Affective Disorders Flashcards
Define Affective disorders.
Mood or ‘affective’ disorders are illnesses where the main feature is excessively high or low mood
Mood disorders generally run a relapsing and remitting course
What are the types of affective disorders?
‘Unipolar’ – recurrent episodes of depression
‘Bipolar’ – episodes of mania and depression
Describe the epidemiology of depression and BPAD?1
What are the causes of affective disorder?
- Genetics
- Childhood and life experiences
- Stressful life events
- Organic causes
What is the genetic component to affective disorders?
o Combination of genes probably increases the risk of mood disorders
o Relatives of depressed people are at higher risk of depression
o Relatives of those with BPAD are at higher risk of both depression and BPAD
o there is a genetic contribution at the level of temperament, behaviour and response to stress
o Serotonin transporter gene
Promoter region has 2 alleles: S (short) and (long)
S allele suffers 3 or more life events – trebles risk of depression
No risk for those with L allele
What is the childhood and life experiences aspect fo affective disorder?
o Adverse childhood experiences are associated with depression
Impact on confidence, trust and self-esteem
Include abuse, relentless criticism, parental loss and perceived lack of affection
o Vulnerability factors
Increase risk of depression in adults by reducing resilience to adverse situations
Include unemployment, lack of a confiding relationship, lower socioeconomic status and social isolation
What is the significance of stressful life events in affective disorders?
o Life events (in order in degree of stressfulness)
Death of spouse
- Divorce
- Marital separation
- Jail term
- Death of close relative
o These may occur in the 3 months before an episode of depression and the risk of depression increases 6-fold in the 6 months following life events
o Loss events are particularly important – include loss of role, loss of autonomy
If cannot mourn, depression may ensue
What are the organic causes of affective disorders?
• Physical Causes: Depression
o Chronic pain
o Cushing’s syndrome
o Hypothyroidism
o Stroke
o Parkinson’s
o MS
o Hyperparathyroidism
o Drugs: beta blockers, antihypertensives, illicit substances e.g. cocaine
•Physical Causes: Mania
o Cushing’s syndrome
o Head injury
o MS
o Steroids
o Antidepressants
o Stimulants
What are the Behavioural and cognitive theories behind affective disorder?
- Learned helplessness model of depression
o Depressed people learn that they cannot change their situation and effectively give up trying
• Beck’s model of depression
o Informs CBT
o Shows how negative thinking can depress mood, which generates negative thoughts, resulting in a downwards spiral towards depression
o Proposed a negative triad of view on the self, the world and the future o In mania he described a positive triad
What are the psychoanalytic theories behind affective disorder?
- Early experience – quality of early relationships
- Depression can be understood as a cruel relationship between a harsh critical judge and helpless inadequate agent
- Mania – the agent rebels and denies vulnerability, defending against depression
What are the neurochemical theories behind affective disorder?
• Monoamine Hypothesis
o Depression is the result of a deficiency in brain monoamine neurotransmitters
o Noradrenaline (NA): affects mood and energy
o Serotonin (5-HT): affects sleep, appetite, memory and mood
o Dopamine (DA): affects psychomotor activity
Drugs that deplete monoamines, e.g. reserpine, can cause depresson
Most antidepressants increase 5-HT and NA levels
In depression there has been shown to be
o Decreased plasma typtophan (5-HT precursor)
o Decreased CSF levels of 5-HIAA (5-HT metabolite) in suicide victims
o Decreased CSF homovanillic acid (dopamine metabolite)
• Hypothesis does not explain the 4-6 week delay in mood elevation by antidepressants Mania may be related to dopamine overactivity
o Bromocriptine = dopamine agonist, amphetamine and cocaine increase dopamine levels and can induce manic symptoms
o Antipsychotics = dopamine receptor antagonists à used in tx of mania
What are the neuroendocrine abnormality theories behind affective disorder?
