Affective Disorders Flashcards
What are the ICD-10 core symptoms of depression?
Depressed mood
Loss of Interest
Lack of energy
What are the DSM-IV core symptoms of depression?
Depressed mood
Loss of interest
Cognitive symptoms of depression?
Poor concentration/indecisiveness
Inappropriate guilt
Worthlessness
Hopelessness
Loss of self esteem/confidence
Suicidal thoughts
Suicidal plans
Suicide attempt
Diurnal variation of mood
Hypochondriacal thoughts
Biological symptoms of depression?
Weight disturbance (loss or gain)
Appetite disturbance (Decrease or increase)
Sleep disturbance (decrease or increase)
Psychomotor agitation or retardation
Fatigue or loss of energy
What should be excluded when considering a diagnosis of depression?
Mixed states
Substance or General Medical Condition
(GMC) induced
Bereavement
Typical symptoms of depression?
Low mood
Anhedonia, a lack of pleasure in activities
Low energy
Anxiety and worry
Clinginess
Irritability
Avoiding social situations (e.g. school)
Hopelessness about the future
Poor sleep, particularly early morning waking
Poor appetite or over eating
Poor concentration
Physical symptoms such as abdominal pain
ICD-10 criteria for depression
2/3 of:
Depressed mood*
Loss of interest*
Reduction in energy*
And at least 2 of:
Loss of confidence or self-esteem
Unreasonable feelings of self- reproach or inappropriate guilt
Recurrent thoughts of death or suicide
Diminished ability to think/ concentrate or indecisiveness
Change in psychomotor activity with agitation or retardation
Sleep disturbance
Change in appetite with weight change
For at least 2 weeks (or shorter if unusually severe and of rapid onset)
What is the DSM–IV major/minor depressive disorder diagnostic criteria?
One of:
- Depressed mood most of the day, nearly every day
- Markedly diminished interest or pleasure in all, or almost all, activities most of the day, nearly every day
And then 2-3 or more of (total of 5 symptoms):
- Significant weight loss or weight gain when not dieting or decrease or increase in appetite nearly every day
- Insomnia or hypersomnia nearly every day
- Psychomotor agitation or retardation nearly every day
- Fatigue or loss of energy nearly every day
- Feelings of worthlessness or excessive or inappropriate guilt nearly every day
- Diminished ability to think or concentrate, or indecisiveness nearly every day
- Recurrent thoughts of death, recurrent suicidal ideation without a specific plan, or a suicide attempt or a specific plan for committing suicide
Present for 2 weeks or more
Reasons why women might have a higher rate of depression?
Hormonal changes in women, particularly during puberty, prior to menstruation, following pregnancy and at perimenopause, suggests that female hormonal fluctuations
Prevalence of sexism in society
Women also experience specific forms of depression-related illness, including premenstrual dysphoric disorder, postpartum depression and postmenopausal depression and anxiety
What questions can screen for depression?
The following two questions can be used to screen for depression:
‘During the last month, have you often been bothered by feeling down, depressed or hopeless?’
‘During the last month, have you often been bothered by having little interest or pleasure in doing things?’
A ‘yes’ answer to either of the above should prompt a more in depth assessment.
What tools exist to assess the degree of depression?
Hospital Anxiety and Depression (HAD) scale and the Patient Health Questionnaire (PHQ-9)
Hospital anxiety and depression scale
consists of 14 questions, 7 for anxiety and 7 for depression
each item is scored from 0-3
produces a score out of 21 for both anxiety and depression
severity: 0-7 normal, 8-10 borderline, 11+ case
patients should be encouraged to answer the questions quickly
Patient health questionnaire (PHQ-9)
asks patients ‘over the last 2 weeks, how often have you been bothered by any of the following problems?’
9 items which can then be scored 0-3
includes items asking about thoughts of self-harm
depression severity: 0-4 none, 5-9 mild, 10-14 moderate, 15-19 moderately severe, 20-27 severe
Which criteria do NICE suggest to diagnose depression?
