Mood disorder

Question 1

Mood

Answer 1

a pervasive and sustained emotion (feeling) that influences a person’s behaviour and colours their perception of being in the world.

Question 2

Mood disorder

Answer 2

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.

Question 3

MMD: Aetiology

Answer 3

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.

Question 4

MDD: Diagnosis

Answer 4

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)

Question 5

Course and prognosis of MDD

Answer 5

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.

Question 6

Medical and Psychiatric conditions that mimic MDD

Answer 6

Hypothyroidism, MS, OSA.
Substances – stimulant withdrawal, ETOH.
Bipolar illness/other depressive disorders (adjustment disorder, persistent depressive disorder).
Grief/bereavement/normal sadness.

Question 7

Investigations

Answer 7

TSH.
FBC.
B12 & Folate.
Baseline electrolytes to ensure no abnormalities.
Urine toxicology.
Others: syphilis serology, HIV, CTB, EEG, etc.

Question 8

Substances and MDD

Answer 8

Use or withdrawals can cause, exacerbate MDD.

Prescription drugs: interferons, steroids, clonidine, methyldopa.

Roaccutane, Varenicline.

COC, beta blockers.

Alcohol-use, stimulant withdrawal.

Question 9

MDD Tx

Answer 9

Use biopsychosociocultural approach.

Rule out suicidality.

Specify if mild, moderate or severe MDD.

Question 10

Psychotherapy: CBT

Answer 10

Standardized therapy, aims to correct cognitive distortions.

Logical analysis and reinterpretations of automatic thoughts.

Group or individual.

Good evidence.

Question 11

Psychotherapy: IPT

Answer 11

Problem focused.

Current relationships and interpersonal events that contribute to and maintain depression.

Question 12

Psychotherapy: Mindfulness-based CBT

Answer 12

Traditional CBT methods + mindfulness and meditation.

Mindfulness: focus on awareness of all incoming thoughts/feelings.

Accepting them without attaching judgement.

Best for maintenance phase.

Question 13

Admission indications

Answer 13

Suicidality.
Homicidality.
Inability to care for self (food/shelter).
The need for diagnostic clarity.
A history of rapidly progressive symptoms and poor social support.

Question 14

Pharmacotherapy

Answer 14

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.

Question 15

SSRIs adverse effects

Answer 15

Serotonin Syndrome: agitation, anxiety, restlessness, disorientation, diaphoresis, pyrexia, tachycardia, N/V, tremor, rigidity, hyperreflexia, myoclonus, dilated pupils, dry mm, flushed skin, etc.

Suicidality

Question 16

SSRIs side effects

Answer 16

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.

Question 17

Other antidepressants: Atypical agents

Answer 17

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.

Question 18

Tx

Answer 18

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)

Question 19

Initial monitoring

Answer 19

Reviewed after 1 – 2 weeks and then 2 – 4 weekly for early response, S/Es and adherence.

Question 20

Neurostimulation therapies

Answer 20

Electroconvulsive therapy (ECT)
Repetitive transcranial magnetic stimulation (rTMS)
Deep brain stimulation (DBS)
Vagal nerve stimulation (VNS)

Question 21

ECT

Answer 21

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.

Question 22

rTMS

Answer 22

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

Question 23

DBS, VNS, CAMS

Answer 23

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.

Question 24

Bipolar disorder

Answer 24

Bipolar 1 disorder – manic episode(s) (usually also hypomanic and depressive episode(s))

Bipolar 2 disorder – hypomanic and depressive episode(s)

Question 25

Epidemiology of Bipolar 1 disorder

Answer 25

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

Question 26

Diagnostic criteria: Manic episode

Answer 26

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.

Question 27

Diagnostic criteria: Hypomanic episode

Answer 27

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.

Question 28

Diagnostic features: Bipolar 1 disorder

Answer 28

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.

Question 29

Course and prognosis: Bipolar 1 disorder

Answer 29

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.

Question 30

Bipolar Mania Tx

Answer 30

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.

Question 31

Bipolar Depression Tx

Answer 31

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