Affective disorder Flashcards
1
Q
symptoms of depression ?
A
- low mood on most days, most of the time
- loss of interest in activities previously found enjoyable
- low energy and increased fatiguability
- loss of confidence and low self esteem
- inappropriate guilt
- thoughts of death and suicide
- reduced concentration/ indecisiveness
- bleak and pessimistic view
- poor appetite (weight loss)
- sleep disturbances
- loss of libido
- psychomotor changes
- anxiety
2
Q
how long do symptoms have to present to make a diagnosis of depression ?
A
2 weeks
3
Q
how is depression categorized ? what is the difference between these groups
A
mild
moderate
severe
- as you move from mild to severe: symptoms increase and function is increasingly impaired
- psychotic symptoms only occur in moderate or severe depression
4
Q
what are symptoms of mania ?
A
- persistently elevated, expansive, or irritable mood
- increase in quantity and speed of physical and mental activity
- inflated self esteem or grandiosity
- decreased need for sleep
- more talkative than usual
- flight of ideas of racing thoughts
- distractibility
- increase in goal directed activity or psychomotor agitation
- excessive involvement in pleasurable activities potential for painful consequences
5
Q
mania vs hypomania
A
mania: increased symptoms, more functional impairment
- psychotic symptoms only occur in mania
6
Q
classification of affective disorders?
A
- bipolar type 1
- bipolar type 2
- single episode depressive disorder
- recurrent depressive disorder
- mixed depressive and anxiety disorder
7
Q
what symptoms of depression are in the affective cluster ?
A
- depressed mood as reported by the individual (e.g feeling down, sad) or as observed (e.g tearful, defeated appearance)
- markedly diminished interest or pleasure in activities, especially those normally found to be enjoyable to the individual
8
Q
what symptoms of depression are in the cognitive-behavioural cluster?
A
- reduced ability to concentrate and sustain attention to tasks or marked indecisiveness
- beliefs of low self worth or excessive and inappropriate guilt that may be manifestly delusional
- hopelessness about the future
- recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation (with or without a specific plan), or evidence of attempted suicide
9
Q
what symptoms of depression are in the neurovegetative cluster?
A
- significantly disrupted sleep (delayed onset, increased frequency of waking during the night, or early morning awakening) or excessive sleep
- significant change in appetite (diminished or increased) or significant weight change (gain or loss)
- psychomotor agitaiton or retardation (observable by others, not merely subjective feelings of restlessness or being slowed down)
- reduced energy, fatigue, or marked tiredness following the expenditure of only a minimum of effort
10
Q
to make the diagnosis of depression, at least one symptom from the …. cluster must be present
A
affective
11
Q
how many symptoms are required to make the diagnosis of depression ?
A
5 (but 1 must be from the affective cluster)
12
Q
to make the diagnosis of depression the symptoms are not better accounted for by …. , the symptoms are not a manifestation of another … condition and are not due to the effects of a … or … on the CNS, including withdrawl effects
A
bereavement
medical
substance
medication
13
Q
to make a diagnosis of depressive episode the mood disturbance results in significant …. in personal, family, social, educational, occupational, or other important areas of functioning. if functioning is maintained, it is only through significant additional effort
A
impairment
14
Q
depression etiology ?
