Affective Disorders Flashcards
What do affective disorders range from on a spectrum?
There is a spectrum of which euthymia (normal mood) is in the middle. Then there is severe mania and severe depression either side.
Unipolar affective disorder - recurrent episodes of depression
Bipolar affective disorder - recurrent episodes of mania and depression
How many someone present with depression? Core Sx vs other sx and how is it categorised?
All symptoms must be present on most days for at least 2 weeks
Core sx:
- > Anhedonia
- > Low mood
- > [Anergia]
Adjunct sx:
- > [Anergia]
- > Biological sx = insomnia (+EMW), reduced appetite and weight loss, low libido
- > Cognitive = reduced concentration, psychomotor agitation
- > Self-harm/suicidal thoughts
- > Feelings of guilt, worthlessness, helplessness, hopelessness
Severity is based on number/severity of symptoms and degree of functional impairment:
[ICD-10]
> Dysthymia (low mood but not depression threshold, usually for long time e.g 2 years)
> MILD = 2 core sx + 2 other sx
> Moderate = 2 core sx + 3 other sx
> Severe = 3 core sx + 4 other sx
> Psychotic depression = severe + psychotic sx (delusions +/- hallucinations)
What are some RF and causes of depression?
RFs:
- Very common (~17%)
- Females»_space; Men
- Other MH history and previous depression
- Chronic medical issues
- Trauma/significant life events
Causes:
- Hypothyroidism, Cushings
- Low vitD, hypercalcaemia
- Hypoglycaemia
- Medications = steroids, COCP, antihypertensives like CCBs and B-blockers, statins, ranitidine, retinoids, HIV medications
What are some depressive psychotic symptoms?
Psychotic sx:
- Delusions = usually mood congruent and therefore usually nihilistic (poverty, guilt, responsibility)
- Hallucinations = often 2nd person, may be
- > Auditory: cries for help/screaming, derogatory voices
- > Olfactory: usually bad smells such as rotting flesh and faeces.
- > Visual: demons, the devil, torturers, dead bodies etc
- Catatonia = marked psychomotor retardation e.g. depressive stupor
What are some other types/subtypes of depression? What MUST you ask when someone is presenting with low mood/depression?
Subtypes:
- > SAD - episodes of depression recurring annually at the same time i.e. in Winter
- > Atypical depression - somatic symptoms (weight gain, hypersomnia)
- > Agitated depression - psychomotor agitation instead of retardation
- > Anxiety induced - increased sleep + eating leads to increased mood
SCREEN for:
- > BPAD
- > Psychotic symptoms
What is the pathophysiology of depression?
Reduced monoamines = NA (mood and energy), 5-HT (sleep, appetite, memory and mood), DA (psychomotor activity, reward)
What Ix would you consider in someone with suspected depression?
Ix:
- FULL history and collateral history
- Physical exam and MSE (checking for mood elevation)
- Bloods - FBC, TFTs, glucose/HbA1c, [Ca/VitD]
- Rating scales - PHQ-9, HADS, BDI-II (adults) or CDI (in children)
What findings would you expect on an MSE in a depressed person?
MSE:
[A] Appearance and behaviour –> signs of neglect, dehydration, miserable, disinterested, anxious movements, poor eye contact, posture, tearful
[S] Speech (quantity, quality, rate, rhythm, tone, appropriateness) –> Slow, quiet, mute
[E] Emotion (mood and affect) –> Restricted range of affect; Nihilism (incl. delusions)
[P] Perception (hallucinations and delusions) –> IF Severe: hallucinations, nihilistic or persecutory delusions, evil images, guilt
[T] Thought (form, content, possession) –> Beck’s triad – worthlessness, hopelessness, helplessness
[I] Insight –> Nil
[C] Cognition –> Psychomotor retardation mimics cognitive impairment
+++ RISK ASSESSMENT - harm to self, harm from others and harm to others
How would you manage depression (based on category)?
Mx:
MILD-MODERATE:
- In primary care)
- Watchful waiting and f/u in 2w
- Self help (MIND UK, depression UK), sleep hygiene, support, diet and exercise
- IF persists after f/u and mild still = low intensity psychological intervention such as: group or computerised CBT, guided self-help
- Antidepressants are not usually advised in this group as poor risk:benefit
MODERATE
- High intensity PI for moderate depression such as individual CBT and interpersonal therapy (IPT- this is also better is due to death)
- Consider medications i.e. SSRIs (sertraline, citalopram, fluoxetine) and f/u’ s every 2w for 3m and every week if suicidal
SEVERE
- Urgent Psych referral to crisis team if actively suicidal, psychotic, risk to others or self or severely agitated
- Antidepressant + CBT/IPT combined
- ECT may be considered in severe patients
- Admit if high risk to self/others, suicidal/SH risk, psychotic sx, poor insight and poor social support (section if needed)
What antidepressants are available? What are particular drugs indicated for?
Medications:
1st line = SSRIs -> citalopram, sertraline, fluoxetine, escitalopram and paroxetine
- stepped increase from 50mg to 200mg over 6w but review after 2w anyway
- 2 trials of SSRIs before moving to second line
- SE = mainly GI such as nausea and vomiting, serotonin syndrome, citalopram has QTc syndrome and also risk of increased suicide ideation in younger patients when initially starting (takes time to act), sexual dysfunction (SEE DRUGS CARDS FOR more)
note: fluoxetine good for children, sertraline has small SE profile (good for co-morbidities) + good for post-MI/IHD, paroxetine good after a major depressive episode, mirtazapine causes weight gain and sedation
2nd line = SNRI -> venlafaxine, duloxetine
- taper down SSRI and switch to SNRI
- V has a stepped increase from 37.5mg BD to 75mg BD to 75mg morning and 150mg evening (becomes SNRI instead of SSRI only at maximum dose)
3rd line (treatment resistance) - Augment treatment with antipsychotic e.g. Quetiapine, lithium or other antidepressant e.g. NASSA (Mirtazapine)
4th line: ECT
What is Cotard syndrome?
Form of psychotic depression where there is a set of nihilistic delusions where the patient believes they are dead and their body parts are rotting
What are some considerations with depression medications in pregnancy?
No major effects found of antidepressants in pregnancy/foetus but lowest dose should be used if possible
- Paroxetine may have mild risks of congenital heart defects (T1) and persistent pulmonary HTN (T3) - all SSRIs
What is BPAD?
Affective disorder in which there are >/=2 episodes where 1 must be manic associated and the other can be depressive AND the mania lasts ~4m, depression lasts ~6m and there is complete recovery between 2 episodes
note: >90% of people with mania go on to have depressive episodes
What is Mania? What is hypomania and mixed - and the types of BPAD?
Mania is a distinct period of abnormally and persistently elevated, expansive or irritable mood with at least 3/+ characteristics of mania, lasting at least 7 days –> impairing social/occupational functioning +/- psychosis
Hypomania is similar with at least 3/+ characteristics of mania, lasting at least 4 days –> doesn’t impair social/occupational functioning and there is no psychosis or delusions
Mixed = mixture or rapid alternation (within hours) of manic/hypomanic and depressive symptoms
Classification:
Type 1 BPAD = manic episodes interspersed with depressive episodes
Type 2 BPAD = recurrent depressive episodes with less prominent hypomanic episodes
Rapid cycling BPAD = at least 4/+ episodes a year - respond to valproate well!
What are some causes/RFs for BPAD?
Biological = genetic component (up to 7x risk in 1st degree relatives), anatomical differences, increased [transmitters]
Psychosocial = stressful life events
