Lecture 2: Introduction to affective disorders Flashcards
What are the types of mixed states that Kraepelin proposed?
- Depressive or anxious mania
- Excited depression
- Manic with thought poverty
- Manic stupor
- Depression with flight of ideas
- Inhibited mania
Which groups have higher rates of lifetime prevalence for MDD?
- Young adults (16.6%)
- Women (2:1)
- Elderly
Which are some factors that increase the risk of MDD?
- Female
- Youger age
- 1 or 2 short alleles of 5HTT polymorphism
- Prior alcohol or drug use
- Prior panic attack
Which are some possible pathways for MDD?
- Monoamines
- Glutamate
- HPA axis
- GABA
- Cholinergic/adrenergic balance
- Endogenous opioid
Which dx has a higher lifetime prevalence of comorbid anxiety: bipolar or MDD?
Bipolar
Name some specifiers for BD and MDD
Clinical features
- Psychotic features (mood congruent or mood incongruent)
- Catatonia
- Mixed states
- Melancholic
- Atypical features
- Anxious distress
Onset:
- Peripartum onset
- Early
- Late
Remission status:
- Partial
- Full
Severity:
- Mild
- Moderate
- Severe
Illness pattern:
- Seasonal pattern
- Rapid cycling (only for BD)
- Single episode
- Seasonal
Briefly define the “melancholic features” specifier for mood disorders
With melancholic features:
➜ a. One of the following is present during the most severe period of the current episode:
1. Loss of pleasure in all, or almost all, activities.
2. Lack of reactivity to usually pleasurable stimuli (does not feel much better, even temporarily, when something good happens).
➜ b. Three (or more) of the following:
- A distinct quality of depressed mood characterized by profound despondency, despair, and/or moroseness or by so-called empty mood.
- Depression that is regularly worse in the morning.
- Early-morning awakening (i.e., at least 2 hours before usual awakening).
- Marked psychomotor agitation or retardation.
- Significant anorexia or weight loss.
- Excessive or inappropriate guilt.
Briefly outline the criteria for the “atypical” specifier of mood disorders
➜ a. Mood reactivity (i.e., mood brightens in response to actual or potential positive events).
➜ b. Two (or more) of the following:
- Significant weight gain or increase in appetite.
- Hypersomnia.
- Leaden paralysis (i.e., heavy, leaden feelings in arms or legs).
- A long-standing pattern of interpersonal rejection sensitivity (not limited to episodes of mood disturbance) that results in significant social or occupational impairment.
Roughly state the comorbidity rates of anxiety with BD and anxiety with MDD
- Anxiety and bipolar: 75%
- Anxiety and MDD: 60%
What is the proportion of patients with MDD that experience severe or very severe impairment?
- Around 59%
How does gender of patients impact in MDD recovery?
Gender not related to recovery
What is the proportion of MDD patients who have recurrent or unremitting course?
- Recurrent: 35%
- Unremitting: 15%
What is the median episode length for MDD?
12 weeks
Name some possible biological processes involved in MDD
- Neuroplasticity
- Neurogenesis
- Neuroendocrine
Name one biological factor than has an impact on the severity of episodes of MDD
- HPA axis
could lead to a more severe mood episode, different episode, or even less severe episode
Name some mental disorders associated with hypoactivity of the HPA axis
- Bipolar II with atypical features
- BD 1
- PTSD
What is the difference between the mood changes in BD and BPD?
BD: spontaneous (no trigger/precipitant)
BPD: due to precipiating events (internal or external)
When do BD patients have a higher rate of suicide attempts?
During their depressive episodes -if recurrent and associated with (internal/external) triggers, consider BPD
Categorise BPD, BD, and MDD in terms of their associated disruptance to the HPA axis
1) BPD
2) BD
- BD1 with more than 5 episodes
- BD1 with less than 5 episodes
3) Unipolar depression
- w/ Atypical (release less cortisol)
- w/ Melancholia (release more but receptors not sensible)
What should be considered when assessing a patient with probable mood disorder?
- Recurrence
- Severity
- Evidence of MDE
- Evidence of mania/hypomania
- Comorbidities (psychiatric and physical)
- Onset
- Family history
- Treatment history
- Neurocognitive and cognitive status
According to the BRIDGE study (Angst 2011), how much of depression is bipolar?
Depends on definition
- 16% depression is bipolar (DSM-IV)
- 31% modified DSM-IV (allows antidepressant/drug induced)
- Up to 54% using wider definitions bipolar spectrum
How prompts us to screen for bipolar depression?
- Family history (mania in first-degree relatives)
- mixed states
- onset before 30
- multiple episodes over lifetime
- not fully recover between episodes
- Shorter episode and cycle length
- More interepisode mood shifts
- More psychomotor retardation
- more psychosis
- More frequent substance abuse
- Hypersomnia, overeating
- Antidepressant switches or poor response
- Atypical symptoms
- mood instability
- Interpersonal sensibility
• Usually, people with bipolar usually have two depressive episodes before they present the manic or hypomanic episode.
How prompts us to screen for bipolar depression?
- Family history (mania in first-degree relatives)
- mixed states
- onset before 30
- multiple episodes over lifetime
- not fully recover between episodes
- Shorter episode and cycle length
- More interepisode mood shifts
- More psychomotor retardation
- more psychosis
- More frequent substance abuse
- Hypersomnia, overeating
- Antidepressant switches or poor response
- Atypical symptoms
- mood instability
- Interpersonal sensibility
• Usually, people with bipolar usually have two depressive episodes before they present the manic or hypomanic episode.
How does childhood adversity impact depression?
- 2 in 3 people with treatment-resistant depression had childhood adversity
- Can impact outcome, severity, chronicity
- Higher risk of suicidal ideation
Who are more vulnerable to depression due to early life stress?
- Females
- Adults
- Use of alcohol/drugs
- Abuse and neglect
Name some comorbidities of mood disorders
- Panic attack
- Phobias
- PTSD
- Metabolic disorders
- Cardiovascular disorders
Name some treatments for mood disorders under the biopsychosocial model
Biological treatments: • Antidepressants • Antipsychotics • Mood stabilisers • ECT • Transcranial magnetic stimulation
Psychological treatments: • Brief CBT • CBT • Interpersonal therapy • Mindfulness • ACT – Acceptance and commitment therapy • Schema therapy
Social treatments • Family psychoeducation • Formal support groups • Community groups • Caregivers • Employment • Enhance their relationship with friends and family • Housing
Lifestyle treatments: • Exercise • Diet • Smoking cessation • Alcohol cessation
What do we mean by Optimised Treatment?
Combination of pharmacotherapy and psychological treatments in mood clinics
How to improve outcomes in BD?
With early, accurate diagnosis and appropriate treatment
How can a clinician manage partial remission in MDD?
1) Review diagnosis
* Clinical management:
- Seek for second opinion
- Re-assess for comorbidities
- Review adherence and dose
- Therapeutic strategies:
- Switch / substitute
- Augment / combine
- Increase dose
Which are the requirements for individualised treatment?
- Accurate diagnosis
- All comorbidities identified and addressed
- Implement strategies: pharmacological (balance efficacy and side effects), psychological (psychotherapy and psychoeducational), social (social support)
- Aim for remission and quality of life
