it is believed that anxiety in mild depression constitutes a distinct syndrome rather than merely a milder variant of anxiety in moderate and severe depressions. Due to the specific nature of these additional symptoms, this syndrome is termed neurotic depression.

In addition to "neurotic" symptoms, mild depressive disorders are characterized by lowered mood, diminished activity, and reduced motivation. Sleep disturbances occur, but without the early morning awakenings that are characteristic of more serious depressive disorders. Instead, difficulties falling asleep are more common, along with awakenings during the night and deep sleep toward the end of the night. Biological symptoms (decreased appetite, weight loss, low libido) are typically absent.

Additional Features of Mild ("Neurotic") Depressive Disorders

These features include anxiety, phobias, obsessions, conversion symptoms, night awakenings, and evening worsening of mood.

Mood may fluctuate throughout the day, but it is typically worse in the evening than in the morning. Psychomotor slowing and retardation of thought are practically absent. Hallucinations and delusions are also not observed.

Masked (Somatized) Depression. The term "masked depression" is sometimes used when individual symptoms of a depressive syndrome are present, but low mood is not noticeable. There is no reason to regard this condition as a separate syndrome, but the term is useful for drawing attention to conditions that are easily overlooked by non-specialists. In this case, diagnosis relies on a thorough search for other features of depressive disorder, particularly sleep disturbances and depressive thoughts. Masked disorders are more common in mild and moderate depressions, but may also occur in severe forms of the illness.

In depressive disorders, the core symptoms—low mood, anhedonia, pessimistic thoughts, and reduced overall activity—lead to a general decrease in productivity. Patients experience significant difficulties in fulfilling social obligations, managing household chores, and continuing their work.

A characteristic appearance includes neglect of personal hygiene and dress. The face is sad, with downturned corners of the Mouth and a vertical frown line between the eyebrows. Blinking frequency may be reduced. Shoulders are slumped, the HEAD is tilted forward so that the gaze is directed downward. The number and amplitude of gestures are diminished. It is important to remember that some patients may force a smile despite a deep feeling of depression, which can mislead an inexperienced physician.

Psychomotor retardation is a frequent symptom in depression. The slowing of the associative process affects the patient's speech; a long pause precedes Answers TO QUESTIONS. Pauses in conversation can be so prolonged that they become agonizing for a healthy person.

A patient's depressed mood does not significantly improve in circumstances where ordinary feelings of sadness would be alleviated, such as in pleasant company or after receiving good news. Depressive mood typically differs from everyday sadness; patients sometimes speak of a “black cloud” enveloping them. Some patients may conceal this mood change from others, at least for short periods. Similar dissimulation can be observed during clinical interviews, which significantly complicates the diagnosis of the pathological condition.

Anxiety is frequently present within the depressive syndrome. Another common symptom is irritability, manifested as a tendency to respond with inappropriate annoyance to minor demands. Agitation is a state of restlessness experienced by the patient as an inability to relax, manifesting as restless activity. In moderate agitation, the patient makes constant movements with their hands and legs, fumbling with objects; in a more severe disorder, they cannot sit still even for a short time.

Symptoms of Depressive Disorder

Depressed mood Psychomotor retardation Anxiety, irritability, agitation Reduced motivation and activity

Biological symptoms:

Early morning awakening

Mood predominantly depressed in the morning

Decreased appetite

Weight loss

Constipation

Amenorrhea

Decreased libido

Depressive thought disorder:

Pessimistic thoughts

Ideas of personal failure

Hopelessness

Suicidal ideation

Self-blame

Hypochondriacal ideas

Loss of interest and a feeling of pleasure are common, although patients do not always voice such Complaints. The patient shows no enthusiasm for activities and hobbies they usually enjoyed. They feel no interest in life and derive no pleasure from everyday things. The patient often avoids social contacts. A decrease in energy is characteristic. The patient finds it difficult to initiate routine activities; everything requires effort, and tasks undertaken remain unfinished. For example, a normally neat woman may leave beds unmade and dirty plates on the table. Many patients attribute this lack of energy to some physical illness they believe they have.

