1- Mental health conditions (Affective disorders) Flashcards
Affective disorders
- Depression
- Bipolar
- Persistent mood disorder
Mood
Refers to a patient’s sustained, experienced emotional state over a period of time.
- It may be reported subjectively (in the patient’s own words) or objectively as dysthymic (low), euthymic (normal) or elated (elevated).
when does a mood become a mood disorder
Fluctuations in mood are a normal part of human experience. It is only when a disturbance of mood is severe enough to cause impairment in the activities of daily living (ADL), that it is considered as a mood disorder.
define mood disorder
Mood disorder: Otherwise known as an ‘affective disorder’, is any condition characterized by distorted, excessive or inappropriate moods or emotions for a sustained period of time, which affects normal life functioning
classification of mood disorder
Primary
- Unipolar
- Bipolar
Secondary
primary mood disorder
a mood disorder that does not result from another medical or psychiatric condition.
- unipolar e.g. depression and dysthmia
- bipolar e.g. bipolar affective disoder, cyclothymia
secondary mood disorder
a mood disorder that results from another emdical or psychiatric condition
- physical e.g. hypothyroidism
- pyschiatric e.g. alcoholism
- drug induced e.g. corticosteroids
define depression
Definition: an affective disorder characterised by a persistent low mood, loss of pleasure and/ or lack of energy accompanied by emotional, cognitive and biological symptoms
prevalence of depression and epidemiology
- 1 in 20 adults in UK experience depression
- F>M
- Onset most common in 40s (F) and 30s (M)
risk factors of depression
(FF,AA,PP,SS)
* Female
* Family history
* 50% in monozygotic twins
* Alcohol
* Adverse events
* Past depression
* Physical co-morbidities e.g. thyroid dysfunction
* Low social support
* Low socioeconomic background
causes of depression can be split into
- Predisposing vs precipitating vs perpetuating
- Biological vs social vs psychological
example biological causes of depression
- Genetic influence
o e.g. deficiency of monoamines (NA, serotonin and dopamine) cause depression - Neuroendocrine e.g. HPA axis
- Neurological illness e.g. MS
example psychosocial factors causing depression
personality type, stressful life events
example social factors causing depression
e.g. poor social support, work, housing, finance
Protective factors for depression
- Current employment
- Good social support
- Being married
presentation of depression
Split into core, cognitive, biological and psychotic
The three typical core symptoms of depression include:
- Low mood (for at least 2 weeks)
- Anhedonia: low interest or pleasure in most activities of the day
- Lack of energy (anergia)
Other core symptoms of depression include:
- Weight change: exclusion of intentional dieting
- Disturbed sleep: insomnia or hypersomnia
- Psychomotor retardation (slowed down actions) or psychomotor agitation (increased restlessness)
- Reduced libido
- Worthlessness or guilt feelings
- Decreased concentration
- Recurring thoughts of harm, death or suicide: nihilistic thoughts
Biological (somatic) symptoms of depression
- Loss of emotional reactivity
- Diurnal mood changes: mood often worse in the morning
- Sleep changes e.g. early morning wakening: typically 2-3 hours earlier than usual
- Psychomotor retardation or psychomotor agitation
- Appetite loss
- Weight loss
- Loss of libido
Cognitive symptoms of depression
- Low self esteem
- Guilt/ blame
- Hopelessness
- Hypochondrical thoughts
- Poor concentration
- Suicidal thoughts
psychotic features of depression
- Delusions: often revolving around guilt and personal inadequacy
- Hallucinations: can be auditory, olfactory or visual
depression presentation acronymn
Acronym- DEAD SWAMP
- Depressed mood
- Energy loss (anergia)
- Anhedonia
- Death thoughts (suicide)
- Sleep disturbance
- Worthlessness or guilt
- Appetite or weight change
- Mentation (concentration) reduced
- Psychomotor retardation (moving slowly)
differential diagnosis for depression
- Low mood
o Feeling low from time to time
o Common after distressing event or major life changes, sometime happen for no obvious reasons
o Low mood will often pass after a couple of days or weeks - Depressive episode linked to substance/ medication use
- Bipolar affective disorder
- Premenstrual dysphoric disorder
- Anxiety disorders
- Alcohol use disorder
Organic illness differentials - Hypothyroidism
- Cushing’s
investigations/diagnosis of depression
1) Screening tool e.g. PHQ-9
2) Diagnostic criteria e.g. ICD-10
3) Risk assessment
