Considerations When Treating Patients for Mood Disorders

Mood disorders are typically associated with a disturbance in mood, which is recognized as the primary symptom presentation. It is estimated that about 20% of the U.S. population report  having at least one depressive symptoms in a given month, and 12% report to having two or more in a given year. 

The symptoms of a mood disorder can range from inappropriate, exaggerated, or a limited range of feelings, and the disorders that are found in this category include major depressive disorder cyclothymic disorder, dysthymic disorder, and bipolar disorder.

Antidepressant therapies are currently considered an effective approach to treating mood disorders, but there are considerations that lead to the selection of one over another. When it comes to prescribing antidepressants, it is important to determine whether there are sustained psychological symptoms that meet the criteria for the mood disorder.¹

Since major depression is usually part of a mood disorder, antidepressants are often prescribed. Selective serotonin reuptake inhibitors (SSRIs), selective serotonin and norepinephrine reuptake inhibitors (SNRIs), tricylic antidepressants, norepineprine and dopamine inhibitors, serotonin-2 antagonist reuptake inhibitors, and monoamine oxidase inhibitors are common classes of antidepressants. Some of these are rarely used today due to their negative side effect profile.

In general, all antidepressants have shown good efficacy, but the various agents have different side-effect profiles that may lead to the selection of one over another.² 

SSRIs are considered to be one of the more safe agents because of their low lethality with overdose, ease of administration and minimal side effect profile, which consist mostly gastrointestinal effects.¹ On the other hand, the tricyclic antidepressants, which act by inhibiting the reuptake of serotonin and norephinephrine, can cause arrhythmias, hypotension, or uncontrollable seizure with overdose and should not be used in a person with a history of cardiac disease.³

SNRIs such as venlafaxine, desvenlafaxine, and duloxetine act by inhibiting the reuptake of both serotonin and norepinephrine.⁴ The side effect profiles of SNRIs are similar to those associated with SSRIs such as the gastrointestinal side effects, but one side effect that is synonymous with the SNRIs is treatment-emergent hypertension which is a noradrenergically-mediated side effect.

Bipolar disorder

Bipolar disorder is a mood disorder characterized by at least one manic and one mixed episode with the first episode usually being mania in men and depression in women. Pharmacotherapy treatment for this condition is typically for the acute and maintenance phase of the disorder, and the common mood stabilizers that are utilized are lithium, valproic acid, carbamazepine, and lamotrigine.⁵ 

All of these agents are more effective in preventing and treating manic episodes than they are for depressive episodes, though lamotrigine is considered to be modestly effective for treating bipolar depression compared with the other mood stabilizers.  

Antidepressants can be used for bipolar, but it must be in conjunction with a mood stabilizer to prevent the development of a manic episode. There are some safety concerns with lithium, carbamazepine, and valproic acid based on the fact that they have levels that determine therapeutic effect from toxicity which must be monitored often during the initial phase of the therapies.

Dysthymic disorder

Dysthymic disorder diagnosis is based on the presence of depressed mood for most of the day, for more days than it is not present, and for a duration of at least two years. Mood stabilizers are used to treat this condition similar to major depression to resolve symptoms of poor appetite, sleep disturbances, low energy or fatigue, poor concentration, and feelings of hopelessness or helplessness.⁶ 

Antidepressants are also the treatment of choice as many patients respond well to them. Cognitive psychotherapy has also been shown to be beneficial in those patients with negative attitudes about themselves. A combination of psychotherapy and pharmacotherapy has been noted to produce the best outcomes.

Obsessive-Compulsive Disorder

The most appropriate first-line medication for obsessive-compulsive disorder (OCD) are SSRIs which have demonstrated efficacy in treating the disorder.¹ Dosing of SSRIs for OCD are generally higher than doses that are used for depression, and the time to response is also longer.

Treating older patients with mood disorders can be quite challenging, because one must consider co-morbid issues before prescribing medications. Geriatric patients experience a decline in renal and hepatic functioning with age and can also be more sensitive to side effects. 

In general, the use of newer antidepressants (such as SSRIs) and electroconvulsive therapy have been shown to be effective in elderly patients. On the other hand, tricyclic antidepressant should be avoided due to their anticholinergic effects, whereas benzodiazepines can cause cognitive impairments.⁴

Anxiety and PTSD

When it comes to treatment of anxiety, including post-traumatic stress disorder, SSRIs are often given as a first-line treatment. However, given these medications have a slower onset of action, benzodiazepines may be given in situations of acute anxiety due to their rapid onset of action.⁷ 

The use of benzodiazepines are not recommended for the management of chronic anxiety disorders — only for acute anxiety reactions for between two and six weeks of therapy. Once the antidepressant starts to work, the benzodiazepine can be tapered off.

Abimbola Farinde, PharmD, MS, is a clinical staff pharmacist at Parkland Hospital in Dallas, Texas.

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