Mood disorder Flashcards
Mood
a pervasive and sustained emotion (feeling) that influences a person’s behaviour and colours their perception of being in the world.
Mood disorder
Significant impact on individual and society.
Affects relationships, employment, future.
Peak incidence 30 y/o – NB time in career, life partner, etc.
Lifetime prevalence of 10%; average duration of 3/12; episodic course.
MMD: Aetiology
Biological factors:
- Monoamines
- Immunological disturbance.
- HPA overactivity is common but not diagnostic.
- Thyroid axis activity changes, second messenger systems, GH, and prolactin.
Genetic factors
Mood disorders are heritable but only ↑ the risk.
Concordance in monozygotic twins is 70-90%, and in dizygotic twins it is 16-35%.
MDD and bipolar disorder may have similar causative genes.
Psychosocial factors
- Life events and environmental stressors.
- Personality factors.
MDD: Diagnosis
Mnemonic to remember the 9 criteria: M SIGE CAPS (Mood, Sleep, Interest, Guilt, Energy, Concentration, Appetite, PSM agitation/retardation, suicidality)
Must meet at least 5 criteria, at least one of which being MOOD or INTEREST (screening tool)
Course and prognosis of MDD
Have long courses and individuals tend to relapse.
Untreated lasts around 6-13 months.
Treated episodes about 3 months.
As individuals have more and more episodes, the time between episodes tends to decrease and the severity of each episode tends to worsen.
Medical and Psychiatric conditions that mimic MDD
Hypothyroidism, MS, OSA.
Substances – stimulant withdrawal, ETOH.
Bipolar illness/other depressive disorders (adjustment disorder, persistent depressive disorder).
Grief/bereavement/normal sadness.
Investigations
TSH.
FBC.
B12 & Folate.
Baseline electrolytes to ensure no abnormalities.
Urine toxicology.
Others: syphilis serology, HIV, CTB, EEG, etc.
Substances and MDD
Use or withdrawals can cause, exacerbate MDD.
Prescription drugs: interferons, steroids, clonidine, methyldopa.
Roaccutane, Varenicline.
COC, beta blockers.
Alcohol-use, stimulant withdrawal.
MDD Tx
Use biopsychosociocultural approach.
Rule out suicidality.
Specify if mild, moderate or severe MDD.
Psychotherapy: CBT
Standardized therapy, aims to correct cognitive distortions.
Logical analysis and reinterpretations of automatic thoughts.
Group or individual.
Good evidence.
Psychotherapy: IPT
Problem focused.
Current relationships and interpersonal events that contribute to and maintain depression.
Psychotherapy: Mindfulness-based CBT
Traditional CBT methods + mindfulness and meditation.
Mindfulness: focus on awareness of all incoming thoughts/feelings.
Accepting them without attaching judgement.
Best for maintenance phase.
Admission indications
Suicidality.
Homicidality.
Inability to care for self (food/shelter).
The need for diagnostic clarity.
A history of rapidly progressive symptoms and poor social support.
Pharmacotherapy
For moderate-severe depression or mild in certain circumstances.
SSRIs: Fluoxetine, Citalopram, Escitalopram, Sertraline.
SNRIs: Venlafaxine, Desvenlafaxine, Duloxetine.
Atypical agents: Mirtazapine, Bupropion.
Serotonin modulators: Trazodone, Vortioxetine.
TCAs and Tetracyclics: Amitryptyline, Notryptyline, Imipramine, Mianserin.
MOAIs: Phenelzine, Selegiline.
SSRIs adverse effects
Serotonin Syndrome: agitation, anxiety, restlessness, disorientation, diaphoresis, pyrexia, tachycardia, N/V, tremor, rigidity, hyperreflexia, myoclonus, dilated pupils, dry mm, flushed skin, etc.
Suicidality
SSRIs side effects
Headache (transient).
Increased activation/anxiety (transient).
LOA, GIT upset (transient).
Sexual dysfunction (usually resolves with AD withdrawal).
QTc prolongation (improves with AD withdrawal).
Hyponatraemia (improves with AD withdrawal).
Bleeding (improves with AD withdrawal).
Abrupt discontinuation can cause discontinuation effects.
Other antidepressants: Atypical agents
Bupropion: fewer sexual side-effects, caution if eating disorder/seizure disorder, activating (so can cause anxiety and insomnia).
Mirtazapine: fewer sexual side effects, sedating and increases appetite so good if Sx of insomnia and LOA, but can cause weight gain.
Tx
Antidepressants take 2-4 weeks or longer to impact mood; but some efficacy (e.g., improved energy levels) should be evident after 1-2 weeks.
Once symptoms resolved, antidepressants must be continued for 6-12 months, or 2 years + if multiple episodes.