Biological symptoms—sleep disturbances, loss of appetite, weight loss, constipation, decreased libido, and amenorrhea in women—are crucial for describing the clinical picture of depressive syndrome. These symptoms are frequent, but not constant, in moderate depressive disorders. They are more characteristic of severe depressive disorders.

Several types of depressive sleep disorders are distinguished. Early morning awakening is the most characteristic, but disturbances in the depth of nighttime sleep and nocturnal awakenings are also observed. Early morning awakening typically occurs two or three hours before the patient's usual wake-up time. They cannot fall back asleep, lying unrefreshed and sleep-deprived, often with a sense of anxiety, agitation, and restlessness. They view the coming day with pessimism, dwell on past failures, and ruminate on a grim, hopeless future. The described combination of early awakening and depressive thoughts is important for the diagnostic process. It should be noted that some depressed patients sleep even more than before, yet still complain of feeling sleep-deprived. Mood is worse in the morning than during the day.

In depressive disorders, weight loss often appears greater than can be explained simply by the patient's reduced appetite. Weight loss is clinically significant if it amounts to at least 5% over the past month. Some patients exhibit the opposite eating disturbance—they eat more and gain weight. It appears as though food brings the patients temporary relief.

Pessimistic thoughts (“depressive cognition”) are important symptoms that can be divided into three groups. In the first group, preoccupation with current circumstances dominates. The patient sees the unfortunate side of every situation, believes that everything they do is doomed to failure, feels that those around them perceive them as a failure, and loses the trust of people who matter greatly to them.

In the second group of thoughts, the emphasis is placed on preoccupation with the future. The patient anticipates the worst possible events in the future. They foresee failure at work, financial catastrophe, misfortune for their family, and the inevitable deterioration of their health. Ideas of hopelessness are often accompanied by the thought that life is no longer worth living and that death would be a long-awaited deliverance. These gloomy reflections may progress to thoughts and plans of suicide. It is crucial to ask questions about these ideas and assess the probability of suicide in each specific case.

In the third group, thoughts are centered around preoccupation with the past. They frequently take the form of self-blame for nonexistent or minor past sins and wrongdoings. For example, a patient may feel guilty about trivial past indiscretions. Typically, these events have not bothered the patient for years, but with the onset of depression, they consume their entire consciousness with intense feelings.

The described variants of preoccupation strongly suggest the presence of a depressive disorder. Some patients experience a similar sense of guilt but do not link it to a specific event. In other patients, memories are focused on past misfortunes; the patient remembers times when they were upset, when they failed, or when their well-being was in decline. These gloomy memories become increasingly frequent as the depression deepens.

Complaints of physical malaise are common in depressive disorders, with complaints of constipation and painful discomfort in various Organs being particularly frequent. Complaints regarding pre-existing physical disorders generally escalate, and hypochondriacal ideas become common.

Certain other psychopathological symptoms may occur as part of a depressive disorder, and sometimes one of them dominates the clinical picture. These include depersonalization, obsessive-compulsive symptoms, fears, and hysterical symptoms such as functional paralyses. Complaints of memory impairment caused by poor concentration are frequent. If additional stimulation in the form of encouragement is provided, it can be revealed that the patient's memory is actually unimpaired. However, sometimes the memory impairment is so severe that clinically the patient resembles someone with dementia. This condition, which is particularly characteristic of elderly individuals, is sometimes referred to as depressive pseudodementia.

Such clinical manifestations are more frequently observed in moderate depressive disorders.

Severe Depressive Disorder

As depressive disorders intensify, all the symptoms described above become more pronounced. In addition, delusions and hallucinations ("psychotic" symptoms) may appear. The pathological condition is then referred to as psychotic depression.

Additional symptoms of severe depressive disorder ("psychotic depression")

These include delusions of self-deprecation (self-blame, worthlessness, poor health, nihilism, sinfulness, impoverishment, physical deformity, persecution, etc.), as well as hallucinations (auditory, rarely visual).