DSM-IV
5 of, including 1 and/or 2
1. Depressed mood most of the day, nearly every day*
2. Markedly diminished interest or pleasure in all, or almost all, activities most of the day, nearly every day*
What is quantified (by DSM-IV) as mild depression?
Few, if any, symptoms in excess of the 5 required to make the diagnosis, and symptoms result in only minor functional impairment
What is quantified (by DSM-IV) as moderate depression?
Symptoms or functional impairment are between ‘mild’ and ‘severe’
What is quantified (by DSM-IV) as severe depression?
Most symptoms, and the symptoms markedly interfere with functioning. Can occur with or without psychotic symptoms
How does NICE simplify the classification of depression?
‘less severe’ depression: encompasses what was previously termed subthreshold and mild depression
a PHQ-9 score of < 16
‘more severe’ depression: encompasses what was previously termed moderate and severe depression
a PHQ-9 score of ≥ 16
Treatment options for less severe depression in order of preference as per NICE
guided self-help
group cognitive behavioural therapy (CBT)
group behavioural activation (BA)
individual CBT
individual BA
group exercise
group mindfulness and meditation
interpersonal psychotherapy (IPT)
selective serotonin reuptake inhibitors (SSRIs)
counselling
short-term psychodynamic psychotherapy (STPP)
What does NICE say about managing less severe depression?
NICE lists a large number of interventions that may be used first-line. It encourages us to discuss treatment options with patients to reach a shared decision.
They recommend considering ‘the least intrusive and least resource intensive treatment first’.
It also recommends not routinely offering ‘antidepressant medication as first-line treatment for less severe depression, unless that is the person’s preference’.
Treatment options for mild depression in order of preference as per NICE
a combination of individual cognitive behavioural therapy (CBT) and an antidepressant
individual CBT
individual behavioural activation (BA)
antidepressant medication
selective serotonin reuptake inhibitor (SSRI), or
serotonin-norepinephrine reuptake inhibitor (SNRI), or
another antidepressant if indicated based on previous clinical and treatment history
individual problem-solving
counselling
short-term psychodynamic psychotherapy (STPP)
interpersonal psychotherapy (IPT)
guided self-help
group exercise
Factors suggesting a diagnosis of depression over dementia?
short history, rapid onset
biological symptoms e.g. weight loss, sleep disturbance
patient worried about poor memory
reluctant to take tests, disappointed with results
mini-mental test score: variable
global memory loss (dementia characteristically causes recent memory loss)
Psychiatric differentials for depression
Bipolar disorders
Schizophrenia
Dementia
Seasonal affective disorder
Bereavement
Anxiety
Biological factors which may increase the risk of depression?
Age - teenage years to early 40s
Female sex
Genetics: family history of depression in the nuclear family increases the risk to almost 30-40% and up to 50% in monozygotic twins
Personality: dependent, anxious, impulsivity and obsessional traits
Physical illness: neurological illnesses such as Parkinson’s disease and multiple sclerosis, hypothyroidism or chronic illnesses
Biochemical theories/monoamine deficiency: serotonin imbalance causes depressive symptoms
Neuroendocrine: hypothalamic-pituitary-adrenal axis
Co-morbid substance misuse
Medications: beta-blockers, steroids
History of other mental illnesses: anxiety
Psychological factors which may increase the risk of depression?
Traumatic life events/childhood experiences: adverse experiences including loss of a loved one, lack of parental care and childhood sexual abuse
Environmental factors (e.g. support)
Low self-esteem and negative automated thoughts (e.g. helplessness, hopelessness, worthlessness)
Lack of education
Social factors that increase the risk of depression
Poor social support
Poor economic status or support
Marital status: separated or divorced
Tests to rule out organic differentials of depression
Thyroid function
Full blood count
B12
Metabolic panel
Neuro imaging
When do NICE reccomend ECT for depression?
Severe depressive episodes that are life threatening or require rapid response
Risk assessment in depression?
