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In the last post we saw some of the hormonal interplay that can exist in mood disorders and we saw that cortisol and some other hormones and their relationship to depressive episodes,

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Depression vector created by pch.vector - www.freepik.com and Inkscape.org

Welcome to Medic Vibes, where we discuss mental health disorders and make sense of them. Dr. Ebingo Kigigha is a medical doctor (aspiring psychiatrist) and creative person (illustration and music). This has been our routine for two consecutive months. This month will be dedicated to BAD, or Bipolar Affective Disorder. The first month, we discussed Depression, and the subsequent month, anxiety. We'll begin with a discussion of a study, as we did two months ago.

In previous posts, we have introduced the study and discussed previous research describing the characteristics of Bipolar Affective Disorder. In this post, we will continue to discuss the study. This research was conducted in Enugu, Nigeria. About 820 thousand people live in the state of Enugu. Today, we will be continuing with the study's discussions.

Patients who are bipolar have these major depressive episodes and manic episodes. Mood disorders are also called affective disorders 2 months ago, we talked about depression, among the types of depression is Major Depressive Disorder which is otherwise known as unipolar depression.

History
King Saul's features in the bible, were typical of mood disorders when he would have David play for him in his palace. Hippocrates believed depression was a result of black bile and he called it Melancholic (meaning Black Bile). The first person to describe depression in English text was done by Robert Burton. His book Anatomy of Melancholy dates back as far back as 1621. Emil Kraepelin developed the criteria that is still used for manic-depressive psychosis. It was called folie circularie.

Demographics
Among all the mood disorders BAD I has the earliest onset. The prevalence of BAD I is equal in men and women. Episodes of mania are seen more in men while depressive episodes occur more in women. Depression appears to have a higher occurrence in rural areas, there is a tendency for schizophrenia to be misdiagnosed by practitioners from a different culture from the patient.

Other Associated Conditions
People who deal with mood disorders are significantly at risk of dealing with alcohol abuse or dependence, anxiety disorders particularly panic, obsessive-compulsive and phobias, particularly for people and socialising. Women particularly have eating disorders when they go through unipolar and bipolar disorders. Biogenic amines affect the concentration and effect of the neurotransmitters at the synaptic cleft. Cholinergic agonists modulate the activities of the pathway between the hypothalamus, Pituitary gland and adrenal gland. GABA inhibits the action of monoamine pathways that ascend especially the mesocortical and mesolimbic.

NMDA receptors bind to a receptor called N- methyl-D-aspartate (NMDA) when there is excess stimulation it leads to toxic effects on the nervous system. This may be because of the effect of glutamate's function in working against neurocognitive decline seen in recurrent severe depression as well as hypercortisolemia. Some drugs that act to synergise with GABA have a noticeable but insignificant antidepressant effect. Patients whose mood disorder is remitting and those that have close relatives have a trait that resembles the sensitivity to cholinergic agonists.

Alterations in Hormone Regulation
The studies were done with Urinary Free Cortisol, 24 house intravenous taps for plasma cortisol, cortisol in saliva and a test of feedback inhibition. There are known documentation about the changes in hormone interplay in the brain and reactions that can be a result of early life stressors. Early trauma can lead to increased hypothalamic–pituitary–adrenal(HPA) activity which is followed by cerebral cortex volume depletion and cellular reduction. HPA activity is being referred to as a clear feature of mammalian stress and it is a link between depression and the biology of chronic stress. 60% of the time cortisol is not suppressed in the morning or it escapes suppression by 4 pm.

This test does not provide a diagnosis for mood disorders because the same results are seen in mania and other psychiatric conditions. 5 to 10% of those who are depressed usually have a thyroid abnormality, this is seen in the amount of thyroid-stimulating hormone or the fact that there is an abnormally high reaction to 500 mg of hypothalamic neuropeptide thyroid releasing hormone. Prolactin is a hormone released in response to serotonin stimulus and inhibited by dopamine stimulus. So far there has not been any major correlation between prolactin and depression.

There are associated sleep patterns in depression that are very notable. These include an associated deep sleep loss also called slow wave loss and easy arousal from sleep. The characteristics of this easy arousal are longer periods of nighttime awakeness, reduced sleep time, an increase in the Rapid Eye Movement (REM) phase of sleep and a rise in body temperature.

