Clinical Practice Guideline

for

MOOD DISORDERS

Developed for the

Aerospace Medical Association

by their constituent organization

American Society of Aerospace Medicine Specialists

 

Overview: These disorders are characterized by a disturbance in mood as the predominant psychological feature.  The mood disorders are divided into four categories:  bipolar disorders, depressive disorders, mood disorders due to a general medical condition and substance-induced mood disorder.  The depressive disorders (major depressive disorder, dysthymic disorder, and depressive disorder not otherwise specified) all include disturbances in emotion, ideation and/or somatic symptoms.  The depressive disorders vary by length and severity.  The bipolar disorders (bipolar I disorder, bipolar II disorder, cyclothymic disorder and bipolar disorder not otherwise specified) are distinguished from the depressive disorders by a history of a manic, hypomanic, or mixed episodes; none of which occurs in the depressive disorders. 

 

DEPRESSIVE DISORDERS

 

Major depression is defined as five of the following nine symptoms that must occur most of the day, nearly every day, and for at least 14 consecutive days.  At least one of the five symptoms must include depressed mood or loss of interest.13 An easy mnemonic for the symptoms other than depressed mood is “Sig E caps.”10

 

Depressed mood

S--Change in sleep pattern (usually waking in early morning and can’t get back to sleep)

I--Loss of interests/pleasure (ask “What are your hobbies/recreational activities?”  “When did you do that activity last?”)

G--Thoughts of worthlessness or guilt (inquire about sudden, incapacitating waves of worthlessness or “guilt attacks”)

E--Loss of energy (Ask if they have more or less energy than usual, given good sleep)

C--Trouble concentrating (Ask if they are having difficulty with things like balancing their checkbook, remembering passwords, keeping lists, etc.)

A--Change in appetite or weight (Ask if they gained or lost weight without trying, or if their diet has changed dramatically without a good reason)

P--Change in psychomotor activity (Look to see if they are fidgeting, tearful, or robotic during the interview)

S--Thoughts about death or suicide (Ask if life has become not worth living or if they have had thoughts of killing or hurting themselves or others).

 

In the general population the prevalence of major depression is 3-5% in males and 8-10% in females.11  Peak onset is in the fourth decade of life, but may occur at any age.11 Most episodes remit spontaneously or with treatment and last from several months to a year.  Persistent major depression, lasting more than 2 years, occurs in 20%.  Ninety percent of patients in the general population diagnosed with major depression will have a recurrence (second episode) in their lifetime.  In the general population, 50% of moderate-to-severe episodes of depression will improve with antidepressant treatment.12 

 

Dysthymic disorder has a similar, less severe list of symptoms that are present for more days than not over a period of at least two years.  Symptom free periods of less than two months may occur.

 

Treatment for depressive disorders may require a multimodal approach that includes pharmacotherapy, education and psychotherapy.  The treatment plan should take into account the individual’s previous treatment outcomes, the mood-disorder subtype, the severity of the current episode of depression, the risk of suicide, coexisting psychiatric and somatic conditions, non-psychiatric medications and psychosocial stressors.12  Pharmacotherapy may include such medication as selective serotonin-reuptake inhibitors (SSRIs), norepinephrine-reuptake inhibitors (NRIs), tricyclic antidepressants, and monoamine oxidase inhibitors (MAOIs).  The average duration of treatment for an episode is six months.

 

Depression may be the initial presentation of bipolar disorder.  Bipolar disorder that manifests with initial depression is frequently under diagnosed.  Patients presenting with depression should be specifically asked about symptoms of mania or hypomania:15

1.  Have you experienced sustained periods of feeling uncharacteristically energetic?

2.  Have you had periods of not sleeping but not feeling tired?

3.  Have you felt that your thoughts were racing but couldn’t be slowed down?

4.  Have you had periods where you were excessive in sexual interest, spending money, religiosity, or taking unusual risks?

 

BIPOLAR DISORDERS

 

Bipolar disorder is defined by periods of elevated mood.  Bipolar I individuals have manic episodes and often experience depressive episodes.  It affects men and women equally. Bipolar II individuals have major depressive episodes and at least one hypomanic episode.  It is more common in women.  The prevalence of bipolar disorder is estimated at around one percent.  The age of onset is typically between 15 and 30 years.  Individuals with bipolar disorders are more likely to present during a depressive disorder than hypomania or mania.4

 

Ninety percent of individuals experiencing a manic episode will have another within 5 years.  There is a 5-10% lifetime risk of bipolar disorder if it is diagnosed in a first degree relative and a 50-60% lifetime risk if both parents diagnosed with bipolar disorder.  There are no clear genetic markers (or blood testing) for bipolar disorder.  The life expectancy of individuals with bipolar disorders is significantly reduced; 25 to 50 % attempt suicide and 15% die by suicide.15

 

Diagnostic criteria for mania include:13

A.  A distinct period of abnormally and persistently elevated, expansive, or irritable mood, lasting at least one week (or any duration if hospitalization is necessary).