Delusions in severe depressive disorders share the same themes as non-delusional ideas in moderate depressions. These themes include sinfulness, guilt, poor health, and less frequently, poverty. A patient with delusions of guilt may believe that a dishonest act, such as minor tax evasion, will be discovered and that they will be severely punished. They are likely to believe that such punishment is deserved. A patient with hypochondriacal delusions may be convinced that they are suffering from Cancer or a sexually transmitted disease. A patient with nihilistic delusions believes that they have no future or that a part of their body has ceased to exist or function (for example, that their bowels are completely blocked). A patient with persecutory delusions is certain that other people are blaming them or are about to take revenge. Characteristically, when this type of delusion is part of a depressive syndrome, the patient believes the anticipated persecution is deserved.

Perceptual disturbances are also frequently characteristic of severe depressive disorders. As a rule, these are true auditory hallucinations in the form of voices that often repeat words and phrases to the patient. The voices frequently reinforce the patient's ideas regarding their inadequacy or sinfulness (e.g., "You are an evil person, you must die") or offer ironic commentary. Some patients experience visual hallucinations, occasionally in the form of scenes of death and destruction.

Other variants of moderate and severe depressive disorder

The term "agitated depression" is applied to depressive disorders accompanied by pronounced agitation. This variant of depression is more commonly observed in middle-aged and elderly patients.

The term "retarded depression" is sometimes applied to depressive disorders in which psychomotor retardation dominates. In its most severe form, retarded depression reaches the level of depressive stupor or depressive akinesia. Depressive stupor is a rare condition encountered in severe depressive disorder. Motor slowing and poverty of speech become so pronounced that the patient appears immobile and mute. Later, the patient may recall events that occurred while they appeared unresponsive. This condition is sometimes interrupted by periods of agitation, during which the patient becomes hyperactive and loud. Depressive stupor has become less frequent due to advancements in treatment Methods.

Mixed Affective Disorders

In mixed emotional disorders, certain manifestations of manic and depressive states may coexist. For instance, a patient's hyperactivity and talkativeness may be driven by deeply depressive thoughts, including suicidal ideation. In some forms of these disorders, states of hyperthymia and depression can transform into one another in a specific sequence over a very short period of time. For example, a manic patient may become tense and depressed for a few hours, and then rapidly return to a manic state.

Sometimes, pronounced states of mania and depression alternate regularly, with intervals of several weeks or months between them.

Classification of Depressive Disorders

Classification based on etiology

Endogenous and reactive depression. In endogenous disorders, symptoms are caused by internal biological factors and are independent of environmental conditions. In reactive disorders, symptoms are a response to an external stressor. In practice, depressive disorders are rarely linked exclusively to internal or external causes; more frequently, they are mixed.

Primary and secondary depressive disorders. According to this framework, a distinction is made between:

— secondary depressive disorders caused by another disorder, such as schizophrenia, neurosis, alcoholism, or The Use of certain medications (e.g., Steroids);

— primary depressive disorders that are not preceded by another underlying disorder.

Classification based on symptoms

Neurotic and psychotic depression. Certain symptoms are often more intense in moderate disorders than in severe ones. Such discrepancies in symptom intensity have led to the suggestion that two distinct forms of depressive disorder exist—neurotic and psychotic.

Classification by Course and Life Period

Unipolar and bipolar disorders. In this classification, a distinction is made between patients with a depressive disorder who have previously experienced a manic episode (bipolar) and those who have never had a manic episode (unipolar disorder). All patients with mania are included in the bipolar group, regardless of the presence of a depressive episode. This is due to the fact that patients with pronounced manic symptoms eventually develop a depressive disorder. Furthermore, there are observations of unipolar depressions transitioning into mania over time, meaning the unipolar group is not "pure."

Recurrent brief depression. This term is applied to repeated brief episodes of depressive disorder (lasting from 2 days to 2 weeks) with complete recovery.

Seasonal affective disorder. In some patients, depressive disorders repeatedly develop at the same time of year. Sometimes this timing reflects additional circumstances related to the patient's work conditions or personal life. In other cases, there are no additional circumstances, and it is assumed that the primary cause is linked to seasonal natural factors, such as changes in day length.

