Affective Disorders Flashcards
What is a Mood Disorder?
Disorders of mental status and function where altered mood is the (or a) core feature
Mania - a term referring to states of depression and of elevated mood
The commonest group of mental disorders
Recognition and management forms a large component of activities for GPs, psychiatrists and clinical psychologists
How do we diagnose affective disorders ?
All by history and Mental State Examination (MSE)
What are the 2 systems used to diagnose affective disorders?
ICD-11 (European) and DSM-5 (American)
How are mood disorders described?
On a spectrum with Euthymia (normal mood) in the middle
Disorders include;
- Cyclothymia
- Recurrent Depressive Disorder
- Depressive Disorder
- Bipolar Affective Disorder
What is Depression?
Depression is both a Symptom and Syndrome
Symptom - An emotion within the range of NORMAL experience
- Describes a state of feeling, or mood, that can range from normal experience to severe, life-threatening illness
- Typically considered as a form of sadness, not just an absence of happiness
Syndrome - A constellation of symptoms and signs
- Single episode/ Recurrent illness
- A leading cause of disability worldwide
- A common condition
When does Depression become abnormal?
Psychiatry places emphasis on;
1. Persistence of symptoms
2. Pervasiveness of symptoms
3. Degree of impairment
4. Presence of specific symptoms or signs
What is the ICD-11 Criteria for Depression?
- Low mood or reduced interest/pleasure (ANHEDONIA)
- Most of the day, nearly every day
- Last for at least 2 weeks
What is Anhedonia?
Reduced interest/pleasure
What are the symptoms of Depression according to ICD-11?
S - Sleep problems
P - Psychomotor retardation or agitation
I - Interest deficit (ANHEDONIA)
C - Concentration deficit
E - Energy deficit, fatigue, motivation
G - Guilt, worthlessness* , hopelessness* , regret
A - Appetite disorder either increased or decreased
S - Suicidality
- P - Psychomotor retardation or agitation - In more severe end, first thoughts go, then movements and get catatonia, psychomotor agitation
What are the 4 final requirements for a Depression diagnosis?
- Significant functional impairment
- No hypomanic or manic episodes in lifetime
- Not attributable to psychoactive substance
use or organic mental disorder - If psychotic symptoms then likely severe
depression with psychotic symptoms (but can
be moderate)
What are the features of Mild Depression ?
Mild Depression - ICD-11;
- The individual is usually distressed by the
symptoms to a mild extent
- Some difficulty in continuing to function in one or more domains (personal, family, social,
educational, occupational)
- There are no delusions or hallucinations during
the episode.
- Usually managed at the GP level
What are the features of Moderate Depression ?
Moderate Depression - ICD-11;
- Several symptoms of a depressive episode are
present to a marked degree
- Or a large number of depressive symptoms of lesser
severity are present overall
- The individual typically has CONSIDERABLE difficulty
functioning in MULTIPLE domains (personal, family,
social, educational, occupational, or other important
domains).
- Usually managed in a psychiatric outpatient clinic
What are the features of Severe Depression ?
Severe Depression - ICD-11;
- Many or most symptoms of a Depressive episode are present to a MARKED degree
- Or a smaller number of symptoms are present and manifest to an INTENSE degree
* The individual has serious difficulty continuing to function in MOST domains (personal, family, social, educational,
occupational, or other important domains).
* With/without psychosis
* Often requires inpatient admission
Suicide ideation, psychomotor retardation
Does asking someone about suede make them more likely to become suicidal ?
NO
How is suicidality viewed/measured?
On a scale from Low - Imminent suicide risk
No suicide Ideation - Normal focus on end of life issues due to advanced age or severe medical illness
- May have occasional thoughts about own morality
- Does NOT feel that they would be better off dead
Management - Periodic Screening
Passive Suicide Ideation - Thoughts that life is not worth living that would be better off dead (“I pray god takes me soon”)
- Has not thought about harming self
Management - Requires further evaluation
Active Suicide Ideation - Has considered a method to self harm (e.g “I’ve thought about taking all my pills but I would never do it”)
- Does not report a specific detailed plan or current intention to harm self
- Demonstrates reasons for living and good impulsive control
Management - Requires immediate evaluation
Detailed Suicide Plan or Intent - Has a specific detailed plan and/or current intention to harm self (e.g “I’m planning to take all my pain medication tomorrow morning”) or does not have good reasons for living or good impulsive control (e.g “I may not be able to stop myself from doing this”)
Management - Requires immediate ER evaluation
What are the features of Post-Natal Depression?