Risk to self: self-harm, suicide or neglect (commonest in depression)
Risk to others: when depression presents with psychotic features, such as command hallucinations, they may be at risk of harming others
Risk from others: patients with depressive symptoms may be more vulnerable to abuse, criminal acts or neglect
When might medication be offered in mild depression?
Past history of moderate or severe depression
Presence of mild depression that has been present for at least 2 years
Presence of mild depressive symptoms after other interventions
Patient preference
Long term management of moderate-severe depression
Risk assessment
Review their response to high-intensity psychosocial intervention compliance and symptoms
Review their response to antidepressant therapy, compliance, side effects and adjust doses if appropriate
Measurement scales to assess response to treatment and quality of life
Relapse prevention plan
Assess social support and previous issues flagged up during the consultation
Complications of depression
Suicide: the risk of suicide in patients with depression is four times higher than in patients without depression
Substance misuse and alcohol use problems: patients are at increased risk of becoming dependent on substances
Persistent symptoms: 10-20% of patients will have persistent symptoms over 2 years
Recurrence of depressive episodes: most patients have a recurrence in later life
Reduced quality of life: patients may struggle with employment and relationships
Antidepressant side effects: may include sexual dysfunction, risk of self-harm, weight gain, hyponatraemia and agitation
What is bipolar disorder
Mood/affective disorder characterised by episodes o depression and mania or hypomania
Incidence of bipolar
Bimodal distribution peaking around age of onset at 15-24 years and 45-54yeata
Roughly equal distribution of prevalence between men and women
Aetiology of bipolar disorders
Invokes genetic environmental and neurobiological components
Heritable within families but genetics not only determine factor
Bipolar disorder - genetic causes
First-degree relatives of a person affected with bipolar disorder are at increased risk of developing bipolar and unipolar mood disorders and schizoaffective disorder
The genetic risk associated with bipolar disorder is a type of polygenic inheritance (the sum effect of many low-penetrance mutations). Some polymorphisms in genes that code for monoamine transporters and brain-derived neurotrophic factor (BDNF) are associated
Evidence suggests there is an overlap in the genetic risk between bipolar disorder and schizophrenia.3 Genetic contributions may also be associated with copy number variants and gene-gene interactions
Bipolar disorder - environmental causes
Negative life events can precipitate depressive or manic episodes potentially mediated in circadian rhythms disruptions in genetically predisposed individuals
Neurobiological factors in bipolar disorder
There is some evidence that increased dopamine activity in the brain may be important in the aetiology of mania, particularly since many drugs that increase dopaminergic signalling in the central nervous system can be associated with symptoms characteristic of mania such as elevated mood, reduced need for sleep and reduction in social inhibitions
The presentation of psychosis in bipolar disorder suggests there may be region-specific increases in dopaminergic neurotransmission, though not necessarily a global increase in dopamine signalling.
Similar to unipolar depression, there are disturbances of the hypothalamic-pituitary-adrenal axis resulting in increased cortisol secretion. Administration of exogenous corticosteroids can also result in symptoms of mania
Risk factors for bipolar disorder
Genetic factors: combined effect of many single nucleotide polymorphisms (SNPs)
Prenatal exposure to Toxoplasma gondii (the parasite that causes toxoplasmosis)
Premature birth <32 weeks gestation
Childhood maltreatment
Postpartum period
Cannabis use
What is cyclothymia
A disorder of persistent instability of mood involving numerous periods of depression and mild elation, none of which are sufficiently severe or prolonged to justify a diagnosis of bipolar affective disorder or recurrent depressive disorder
Early onset
Chronic course
Common in relatives of BPD
Bipolar I vs Bipolar II
In bipolar I, the person has experienced at least one episode of mania
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.