4) Mental state examination
5) Further investigations: bloods and imaging
screening tool for depression
PHQ-9
- Can be used to screen for symptoms of a depressive episode
diagnosis of depression uses
ICD-10/ criteria
Diagnosis of depressive episode is clinical according to ICD-01-11 diagnostic criteria:
- The presence of symptoms for at least 2 weeks (this may be less if depression is severe)
- The symptoms are not attributable to other organic or substance causes (e.g. normal bereavement)
- The symptoms impair daily function and cause significant distress
risk assessment for depr
- Risk to self self harm, suicide or neglect
- Risk to other depression with psychotic features
- Risk from others more vulnerable to abuse, criminal acts or neglect
mental state examination for depression
further investigations for depression
- blood tests
- imaging
blood tests for depression
- Full blood count: anaemia
- Thyroid function tests: hypothyroidism
- Vitamin B12: B12 def
imaging for depression
Imaging if atypical features e.g. memory loss and personality change
- CT head
- MRI head
management of depression is based
Based on the bio-psycho-social model and divided in short term and long term strategies
- Depends on symptoms the patient has
- Depends on level of depression
general management of depression
- Managing comorbidity i.e. alcohol substance abuse, eating disorder etc
- Managing safeguarding issues
- Assessing and mitigating suicide risk
- CBT
- Counselling
- Antidepressants
- Social prescribing i.e. physical activity programmes in groups
Mild depression management
Short term
- Antidepressants not routinely offered unless past history of moderate or severe depression or other interventions have failed
- Guided self-help
- CBT
- Counselling
Long term
- Risk assessment
- Ongoing review
- Relapse prevention plan
- Assess social support
Moderate or severe depression management
Short term
First line: combination of an antidepressant and high-intensity psychosocial intervention
1) Antidepressants
- Selective serotonin reuptake inhibitors (SSRIs) are first line (less toxic in overdose and same effectiveness as tricylic) (Citalopram, Fluoxetine, Sertraline)
- SNRI (serotonin noradrenaline reuptake inhibitors) used as second line (Duloxetine)
2) Psychosocial intervention
- CBT
- Counselling
- Psychotherapy
Long term
- Risk assessment
- Review response to treatment
- Relapse prevention
- Assess social support
ECT
a treatment which invovles sneding an electric current throught the brain to trigger an epileptic seizure
indication for ECT in depression
- severe depressive illness where other treatments have not been effective
- rapid treatment required e.g. life threatening e.g. food/fluids
- catatonia
- high suicide risk
- ## severe psychomotor retardation
severe depression with psychotic symptoms management
Antidepressants + antipsychotic (quetiapine or olanzapine)
Monitoring depression
- See patients who are not considered to be at increased risk of suicide within 2 weeks of starting treatment and review as reg as appropriate
- See patients with increased risk of suicide who are younger than 30 within one week of starting treatment and review reg
If pt high risk of suicide- prescribe a limited quantity of antidepressants - Monitor for signs of akathisia, suicidal ideas and increase anxiety and agitation
Treatment duration for depression
- For patients who have benefited from SSRI- continue for at least 6 months after remission to reduce risk of relapse
- When stopping antidepressants reduce dose gradually over a four week period
complications of depression
- Suicide
- Substance misuse and alcohol
- Recurrent episodes
- Antidepressant side effects
o Sexual dysfunction
o Self harm
o Weight gain
o Hyponatraemia
o Agitation
Prognosis of depression
- Average length is 6-8 months
- Risk of recurrence is 50-%
- Prognosis worse when psychotic features, anxiety and underlying personality disorder
depression history taking
Postnatal depression
Postnatal depression is similar to depression that occurs outside of pregnancy, with the classic triad of:
- Low mood
- Anhedonia (lack of pleasure in activities)
- Low energy
Typically, women are affected around three months after birth.
RF for postnatal depression
o Personal or family history of depression
o Older age
o Single mother
o Unwanted pregnancy
o Poor social support
o Previous PND
prevalence of postnatal depression
- 10-15% of women usually within 1-2 months post partum but can appear later in some women
- 1 in 4 still depressed a year after delivery
Edinburgh Postnatal Depression Scale
.
