Gargi's & Emma's notes - Affective Disorders Flashcards
What is an affective disorder?
Describe the features of affective disorders
- Main feature is excessively high or low mood
- Run a relapsing/remitting course
- Unipolar – recurrent episodes of depression
- Bipolar – recurrent episodes of mania and depression
Define the depression triad
Triad of
- low mood,
- anhedonia (loss of enjoyment in previously enjoyable activities),
- low energy/increased fatiguability.
Depression is a unipolar affective disorder
What are the causes of depression?
What are the risk factors for depression?
What is Beck’s cognitive triad?
negative views about self (worthlessness) = world (helplessness) = future (hopelessness)
What are the core features of depression (ICD-10)?
low mood, low energy, anhedonia lasting 2 or more weeks
What are the biological features of depression?
- early morning wakening
- diurnal variation (symptoms worse in the morning)
- appetite change with weight change,
- Usually decreased, can be increased (atypical)
- Psychomotor retardation or agitation
- Slow, monotonous speech, blunted affect, lack of emotional reactivity
- Or inability to sit still, fidgeting, pacing or hand-wringing, rubbing/scratching skin/clothes
- Marked loss of libido
What are some additional symptoms of depression?
- decreased attention/concentration,
- low self-esteem,
- ideas of guilt,
- hopelessness
- pessimistic view of the future
- ideas of self-harm/suicide
- disrupted sleep,
- Difficulty falling asleep (insomnia), hypersomnia (atypical)
- early morning waking, insomnia,
- loss of libido
How many symptoms are required for mild, moderate and severe depression?
- MILD: 2 core + 2 bio
- MOD: 2 core + 6 bio
- SEVERE: more than 8 symptoms, including all 3 core
What else is required in a psych depression Hx?
- Any psychotic symptoms (hallucinations, delusions)
- Look out for suicidality, self-neglect, psychosis
- Can be with or without somatic symptoms
What are the subtypes of depression?
What is the mneumonic for MMSE?
ASEPTIC
A ffect
S peech
E ffect
P sychosis
T houghts
I
C ognition
What must be asked/observed in the MMSE (ASEPTIC)?
A: signs of neglect, weight loss, dehydration, looks miserable, disinterested, anxious movements, poor eye contact, tearful, posture, tearful, agitated depression = increased activity (restless, pacing, hand-wringing)
S: slow, quiet, psychomotor retardation can make mute
E: restricted range of affect
P: severe = hallucinations, visuals of evil images, auditory with unpleasant derogatory voices, delusions – guilt, nihilistic (nothingness), persecutory
T: concerned about, pessimistic, guilt and worthlessness thoughts, nihilistic delusions worthlessness, helplessness, negative triad, suicidal thoughts
I: insight is usually good
C: psychomotor retardation may mimic cognitive impairment, poor concentration
What are the differential diagnoses for ?depression?
- Physical causes – hypothyroid, head injury, cancer, quiet delirium, meds
- Adjustment disorder – following life event but not as severe
- Normal sadness – part of life
- Bereavement – concern when grief (numbness, pining, depression, recover) is very intense, > 6 months or delayed
- Chronic schizophrenia – blunt affect
- Substance withdrawal
- Bipolar disorder
- Postnatal depression/puerperal illness
- Dementia – changes from depression may mimic dementia, but dementia can start with affective changes
- Dysthymia – low-intensity but chronic low mood
- Can co-morbid with panic disorder, agoraphobia, OCD, eating/personality dis
What further investigations are required for ?depression?
- Collateral Hx
- Physical exam to rule out organics
-
Bloods –
- TFT - rule out hypothyroid
- FBC - rule out anaemia
- glucose/HBA1C – rule out diabetes
- U&Es
- LFTs (alcohol),
- Ca
- Assess severity on Becks Depression Inventory (BDI) or Hospital Anxiety and Depression Scale (HADS)
When must a depressed patient be referred to secondary psych?
high suicide risk, severe depression, unresponsive to tx
Which severity of depression requires Tx?
Depressive episodes don’t qualify as dx (subthreshold) or mild that do not need treatment
→ wait and watch, sleep hygiene advice, give information about depression and follow up in 2 weeks
When may in-patient admission necessary in patients with depression?
- Highly distressing psychotic symptoms
- Active suicidal ideation or planning
- Extreme self-neglect (e.g. dehydration, starvation)
What lifestyle advice may be given to patients with depression?