What features is mania characterised by in the ICD-10
Elevated mood out of keeping with the patient’s circumstances
Elation accompanied by increased energy resulting in overactivity, pressure of speech, and a decreased need for sleep
Inability to maintain attention, often with marked distractibility
Self-esteem which is often inflated with grandiosity and increased confidence
Loss of normal social inhibitions
Mania diagnosis
For a diagnosis, the manic episode should last for at least seven days and have a significant negative functional effect on work and social activities. Mood changes should be accompanied by an increase in energy and several of the other symptoms mentioned in the ICD-10
What are the characteristic clinical features of mania
Elevated mood
Increased activity level
Grandiose ideas of self importance
Psychotic symptoms in bipolar disorder
Mania can also occur alongside psychotic symptoms such as delusions and hallucinations, which are often auditory.8
Psychotic symptoms are mood-congruent in bipolar disorder, so therefore grandiose in nature. Flight of ideas and thought disorder may also be present.
What is hypomania
Hypomania is less severe than mania and is characterised by an elevation of mood to a lesser extent than that seen in mania.
Although hypomania does involve some extent of functional impairment, this is lesser than that seen in mania and is not severe enough to cause the more marked impairment in occupational or social activities
ICD-10 hypomania episode characteristics
Persistent, mild elevation of mood
Increased energy and activity, usually with marked feelings of wellbeing
Increased sociability, talkativeness, over-familiarly, increased sexual energy and a decreased need for sleep (but not to the extent that there is a significant negative effect on functioning regarding work or social activities)
Irritability may be present
Absence of psychotic features (delusions or hallucinations)
For a diagnosis, more than one of these features should be present for at least several days.
Bipolar disorder differential diagnoses
Schizophrenia (both can have delusions and hallucinations)
Organic brain disorder (frontal lobe pathologies)
Drug use (psychotropic drugs, steroids can cause elation)
Recurrent depression
BPD (affective instability can present similarly to rapid cycling bipolar disorder)
Cyclothymia (chronic mood disturbance with both depressive and hypomania periods)
Bipolar vs schizophrenia
Delusions and hallucinations can occur in both bipolar disorder and schizophrenia.
In bipolar disorder, these are mood congruent and so tend to be grandiose
In schizophrenia, they tend to be more bizarre and difficult to understand.
Where features of schizophrenia and bipolar disorder are present in a roughly equal proportion, the diagnosis of schizoaffective disorder should be considered
BPD/EUPD vs bipolar disorder
BPD is characterised by affective instability which can present similarly to rapid cycling bipolar disorder.
However, mood changes tend to occur more quickly in BPD/EUPD. Other features of mania such as grandiose ideas and a marked increase in energy are generally not seen in EUPD
What is a mixed affective state
Mixture of both manic, hypomania and depressive features
Changing between states multiple times a day
What evidence should lead to a consideration of bipolar disorder?
Mania: symptoms should have lasted for at least seven days
Hypomania: symptoms should have lasted for at least four days
Depression (characterised by low mood, loss of interest or pleasure, and low energy) with a history of manic or hypomanic episodes
Acute management of mania
In an acute episode of mania, people with a new diagnosis of bipolar disorder should be managed in secondary care with a trial of oral antipsychotics:11
Haloperidol
Olanzapine
Quetiapine
Risperidone
If the patient is on antidepressant medication, this should be tapered off and discontinued. Benzodiazepines may be used as an adjunct to manage symptoms of increased activity and allow for better sleep
Acute management of depression in bipolar disorder?