Poor response options (do one thing at a time!):
1. Optimize does (increase)
2. Switch to another antidepressant
3. Combine/augment (add another AD/add a different Rx)
Initial monitoring
Reviewed after 1 – 2 weeks and then 2 – 4 weekly for early response, S/Es and adherence.
Neurostimulation therapies
Electroconvulsive therapy (ECT)
Repetitive transcranial magnetic stimulation (rTMS)
Deep brain stimulation (DBS)
Vagal nerve stimulation (VNS)
ECT
Application of electrical current to the brain to induce a therapeutic seizure.
Use of informed consent (if capacity), and anaesthesia and muscle relaxant medication to prevent a motor seizure.
Indications: highly effective in MDD – 80-90% remission; 50-60% remission in treatment-resistance + it works quickly.
Main side effects are antero- and retrograde amnesia, nausea and headache.
Therefore, reserved for life-threatening depression (psychotic depression, suicidality, catatonia/unable to care for self), those with a prior good response to ECT/patient preference, and treatment-resistant depression.
rTMS
Uses a magnetic field to induce electrical currents in the brain.
Main difference to ECT – can target specific brain regions, does not cause memory impairment, does not require anaesthetic
But: not as effective as ECT (25-30% response rate)
As it is better tolerated but less effective than ECT, it is second-line for treatment-resistant MDD
DBS, VNS, CAMS
DBS is invasive, requires surgery.
Both are experimental still and rarely used.
Complimentary and alternative medications (CAMs): healthy diet, exercise, and sleep schedule should be encouraged in all individuals.
Bipolar disorder
Bipolar 1 disorder – manic episode(s) (usually also hypomanic and depressive episode(s))
Bipolar 2 disorder – hypomanic and depressive episode(s)
Epidemiology of Bipolar 1 disorder
Lifetime prevalence 0.7 – 1%
M=F
Mean age of onset 30s (wide range)
Commoner in those with a higher SES
Comorbidity is common and worsens the prognosis
Diagnostic criteria: Manic episode
A specific period of persistent and abnormal change in mood (elevated/expansive/irritable) AND increased energy/activity lasting at least ONE WEEK (or any period if hospitalization required)
During this period, THREE of the following must be present (FOUR if mood is only irritable):
Distractibility (poor attention).
Indiscretion (in spending, sexual activity, etc.).
Grandiosity (inflated self-esteem).
Flight of ideas (racing thoughts).
Activity increased (GDA or agitation).
Sleep need decreased (NOT insomnia)
Talkativeness increased.
Symptoms are severe enough to cause marked impairment in functioning, or require hospitalization, or there is psychosis.
Not due to a substance or another medical condition.
Diagnostic criteria: Hypomanic episode
There is a definite change in functioning for that person.
The change in mood and functioning is observable by others.
The episode is NOT severe enough to cause marked impairment in functioning, or require hospitalization. If there is psychosis – it is a manic episode
The change is not due to substances or another medical condition.
Diagnostic features: Bipolar 1 disorder
Characterized by recurrent mood episodes.
The mood is often described as euphoric, excessively happy, high, excited, fantastic, “up”, “on top of the world”, or else is predominantly irritable (easily angered).
The mood is often infectious to those around the patient (including the clinician) – a helpful clue.
Rapid mood shifts often occur (from euphoric to irritable to dysphoric).
The individual often feels as if he/she can accomplish anything and often engages in multiple overlapping tasks that are rarely completed, often through the night.
Insight is usually very poor.
Course and prognosis: Bipolar 1 disorder
About 75% of bipolar 1 disorders start with a depressive episode.
Most patients experience both manic and depressive episodes; 10 – 20% experience only manic episodes.
Manic episodes tend to have a rapid onset (hours to days), but may evolve over a few weeks.
Untreated manic episodes tend to last about 3 months.
After an index manic episode, 90% will go on to have a second episode.
The prognosis is poorer than in MDD – a third of patients will have chronic symptoms and significant social decline.
Bipolar Mania Tx
For acute severe mania: a second-generation antipsychotic or a mood stabiliser or both (preferably).
SGA options: risperidone, olanzapine, quetiapine, aripiprazole, (haloperidol).
Mood stabiliser options: lithium, valproate.
If there is no/a poor response over 1-3 weeks, switch the mood stabiliser or the antipsychotic.
If no/poor response to 4-6 different treatment combinations, consider ECT or clozapine (either clozapine monotherapy or clozapine + lithium/valproate).
Treat agitation and lack of sleep with benzodiazepines temporarily, while giving the treatment time to work e.g., clonazepam or lorazepam.
Bipolar Depression Tx
Psychopharmacology is the cornerstone of treatment, often with adjunct psychotherapy.
Antidepressants are often unhelpful and may cause rapid cycling and/or manic switch.
First line: quetiapine monotherapy.
Second line (if no/poor response or poorly tolerated):
Olanzapine + fluoxetine
Valproate
Quetiapine + lithium/valproate
Lithium + valproate/lamotrigine