Cortisol = stress hormone
Stressful life events may damage hippocampal neurons
Dexamethasone (synthetic glucocorticoid) fails to suppress cortisol secretion in 50% of depressedpatients
Non-suppression also occurs in mania, schizophrenia and old age – therefore not diagnosticallyuseful
What are the neuroanatomical abnormality theories behind affective disorder?
Depression is associated with neuroimaging abnormalities of the left anterior cingulate cortex, but it’s unclear whether this is a cause or effect.
Deep brain stimulation targets this area, and is a potential treatment for severe, treatment- resistant depression.
What are the core symptoms of depression according to ICD-10?
- Low mood - Low mood may include irritability, anxiety, or tearfulness and can show diurnal variation (typically, mornings feel worst).
- Anergia - Low energy (anergia) is often described as feeling ‘tired all the time’, ‘worn out’, or struggling to do everyday activities
- Anhedonia (inability to feel pleasure in normally pleasurable activities)
What is recurrent depressive disorder?
Recurrent depressive disorder is when someone experiences at least two depressive episodes, separated by several months of wellness
What are the cognitive symptoms of depression?
- Feeling worthless, useless and unloveable
- Guilt and dwelling on past misdeeds
- Pessimistic view of the future
- Loss of self-confidence
- Poor concentration and memory
- o In the elderly, this can mimic dementia - Slowing of thinking
What are the biological symptoms of depression?
• Altered sleep pattern
o Initial insomnia: difficulty falling asleep
o Early morning waking: 2 hours earlier than normal
o Hypersomnia (less common)
- Hyperphagia and weight gain
- More commonly, loss of appetite for food and sex
o Weight loss
o Strain on relationships
Constipation
Aches and pains
Dysmenorrhoea
What are the psychotic symptoms of depression?
- Usually emerge in very severe depression
- Auditory hallucinations
o Unpleasant derogatory voices
• Visual hallucinations
o Scenes of destruction or evil spirits
• Delusions
Nihilistic: follow theme of ‘nothingness’
- Patient is dead
- Organs are rotting or blocked
- World has ended
Persecutory
- Feelings of deserving persecution or punishment
- Link in with feelings of guilt
- Can believe they have committed a terrible crime
How do we grade depression?
Grading: reflects number and severity of symptoms, and effect on functioning
- Mild = 2 core symptoms + 2 other symptoms
- Moderate = 2 core symptoms + 3 other symptoms
- Severe = 3 core symptoms + 4 other symptoms
- Severe with psychotic features = Severe depression + psychotic symptoms (delusions +/- hallucinations)
What is the differential diagnosis for depression?
Physical Causes Dementia
- Hypothyroidism
- Head injury
- Cancer
- ‘Quiet’ delirium
- Memory affected so badly, the patients appears to have dementia
- Dementia can begin with affective changes
Adjustment Disorder
- Unpleasant but mild affective symptoms follow a life event
- Do not reach severity required to diagnose depression
Normal Sadness
• Try not to medicalise – people are allowed to be sad sometimes
BPAD/Schizoaffective disorder/Schizophrenia
• Look for previous manic or psychotic features
Substance Misuse
• Alcohol/drugs can cause depression or be a form of self-medication
Postnatal depression or puerperal illness
Bereavement
• Normal grief should not be diagnosed as depression
• Grief is a normal response to loss
• Normal stages
o Numbness
o Pining
o Depression
o Recovery
- May feel like they are going mad or that they will never recover
- May see or hear the dead person, experience immense anger, guilt, anxiety or sadness
**• Abnormal grief reaction** o Extremely intense (reaching the level of depression, disabling the person) o Prolonged (\>6 months) without relief o Delayed (no sign of an emotional response)
Dysthymia: chronic low mood for more days than not, lasting years, but not continuous enough to diagnose depression.
Burnout: exhaustion, disengagement, and reduced productivity in response to chronic work stress.
What are the investigations for depression?
