Mood Flashcards
Core symptoms of low mood
At least 2 weeks of daily:
- low mood
- loss of interest or pleasure (anhedonia)
- fatigability (anergia)
Symptoms to ask (deppression)
Bio
- Sleep (early morning waking (2 hrs),insomnia or waking regularly)
- Depression worse in morning
- Marked decrease in appetite or weight loss (5% in a month)
- psychomotor retardation
- Agitation
- Loss of libido or sex drive
Cognitive
- reduced concentration and memory (destracted/indecisive, ‘can you follow your favourate TV programme’)
- Poor self esteem (efficacy or self worth)
- Guilt (innapropriate)
- Hopelessness (pessimistic)
- self harm/ suicide (ideation or planning?, ‘its common for people to feel . . .’)
Psychotic
- severe cases (delusions, hallucinations or depressed stupor)
- congruent or incongruent
- persecutory 2nd person or smell of rotting flesh
- psychomotor retardation and mutism
Low mood DDX
Episode of depression
-See ICD-10
recurrent depressive disorder
-80% have another after first . . . need 2 episodes
Dysthymia
- chronically > 2 years
- often from childhood
- seldom severe enough to meet criteria
Bipolar Affective disorder
- unipolar without manic
- Cyclothymia - below criteria
Schizoaffective disorder
-sepressed or manic with simultaneous schizophrenic symptoms
Anxiety Disorder
- associated . . . treat depression first
Adjustment Disorder
- meet criteria but obviously related to life event
Personality/neurodevelopment
-no baseline and significal psychosocial functioning affected
Dementia/delirum
-low mood apathy and hypsomia can be delirium and dementia can have cognitive decline
Secondary to general medica and psychoactive substances
-see other card
Depressive episode ICD-10
sx present for at least 2/52 with at least 2 of the following: -depressed mood -loess of interest or enjoyment -reduced energy or increased fatigability and some of; -disturbed sleep -diminished appetite -psychomotor retardation or agitation -reduced concentration or attention -decrease self esteem or confidence -ideas of guilt -hopelessness -ideas of self harm and suicide
depression severity
mild = some difficulty in continuing with normal activities
moderate = considerable difficulty but still fuction ins some domains
severe = unable to continue normal activities
severe with delusions
Ax questions
core
- have you been cheerful or quite low in mood or spirits lately?
- do you find that you no longer enjoy the things like you used to?
- do you find yourself being tired or wawrn out?
bio
- is your mood worse in the mornings or the evenings?
- has anyuomne mentioned you seem slow/restless?
- sometimes people find they have poor sex drive . . . does this happen to you?
Cognitive
- how do you see things turning out in the future?
- do you ever feel life is not worth living?
- are you able to concentration on your favourite TV programme?
Psychotic Sx
- do you hear people say bad things about you when they are not there?
- do you ever smell something that you find hard to explain?
- Do you feel your body is healthy?
ax general
-history (remember collateral)
-examination (neurological/endocrine)
Investigations - (bloods?)
Bloods for low mood?
FBC (anaemia, infection and increased MCV(alcohol))
U&E - hyponatraemia and renal function
LFTs -Alcohol intake
TFTs - hypo/erthyroidism
Calcium (hypercalcaemia
if indicated
- crp and esr
- vit b12/folate
- urine drug screen
- ecg
- CT head?
Mood epidemiology
recurrent depressive disorder
- lifetime risk = 10-25% (f) and 5-12% (M)
- onset = late 20s
- F:M 2:1
Bipolar
- risk - 1%
- onset 20 years
- 1:1
cyclothymia
- risk =0.5-1
- onset adolescence
- 1:1
dysthymia
- 3-6%
- onset adolescence/early adulthood
- 2-3:1
Mood aetiology
Genetics
- 40-50% heritability
early life experiences -parental separation -childhood adversary (negect, abuse etc) -postnatal depresseion -affect child personality -personality disorders eg Borderlin or OCD
Acute stress
- loss
- humiliation
- bereavement
- reklationship breakdown
- redundency
chronic stress
- child support
- unemployment
- raising child alone
- relationship ending
- chronic pain/illness
neurobiology
- structural shrinking or infarcts in old
- hyperactivity of the hypothalamic pituitary adrenal axis
- deficiency in monoamines (NA, serotonin and dopamine)
depression Setting
- Primary usually
- day hospital to get up?
intensive home support or inpatient if:
- highly distressing hallucinations/delusions
- high suicide/sellf harm risk
- extreme self neglect
Detentiona may be necessary
depression Tx general
Bio
- pharmacology
- lifestyle
- sleep hyegine
Psycho
- CBT
- IPT
- Family intervention
- psychodynamic therapy
- marital interventions
- mindfulness based cbt
Social
- social care?
- carer support?
- group sessions?
deppreseion lifestyle
- avoid alchol/substances
- healthy diet
- exercise
- sleep hyegine
depression pharmacologiucal tx
Use: first line mod/severe and 2nd line for mild
1st line - SSRI
considerations
- previous medications work?