- Avoid alcohol and substance use
- Eat healthily
- Exercise regularly
- Good sleep hygiene (avoid caffeine and smoking in the evenings, do not nap, don’t use bedroom for TV etc.)
- Minimise adverse life events where possible
How do you treat persistent subthreshold symptoms/mild-moderate depression?
low intensity psycho-social interventions (CBT, computerised CBT, structured group physical activity programme)
- Do not use antidepressants routinely in subthreshold/mild-mod depression because of poor risk/benefit ratio*
- But consider for people with PMH of mod/severe depression, 2 years subthreshold/mild persisting after other interventions*
How do you treat persistent subthreshold symptoms/mild-moderate depression that is unresponsive to 1st line Tx?
If not responsive: consider
(1) high-intensity therapy (individual CBT, interpersonal therapy, couple behavioural therapy, behavioural activation) OR
(2) antidepressant
* SSRI – fluoxetine, sertraline, paroxetine, citalopram, escitalopram
How do you treat the initial presentation of severe depression?
= high intensity therapy AND antidepressant,
treat until no longer depressed
What must be done if there is no positive impact of antidepressants?
check compliance, SE before changing
What are the side effects of SSRIs?
- D/V,
- weight change,
- blurred vision,
- anxiety,
- agitation,
- insomnia,
- tremor,
- dizziness,
- headache,
- sweating
What must be prescribed in older patients who are on aspirin or NSAIDs?
- gastroprotective (PPI) - risk of GI bleeding
- also risk in older patients
Must antidepressant Tx be continued after symptom remission?
yes (6 months)
What are some psychotic symptoms seen in depression?
- Delusions and hallucinations are normally mood-congruent à irrational guilt, nihilistic delusions, accusatory voices
- In severe cases, psychomotor retardation may progress to depressive stupor à unresponsiveness, lack of voluntary movement (akinesis), mutism
What are the complications of depression?
- Social isolation, unemployment
- Self-harm, suicide
- Substance misuse
- SEs of antidepressants (incl unmasking mania)
What is the prognosis of depression?
- Lifetime suicide is 15% (20x higher than general population)
- Initial episode usually lasts 6 months – 1 year
- 80% have further episode (risk increases with each relapse)
- 10% have chronic unremitting course
- Pharmacological treatment failure is usually due to inadequate dose, duration or poor adherence
When is pscychological advice indicated in depressed patients?
- 1st line for mild depression,
- In combination with drug treatments for moderate-severe depression
Which psychological Txs are useful in depression?
- CBT (may be self-help or individual, depending on severity)
- Mindfulness-based cognitive therapy
- Interpersonal therapy
- Family and marital therapy
- Psychodynamic therapy
When is drug Tx required in depression?
- For moderate-severe depression
- OR milder depression not responsive to psychological therapy alone
What must patients be warned/counselled of before starting SSRIs?
- anxiety/suicidal thoughts at first
- Warn patients of gradual development of full anti-dep effect
- Continue treatment after remission
- Non-addictive
What should be prescribed next if there is no response to SSRIs for depression?
- Change to another SSRI
- try TCA/different class
- augment another antidepressant/antipsychotic (e.g. quetiapine)/lithium
What may be prescribed prophylactically if there are multiple episodes of depression?
SSRIs
What should a depressed patient be prescribed if they express psychotic symptoms?
antipsychotics
When is ECT indicated in depression?
- Poor response or intolerance to antidepressants
- Severe suicidal ideation, psychotic features, psychomotor retardation or stupor
- Severe self-neglect (poor fluid and food intake)
- Previous good response to ECT
What is the Tx for initial presentation of moderate depression?
high-intensity therapy (individual CBT, interpersonal therapy, couple behavioural therapy, behavioural activation
What is the Tx for initial presentation of severe depression?
high-intensity therapy (individual CBT, interpersonal therapy, couple behavioural therapy, behavioural activation) AND antidepressant,
treat until no longer depressed
What must you do if patient is non-responsive to antidepressant?
- check compliance & SE
- before changing
Can antidepressants be stopped suddenly?
- Antidepressants cannot be stopped suddenly
- need to wean over weeks
When is a secondary care pscyh referral indicated?
- high suicide risk
- severe depression
- unresponsive to tx
What is the definition of bipolar affective disorder?
- At least 2 episodes, one must be hypomania or mania or mixed (other can be depressive) with complete recovery between 2 episodes + depressive episodes
- Mania lasts 2w-4m, depression longer
Name the types of BAD
- Type 1
- Type 2
- Rapid-cycling
- repeated episodes of mania/hypomania (with no depression)
What is Type 1 BAD?