Collateral hx
Physical examination
Blood tests
o TFT – rule out hypothyroidism
o FBC – anaemia causes fatigue
o Glu or HbA1c – diabetes causes fatigue
– Vitamin D and B12 (low levels cause fatigue).
– Calcium (hyperparathyroidism can cause depression).
• Rating scales can measure severity or monitor tx response
o Beck Depression inventory (BDI)
o Hospital Anxiety and Depression Scale (HADS)
o Patient Health Questionnaire PHQ-9
• CT or MRI head are never routine but may help to rule out suspected cerebral pathology
Cognitive assessment if suspect dementia
What is the management of mild to moderate depression?
Mild To Moderate Depression
o Sleep hygiene advice
o Arrange further assessment within 2weeks
o Low-Intensity Psychosocial Intervention
-
Individual-guided self-help based on the principles of CBT
- Provision of written materials, supported by a trained practitioner who reviews progress and outcome
- Consists of 6-8 sessions (face-to-face or telephone) usually taking place over 9-12 weeks including follow-up
-
Computerised CBT
- Include an explanation of the CBT model
- Encourage tasks between sessions, use thought-challenging and active monitoring of behaviour and thought patterns
- Supported by a trained practitioner who reviews progress and outcomes
- Typically takes place over 9-12 weeks including follow up
-
Structured group physical activity programme
- Delivered in groups with support from a trained practitioner
- Usually 3 sessions per week (45-60 mins) over 10-14 weeks
o Group CBT
- Considered if low-intensity psychological intervention is declined
- Based on a structured model such as ‘Coping with Depression’
- Should be delivered by 2 trained practitioners
- Consists of 10-12 meetings of 8-10 participants
- Normally lasts 12-16 weeks including follow up
o Do not routinely consider medication unless:
- Past history of moderate or severe depression
- Symptoms have been present for a long time (> 2 years)
- Symptoms persist after other interventions
- NOTE: Do not advise St. John’s wort but warn patients about uncertainty in dosing and drug interactions, including oral contraceptives, anticonvulsants and anticoagulants
How should you manage Moderate to Severe Depression?
o Provide a combination of:
- Antidepressant medication
- High-intensity psychological intervention (CBT or interpersonal therapy (IPT))
o Antidepressant Medication
- 1st line: SSRI (e.g. sertraline)
After starting antidepressant medication, review after 2 weeks (if low suicide risk), then every 2-4 weeks thereafter for 3 months
Patients <30 years old or at increased risk of suicide should be followed-up after 1 week
Review response to treatment after 3-4 weeks
o High-Intensity Psychological Interventions
Individual CBT
16-20 sessions over 3-4 months
Consider 2 sessions per week in the first 2-3 weeks
Consider follow-up sessions over the following 3-6 months
Interpersonal Therapy
16-20 sessions over 3-4 months
Consider 2 sessions per week in the first 2-3 weeks
How long should depression treatment be given for?
Treatment should continue for 6– 9 months after recovery, to prevent relapse. In recurrent depressive disorder, treatment should continue for longer (≥2 years)
In what cases should you be cautious about switching antidepressants?
From fluoxetine to other antidepressants (as fluoxetine has a long half-life)
From fluoxetine or paroxetine to a TCA (both drugs inhibit TCA metabolism so a lower starting dose may be needed)
To a new serotoninergic antidepressant or MAOI (because of risk of serotonin syndrome)
From non-reversible MAOI: a 2-week washout period is required (other antidepressants should not be prescribed during this period)
How common is treatment resistance? How should it be managed?
At least a third of people don’t recover with a first antidepressant.
Medication concordance and the diagnosis are reviewed, before considering a higher dose, different medication, or different class of antidepressant. Specialists can use augmentation strategies (adding something to the antidepressant), e.g.:
- Lithium.
- Second- generation antipsychotics (SGAs); lower doses than for psychosis.