A
- endocrine
- half of the patients with cushings disease suffer from depression which remits on correction of cortisol abnormalities
- 50% of depressed patients show non-suppression on the dexamethasone suppression test (more common in melancholia/somatic syndrome)
- thyroid abnormalities: free thyroxine levels are normal in depressed patients
- 25% of depressed patients have a blunted TSH response to TRH - neurotransmitters
- monoamine theory of depression; serotonin (decreased levels in depressed patients, dopamine (levels of dopamine metabolites low in CSF), noradrenaline (patients given NA depletion agents become depressed) - genetics
- family studies: relatives of suffers of unipolar depression have a higher rate of unipolar depression (9.1%). monozygotic concordance of 40-50%
- proposed mechanism: influencing the risk of depression by altering an individuals susceptibility to life’s stressors - psychological theories
- psychodynamic theories: link between depression with loss and interpersonal relationships in childhood
- cognitive theories: link between thoughts, and feelings learned through early experience reactivated by events later in life leading to a cycle of negative thinking and depressed mood
- other theories: seligman “learned helplessness” - Social
- brown and harris study: 3 factors were found to be associated with the development of depression in females: 1) having 3 or more children under the age of 14. 2) no confiding relationships. 3) not working outside the home
- married subjects have lower rates of depression than single/ divorced individuals or widows/ widowers
- 6 fold increase in life events in the 6 months prior to the development of a depressive episode; loss events are typically associated with depression whilst threat events were associated with development of anxiety - integrate model
15
Q
what is the integrate model of depression
A
16
Q
depression - diagnostic classification
A
** assessment of function is essential when assessing severity
1. mild depressive episode
2. moderate depressive episode without psychotic symptoms
3. moderate depressive episode with psychotic symptoms
4. severe depressive episode without psychotic symptoms
5. severe depressive episode with psychotic symptoms
17
Q
describe a mild depressive episode
A
the individual is usually distressed by the symptoms and has some difficulty in continuing to function in one or more domains (personal, family, social, educational, occupational, or other important domains). There are no delusions or hallucinations during the episode
18
Q
describe a moderate depressive episode without psychotic symptoms
A
several symptoms of a depressive episode are present to a marked degree, or a large number of depressive symptoms of a lesser severity are present overall. the individual typically has considerable difficulty in functioning in multiple domains
19
Q
describe a moderate depressive episode with psychotic symptoms ?
A
same as moderate depressive episode without psychotic symptoms and there are delusions or hallucinations during the episode
20
Q
describe a severe depressive episode without psychotic symptoms ?
A
many or most symptoms of a depressive episode are present to a marked degree, or a smaller number of symptoms are present and manifest with intense degree. the individual has serious difficulty continuing to function in most domains
21
Q
describe a severe depressive episode with psychotic symptoms
A
same as severe depressive episode without psychotic symptoms and there are delusions or hallucinations during the episode
22
Q
depression - prevalence/ age of onset
A
- lifetime prevalence: 20% (varies depending on studies)
- peak age of onset: late 20s
- gener distribution: M:F = 1:2. Gender differences even out with older age with sex distribution equalizing out in the over 55 age group
- urban vs rural: higher rates of depression in urban areas
23
Q
depression - investigations
A
- history
- patient
- collateral (family, GP etc) - MSE
- relevant blood tests
- urine drug screen if appropriate
- alcometer if appropriate
- others: ECG, EEG, CT/MRI etc as needed
- psychological assesment: cognitive, personality
24
Q
management of depression ? (biological)
A
biopsychosocial approach also when addressing psychiatric disorders
- treat medical co-morbidities
- address substance misuse
- antidepressant medication
- SSRI: advise about side effects, monitor response
- switch medication: SNRI, TCA - augment: mood stabilizer (lithium), antipsychotic (quetiapine), ECT
25
Management of depression ? (psychological)
1. psychological support
2. psychoeducation
3. counselling
4. CBT
5. other psychotherapies
26
Management of depression (social) ?
lifestyle including;
- exercise
- sleep hygiene
- stress management
- advice re alcohol
- social supports
- employment supports
27
treatment of depression with psychotic symptoms ?
- patients with psychotic symptoms generally have a more severe depressive illness
- use an antidepressant and an antipsychotic: monitor for side effects, baseline ECG and bloods
- combination of antidepressant and antipsychotic is more effective than an antipsychotic alone
- consider lithium
- consider Electroconvulsive therapy (ECT): associated with good outcome and fewer side effects, monitor cognitive function
28
depression - course and prognosis; average length of a depressive episode, recurrent depresssion, suicude, all cause mortality
1. average length of a depressive episode is 6 months
- 25% will have an episode that lasts longer than 1 year
- 10-20% will have chronic, relapsing remitting course
2. recurrent depression
- of patients who have one episode of major depression: 50-85% will go on to have a second episode
- 80-90% of those who have a second episode will go on to have a third
- average number of episodes over 25 years is 5
- 25% of patients will achieve 5 years without symptoms
- medication and therapy are highly effective
3. Suicide
- 15% completed suicide rate in depression
- suicide rate 12 times greater than that of general population
- suicide rate reported higher earlier in the disease
- suicide rate higher at diagnosis or with any relapse
- post-discharge high risk period
4. all cause mortality
- is 2x general public (not only due to suicide) --- cardiovascular mainly
29
depression - prognostic factors (antidepressant - how long to remain on meds and what factors to consider, what factors increase the liklihood of future episode?
