Affective/Mood disorders Flashcards
Affective disorders general
Main feature is excessively high or low mood
Run a relapsing and remitting course
Unipolar or bipolar
Aetiology
Genetics - runs in fams, combo of genes, some specific e.g. serotonin transporter gene
Childhood and life experiences - adverse experiences via impact on confidence/trust/self-esteem (abuse, criticism, parent loss). adult vulnerabiliity factors impact resilience (unemploy, relationship, socio-econ, soc isolation)
Life events - Holmes-Rahe Social Adjustment scale - deaths, divorce, jail, physical illness. Postnatal, sleep depr, across time zones can triggermanic eps.
Physical causes - chronic pain, illnesses that directly cause, drugs (b-blockers, antiHTN, cocaine)
Physical illnesses that directly cause depression
Cushings syndrome
Hypothyroidism
Parkinson’s disease
Physical disorders that can cause mania
Cushings syndrome Head injury MS Steroids Antidepressants Stimulants
Theories of affective disorders
Behavioural and cognitive - Beck’s model: Bases of CBT; early adverse events+negative thought of self/world+life events -> cognitive distortions/negative thoughts - cycle of negative thoughts, low mood (guilty,discouraged,inadequate) and reduced behaviour (less active, avoid ppl/situations)
Psychoanalytical - Early experience, quality of early relationships determines risk of later depression
Neurochemical - Monoamine hypothesis: depression from deficiency in NTs - NA (mood, energy), Serotonin (sleep, appetite, memory, mood), Dopamine (psychomotor activity). Drugs that deplete -> depression., low NT metabolites in CSF suicide, drugs that increase monamine levels can precipitate mania, antipsychotics can treat mania
Endocrine abnormalities - cortisol maybe links stressful life events and depression ?damage to hippocampal neurones
Depression symptoms
Clinically low in mood with physical+psychological associated Sx which distort thinking and reduce motivation
> 2 weeks
Core:
- Anhedonia - loss of pleasure in activities they previously enjoyed
- Anergia - tired all the time
- Low mood - Pervasively low, irritability, anxiety, tearfulness
Others:
- Cognitive Sx - low confidence, low self esteem, ideas of guilt and unworthiness, bleak/pessimistic view of future, poor concentration and memory, self harm/suicide ideation
- Biological Sx - disturbed sleep, diminished appetite/sex drive, physical Sx (constipation, aches/pains, dysmenorrhoea)
Psychotic: in SEVERE; unpleasant derogatory audio halluc; destruction/evil spirit visual halluc.; nihilistic/persecutaory delusions
Classification of depression
Mild - 2 core + 2 others.
Moderate - 2 core, 5-6 total Sx
Severe - 3 core, 7 total OR psychotic OR self-harm/self-neglect/suicidal. Marked functional impairment.
Differentials for depression
Organic causes
- hypothyroid
- hyperCa
- Cushings
- Addisons
- Head injury
- Cancer
- Chronic disease
Adjustment disorder - unpleasant but mild; following life event
Normal sadness/bereavement
BPAD/schizoaffective disorder/schizophrenia
Substance misuse - Alcohol/drugs as cause of depression or form of self-medication
Postnatal depression
Dementia
Subtypes of depression
SAD - low mood in winter; usually biological Sx of sleeping and eating
Atypical depression -
Agitated depression - with psychomotor agitation (instead o retardation) i.e. restlessness, pacing, hand-wringing
Depressive stupor - Psychomotor retardation so severe that the person grinds to a halt. Becomes mute, stops eating/drinking/moving
Ix for depression
Collateral Hx
Physical exam
Bloods - TFTs, FBC (anaemia->fatigue?), HbA1c (diabetes->fatigue?), Vit D, B12, Ca
Rating scale to measure/monitor severity/Tx response
CT/MRI - not routine, but can rule out suspected cerebral pathology
NICE management of depression: first step
Step 1:
- Thorough assessment
- Support
- Psychoeducation: advice on sleep hygiene, physical exercise
- Active monitoring - further assessment WITHIN 2 WEEKS!!
NICE management of depression: For subthreshold Sx/mild-moderate depression
Step 2: For subthreshold Sx/mild-moderate depression
- Low intensity psychosocial intervention - self/e- guided CBT principles, structure d group physical activity, 6-8 sessions
- Psychological interventions
- Medication not routinely used in subthreshold/mild/moderate
- Active monitoring - further assess in 2 weeks
NICE management of depression: For subthreshold/mild-moderate with inadequate response to initial Tx OR moderate/severe depression
Step 3: For above with inadequate response to initial Tx OR moderate/severe depression
- Persistent subthreshold/mild-mod: SSRI OR psych intervention
- Moderate-severe: SSRI (First-line usually sertraline) AND psych intervention
- High-intensity psychological interventions: CBT, interpersonal therapy, behavioural activation, behavioural couples therapy; 16-20 sessions over 3-4 months
- Combined treatments and collaborative care
NICE management of depression: For severe and complex depression; risk to life; severe self-neglect
Step 4: Severe and complex depression; risk to life; severe self-neglect
- Medication
- High intensity psychological interventions
- Crisis service - crisis resolution and home treatment teams
- Crisis plan to identify triggers and manage
- Combines Tx
- Multi-professional and inpatient care
- Consider ECT for acute Tx for severe depression and when a rapid response is required
Biopsychosocial approach to depression
Biological: Anti-depressants
Psychological: CBT, psychodynamic psychotherapy, interpersonal therapy,
Social: Housing, substance misuse/support groups
ECT indications, effects, side effects and contraindications
Electroconvulsive therapy indications: treatment resistant depression, catatonic schizophrenia and severe mania
Electrodes to produce generalised tonic-clonic seizure while the pt is anaesthetised. Can be fast, life-saving Tx in severe or psychotic depression e.g. stopped eating/drinking
Short term SI: headache, nausea, memory impairment/loss, arrhythmias; may get long term memory issue
If on antidepressant - reduce safely to minimum dose
Absolute contraindications: phaeochromocytoma, raised ICP
Relative: recent MI/stroke, raised ICP/SOL, arterial HTN, narcotic intolerance, acte glaucome, cerebral aneurysm/angioma
Pregnancy/pacemaker ok
What is discontinuation syndrome, Sx, onset, how to prevent
Occurs following discontinuation of an antidepressant
Sx: flu-like, sleep trouble, N&V, diarrhoea, abdo cramping, poor balance, anxiety, dizziness, electric shock sensations in the hands and legs
Begin within 3 days and can last months
Prevent by tapering drug over 4 weeks
What is serotonin syndrome, triggers, symptoms and management
Uncommon, but potentially serious high levels of synaptic serotonin
Triggered usually by use of 2+ serotonergic drugs. Others: St John’s wort, opioids, amphetamins, MDMA
MAOi associated with severe serotonin syndrome
Sx: confusion, agitation, shivering, D&V, hyperthermia, HTN, tremor, rigidity, hyperreflexia, + Babinski, clonus,
Severe: seizures, arrhythmia, unconsciousness
Management: Stop seratonergic drugs, supportive care, sedation with benzos, short-acting agents to manage autonomic instability, hyperthermia Tx, if severe: cyproheptadine (antidote therapy)