- Tri- iodothyronine (T3).
- Combining two antidepressants.
How does CBT work?
o Views psychological problems are as result of the patient’s distorted perceptions of themselves, the world or the future
o Therapist helps patient to notice negative automatic thoughts (NATs), triggered by day to day situations and resulting in unhelpful moods and behaviours
o Mood, thought and behaviour are mutually reinforcing
o Patient learns how distorted core beliefs and dysfunctional assumptions, often set up in childhood, feed into a vicious circle
o CBT targets thoughts and behaviours with the aim of making changes that have a knock-on effect on mood
o Depressed people often believe they are worthless and life is hopeless
Activity scheduling helps patient to engage in behaviours that will enhance energy levels, develop interests and provide sense of achievement
o Common thinking errors include
Generalisation (I always mess everything up)
Minimisation (I only passed that by chance)
Distorted beliefs are tested through discussion during sessions and behavioural experiments
How does psychodynamic therapy work?
The developing relationship between the person and their therapist is the focus.
The patient’s past experiences of relationships cause them to behave (unconsciously)in certain ways, e.g. expecting the therapist to let them down.
This distorted transference is picked up by the therapist, who can draw it to the person’s conscious awareness through interpretations and comments, e.g.‘You’re afraid I’ll humiliate you’, ‘You expect me to dislike you’
o Putting words to patient’s feelings can allow them to recognise hidden beliefs and re-evaluate them with current reality
Srticulating these feelings allows the person to recognize and re- evaluate them, changing the way they see themselves and others, influencing their behaviour outside therapy. Although classical psychodynamic psychotherapy is provided over a year or more, a focused course can be delivered over 16– 20 weeks
How does interpersonal therapy work?
Focuses on themes of unresolved loss, psychosocial transitions, relationship conflict and social skills therapy
How should complex and severe depression be managed?
o Use crisis resolution and home treatment teams to manage crises
o Develop a crisis plan that identifies potential triggers and strategies to manage triggers (share with the GP and any other people involved in the patient’s care)
o Consider inpatient treatment if significant risk of suicide, self-harm or neglect
o Consider ECT for acute treatment of severe depression that is life-threatening and when a rapid response is required, or when other treatments have failed
How does ECT work?
• ECT (electroconvulsive therapy)
o Fast and life-saving in severe or psychotic depression e.g. if stopped eating and drinking
o Use of electrodes to induce tonic-clonic seizure while the patient is anaesthetised
o Main concern is degree of memory loss after the procedure
It’s usually given twice- weekly for 6– 12 sessions, but the continuation is reviewed after each session
What is light therapy?
Seasonal depressive disorder (formally seasonal affectivedisorder, SAD) occurs in autumn/ winter, often with reversed biological symptoms of hypersomnia and hyperphagia. A light box or dawn simulator can compensate for reduced daylight which is thought to be causative
Summarise tx of depression.
What should you do for patients with psychotic depression?
Add an anti-psychotic earlier
What should do when stopping an antidepressant?
Dose should be tapered down over a period of 4 wks
What social interventions are available for depression?
- Psychoeducation is essential and may include self- help books, websites, or apps.
- Support groups may help by providing further information, peer support, and social inclusion activities.
- People should be supported to tell family and friends, rather than feeling ashamed of their struggles; this can mobilize their social network to offer practical and emotional support
- Exercise, sleep hygiene, healthy diet - good strategy
- Problem solving for social stressors: e.g. brief sick leave if work is over- whelming, respite for carers, referral for debt or benefits advice, housing assistance, and signposting to support groups for substance misuse and other chronic problems
How should you explain diagnosis and management of depression to a pt?
What is the prognosis of depression?
Approx. 50% patients will have at least one more episode
Each episode lasts 8-9 months
Treatment can reduce this to 2-3 months
Psychotic depression has poorer prognosis, but shows response to ECT
15% of patients with major depression eventually commit suicide
Name a few classes of antidepressants, examples of them. How they work and side effects.