- manic episodes interspersed with depressive episodes
- At least 1 manic episode
What is Type 2 BAD?
- mainly recurrent depressive episodes, with less prominent hypomanic episodes
- Never had a full manic episode; at least 1 hypomanic episode and 1 depressive episode
What is Rapid-cycling BAD?
4 or more affective episodes in a year
What is a mixed episode of BPAD?
manic/hypomanic and depressive symptoms in a single episode,
present every day for at least 1 week
What is Ultra rapid cycling BPAD?
fluctuations over days or even hours
Are repeated episodes of mania/hypomania (with no depression) also classified as BAD?
Yes
What is the biological aetiology of BAD?
-
Genetics
- Strong genetic component –> 80% heritability
- 10% risk in 1st degree relatives (also higher risk of depression and schizophrenia/schizoaffective disorder)
- Due to multiple alleles in genes related to neuronal development, DA/5-HT metabolism and ion channels
-
Neurobiology:
- Due to structural and functional abnormalities in brain regions linked to emotion (esp hippocampus)
- Decreased activation and reduced grey matter in areas controlling emotional regulation, increased activity in ventral limbic areas that mediate and generate emotional responses
- Multiple NTs have been implicated –> may be due to DA overactivity
- Substance use (incl antidepressants) can trigger mania
What is the biological cause of mania?
- Increased adrenaline, NA, dopamine, serotonin → mania
What are the risk factors for rapid cycling BAD?
female sex
What is the social aetiology of BAD?
- Most important environmental RF is childbirth –> 50% risk of mania post-partum in untreated bipolar
- Stress can trigger manic episodes
What is the epidemiology of BAD?
- 1% prevalence
- Average age of onset is 20yo; usually presents with mania
- M:F equal
- Rapid cycling BAD is more common in F
What are the symptoms of BAD?
- mania/hypomania episodes
- depressive episodes
What is mania?
- Elevated mood (or irritability) lasting >1wk duration with complete disruption of work and social life
What are the signs and symptoms of mania?
Appearance/behaviour
- Excitement, irritable, aggro
- Increased energy, over-active, reduced concentration, increased distractibility, over familiarity, self-neglect
- reduced sleep
Speech
- Pressured speech → can lead to loosening of associations
Emotion –
- mood/affect → increased self esteem
Perception
- grandiose delusions, paranoia, catatonic behaviour (manic stupor)
Thought
- flight of ideas, racing thoughts, overoptimistic ideation
- May have psychotic symptoms: grandiosity, auditory hallucination
Cognition
- risk taking behaviour: Excessive expenditure (debts), Sexual disinhibition, Alcohol/drug use
Insight
- Can be minimal, totally lost with psychotic symptoms
- Reckless behaviour – spending, promiscuity, driving, violence ▪ Biological – reduced need for sleep and food
- Difficulty completing tasks
- Significant disruption to work, family life
What is hypomania?
- Persistent mild elevation of mood (>3d)
- More than 3 characteristic symptoms of mania lasting at least 3/4 days, not clearly different from normal mood (collateral hx)
What are the signs and symptoms of hypomania?
- Persistent mild elevation of mood (>3d)
- Patient can usually still function reasonably normally
- Increased activity and energy
- Decreased sleep
- Talkative, overfamiliarity
- Increased libido
What is a major difference between mania and hypomania (with the exception of intensity of symptoms)?
- mania can have psychotic symptoms
- once a hypomanic patient has pscyhotic symptoms. the diagnosis becomes mania
Describe the MSE of someone in a BPAD manic episode
- A: inappropriate/bright/outlandish, may be neglect of personal hygiene
- B: increased psychomotor activity, overfamiliar, flirtatious, distractible
- S: loud, pressure of speech, uninterruptible, flight of ideas, puns and rhymes, circumstantiality/tangentiality
- M: elated, can quickly turn to irritability/anger
- T: grandiose delusions (sometimes persecutory), thought disorder
- P: auditory hallucinations, often mood-congruent
- C: impaired attention and concentration
- I: poor
What investigations are required for ?BPAD?
-
Thorough Hx and MSE
- Previous depression/mania
- Risk –> suicide, spending money, promiscuity, substance misuse, self-neglect
- Assess whether psychotic or affective symptoms are predominant (could be schizoaffective disorder)
- Various screening tools can be used
- Patient health questionnaire (PHQ-9) –> screen for depression
- Mood disorder questionnaire (MDQ) –> screen for Hx of mania/hypomania
-
Exclude other causes for manic episode
- FBC, TFTs, CRP, glucose (hyperthyroid, infection, renal failure, SLE, vit B12 and niacin deficiency)
- UDS (substance misuse)
- CT/MRI if indicated (trauma, SOL)
- Pregnancy test/STI screen if necessary
What are the differential diagnoses for acute mania?
