Affective disorders Flashcards
Aetiology depression (molecular)
Decreased availability of monoamine neurotransmitters plus hypercortisolaemia in severe –> Decrease in BDNF (brain derived neurotrophic factor) which promotes neurogenesis.
Dysfunctional limbic system and related areas
What are the monoamine neurotransmitters?
Noradrenaline and serotonin
Risk factors for depression
Genetics/gene - environment interaction
PMH treatment with interferons (cytokines)
Physical illness
Medications e.g. steroids, isotretinoin
Female
LT alcohol or drugs
History of abuse, childhood stress, parental loss
Poor resilience/catastrophising
Recent adverse life events (housing, financial, employment, relationships etc)
three cardinal signs of depression
Low mood
Anhedonia
Anergia (low energy)
Diagnostic criteria for depression (ICD-10)
2 or more of the three main symptoms for 2w or more
What are the three affective disorders?
Bipolar
Mania
Depression
ICD-10 criteria for mild/mod/severe depression?
Mild: 2 core and 2 other
Moderate: 2 core and 3 other
Severe: 3 core and 4 other
But also depends on freq and number of sx, degree of distress and interference with ADLs
What other sx do you get in depression?
Decreased: concentration, self esteem, sleep, appetite
guilt, wortheless
Hopeless
Self-harm
Psychomotor retardation or agitation
How might an older person’s profile of sx differ in depression?
More biological sx than mood
What three things do depressed people have depressed thoughts about? What is this known as?
Self
World
Future
Beck’s cognitive triad
What diurnal variation might you get in depression?
Mood worse in am
Depressive retardation may be similar to
Flat affect chronic schizophrenia
Differentials for depression
Normal sadness
Schizophrenia (for psychotic depression)
Alcohol/drug withdrawal
Management of depression
Mostly primary care
Treat co-morbs and substance misuse in all
Self help, exercise, computer CBT
CBT/interpersonal therapy
Mod/severe: psych therapy and antidepressant
Could augment the antidepressant
Severe: ECT
What would indicate psych referral in depression?
Severe, unresponsive, bipolar, recurrent, high suicide risk
How long does depression normally last?
3-8m
20% >2y
What percent of depression recurs? What about if it was severe?
50% (80% severe)
Do recurrent episodes of depression tend to be similar?
no get worse so prophylaxis is good
Lifetime suicide risk in severe depression
15%
Severe depression is associated with _____ disease
Cardiac
what is hypomania?
Less severe mania, no psychosis
ICD-10 criteria for bipolar diagnosis?
At least 2 episodes, including at least one hypomanic/manic
Onset of bipolar age?
Early 20s
How genetic is bipolar?
at least 60% inherited
What is the neurophysiological basis for bipolar?
Abnormal hypothalamic pituitary adrenal axis
MRI- smaller prefrontal lobes, enlarged amygdala and globus pallidus.
Hypothyroid involved in 25% rapid cycling
What, earlier in life, can lead to abnormal hypothalamic pituitary adrenal axis dysfunction (in bipolar)
prolonged psychosocial stressors in childhood
Two things that might induce mania in bipolar?
Post-partum
Sleep deprivation
How does mania present?
Elated mood
Irritable
Psychomotor agitation
Decreased need for sleep
High self esteem
Disinhibited
Pressured speech, flight of ideas
Mood-congruent delusions and hallucinations, usually auditory
What is rapid cycling bipolar defined as?
at least 4 episodes per year
Do people with bipolar have insight?
Often no
Median duration of manic episode in bipolar?
4m
Median duration of depressive episode in bipolar?
6m
Differentials in a manic episode?
Substance abuse e.g. cocaine
Due to endocrine/epilepsy/medication
Schizophrenia/schizoaffective disorder
Personality disorder
ADHD (although high mood is rare)
Most effective LT treatment for bipolar?
Lithium
How would you start someone on lithium for biploar including monitoring
125mg-1g PO BD
Check U&Es, ECG, TFTs
Adjust dose until plasma level 0.6-1 mmol/L
First check on day 4-7. 12h after they’ve taken it.
Check weekly until they are stable for 4w, then monthly for 6m then 3 monthly
Check TFT and U&E at 6m
Warn signs toxicity
progressively increasing lithium levels could indicate what
nephrotoxicity
SEs lithium
Hypothyroid
nephrogenic diabetes insipidus
toxicity
What are the signs of lithium toxicity
Worsening vision
D&V
Hypokalaemia
Ataxia
Tremor
Dysarthria
Coma
Can you stop lithium cold turkey?
No taper over 2-4w or else it will induce mania in 50%
Second line treatment for bipolar?
Anticonvulsants: semisodium valproate (±lithium) or olanzapine or quetiapine
Can you prescribe an antidepressant in bipolar?
Must also have a mood stabiliser. Stop the AD at onset of acute manic episode
How would you treat episodes of mod/severe depression in bipolar?
Quetiapine, olanzapine, lamotrigine
Olanzapine and fluoxetine combination
Prognosis for a single manic episode?
90% have manic/depressive recurrence. Frequency and severity tend to increase for 4/5 episodes then plateau.
Bipolar increases risk of what
Premature mortality, only partially explained by suicide rate of 10%
What is cyclothymia?
Chronic mood fluctuation over 2y of depression and hypomania but not severe enough to be diagnosed)
30% will develop full bipolar
What is mood like in mania
Irritable
Euphoric
Labile
What is cognition like in mania?
Grandiose, flight of ideas, low concentration, confused, lack insight
What is behaviour like in mania?
Rapid speech
hyperactive
reduced sleep
hypersexuality
extravagance
Psychotic symptoms in mania?
Delusions and hallucinations
Causes of mania
Bipolar
Physical- infection, hyperthyroid, SLE, TTP, stroke, hyponatraemia, ECT
Drugs- amphetamines, cocaine, antidepressants, catopril, steroids, procyclidine, L-dopa, baclofen
Which antidepressant especially increases risk of mania?
Venlafaxine
Management of first presentation of mania?
Ask about infection, drug use, FHx psch
CT head, EEG, drug screen
Treatment for mod/severe mania
Olanzapine 10mg PO or semisodium valproate
SEs olanzapine
Weight gain and glucose desensitivity.
Symptoms of mania in primary care management?
Urgent referral to CMHT