Involutional and senile depression. In the past, depressive disorders beginning in mid-life were considered a distinct group characterized by agitation and hypochondriacal symptoms. It was assumed that these disorders had a different etiology, namely the involution of the Gonads. Depression in elderly patients was regarded as a separate condition known as senile depression. Despite the lack of clear Evidence for the existence of these specific groups of depressions, these terms are still used by some clinicians.

Class="center">DIAGRAM OF EMOTIONAL DISORDERS

Course and Prognosis of Affective Disorders

Bipolar disorders typically begin in the first half of life, in 90% of cases before the age of 50. Each episode lasts an average of about 3 months. The majority of patients experience both depressive and manic episodes, while some experience only manic episodes.

Unipolar disorders can begin at any time from adolescence to advanced old age (they may even occur in childhood). With timely treatment, each episode lasts an average of 2-3 months, and rarely for several years. Most patients, except for the elderly, eventually recover from an episode, although relapses may occur.

Suicide is statistically more common among patients with affective disorders than in the general population. Statistics show that 10-17% of patients with severe depressive disorder eventually commit suicide.

Chronic (Affective) Mood Disorders

Disorders within this category are chronic and typically fluctuating in nature, where individual episodes are not deep enough to be classified as hypomania or even mild depression. Because they persist for years, and sometimes throughout the patient's entire life, this causes significant distress and can lead to impaired functioning. In some cases, recurrent or single episodes of manic disorder, mild or severe depressions may be superimposed on a chronic affective disorder. Both early- and late-onset cases of cyclothymia and dysthymia have been described.

Etiology

Family history indicates that affected individuals are genetically related to relatives who suffer from mood disorders. Sometimes such patients respond well to the same treatments used for affective disorders.

Clinical Manifestations of Cyclothymia

A state of chronic mood instability with numerous episodes of mild depression and mild elation. This instability usually develops at a young age and takes on a chronic course, although the mood may occasionally remain normal and stable for many months. Mood swings are typically perceived by the individual as unrelated to life events. Because the mood shifts are relatively mild and the periods of elation are pleasant, cyclothymia rarely comes to the attention of physicians.

Clinical Manifestations of Dysthymia

This is a chronic depressed mood that currently does not meet the criteria for recurrent depressive disorder in terms of either severity or the duration of individual episodes. The balance between individual episodes of mild depression and periods of normal mood is highly variable. Such patients do have periods (days or weeks) that they themselves consider good. However, for the most part (often for months), they experience fatigue and a depressed mood. Everything feels burdensome, and nothing brings pleasure. They are prone to gloomy rumination, complain of poor sleep and a sense of discomfort, but generally manage to cope with the basic demands of daily life.

Cytology/practical/136.html">Differential diagnosis OF Affective Disorders

Affective disorders are observed in many endocrine conditions (thyrotoxicosis and hypothyroidism), Parkinson's disease, and cerebrovascular pathology. Organic affective disorders present with symptoms of cognitive deficit or impaired consciousness, which is not characteristic of endogenous affective disorders. They must also be differentiated from schizophrenia; however, the latter presents with other characteristic positive or negative symptoms, and manic and depressive states are typically atypical, resembling manic-hebephrenic or apathetic depressions. The greatest difficulties and controversies arise in the differential diagnosis with schizoaffective disorder if secondary ideas or overvalued ideas of self-blame emerge within The Structure of affective disorders. However, in true affective disorders, these disappear as soon as the affect is normalized and do not define the clinical picture.

Treatment of Affective Disorders

Treatment of Depressive Disorder

Standard Antidepressants

The first-line agents, which remain the standard for evaluating the efficacy of other antidepressant medications, are the tricyclic antidepressants imipramine and amitriptyline. These drugs are effective in both mild and severe depressive disorders. In severe disorders, they are just as effective as electroconvulsive therapy (ECT), though it takes at least 2 weeks to achieve the desired effect, whereas ECT has a more rapid onset of action.

