Substance-induced mood disorder

Substance-Induced Mood Disorder

Diagnostic Features

The essential feature of Substance-Induced Mood Disorder is a prominent and persistent disturbance in mood (Criterion A) that is judged to be due to the direct physiological effects of a substance (i.e., a drug of abuse, a medication, other somatic treatment for depression, or toxin exposure) (Criterion B). Depending on the nature of the substance and the context in which the symptoms occur (i.e., during intoxication or withdrawal), the disturbance may involve depressed mood or markedly diminished interest or pleasure or elevated, expansive, or irritable mood. Although the clinical presentation of the mood disturbance may resemble that of a Major Depressive, Manic, Mixed, or Hypomanic Episode, the full criteria for one of these episodes need not be met. The predominant symptom type may be indicated by using one of the following subtypes: With Depressive Features, With Manic Features, With Mixed Features. The disturbance must not be better accounted for by a Mood Disorder that is not substance induced (Criterion C). The diagnosis is not made if the mood disturbance occurs only during the course of a delirium (Criterion D). The symptoms must cause clinically significant distress or impairment in social, occupational, or other important areas of functioning (Criterion E). In some cases, the individual may still be able to function, but only with markedly increased effort. This diagnosis should be made instead of a diagnosis of Substance Intoxication or Substance Withdrawal only when the mood symptoms are in excess of those usually associated with the intoxication or withdrawal syndrome and when the mood symptoms are sufficiently severe to warrant independent clinical attention.

A Substance-Induced Mood Disorder is distinguished from a primary Mood Disorder by considering the onset, course, and other factors. For drugs of abuse, there must be evidence from the history, physical examination, or laboratory findings of Dependence, Abuse, intoxication, or withdrawal. Substance-Induced Mood Disorders arise only in association with intoxication or withdrawal states, whereas primary Mood Disorders may precede the onset of substance use or may occur during times of sustained abstinence. Because the withdrawal state for some substances can be relatively protracted, mood symptoms can last in an intense form for up to 4 weeks after the cessation of substance use. Another consideration is the presence of features that are atypical of primary Mood Disorders (e.g., atypical age at onset or course). For example, the onset of a Manic Episode after age 45 years may suggest a substance-induced etiology. In contrast, factors that suggest that the mood symptoms are better accounted for by a primary Mood Disorder include persistence of mood symptoms for a substantial period of time (i.e., a month or more) after the end of Substance Intoxication or acute Substance Withdrawal; the development of mood symptoms that are substantially in excess of what would be expected given the type or amount of the substance used or the duration of use; or a history of prior recurrent primary episodes of Mood Disorders.

Some medications (e.g., stimulants, steroids, l-dopa, antidepressants) or other somatic treatments for depression (e.g., electroconvulsive therapy or light therapy) can induce manic-like mood disturbances. Clinical judgment is essential to determine whether the treatment is truly causal or whether a primary Mood Disorder happened to have its onset while the person was receiving the treatment. For example, manic symptoms that develop in a person while he or she is taking lithium would not be diagnosed as Substance-Induced Mood Disorder because lithium is not likely to induce manic-like episodes. On the other hand, a depressive episode that developed within the first several weeks of beginning alpha-methyldopa (an antihypertensive agent) in a person with no history of Mood Disorder would qualify for the diagnosis of Alpha-Methyldopa-Induced Mood Disorder, With Depressive Features. In some cases, a previously established condition (e.g., Major Depressive Disorder, Recurrent) can recur while the person is coincidentally taking a medication that has the capacity to cause depressive symptoms (e.g., l-dopa, birth-control pills). In such cases, the clinician must make a judgment as to whether the medication is causative in this particular situation. For a more detailed discussion of Substance-Related Disorders, see p. 191.

Subtypes and Specifiers

One of the following subtypes may be used to indicate which of the following symptom presentations predominates:

With Depressive Features. This subtype is used if the predominant mood is depressed.
With Manic Features. This subtype is used if the predominant mood is elevated, euphoric, or irritable.
With Mixed Features. This subtype is used if the symptoms of both mania and depression are present but neither predominates.