The recommended pharmacological options for managing depressive episodes in the context of bipolar disorder are:
Fluoxetine + olanzapine
Quetiapine alone
Olanzapine alone
Lamotrigine alone
As well as these pharmacological options, psychological interventions such as cognitive behaviour therapy (CBT) may also be useful.11
Long term management of bipolar disorder
Mood stabilisation with lithium
If not effective can use sodium valproate (if pt not woman of child bearing age (unless pregnancy prevention plan))
Structures psychotherapies such as CBT or family focused therapies
Effect of lithium in bipolar disorder
Significant reduction in risk of relapse with a manic episode
Significant reduction in death by sucked
Around half of patients will show a good response to lithium, although those with rapid-cycling bipolar disorder, mixed affective states or mood-incongruent features of psychosis may be less likely to respond well
Complications of bipolar disorder
Increased risk of death by suicide
Increased risk of death by general medical conditions such as cardiovascular disease
Side effects of antipsychotic drugs: these can include metabolic effects, weight gain and extrapyramidal symptoms
Socioeconomic effects: major mental illness is associated with a negative drift down the socioeconomic ladder
Hypomania vs mania
Common to both:
mood - predominantly elevated, irritable
speech and thought - pressured, flight of ideas, poor attention
Features such as the length of symptoms, severity and presence of psychotic symptoms (e.g. delusions of grandeur, auditory hallucinations) helps differentiates mania from hypomania
behaviour - insomnia, loss of inhibitions, increased appetites
What is flight of ideas
C haracterised by rapid speech with frequent changes in topic based on associations, distractions or word play
Physical comorbidities in bipolar disorder
2-3 times increased risk of diabetes, cardiovascular disease and COPD
Primary care referral: mania vs hypomania
if symptoms suggest hypomania then NICE recommend routine referral to the community mental health team (CMHT)
if there are features of mania or severe depression then an urgent referral to the CMHT should be made
Depressive episodes in bipolar
The DSM states that a major depressive episode must have at least four of the following symptoms,
They should be new or suddenly worse, and must last for at least two weeks:
Changes in appetite or weight, sleep, or psychomotor activity
Decreased energy
Feelings of worthlessness or guilt
Trouble thinking, concentrating, or making decisions
Thoughts of death or suicidal plans or attempts
What are the stages of grief?
Denial: this may include a feeling of numbness and also pseudohallucinations of the deceased, both auditory and visual. Occasionally people may focus on physical objects that remind them of their loved one or even prepare meals for them
Anger: this is commonly directed against other family members and medical professionals
Bargaining
Depression
Acceptance
It should be noted that many patients will not go through all 5 stages.
What might increase the risk of an atypical grief reaction?
Abnormal, or atypical, grief reactions are more likely to occur in women and if the death is sudden and unexpected.
Other risk factors include a problematic relationship before death or if the patient has not much social support.
Features of an atypical grief reaction
delayed grief: sometimes said to occur when more than 2 weeks passes before grieving begins
prolonged grief: difficult to define. Normal grief reactions may take up to and beyond 12 months
What is SAD
Seasonal affective disorder (SAD) describes depression which occurs predominately around the winter months.
Management of SAD
SAD should be treated the same way as depression, therefore as per the NICE guidelines for mild depression, you would begin with psychological therapies and follow up with the patient in 2 weeks to ensure that there has been no deterioration.
Following this an SSRI can be given if needed. In seasonal affective disorder, you should not give the patient sleeping tablets as this can make the symptoms worse.
Finally, the evidence for light therapy is limited and as such it is not routinely recommended.
What is the DSM-V definition of insomina?
In the DSM-V, insomnia is defined as difficulty initiating or maintaining sleep, or early-morning awakening that leads to dissatisfaction with sleep quantity or quality. This is despite adequate time and opportunity for sleep and results in impaired daytime functioning.
How do patients present with insomina?
Patients typically present with decreased daytime functioning, decreased periods of sleep (delayed sleep onset or awakening in the night) or increased accidents due to poor concentration. Often the partner’s rest will also suffer.
Risk factors for insomnia
Associated with:
Female gender
Increased age
Lower educational attainment
Unemployment
Economic inactivity
Widowed, divorced, or separated status
Other risk factors:
Alcohol and substance abuse
Stimulant usage
Medications such as corticosteroids
Poor sleep hygiene
Chronic pain
Chronic illness: patients with illnesses such as diabetes, CAD, hypertension, heart failure, BPH and COPD have a higher prevalence of insomnia than the general population.
Psychiatric illness: anxiety and depression are highly correlated with insomnia. People with manic episodes or PTSD will also complain of extended periods of sleeplessness.
Less common diagnostic factors associated with insomnia
Daytime napping
Enlarged tonsils or tongue
Micrognathia (small jaw) and retrognathia
Lateral narrowing of oropharynx
Investigating insomnia?
Diagnosis is primarily made through patient interview, looking for the presence of risk factors
.