1. antidepressants - how long to remain on meds? what factors to consider?
- following a first episode of depression, patients should remain on medication at least 6 months from the point of remission of symptoms
- patients who have had 2+ episodes of depression should be maintained on antidepressants for at least 2 years
- patients should be reevaluated taking into account age, co-morbid illness, and other risk factors in deciding whether to discontinue meds
2. what factors increase the likelihood of future episodes?
- previous episodes
- incomplete remission (residual symptoms)
- bipolar illness as opposed to unipolar illness
- poor social supports
- poor physical health
- substance misuse
- personality disorder
- unemployment
- poor treatment adherence
30
what are other depressive disorders ?
1. Dysthymia
2. seasonal affective disorder
3. atypical depression
31
dysthymia (persistent depressive disorder) define?
- chronic pervasive low mood (at least 2 years in adults and 1 year in children and teens) which remains below the threshold for diagnosis of a depressive episode
- periods of feeling well but largely patient experiences chronic brooding, tiredness, sleep disturbances and feelings of insecurity
- lifetime prevalence of 6%
- treatment: guided self help/CBT/group activity programmes, treatment with SSRIs if persistent
- prognosis is poor with ongoing symptoms
32
discuss seasonal affective disorder
- recurrent depressive episodes with a clear seasonal pattern of recurrence related to length of daylight
- treat with light therapy during winter time
33
discuss atypical depression
- not defined as a unique clinical entity but rather as a depression sub-type
- depressed mood which remains reactive; hypersomnia (sleeping more than 10 hours daily), hyperphagia (excessive eating with weight gain)
- historically MAOIs used
34
discuss mania
- an extreme mood state characterized by euphoria, irritability, or expansiveness that represents a significant change from the individuals typical mood and increased activity or a subjective experience of increased energy that represents a significant change from the individuals typical level occuring concurrently and persisting for most of the day, nearly everyday, during a period of at least 1 week, unless shortened by a treatment intervention
- several of the following symptoms
1. increased talkativeness or pressured speech
2. flight of ideas or experience of rapid or racing thoughts
3. increased self-esteem, or grandiosity. In psychotic presentations of mania, this may be manifested as grandiose delusions
4. decreased need for sleep
5. distractibility
6. impulsive reckless behaviour
7. an increase in sexual drive, sociability, or goal-directed activity
- the symptoms are not a manifestation of another medical condition and are not due to the effects of a substance or medication on the Central nervous system
- the mood disturbance results in significant impairment in personal, family, social, education, occupational, or other important areas of functioning, requires intensive treatment (e.g hospitalization) to prevent harm to self or others, or is accompanied by delusions or hallucinations
35
discuss hypomania
- persistent elevation of mood/increased irritability that represents a significant change from the individuals usual range of moods and increased activity or a subjective experience of increased energy occuring concurrently and persisting for most of the day, nearly every day, for at least several days
- in addition, several of the following;
1. increased talkativeness or pressured speech
2. flight of ideas or experience of rapid or racing thoughts
3. increased self esteem or grandiosity
4. distractibility
5. impulsive reckless behaviour
6. an increase in sexual drive, sociability or goal-directed activity
- the symptoms are not a manifestation of another medical condition and not due to the effects of a substance or medication on the central nervous system
- the mood disturbance is not sufficiently severe to cause marked impairment in occupational functioning or in usual social activities or relationships with others and is not accompanied by delusions or hallucinations
36
difference between mania and hypomania
1. mania
- extreme mood state change characterized by euphoria, irritability or expansiveness
- needs to be present at least 1 week, unless shortened by a treatment intervention