There is a reduction in REM latency this is because there is increased REM drive and reduced slow wave sleep that results in a reduced first period of non-Rapid Eye movement (NREM).

Reduced REM latency and reduced slow wave sleep usually continue even after an episode of depression. Reduced secretion of growth hormone is linked with this reduced slow wave sleep.

In 40% of outpatients with depression and 80% of inpatients the features of reduced REM latency, raise in density and depressed sleep continuity are seen.

This can not be used totally to exclude patients because in patients who are hypersomnolence or sleep a lot, there may be false negatives and they may experience slow wave sleep. Also, 10% of normal people may have poor sleep features. Similar to dexamethasone non-suppression there might be false positive cases.

When a patient has an abnormal sleep pattern they are usually not very responsive to psychotherapy like CBT and tend to have reoccurrences after treatment.

Discussions (Demographics Part 3)

When Patients in this study are compared to those in developed countries they appear to have more episodes of mania. This is a very important finding because earlier studies done in 1895 on a population of western Nigerians show that mania is more common. In the 1985 study, however, the average duration of the illness was 24 years which is much longer than the average duration of 9.6 in this study.

70% of the study had patients who we manic in their first episode and 30% were depressed, when compared to the Systematic Treatment Enhancement Program for Bipolar Disorder (STEP-BD) and the Stanley Foundation Bipolar Network (SFBN) where the elevated mood was 26.1% and 19% respectively and 52% for depression,

There is also the possibility that Southeastern Nigeria may not take depression as a serious disorder and may have not noted if this was the initial presentation. They are more likely to remember the episode of mania and would take the presentation more seriously and would report to a prayer house or unorthodox medicine.

Systematic Treatment Enhancement Program for Bipolar
Disorder (STEP-BD). Stanley Foundation Bipolar Network

In this study also 45.7% of the patient were reported to be euthymic and STEP-BD had 48.9% of euthymic patients.

At the beginning of the study, there is also a note-worthy occurrence. Up to 30% of the patients had an elevated mood and close to half were depressed. When compared to STEP-BD, 25% were depressed and 6% had mania. This reverse occurrence can be accounted for the same way above but it does not appear to be the case as only a few studies in developing countries have had similar occurrences.

What is worth noting is that there appear to be more cases of mania in developing countries and developed countries there are more cases of depression than in the initial presentation.

The proportion of patients with BAD I is similar to what is seen in STEP-BD but then it is different from what is seen in SFBN. The Jorvi study’s prevalence of BAD I is also different from this study’s prevalence and STEP-BD and different from SFBN illustrating that different methods achieve different results.

Tips

Interpersonal therapy was first practised by Gerald Klerman and concentrates on the subject's interpersonal problems. Interpersonal problems are of one or two kinds which are. The first interpersonal problem which the patient has a high chance of having is usually caused by malfunctioning relationships and the next problem is likely to be precipitated or continued because of the patient’s present depressive features.

Studies done show that Interpersonal therapy is very useful for major depression, particularly for interpersonal problems. Some studies also show that for major depression this is the therapy method of choice.

The interpersonal therapy program usually consists of 12 to 16 weekly sessions and is
characterized by an active therapeutic approach. Intrapsychic phenomena, such as
defence mechanisms and internal conflicts, are not addressed. Discrete behaviours—such
as lack of assertiveness, impaired social skills, and distorted thinking—may be addressed
but only in the context of their meaning in, or their effect on, interpersonal
relationship

This therapy method is done for 12 to 16 weekly sessions and the therapy method is active. Intrapsychic phenomena are not touched on in this therapy they include defence mechanisms and inernal conflicts. Any lack of assertiveness, lack of social skill and thinking distortion are dealt with but sonly in relation to interpersonal relationships.

Hive Stories

this post by @larissalugo explains the types of Bipolar conditions and how they present in an easy to understand fasion. It starts with a definition adn explains the symptoms seen in the condition.

Read this post here

Questions

• What did you learn about mood disorders?
• What did you learn about Bipolar disorder?
• What's the most interesting aspect of this study?

Conclusion

We saw the relationship betern sleep parameters and depression. It pears to be non specific.

In the study discussion mania was more common than the what is seen in studies done by STEP BP and other studies in developed countries.

I hope that you learned a lot from this post.

To book me for illustration gigs click Here

References

• Kaplan-Sadocks-Comprehensive-Textbook-Psychiatry
• Psychiatria
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