The Edinburgh postnatal depression scale can be used to assess how the mother has felt over the past week, as a screening tool for postnatal depression
presentation of postnatal depression
Thought content may include worries about the baby’s health or her ability to cope with the baby
management of postnatal depression
* Mild cases may be managed with additional support, self-help and follow up with their GP
* Moderate cases may be managed with antidepressant medications (e.g. SSRIs) and cognitive behavioural therapy
* Severe cases may need input from specialist psychiatry services, and rarely inpatient care on the mother and baby unit
summarise hypomania
Usually a part of bipolar disorder
Several of the following features with considerable interference with work/social activity for at least several days
Presentation
- Mildly elevated expansive or irritable mood
- Increased energy
- Increased self esteem
- Sociability, talkativeness, over familiarity
- Increased sex drive
- Reduced need for sleep
- Difficulty in focussing on one task alone
summarise mania
Again seen with bipolar
- Elevated/expansive/irritable mood for 1 week
- Increased energy (inc agitation)
- Grandiosity
- Pressure of speech
- Flight of ideas/racing thoughts
- Distractible
- Reduced need for sleep
- Increased libido
- Psychotic symptoms
o Superpowers
o Religious delusions - Lack of judgement
o E.g. spending
o E.g. dangerous activities
define bipolar
A chronic mood disorder characterised by episodes of depression and mania or hypomania. Either one can occur first but the term bipolar also includes those who at the time of diagnosis have suffered only manic episodes, as all cases of mania will eventually develop depression.
- A mixed affective state
prevalence of bipolar disorder
o 1-3% pre valence
o Bimodal
15-24 yp
45-54 yo
o M:F
Risk factors for BAD
causes of bipolar can be split into
Biopsychosocial
Biological causes of BAD
Genetic
- combined effect of many single nucleotide polymorphisms (SNPs)
- Monzygotic 60%
- Polygenic inheritance e.g. polymorphisms in genes which code for monoamine transporters
Neurobiological factors
- Increased dopamine
- HPA axis disturbance causing increased cortisol secretion
- Admin of exogenous corticosteroids can cause mania
Antenatal/ birth
- Prenatal exposire to toxoplasma gondii
- premature birth
Environmental causes of BAD
- childhood maltreatment
- negative life events
- cannabis use
Classification of bipolar affective disorder
- Bipolar I
- Bipolar II
- Cylothymia
bipolar I
bipolar I, the person has experienced at least one episode of mania +/- 1 or >depressive episodes
In bipolar II
In bipolar II, the person has experienced at least one episode of hypomania, but never an episode of mania. They must have also experienced at least one episode of major depression.
Cyclothymia
a related disorder characterised by persistent instability of mood
* Involves numerous periods of depression and mild elation, none of which are sufficiently severe or prolonged to justify a diagnosis of BAD
Differential diagnoses
- Schizophrenia
o In bipolar delusions are more grandiose, rather than bizarre - Organic brain disorder
o Frontal lobe pathologies e.g SoL - Drug use e.g. steroids
- Recurrent depression
o Distinguished by episodes of hypomania - Emotionally unstable personality disorder
o Grandiose ides and marked increase in energy in mania not seen in EUPD - Cyclothymia
Presentation of bipolar
Mania or depression
Severity of mania is divided into
1) Mania
2) Hypomania
3) Mania with psychosis
presentation of mania
- Irritability
- Distractibility
- Disinhibited/ reckless
o Sexual
o Spending - Impaired insight
- Increased libido
- Grandiose delusion
- Flight of ideas
- Energy increase
- Pressure of speech
- Sleep decreased
- Elevated mood
- Reduced concentration
Diagnosis/Investigations of BAD
To confirm a diagnosis of bipolar disorder, a referral should be made to a specialist mental health service.
1) History taking- used ICD-10 criteria
2) Mental state exam
3) Neurological examination
4) investigations
- Self rating scale
- Blood tests
- HIV test
- urine test
- CT head
bipolar should be considerd when there is evidence of
- Mania: symptoms should have lasted for at least 7 days
- Hypomania: symptoms should have lasted for at least 4 days
- Depression (characterised by low mood, loss of interest or pleasure, and low energy) with a history of manic or hypomanic episodes
ICD-10 criteria for BAD
- Mania requires 3/9 symptoms to be present.