What are the different types of BPADs?
What is a cyclothymic disorder?
What are the core symptoms of mania?
Mood, energy, and enjoyment, lowered in depression, are elevated in mania.
The person is elated, excited, irritable, with rapidly changing (labile) mood, including brief tearfulness and distress.
They’re energetic, overactive, restless, and talkative, with rapid or pressured speech.
They may take up new activities and make many acquaintances
What are the cognitive symptoms of mania?
- Inflated self esteem and confidence
- Believe they are gifted, attractive, creative, intelligent and extremely special
- Optimism
- Pressure of speech and flight of ideas
What are the biological symptoms of mania?
Reduced sleep
Increased appetite for food and sex
Reckless and disinhibited behaviour
Inappropriate behaviour with raised libido
Excessive spending, reckless driving and gambling
Increased consumption of drugs and alcohol
What are the psychotic symptoms of mania?
Optimism develops into grandiose delusions
Examples include an important mission, fame or special manners
Persecutory delusions may arise if patient believes others are jealous of them
Auditory hallucinations reflect elevated mood e.g. prime ministers or saints talking to them
What is the risk associated with mania?
What is the acute management of hypomania/mania?
o Stop all medications that may induce symptoms (e.g. anti-depressants, recreational drugs, steroids and dopamine agonists)
o Monitor food and fluid intake to prevent dehydration
o If not currently on treatment
Give an antipsychotic and a short course of benzodiazepines
o If already on treatment
o Optimise the medication
o Check compliance
o Adjust doses
o Consider adding another medication (e.g. antipsychotic added to mood stabiliser)
Short-term benzodiazepines may help
o ECT may be used if patients are unresponsive to medication
What are the adverse effects of lithium? What’s good to know about it?
Describe lithium toxicity. How do you manage it?
Describe the use of valproate in BPAD? What are the adverse effect and what’s good to know?
- Anticonvulsant
- Treats acute mania
- Prophylaxis in BPAD
- Given as sodium valproate because of reduced side effects Plasma levels do not need monitoring
- No widely accepted therapeutic range
- Dose-related toxicity is not usually an issue
- Check BMI, FBC and LFTs before starting
Describe the use of carbamazepine BPAD? What are the adverse effect and what’s good to know?
• Carbamazipine
o Anticonvulsant which causes toxicity at high doses (unlike valproate)
o Liver enzyme inducer – need to monitor liver enzymes and check for interactions before prescribing drugs
o Less effective than lithium, second line in BPAD prophylaxis
What should we consider about mood stabilisers and pregnancy?
Mood stabilisers are teratogenic
Risk of harm to fetus should be weighed against harm of manic relapse Lithium - Ebstein’s anomaly
Valproate and carbamazepine - spina bifida
Women of childbearing age should be given contraceptive advice and prescribed a folate supplement if using valproate
Closely monitor the fetus if mood stabilisers are used in pregnancy
How should you counsel the patient with BPAD?
What are the risk/protective factors of completed suicide?
Precautions against discovery ✓ ✗
Substance use involved ✓ ✗
Discovery Found accidentally Sought help
Help- seeking Refusing/ resisting Engaging
Hope Hopeless *Hopeful
Ongoing suicidal plans ✓ ✗
How does NAC work in a paracetamol overdose?
What are strategies to prevent self-harm?
o Distraction techniques
o Mood-raising activities(e.g.exercise, writing)
o Strategies to Decrease or Avoid Self-Harming
- Put tablets and sharp objects away
Avoid triggers (e.g. photos online)
Stay in public places or with supportive people when tempted to self-harm Call a friend or support line
Avoid drugs and alcohol
Squeeze ice cubes
Snap a rubber band around their wrist
Bite into something strongly flavoured (e.g. lemon)
• Offer emotional support to relatives/carers if possible