- 10-15% women having babies
- Often within a month or two of giving birth
- Can start several months postpartum
- A third of cases begin in pregnancy and persist
- Increased risk of psychiatric admission in the 30 days following childbirth
- 75% of women experience ‘blues’ within 2 weeks
- ‘Puerperal psychosis’ - 1 in 1000 deliveries with a risk of recurrence with subsequent deliveries
- No association with hormonal changes has ever been demonstrated but research ongoing
What are the differential diagnosis’ to Depression ?
- Normal reaction to life event
- Seasonal Affective Disorder (SAD)
- Dysthymia (Chronic unhappiness - not fully fitting mild depression criteria)
- Cyclothymia (a mental state characterised by marked swings of mood between depression and elation, not as extreme as bipolar but similar)
- Bipolar
- Stroke, tumour, dementia
- Hypothyroidism, Addison’s, Hyperparathyroidism
- Infections — Influenza, infectious mononucleosis, hepatitis, HIV/AIDS
- Drugs
What are the treatments for Depression?
Antidepressants;
- Selective Serotonin Reuptake Inhibitors (SSRls)
- Serotonin and norepinephrine reuptake inhibitors (SNRls) (Venlafaxine and Duloxetine)
- Tricyclic antidepressants (TCAs) (Amitriptyline) (CVS risk and arrhythmia, intestinal mobility reduction, reduce secretions)
- Monamine Oxidase Inhibitors (MAOIs) (Lots of interactions and with foods like cheese, venison, alcohol)
- Other antidepressants (eg Mirtazapine)
Antipsychotics
Mood stabilisers
- Lithium
Psychological Treatments;
- CBT, IPT, Individual dynamic psychotherapy
Physical Treatments — severe or treatment resistant;
- ECT, TMS, Psychosurgery, ketamine
How do we measure Depression? (Common Exam Question!)
Common Exam Question!
Measurement Tools;
- SCID (Structured Clinical Interview for DSM disorders)
- SCAN (Schedules for Clinical Assessment in
Neuropsychiatry)
Key ones!:
- HDRS (Hamilton Depression Rating Scale)
- BDI-II (Beck Depression Inventory Il)
HADS (Hospital Anxiety and Depression Scale)
PHQ-9 (Patient Health Questionnaire 9)
What is Mania?
A manic episode is an extreme mood state lasting at least one week unless shortened by a treatment intervention
Symptoms;
- euphoria, irritability, increased activity, increased energy
- rapid or pressured speech, flight of ideas, increased self-esteem or grandiosity, decreased need for sleep, distractibility, impulsive or
reckless behaviour, and rapid changes among different mood states (i.e., mood lability).
- Delusions of grandeur /religious delusions can be present
- Hypomania indicates a less severe episode with minimal functional impairment, no hospitalisation, no psychosis
What is the Mnemonic for the Mania Symptoms?
Mania
- D - Distractibility (thought disorder)
- I - Impulsivity Poor judgment, spending sprees, reckless driving (DVLA chat)
- G - Grandiosity - Increased self-esteem
- F - Flight of ideas - Racing thoughts
- A - Activities - Psychomotor agitation
- S Sleep - Decreased need
- T - Talkativeness - Pressured speech
Always ask bipolar patients about how they are sleeping, starts all off (1 hour less here and there)
What is a mixed affective state?
A mixed episode is characterised by the presence of several prominent manic and several prominent depressive symptoms,
which either occur simultaneously or alternate very rapidly (from day to day or within the same day).
Symptoms are present most of the day, nearly every day, during a period of at least 2 weeks, unless shortened by a treatment intervention.
Disinhibition can be very dangerous here, do things out of control
What are the ICD-11 classifications of mood disorders?
- Bipolar Type 1
- Bipolar Type 2
- Cyclothymic Disorder
- Substance Induced Mood Disorder
- Secondary Mood Disorder
What is the ICD-11 criteria for Bipolar Type 1 ?
Bipolar 1;
At least one Manic or Mixed Episode
- With/without psychosis
Typical course of the disorder is characterised by recurrent Depressive and Manic or Mixed Episodes
Although some episodes may be Hypomanic, there must be a history of at least one Manic or Mixed Episode.
*(Range of depressed and manic episodes)
What is the ICD-11 criteria for Bipolar Type 2 ?