Sleep diaries and actigraphy may aid diagnosis. Actigraphy is a non-invasive method for monitoring motor activity.
Polysomnography is not routinely indicated. It may be considered in patients with suspected obstructive sleep apnoea or periodic limb movement disorder, or when insomnia is poorly responsive to conventional treatment.
Short-term management of insomnia
Identify any potential causes e.g. mental/ physical health issues or poor sleep hygiene.
Advise the person not to drive while sleepy
Advise good sleep hygiene: no screens before bed, limited caffeine intake, fixed bed times etc.
ONLY consider use of hypnotics if daytime impairment is severe.
Potential pharmacological options to manage insomnia
The hypnotics recommended for treating insomnia are short-acting benzodiazepines or non-benzodiazepines (zopiclone, zolpidem and zaleplon).
Diazepam is not recommended but can be useful if the insomnia is linked to daytime anxiety.
Use the lowest effective dose for the shortest period possible.
If there has been no response to the first hypnotic, do not prescribe another. You should make the patient aware that repeat prescriptions are not usually given.
It is important to review after 2 weeks and consider referral for cognitive behavioural therapy (CBT).
Other sedative drugs (such as antidepressants, antihistamines, choral hydrate, clomethiazole and barbiturates) are not recommended for managing insomnia.
What is stupor?
Patients are unable to speak or move but remain fully conscious. A severe form of depressive retardation
What are cyclothymia and dysthymia examples of
Recurrent mood disorders
What is Anhedonia
Reduced ability to experience pleasure - i.e. enjoyment of things they would have previously enjoyed
Possible sleep disturbance complaint
Poor sleep pattern - daytime napping, sleeping in late
Trouble falling asleep
Trouble staying asleep
Early morning wakening
Mild depression
2 core symptoms + 2 additional symptoms
Able to function
Moderate depression
2 core symptoms +3/4 others
Still functional but struggling to function
Severe depression
3 core + at least 4 other symptoms
Psychotic features of psychotic depression
Hallucinations
Delusions: Hypochondriacal/ Guilt/ Nihilistic/ Persecutory
What thought content might occur in post natal depression
Worries about the baby’s health or ability to cope with the baby
Features of hypomania
Mildly elevated, expansive or irritable mood
Increased energy/activity
Increased self esteem
Sociability, talkativeness, over familiarity
Increased sex five
Reduced need for sleep
Difficulty focusing on and completing tasks
Features of mania
Elevated/expansive/irritable mood for at least 1 week
Increased energy/activity
Grandiosity/increased self esteem
Pressure of speech
Flight of ideas/racing thoughts
Distractible
Reduced need for sleep
Increased libido
Social inhibitions lost
Psychotic symptoms (grandiose delusions or hallucinations)
Mania early warning sign in known bipolar disorder
Reduced need for sleep
What is dysthymia
Chronic low mood not fulfilling the criteria of depression
Causes of mood disorders
Genetic
Physical illnesses
Childhood experiences
Personality traits
Work, housing finance, relationships, support
International Classification of Diseases 10th edition (ICD-10) criteria: differences from DSM-IV in diagnosis of bipolar
International Classification of Diseases 10th edition (ICD-10) criteria: differences from DSM-IV
ICD-10 does not discriminate between bipolar disorder types I and II
ICD-10 requires two discrete mood episodes, at least one of which must be manic, for a bipolar disorder diagnosis. In DSM-IV, one episode of mania (or mixed mood), or one episode of hypomania plus a major depressive episode, suffice for a BD diagnosis
Severe depression can mimic dementia but differs how
Severe depression can mimic dementia but gives a pattern of global memory loss rather than short-term memory loss - this is called pseudodementia
What is an affective disorder
disorders in which the fundamental disturbance is a change in affect or mood to depression (with or without associated anxiety) or to elation. The mood change is usually accompanied by a change in the overall level of activity; most of the other symptoms are either secondary to, or easily understood in the context of, the change in mood and activity. Most of these disorders tend to be recurrent and the onset of individual episodes can often be related to stressful events or situations.