B.  During the period of mood disturbance, at least three or more of the following symptoms are present:  inflated self esteem or grandiosity; decreased need for sleep; more talkative than usual; racing thoughts or flight of ideas; distractibility; increase in goal-directed activity; and excessive involvement in pleasurable activities that have a high potential for painful consequences, such as spending money or sexual indiscretion.

C.  The mood disturbance leads to significant impairment in social or occupational functioning.

D.  The symptoms are not directly due to substance use or a general medical illness.

 

Hypomania involves milder, briefer manic symptoms (at least 4 days).  There are no psychotic episodes or hospitalizations in hypomanic episodes.  Functioning is only mildly impaired or may even be improved during a hypomanic episode.

 

Cyclothymic disorder has numerous periods with hypomanic symptoms and numerous periods with depressive symptoms that do not meet the criteria for major depression and symptoms that are present for more days than not over a period of at least two years.  Symptom free periods of less than two months may occur.

 

Treatment for bipolar disorders include pharmacologic (lithium, valproate and carbamazepine), psychoeducation, and psychotherapeutic interventions.  Treatment is a challenge in bipolar disorders as patients frequently discontinue their medications (many of which have unpleasant side effects) during their mood elevation associated with the manic phase.

 

MOOD DISORDERS DUE TO A GENERAL MEDICAL CONDITON

 

This disorder has a prominent and persistent disturbance of mood (depressed mood, diminished interest or pleasure, or elevated, expansive, irritable mood) that is due to the direct physiological effects of a medical condition.  Common medical conditions where this is seen are central nervous system (stroke, traumatic brain injury, Parkinson’s disease, Huntington’s disease, multiple sclerosis, Alzheimer’s disease), cardiovascular disorders, cancer, and conditions involving the immune system.

 

SUBSTANCE-INDUCED MOOD DISORDERS

 

This disorder has a prominent and persistent disturbance in mood (depressed mood, diminished interest or pleasure, or elevated, expansive, irritable mood) that is due to the direct physiological effects of a substance (i.e. drug of abuse, medication [stimulants, steroids, L-dopa, antidepressants], other somatic treatment of depression [electroconvulsive therapy or light therapy], or toxin exposure).

 

Aeromedical Disposition (military): Mood disorders can be associated with a variety of cognitive, emotional and behavioral anomalies including depressed mood, impaired judgment, slowed information processing speed, impaired memory and/or attention and concentration, inflated self-esteem or grandiosity, disturbances in energy and sleep, significant weight loss or gain, psychomotor agitation or retardation, fatigue, distractibility, flight of ideas, inappropriate guilt feelings, indecisiveness, suicidal ideation and excessive involvement in pleasurable activities that have a high potential for untoward consequences (spending sprees, promiscuity, etc.).  These cognitive, emotional and behavioral anomalies are incompatible with aviation safety and flying duties.

 

Most aviators with a mood disorder are diagnosed with depression (e.g., depressive disorder NOS, major depressive disorder).  Many of the emotional and behavioral manifestations of depression can impair an aviator’s cognitive abilities (e.g., ability to focus, sustain attention and concentration, working and general memory, psychomotor coordination, reasoning, spatial judgment, and reaction time).  Some of the more severe symptoms of depression, (e.g., suicidal ideation, impaired reality testing) may be acutely disabling.  Furthermore, depression often co-exists with anxiety and psychosomatic complaints, as well as substance misuse, particularly alcohol.

 

The aeromedical concerns with the use of psychoactive drugs are not only the medical condition being treated but the side effects of the medications.  All psychoactive drugs have potentially undesirable or dangerous side effects.  Common side effects of antidepressants include nausea, diarrhea, cramping, emesis, insomnia, jitteriness, agitation, restlessness, dizziness, headache, syncope, tremor, perspiration and altered sexual function.9, 14  Waivers are not being granted for individuals on antidepressants, although a few case-by-case waivers have been granted by the Army.  The following discussion of waiver considerations for the Army, Air Force, and Navy should not be construed as official DOD policy.  Individuals are advised to consult with their respective service for the appropriate disposition.

 

Waiver Considerations (Army)6: The Army is considering waivers for aviators on SSRIs on a case by case basis.  The package may be submitted when the aviator has been on maintenance therapy for 4 months.  It should include:

  • An aviation psychiatry consultant review; notes including symptoms, medication history, diagnostic conclusions
  • A treatment summary from the treating physician with discussion about the lack of psychosis or suicidal behavior, medications tried, and titration to therapeutic effect
  • Neurocognitive testing on medication
  • Operational assessment and command endorsement to include an in-flight performance evaluation

 

Waiver Considerations (Air Force and Navy)5,7: Any aviator with one of the bipolar disorders is permanently disqualified due to the risk of recurrence, the presenting symptoms of loss of insight, tenuous reality-testing, the unlikelihood of self-referral and poor treatment compliance.  A family history of bipolar disease in both parents is disqualifying for Air Force student pilots. 

If the diagnostic criteria for major depressive disorder, dysthymic disorder or depressive disorder not otherwise specified are met, the aviator is disqualified.  If the aviator completes treatment successfully and remains asymptomatic off medications for six months, a waiver may be requested.  Recurrent episodes of the depressive disorders are generally not waiverable because of the likely emerging repetitive pattern.