Bipolar 2;
* One or more hypomanic episodes
* At least one depressive episode
* No hx manic/mixed episodes
*(Full depressed episodes but hypomanic, never getting into full mania and loosing control)
What is the ICD-11 criteria for Cyclothymic Disorder ?
- Persistent instability of mood over a period of at least 2 years
- Numerous periods of hypomania
- Depressive (e.g., feeling down, diminished interest in activities, fatigue) symptoms that are present during more of the time than not
- The depressive symptomatology has never been sufficiently severe or prolonged to meet the diagnostic requirements for a depressive episode
*(Mild depression to hypomania but not further)
What is Psychosis?
Usually mood congruent
Paranoia and persecutory experiences more suggestive of schizophrenia and schizoaffective disorder
What are the features of Psychosis in Depression and Mania?
Depression Psychosis;
- Body is rotting / Dying (Cotards)
- Delusions of guilt - Stole something and police are going to arrest them
- Voices telling them to hurt
themselves
- Voices of family members saying horrible things
Mania Psychosis;
- Religious (I am god/Jesus, Hearing voice these individuals, Special purpose)
- Grandiose (I am the king of Scotland, l am rich)
- De clerambault syndrome (delusions someone is in love with them - usually a celebrity e.g Lana Del Ray)
Give a summary of the different Affective Mood Disorders and how they fluctuate?
See image
What are the differential diagnoses for Mania?
Psychiatric;
- Schizoaffective disorder
- Schizophrenia
- ADHD
- Drugs and Alcohol
Medical;
- Stroke, MS, Tumour, epilepsy, AIDS, Neurosyphilis
Endocrine — Cushing’s, hyperthyroidism
SLE
What tools do we use to assess Mania?
- SCID
- SCAN
- YMRS (Young Mania Rating Scale)
What are the treatments for Mania?
Benzodiazepines (Sedative to help manic person get sleep and rest for a bit)
Antipsychotics
- Olanzapine (Commonly used in Bipolar)
- Risperidone
- Quetiapine (Commonly used in Bipolar)
Mood Stabilisers
- Sodium Valproate (More complicated in using in males due to fertility concerns, teratogenic in females)
- Lithium (Lots of evidence for preventing suicidal attempts, in water in some countries)
- Carbemazepine (Interacts with basically everything which is hard)
Electroconvulsive Therapy (ECT) - used less in mania but in depression
How common is Bipolar Disorder?
Epidemiology of Bipolar Disorder;
- early onset (15-19) usually
with positive FH
- no differential prevalence
according to income,
occupation or educational
status
- prevalence consistently
increased in 1st degree relatives
- other forms of depression
also more common
*Genetic link more common in families, in 20’s and 2nd peak in 40’s
- lifetime prevalence rate (n per 100) : 0.7 - 1.6
- industrialised nations = non-industrialised
- rates for males = rates for females
- mean age of onset = 21 (unusual >30)
- some studies - 1/3 onset < 20
How common is Depression?
Epidemiology of Depression;
- No overall association with socioeconomic
status
- Less common in those employed
- Less common in those financially independent
(N.B. - direction of effect)
- Association with lower educational attainment
- Stable marriage negatively associated
- Increased risk in 1st degree relatives where proband has Major Depressive Disorder (x3) or Bipolar (x2)
- Twin studies: Monozygotes 27% vs Dizygotic 12%
- Onset of depression (first episode) associated
with excess of adverse life events - ‘Exit events’ - separations, losses
- lifetime prevalence rate (n per 100): 2.9 - 12
- point prevalence rate of depression: 3.7 - 7.7
- lifetime risk for less severe manifestations - 20
- rates for females exceed rates for males - 2:1
- highest risk from age 18-44 (median 25)
- mean age of onset = 27
- onset during old age is not unusual
*2nd peak at 40. If late onset need to be sure isn’t a tumour or something sinister
What medications is there for Bipolar?
Bipolar isn’t a condition we can give 1 medication for, it fluctuates, medication decreases fluctuations but always will be there. Drugs increase fluctuations.
What is the trend for Major Depression?
- Typical episode lasts 4-6 months
- 54% recovered at 26 weeks
- 12% fail to recover
- 80+% have further episodes
- 15% die by suicide
*Medication compliance reduces suicide
What is the trend for Bipolar Disorder/Mania?
- Typical manic episode lasts 1-3
months - 60% recovered at 10 weeks
- 5% fail to recover
- 90% have further episodes
- 1/3 have poor outcome
- 1/3-1/4 have good outcome
- 10% die by suicide
*Medication compliance reduces suicide