- BAD requires at least two episodes in which a persons mood and activity levels have been significant disturbed
- 5 states of bipolar disorder
o Currently hypomanic
o Currently manic
o Currently depressed
o Mixed disorder
o In remission
mental state examination for BAD
Further investigations for BAD
1) Self rating scales e.g. mood disorder questionnaire
2) Blood tests
* FBC
* TFTs (hyper/hypothyroidisms
* UE (with view to starting lithium)
* LFTS (review to starting mood stabilisers)
* Glucose and calcium (biochemical disturbance can cause mood symptoms)
3) HIV testing
4) Urine test- illicit drugs
5) CT head
- Rule out SoL- can cause manic symptoms such as disinhibition
management summary for BAD
- Full risk assessment is vital including suicidal ideation and risk to self (e.g. financial ruin from overspending). This will determine the urgency of referral to specialist mental health services.
- Remember to ask about driving. The DVLA has clear guidelines about driving when manic, hypomanic or severely depressed.
- The Mental Health Act is needed if the patient is violent or a risk to self. Hospitalization will be required if there is: (1) reckless behaviour causing risk to patient or others; (2) significant psychotic symptoms; (3) impaired judgement; (4) or psychomotor agitation.
- The pharmacological management of bipolar affective disorder is shown in Table 3.3.4. Also see Section 12.4, Mood stabilizers.
- For bipolar depression, offer a high-intensity psychological intervention (e.g. CBT).
- ECT is not first-line, but it can be used when antipsychotic drugs are ineffective and the patient is so severely disturbed that further medication or awaiting natural recovery is not feasible.
- Patients who present with an acute episode should be followed-up once a week initially and then 2–4 weekly for the first few months.
The bio-psychosocial approach to BPAD
Pharmacological management of BPAD: acute manic episode/ mixed episode :
First line: antipsychotic rapid onset compared to mood stabilisers
- Olanzapine or risperidone or quetiapine
Second line: Mood stabilisers
- Lithium
- Sodium Valproate if lithium not suitable
Symptoms management
Benzodiazepine for sleep and agitation
- Lorazepam
Rapid tranquilisation
- Haloperidol
- And/Or Lorazepam
Pharmacological management of BPAD: bipolar depressive episode
First line: Atypical antipsychotics
- Olanzapine (combine dwith fluoxetine), olanzapine alone or quetiapine
Mood stabilise- prophylactic
- Lamotrigine
**
ANTIDEPRESSANTS ALONE ARE USUALLY AVOIDED **
why are antidepressant alone avoided in BAD
- They have the potential to induce mania
- If prescribed should be prescribed with cover of anti-manic e.g. antipsychotic medication
Long term management of bipolar affective disorder
- 4 weeks after an acute episode has resolved, lithium should be offered first-line to prevent relapses.
- If lithium is ineffective consider adding valproate. Olanzapine or quetiapine are alternative options- First line treatment for rapid cycling
use of sodium valproate in BAD
Sodium valproate should not be used in pregnant women due to its teratogenic effects and is not recommended in women of childbearing age unless the illness is very severe and there is no effective alternative. In this circumstance, the patient should have a pregnancy prevention plan.
first line trreatment for manic episode of bipolar
olanzapine or risperidone or quietapine
which drug minimises bipolar relpase
lithium
lithium toxicity
narrow therapeutic window so drug levels need to be monitored regularly
- 12h following first dose
- Weekly until therapeutic level (0.5-1.0mmol/l) has been stable for 4 weeks
- Once stable check every 3 months
o U+Es every 6 months
o TFTs every 12 months
tests prior to starting lithium
o UEs
o TFTS
o Pregnancy status
o Baseline ECG
specific complications of lithium
- hypothyroidism- reversible
- renal damage- irreversible
side effects of lithium
o Polydipsia
o Polyuria
o Fine tremor
o Weight gain
o Oedema
o Hypothyroidism
o Impaired renal function
o Memory problem
o Teratogenicity
signs of toxicity due to lithium
- Signs of toxicity (1.5-2.0 mmol/l)
o N+V
o Tremor
o Ataxia
o Muscle weakness
o Apathy - Signs of severe toxicity (>2.0 mmol/l)
o Nystagmus
o Dysarthria
o Hyperreflexia
o Oliguria
o Hypotension
o Convulsions
o Coma
Dysthymia
Chronic low mood not fulfilling the criteria of depression