 

A review of the Air Force Waiver database (AIMWTS) from 2001 through mid Sept 2007 (6 years) showed 440 cases of mood disorders, mostly depression (only 13 cases of bipolar); 30 student pilots (7%), 142 trained pilots (32%), and 268 other aircrew (61%).  Waivers were granted as follows 26/30 student pilots (87% waiver rate), 67/142 established pilots (47% waiver rate), and 107/268 other aircrew (40% waiver rate).  Eighty-eight aeromedical summaries were reviewed; 58 disqualified (all [12] bipolar and 46 randomly selected) and 29 randomly selected approved waivers.  Trends in depression waiver disapprovals included ongoing medication use, incomplete treatment, and “motivation to fly” unsatisfactory rating.  The only bipolar case that received a waiver was an asymptomatic flyer with a family history of bipolar disorder.

 

Aeromedical Disposition (civilian): Bipolar Disorders, Psychoses, and a Personality disorder manifesting itself by overt acts are all Specifically Disqualifying Defects in civil aviation.  Airmen with these conditions are rarely granted medical certification.  Depressive illness in a pilot is not a cause for disqualification in civil aviation if the individual is stable off medications for at least 90 days.  These airmen are given the warning that they must cease flying and notify the FAA if there are any changes in their medical condition.  Normally all cases that have involved suicidal ideation or attempt are reviewed by the agency’s Chief Psychiatrist prior to any granting of medical certification.  Use of psychotropic drugs, antipsychotic and antidepressant medications are not permitted in civil aviation.

 

Waiver Experience (civilian): At the time of this writing, the pathologic coding system at the Aeromedical Certification Division of the FAA does not utilize the ICD-9 coding system.  The FAA path code for most depressive disorders also includes anxiety disorders.  In calendar years 2005-2008 there were 2510 first-class, 2727 second-class, and 7466 third-class airmen certified with these conditions.  The path code for Major Affective Disorder includes Major depression, manic depressive illness-manic, manic depressive illness-depressive, and Bipolar Disorder.  In calendar years 2005-2008 there were 18 first-class, 18 second-class, and 52 third-class airmen certified with these conditions.    

 

References:

 

  1. Belmaker RH.  Bipolar disorder.  N Engl J Med.  2004; 351:  5.

 

  1. Boland RJ, Keller MB.  Course and outcome of depression.  In: Handbook of Depression.  Gotlib IH, Hammen CL (Eds).  Guilford Press, New York.  2002. p.43.

 

  1. Craddock N, Jones I.  Genetics of bipolar disorder.  J Med Genet.  1999; 36:  585.

 

  1. Das AK, Olfson M, Gameroff MJ, et al.  Screening for bipolar disorder in a primary care practice.  JAMA.  2005; 293:  956.

 

  1. Department of the Air Force, Waiver Guide, https://kx.afms.mil/kxweb/dotmil/file/web/ctb_071808.pdf, pp 331-337, accessed 31 Jan 08.

 

  1. Department of the Army, SSRI/MMRI Policy letter, https://aamaweb.usaama.rucker.amedd.army.mil/AAMAWeb/policyltrs/SSRI_Update_Jan06.pdf., accessed 26 Mar 08.

 

  1. Department of the Navy, Waiver Guide, http://www.nomi.med.navy.mil/NAMI/WaiverGuideTopics/pdfs/Waiver%20Guide%20-%20Psychiatry.pdf, chapter 14.8, accessed 31 Jan 08.

 

 

  1. Hilty DM, Brady KT, Hales RE. A review of bipolar disorder among adults.  Psychiatr Serv 1999; 50:201.

 

  1. Ireland RR.  Pharmacologic considerations for serotonin reuptake inhibitor use by aviators.  Aviation, Space and Environ Med.  2002;73(5):  421-9.

 

  1. Lyness J.  Depression: clinical management and diagnosis.  www.utdol.com V15.2; accessed 24 September 2007

 

  1. Lyness J.  Depression: epidemiology and pathogenesis. www.utdol.com V15.2; accessed 24 September 2007.

 

  1. Mann JJ.  The medical management of depression.  N Engl J Med.  2005; 353:  17.

 

  1. Mood disorders.  In Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR).  American Psychiatric Association.  Washington, DC; 2000:  345-428.

 

14.   Rayman RB, Hastings JD, Kruyer WB, Levy RA, Pickard JS.  Clinical Aviation Medicine, 4th Ed.  Professional Publishing Group, Ltd., New York.  2006:  309-12.

 

  1. Stovall J.  Bipolar disorder. www.utdol.com V15.2; accessed 24 September 2007.

 

 

DSM IV Codes

 

 

ICD-9-CM for mood disorders

296.2

Major depressive disorder, first episode

296.3

Major depressive disorder, recurrent

300.4

Dysthymic disorder

301.13

Cyclothymic disorder

311

Depressive disorder not otherwise specified (NOS)

296.0

296.4-7

Bipolar I disorder (and variants)

296.89

Bipolar II disorder

296.80

Bipolar disorder NOS

296.90

Mood disorder NOS

 

 

4/4/08