- the mood disturbance results in a significant impairment in an area of important areas of functioning, requires intensive treatment (e.g hospitalization) to prevent harm to self or others, or is accompanied by delusions or hallucinations
2. hypomania
- persistent elevation of mood/increased irritability
- can be present for only several days
- the mood disturbance is not sufficiently severe to cause marked impairment in any domains of functioning and is not accompanied by delusions or hallucinations
- does not require intensive treatment (e.g hospitalization)
- person does not pose a harm to self or others
37
Bipolar affective disorder - epidemiology (lifetime prevalence, age of onset, gender, recurrence, suicide, high co-morbidity_
1. lifetime prevalence
- BPAD type 1: 1-1.6%
- BPAD type 2: 0.5%
2. age of onset: late teens/20s
3. Gender
- M=F
4. recurrence
- 90%
5. Suicide
- 25% attempt
6. high co-morbidity: substance misuse
38
Bipolar affective disorder type 1 - diagnostic classification
1. history of at least 1 manic or mixed episode. Although a single manic or mixed episode is sufficient for a diagnosis of BPAD type 1, the typical course of the disorder is characterized by recurrent depressive and manic or mixed episodes
2. Although some episodes may be hypomanic, there must be a history of at least one manic or mixed episode
39
Bipolar affective disorder type 2 - diagnostic classification
1. a history of at least one hypomanic episode and at least one depressive episode. the typical course of the disorder is characterized by recurrent depressive and hypomanic episodes
2. there is no history of manic episodes or mixed episodes
40
what are the difference between bipolar affective disorder type 1 and type 2
1.type 1
- episode of 1 manic or mixed episode is sufficient to make the diagnosis
- typical course is characterized by recurrent depressive and manic or mixed episodes
2. type 2
- need history of 1 hypomanic episode and at least one depressive episode
- the typical course of the disorder is characterized by recurrent depressive and hypomanic episodes only
- cannot have history of manic or mixed episodes to make the diagnosis
41
discuss mixed affective episode
- the presence of several prominent manic and depressive symptoms consistent with those observed in manic episodes and depressive episodes, which either occur simultaneously or alternate very rapidly (from day to day or within the same day). Symptoms must include an altered mood state consistent with a manic and/or depressive episode, and be present most of the day, nearly everyday, during a period of at least 2 weeks, unless shortened by intervention
- when manic symptoms predominate in a mixed episode, common depressive symptoms are dysphoric mood, expressed belief of worthlessness, hopelessness and suicidal ideation
- when depressive symptoms predominate in a mixed episode, common manic symptoms are irritability, racing or crowded thoughts, increased talkativeness and increased activity
- the mood disturbance results in significant impairment in personal, family, social, educational, occupational or other important areas of functioning or is accompanied by delusions or hallucinations
42
Bipolar affective disorder - course and prognosis
1. in generaly depressive episodes last longer than manic episodes
2. patients with bipolar disorder have more episodes of mood disturbances than patients with unipolar depression
3. 40% of patients with bipolar disorder initially present with a depressive episode
4. 16% of patients remain symptom free for 5 years
5. suicide rate in bipolar disorder are lower than in unipolar depression
43
Bipolar affective disorder - differential diagnoses
1. schizophrenia/ schizoaffective disorder/ other psychotic disorders
2. personality disorder (borderline personality disorder)
3. ADHD
4. substance misuse (e.g alcohol, amphetamines, cocaine, hallucinogens, opiates)
5. medication (e.g antidepressants, bromocriptine, captopril, cimetidine, corticosteroids, cyclosporine, disulfram, hydralazine, isoniazid, levodopa, methylphenidate, procyclidine)
44
Bipolar affective disorder management ? (biological)
- remember to address any substance misuse
45
Bipolar affective disorder management ? psychlogical
role of psychological treatment
1. psychoeducation
2. insight
3. relapse prevention
4. psychological triggers
46
bipolar affective disorder management ? Social
role of social treatment
1. lifestyle choices - re sleep, diet, exercise, substances
2. family support - "spotters"
3. peer support organizations - e,g aware
4. support re finances, occupation, housing