- overdose risk (greater with TCAs and venlafaxine)
- Venlafaxine and TCA work better though (hospital use?)
comorbidity and intercations
- SSRIs with hyponataemia and NSAIDs, warfarin and heparin
- increased bleeding risk on SSRIs
- TCAs in MIs and arythmia
ADDs not working
- confirm concordance
-at least 4 weeks - reassess diagnosis, substances and stresses
-Psychotherapy
-increase dose
-change SSRI or trial 2
-try venaalfaxine or mirtaxapine
aygment with mirtaxipine, lithium or antipsychotic
-consider ect
ECT indications
- poor response to ADDs
- ADD intolerance
- depression with severe suicidal ideation
- psychotic features, sever psychomotorretardation
- severe self neglect (fluid/food/food intake)
- Previous good response to ECT
hypomanic/ manic state
ICD-10
-sustained elated, irritable or expansive mood
and
-excessive activity or feelings of energy
- irritability 80%)
- fluctuation mood (69%)
- euphoria (71%)
Mania/hypomania sx areas
Bilogical
-decreased sleep not ax with fatigue
Cognitive symptoms
- elecated sence of self esteem or grandiosity
- poor concecntration
- accelerated thinking and speech (pressure and flight of idease)
- impaired judgement and lack of insight
Psychotic sx
- Disorderd thought form (circumstantiality>tangentially>flight of ideas)
- abnormal beliefs (grandious or persecutory) . . . but more often overvalued ideas
- perceptual disturbance (usually just louder sounds and brighter colours)
Pretty sure? still ask for:
- decreased need for sleep (81%)
- grandiosity (78%)
- racing thoughts (71%)
- distractability (68%)
- sexual disinhibition (57%)
Elated mood DDX
- rule out other medical cause or substances
- define if hypomania, mania w/o psychotic symptoms of mania with psychotic sx
hypomania = considerable interference with work or sx activities Mania = complete disruption of work or social activities
minimal interference consider cyclotymia or another diagnosis
mixed affective disorder . . . . . fluctuating throughout day
Bipolar disorder - usually previous mood episode but not needed
depression
- agitated depression
- Transient elation from ADDs or ECT
- misidentified euthymia
Schizoaffective disorder
Personality/neurodevelopmental disorder
- ADHD?
- personality == no baseline
elated mood other medical causes and substance causes
m:
- cerebral neoplasms/infarcts/infection/encephalitis
- cushjhings
- huntingtons
- hyperthyroidism
- ms
- renal failure
- sle
- temporal lobe epilepsy
- vit b12/ niacin deficiency
S: amphetamines -cocaine -hallucinogens -Novel psychoactive substances
P:
- anabolic steroids
- ADDs
- Corticosteroids
- dopaminergic agents (L-dopa, selegiline, bromocriptine)
Bipolar aetiology
65-80% heritability
1st degree relative has it? increase risk:
-7 times bipolar
-2-3 times unipolar
-schixophrenia/schizoaffective disorder and vice versa
thought to involve dopaminergic pathways more than serotonin
90% WILL GO ON FOR MORE EPISODES
6 times greater risk of compelted suicide 4 mood episodes in 10 years
biplar mx
treatment dependent on their state
- setting
- pharmacological
- psychological
- physical
BD acute mania/hypomania tx
setting
-manic episode = secondary care
Hospitalisation?
a) impaired judgement (risk) eg sexual indiscretion, overspending, aggression
b)psychotic sx?
c) psychomotor with risk of self injury malnutrition and exhaustion
d) thought so self haerm or harming others
Pharmacological
- stop Adds (gradual)
- benzodiazepam short term
- antimanic - antipsychotic (haloperidol, olanzapine, quetiapine or respiridone)
- increase lithium if already on or augment with antipsychotic
BD Acute depressive episode tx
-antimanic agent to avoid inducing mania
-ADD only mod-severe sx and titrate up
1st line (quetiapine or combo of gluoxitine/olanzapine)
second line = lamotrigine alonge
avoid long term ADD - discontinue after at least 3 month remission
BD maintenance tx
- NOT for everyone . . . likely to relapse or serious mania
- lithium first line but only if commit to two years
- 2nd line augment with valproate (olanzapineor quetiapine if pregnant)
- 3rd line = lamotrigine (not v protective against mania) or carbamazepine (liver function and interations
BD monitoring
- increased risk of CVD even without drugs so yearly check up (weight, pulse, fasting, blood glucose, glycosylated haemoglobin, lipids and liver function)
- and lithium check ups
BD Psychological tx
- educate warning and coping strategies
- family intervention
- CBT
- 4 mood episodes every 10 years
dysthymia /cyclothymia tx
mainly low intesnsity therapy
- rarely pharmacological
- but if you do then lithium 1st line and olanzapine/quetiapine 2nd
Suicide risk factors
The following is a list of suicide risk factors taken from the Preventing suicide in
England paper from the Government:
Gender - males are three times as likely to take their own life as females
Age - people aged 35-49 years now have the highest suicide rate
Mental illness
The treatment and care they receive after making a suicide attempt
Physically disabling or painful illnesses including chronic pain
Alcohol and drug misuse
The loss of a job
Debt
Living alone - becoming socially excluded or isolated;
Bereavement
Family breakdown and conflict including divorce and family mental health problems
Imprisonment