The context of the development of the mood symptoms may be indicated by using one of the following specifiers:

With Onset During Intoxication. This specifier should be used if criteria for intoxication with the substance are met and the symptoms develop during the intoxication syndrome.
With Onset During Withdrawal. This specifier should be used if criteria for withdrawal from the substance are met and the symptoms develop during, or shortly after, a withdrawal syndrome.

Recording Procedures

The name of the Substance-Induced Mood Disorder begins with the specific substance or somatic treatment (e.g., cocaine, amitriptyline, electroconvulsive therapy) that is presumed to be causing the mood symptoms. The diagnostic code is selected from the listing of classes of substances provided in the criteria set. For substances that do not fit into any of the classes (e.g., amitriptyline) and for other somatic treatments (e.g., electroconvulsive therapy), the code for "Other Substance" should be used. In addition, for medications prescribed at therapeutic doses, the specific medication can be indicated by listing the appropriate E-code (see Appendix G). The name of the disorder (e.g., Cocaine-Induced Mood Disorder) is followed by the subtype indicating the predominant symptom presentation and the specifier indicating the context in which the symptoms developed (e.g., 292.84 Cocaine-Induced Mood Disorder, With Depressive Features, With Onset During Withdrawal). When more than one substance is judged to play a significant role in the development of mood symptoms, each should be listed separately (e.g., 292.84 Cocaine-Induced Mood Disorder, With Manic Features, With Onset During Withdrawal; 292.84 Light Therapy-Induced Mood Disorder, With Manic Features). If a substance is judged to be the etiological factor but the specific substance or class of substances is unknown, the category 292.84 Unknown Substance-Induced Mood Disorder may be used.

Specific Substances

Mood Disorders can occur in association with intoxication with the following classes of substances: alcohol; amphetamine and related substances; cocaine; hallucinogens; inhalants; opioids; phencyclidine and related substances; sedatives, hypnotics, and anxiolytics; and other or unknown substances. Mood Disorders can occur in association with withdrawal from the following classes of substances: alcohol; amphetamine and related substances; cocaine; sedatives, hypnotics, and anxiolytics; and other or unknown substances.

Some of the medications reported to evoke mood symptoms include anesthetics, analgesics, anticholinergics, anticonvulsants, antihypertensives, antiparkinsonian medications, antiulcer medications, cardiac medications, oral contraceptives, psychotropic medications (e.g., antidepressants, benzodiazepines, antipsychotics, disulfiram), muscle relaxants, steroids, and sulfonamides. Some medications have an especially high likelihood of producing depressive features (e.g., high doses of reserpine, corticosteroids, anabolic steroids). Note that this is not an exhaustive list of possible medications and that many medications may occasionally produce an idiosyncratic depressive reaction. Heavy metals and toxins (e.g., volatile substances such as gasoline and paint, organophosphate insecticides, nerve gases, carbon monoxide, carbon dioxide) may also cause mood symptoms.

Differential Diagnosis

Mood symptoms occur commonly in Substance Intoxication and Substance Withdrawal, and the diagnosis of the substance-specific intoxication or substance-specific withdrawal will usually suffice to categorize the symptom presentation. A diagnosis of Substance-Induced Mood Disorder should be made instead of a diagnosis of Substance Intoxication or Substance Withdrawal only when the mood symptoms are judged to be in excess of those usually associated with the intoxication or withdrawal syndrome and when the mood symptoms are sufficiently severe to warrant independent clinical attention. For example, dysphoric mood is a characteristic feature of Cocaine Withdrawal. Cocaine-Induced Mood Disorder should be diagnosed instead of Cocaine Withdrawal only if the mood disturbance is substantially more intense than what is usually encountered with Cocaine Withdrawal and is sufficiently severe to be a separate focus of attention and treatment.