Modern Antidepressants

Monoamine oxidase inhibitors (MAOIs). These drugs are generally less effective than tricyclic antidepressants in severe depressive disorders and no more effective in mild ones. However, they are essential in certain cases where patients are resistant to tricyclic antidepressants yet responsive to MAOIs. These medications reach their maximum effect slowly and should be taken for at least 6 weeks. Because MAOIs potentiate the action of pressor amines—including tyramine (found in certain common foods such as cheese) and synthetic amines used as decongestants and vasoconstrictors—their interaction can cause a dangerous rise in Blood pressure. Therefore, it is recommended to prescribe MAOIs as monotherapy while adhering to a dietary regimen, avoiding their use as a first-line treatment and reserving them for patients resistant to tricyclic antidepressants.

Electroconvulsive Therapy

This is most effective in severe depressive disorders, particularly when accompanied by weight loss, early morning awakenings, psychomotor retardation, and delusions. Lower efficacy has been noted when the clinical picture features hypochondriacal and hysterical symptoms, a fluctuating course, or a poor response to imipramine. Delusions and psychomotor retardation are the best predictors of electroconvulsive therapy effectiveness. Patients with depressive disorder and psychotic features also respond better to electroconvulsive therapy than to tricyclic antidepressants.

Lithium

Lithium is used to prevent mood disorders and can also be employed in the treatment of depressive disturbances. The drug is effective in the acute stage of depressive disorders, though to a lesser extent than tricyclic agents. Consequently, lithium is rarely used for this specific purpose; rather, it is applied as initial treatment or after tricyclic antidepressants have proven ineffective. Evidence exists supporting the combined use of lithium and tricyclic antidepressants, or lithium and MAOIs, in patients who have shown unresponsiveness to monotherapy. Both combinations should be prescribed and monitored by a psychiatrist, particularly when lithium is used alongside an MAOI.

Psychotherapy

All depressive patients require an exceptionally supportive and attentive approach throughout the period leading up to recovery. Psychotherapy is less effective than pharmacotherapy in treating depression, but it can help alleviate patients' communication difficulties, which play a significant role in maintaining depressive symptoms.

Treatment of Manic Syndrome

Antipsychotic Medications

Antipsychotic drugs such as chlorpromazine and haloperidol have proven effective in treating acute mania. Lithium carbonate also produces a positive effect; however, achieving a therapeutic response requires a week or more of administration, making it a non-first-choice option for acutely ill patients.

Electroconvulsive Therapy

Electroconvulsive therapy for mania is as effective as it is for depression. However, to achieve a sustained effect in patients with manic syndrome, this Procedure must be performed more frequently than for depression (three times versus two times per week). Therefore, it is not a first-line treatment method. Electroconvulsive therapy is rarely used—specifically when antipsychotic drugs are ineffective and the patient is so severely ill that waiting for natural recovery is not viable.

Prevention of Relapse and Recurrence of Affective Disorders

Relapse refers to the return of symptoms following a period of improvement during a single episode of illness, whereas recurrence denotes the onset of a new episode of illness after recovery from the first. In practice, the two terms are often used interchangeably.

The relapse rate for unipolar depressive disorders is reduced through antidepressant therapy maintained for 6 months following recovery from the acute illness. Longer-term maintenance treatment prevents the onset of recurrence. Lithium carbonate also reduces the likelihood of recurrence, albeit less effectively than tricyclic antidepressants.

In bipolar depressive disorders, maintenance treatment with lithium carbonate is effective in preventing the recurrence of mania and is just as effective as antidepressants in preventing the recurrence of depression. Carbamazepine may be used for patients resistant to the effects of lithium. Manic relapse can be triggered by the prolonged use of antidepressants.

Social and psychological factors can also contribute to relapses in both unipolar and bipolar disorders. Marital discord exerts a significant impact, particularly in the form of frequent criticism of the patient by their spouse. Consequently, it is advisable to implement measures aimed at reducing social stress in patients experiencing relapses despite adequate pharmacotherapy.