- Schizophrenia, schizoaffective, delusional disorder, psychotic disorders
- Anxiety, PTSD
- Circadian rhythm disorder
- ADHD/conduct disorder
- ETOH/Drug misuse
What is the Tx setting for acute mania?
- Usually needs inpatient admission, often under MHA
- Esp if reckless behaviour, significant psychotic symptoms, excessive psychomotor agitation, thoughts of harm to self/others
What is the pharmacological Tx for an acute manic episode?
- Antipsychotics
- 1st line: Olanzapine, aripiprazole, quetiapine, risperidone
- For rapid control of acute behavioural disturbance
- IM for agitation; oral if milder
- Benzodiazepine e.g. lorazepam
- Adjunct for agitation
- Mood stabilisers e.g. lithium
- Take longer (3-7d) to achieve therapeutic effect
- Discontinue antidepressants (may need to be gradual) – as they can cause mania
When should a manic patient be admitted to secondary care?
- high risk of suicide/homicide,
- severe psychotic/mania/depressive symptoms,
- severe cycling,
- catatonic symptoms
What is the pharmaceutical Tx for a severe behavioural disorder in BPAD?
haloperidol and clonazepam
What is the Tx for Treatment of acute depression in the context of bipolar?
- Co-prescribe antidepressants with anti-manic agent to avoid precipitating a manic episode
- Only prescribe antidepressants for moderate-severe episodes
- Start dose low and increase gradually
- SSRIs are first line, quetiapine can be considered if not already on an antipsychotic
- Long-term antidepressants should be avoided à gradual discontinuation once depression has been in remission for 8 weeks
What is the Prophylactic Tx for BPAD?
- Most clinicians think that one episode of mania is an indication for prophylactic treatment; others treat if manic episode had severe consequences or patient has also had another disordered mood episode
- Mood stabilisers:
- Treatment for at least 2yrs is recommended
- Lithium and sodium valproate are the main treatments
- Contraception for females; valproate is the most teratogenic (avoid if possible in females)
- Monitoring (lithium levels, hepatic/renal function in valproate)
- Rapid-cycling bipolar responds better to valproate than lithium
- If ineffective, consider switching (or trying olanzapine)
- NB lithium can be harmful if taken for <2yrs (discontinuation can cause mania) à not advisable to start in patients who are unlikely to adhere to long-term treatment
- Olanzapine is being increasingly used for prophylaxis
- Monitor for metabolic syndrome
- Carbamazepine
- Can be used as an adjunct if above are not effective
- Lamotrigine
- 1st line if depression is the more predominant feature
- ECT
- If no response to pharmacotherapy or very severe depressive symptoms or mixed states
- May precipitate mania
- Regular monitoring and enhancing adherence
What are the complications of BPAD?
- Suicide (10%)
- Alcohol and substance misuse
- Non-compliance with prophylaxis
- Often due to SEs or prolonged period of well-being
- Abrupt withdrawal of a mood stabiliser has a high risk of mania/depression à 50% relapse within 5 months if lithium is stopped
- 5-15% develop rapid-cycling à poor prognosis
What is the prognosis of BPAD?
- >90% of patients who have a single manic episode go on to have future episodes
- Most relapses are related to poor compliance
- Predictors of poor outcome: early onset of illness, poor compliance, persistent depressive symptoms, severe mania, co-morbid personality disorder, substance misuse, rapid-cycling
What is cyclothymia? Describe it
- Persistent instability of mood involving numerous periods of depression and mild elation, none of which is sufficiently severe or prolonged to justify a diagnosis of bipolar or recurrent depressive disorder
- Lifetime risk 0.5-1%; M=F; average onset is adolescence/early adulthood
- Common in relatives of people with BAD
- Management:
- May benefit from same treatment as bipolar
- Use antidepressants with caution (risk of mania)
- Psychological therapy
What is dysthymia? Describe it
- Chronic depression of mood, lasting several years, which is not sufficiently severe or individual episodes are not sufficiently prolonged to justify a diagnosis of recurrent depressive disorder
- Lifetime risk of 3-6%; M>F; onset in childhood/adolescence/early adulthood
- Management:
- Similar to depression
- Psychological therapy