If substance-induced mood symptoms occur exclusively during the course of a delirium, the mood symptoms are considered to be an associated feature of the delirium and are not diagnosed separately. In substance-induced presentations that contain a mix of different types of symptoms (e.g., mood, psychotic, and anxiety symptoms), the specific type of Substance-Induced Disorder to be diagnosed depends on which type of symptoms predominates in the clinical presentation.

A Substance-Induced Mood Disorder is distinguished from a primary Mood Disorder by the fact that a substance is judged to be etiologically related to the symptoms (p. 405).

A Substance-Induced Mood Disorder due to a prescribed treatment for a mental disorder or general medical condition must have its onset while the person is receiving the medication (e.g., antihypertensive medication) or during withdrawal, if there is a withdrawal syndrome associated with the medication. Once the treatment is discontinued, the mood symptoms will usually remit within days to several weeks (depending on the half-life of the substance and the presence of a withdrawal syndrome). If symptoms persist beyond 4 weeks, other causes for the mood symptoms should be considered.

Because individuals with general medical conditions often take medications for those conditions, the clinician must consider the possibility that the mood symptoms are caused by the physiological consequences of the general medical condition rather than the medication, in which case Mood Disorder Due to a General Medical Condition is diagnosed. The history often provides the primary basis for such a judgment. At times, a change in the treatment for the general medical condition (e.g., medication substitution or discontinuation) may be needed to determine empirically for that person whether the medication is the causative agent. If the clinician has ascertained that the disturbance is due to both a general medical condition and substance use, both diagnoses (i.e., Mood Disorder Due to a General Medical Condition and Substance-Induced Mood Disorder) may be given. When there is insufficient evidence to determine whether the mood symptoms are due to a substance (including a medication) or to a general medical condition or are primary (i.e., not due to either a substance or a general medical condition), Depressive Disorder Not Otherwise Specified or Bipolar Disorder Not Otherwise Specified would be indicated.

Diagnostic criteria for Substance-Induced Mood Disorder

A prominent and persistent disturbance in mood predominates in the clinical picture and is characterized by either (or both) of the following:
1. depressed mood or markedly diminished interest or pleasure in all, or almost all, activities
2. elevated, expansive, or irritable mood
There is evidence from the history, physical examination, or laboratory findings of either (1) or (2):
1. the symptoms in Criterion A developed during, or within a month of, Substance Intoxication or Withdrawal
2. medication use is etiologically related to the disturbance
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 following: the symptoms precede the onset of the substance use (or medication use); the symptoms persist for a substantial period of time (e.g., about a month) after the cessation of acute withdrawal or severe intoxication or are substantially in excess of what would be expected given the type or amount of the substance used or the duration of use; or there is other evidence that suggests the existence of an independent non-substance-induced Mood Disorder (e.g., a history of recurrent Major Depressive Episodes).
The disturbance does not occur exclusively during the course of a delirium.
The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.

Note: This diagnosis should be made instead of a diagnosis of Substance Intoxication or Substance Withdrawal only when the mood symptoms are in excess of those usually associated with the intoxication or withdrawal syndrome and when the symptoms are sufficiently severe to warrant independent clinical attention.

Code [Specific Substance]-Induced Mood Disorder:

(291.89 Alcohol; 292.84 Amphetamine [or Amphetamine-Like Substance]; 292.84 Cocaine; 292.84 Hallucinogen; 292.84 Inhalant; 292.84 Opioid; 292.84 Phencyclidine [or Phencyclidine-Like Substance]; 292.84 Sedative, Hypnotic, or Anxiolytic; 292.84 Other [or Unknown] Substance)

Specify type:

With Depressive Features: if the predominant mood is depressed
With Manic Features: if the predominant mood is elevated, euphoric, or irritable
With Mixed Features: if symptoms of both mania and depression are present and neither predominates

Specify if (see table on p.193 for applicability by substance):

With Onset During Intoxication: if the criteria are met for Intoxication with the substance and the symptoms develop during the intoxication syndrome
With Onset During Withdrawal: if criteria are met for Withdrawal from the substance and the symptoms develop during, or shortly after, a withdrawal syndrome