Mood Disorders Flashcards
What is mood?
Refers to patient’s sustained, experienced emotional state
Subjective - in patient’s own words, or objective as dysthymic (low) euthymic (normal) or elated
What is affect?
Transient flow of emotion in response to a particular stimulus
What is a mood disorder?
Affective disorder
Any condition characterised by distorted, excessive or inappropriate moods or emotions for a sustained period of time
What is the ICD-10 classification of affective disorders?
Manic episode - hypomania, mania without psychotic symptoms or with them.
Bipolar affective disorder
Depressive episode
Recurrent depressive disorder
Persistent mood disorders - cyclothymia, dysthymia
Other mood disorders
Unspecified mood disorders
What is the classification of a mood disorder?
Primary - does not result from another medical or psychiatric condition. Either unipolar or bipolar
Secondary - results from another condition
What are causes of secondary mood disorders?
Physical e.g. anaemia, hypothyroidism, malignancy, MS
Psychiatric - schizophrenia, alcoholism, dementia, personality disorder
Drug-induced - corticosteroids, digoxin, antiepileptic drugs, antidepressants can induce mania
What is depressive disorder?
Affective mood disorder
Characterised by a persistent low mood, loss of pleasure and/or lack of energy
Accompanied by emotional, cognitive and biological symptoms
What is the monoamine hypothesis?
That a deficiency of monoamines; NA, serotonin and dopamine causes depression.
Overactivity of the hypothalamic pituitary adrenal axis has also been linked to depression.
What are the risk factors for depression?
Bio: - Low monoamines - Being female - Chronic health problem Psycho - Personality type - Poor coping strategies - Mental health co-morbidities Social: - Poor support network - Stressful events
What is beck’s triad for depression?
Negative views about the world
Negative views about oneself
Negative views about the future
What are the core symptoms of depression?
Low mood
Lack of energy
Anhedonia - no pleasure in normally pleasurable activities
What are the other symptoms of depression?
Cognitive:
- Suicidal ideation
- Guilt/worthlessness
- Lack of concentration
Biological:
- Diurnal mood variation
- Loss of appetite
- Early morning wakening
- Loss of libido
- Psychomotor retardation
Psychotic:
- 2nd person auditory hallucinations
- Persecutory, nihilistic, guilt, hypochondriacal delusions
How long must symptoms be present for before considering a diagnosis of depression?
> 2 weeks
What are the DSM-IV (NICE guidelines) stages of depression?
Subthreshold: <5 symptoms
Mild: 5 symptoms with minimal functional impairment, 2 core, 2 other
Moderate: Somewhere between mild and severe, 2 core +3-4 other symptoms
Severe: Most symptoms with significant impairment
With psychosis - 3 core +>4 other and psychosis
What differentials would you consider for depression?
Functional - bipolar, schizophrenia, seasonal affective disorder
Organic - drug use, dementia, hypothyroidism
How is subthreshold and mild depression managed?
Watchful waiting with monitoring and sleep hygiene advice
Low intensity therapy: Self help, computerised CBT, group physical activity class
Group based CBT
Antidepressants if:
- > 2 years
- Past episode of severe
- Physical health complications
- Failure of other interventions
How is moderate-severe depression managed?
Suicide risk assessment
Psychiatry referral indicated if suicide risk is high, depression severe, recurrent depression or unresponsive to treatment
SSRI are first line e.g. citalopram
Other anti-depressants include tricyclic, SNRIs or monoamine oxidase inhibitors prescribed only by specialists
Should be continued for 6 months after resolution of first episode or 2 years after second
High intensity therapy: CBT, IPT, behavioural activation
ECT
When is ECT used in depression?
Life threatening
Psychotic
Severe psychomotor retardation
Failure of other therapies
What are predisposing factors for depression?
Female gender
Neurochemical inbalance
Physical comorbidities
Past history of depression
Personality type Poor coping strategies Other mental health problems Stressful life events Lack of social support
What are the precipitating factors to depression?
Poor compliance with meds Corticosteroids Acute stressful life events Unemployment Poverty Divorce
What are the perpetuating factors to depression?
Chronic health problems e.g. diabetes, COPD, CF
Poor insight, negative thoughts - Beck’s triad
Alcohol and substance misuse
Poor social support and social status
What is the mnemonic for risk factors of depression?
FF, AA, PP, SS
Female, family history
Alcohol, adverse events
Psst depression, physical co-morbidities
Social support, SE status
What are the main symptoms of depression mnemonic?
DEAD SWAMP
Depressed mood
Energy loss
Anhedonia
Death thoughts
Sleep disturbance Worthlessness/guilt Appetite or weight change Mentation - conc reduced Psychomotor retardation
What can be extracted from the history when diagnosing depression?
Explore core symptoms - mood, still enjoy doing things, feel more tired or worn out
Explore cognitive symptoms - lack of concentration, negative thoughts, suicidal thoughts
Biological symptoms - mood worse at certain times of day, early morning wakening, low or restless, loss of libido
What is seen in a MSE in depression?
Appearance - signs of self-neglect, thin, unkempt, tearful
Behaviour - poor eye contact, tearful, slow movements and responses
Speech - slow, reduced volume and tone
Mood - low and depressed
Thought - pessimistic, guilty, worthless, helpless, suicidal or delusional
Perception - second person auditory derogatory hallucinations
Cognition - impaired concentration
Insight - usually good
What are the investigations for depression?
Diagnostic questionnaires e.g. PHQ-9, HADS, Beck’s triad
Bloods: FBC (anaemia) TFTs, U&Es, LFTs, calcium
Glucose - diabetes can cause anergia
Imaging - CT or MRI if presentation or examination is atypical, or features of intracranial lesion
What are differentials for depression?
Other mood disorders e.g. bipolar, other depressive disorders
Secondary to physical condition e.g. hypothyroid
Secondary to psychoactive substance abuse
Secondary to other psychiatric disorder e.g. anxiety, adjustment disorder, personality disorder, ED
Normal bereavement
What are other depressive disorders?
Recurrent depressive disorder - recurrent after first episode
Seasonal affective disorder - depressive episodes annually at same time each year, usually the winter
Masked depression - depressed mood not particularly prominent, other symptoms e.g. sleep disturbance present
Atypical
Dysthymia
Cyclothymia
Baby blues
Postnatal depression
What is dysthymia?
Depressive state for >2 years which doesn’t meet depression criteria
What is cyclothymia?
Mood fluctuations for >2 years where elation and depression do not meet criteria
What is atypical depression?
Mild-moderate depression with reversal of biological symptoms: e.g. overeating, hypersomnia
What is bipolar affective disorder?
Prev known as manic depression
Chronic episode mood disorder
Characterised by at least one episode of mania or hypomania and further episodes of mania or depression
What is the pathophysiology of bipolar affective disorder?
Biological - genetic FH, neurochemical - increase in dopamine and serotonin, endocrine - increase in cortisol, aldosterone, thyroid
Environmental - adverse life events, exams, post partum period, loss of loved one
What is the epidemiology and risk factors for bipolar?
Mean age onset 19 years
Incidence higher in UK in black and minority ethnic groups
Male:female is 1:1
AAA, SSS
Age in early 20s, anxiety disorders, after depression
Strong FH, substance misuse, stressful life events
What can the severity of mania in bipolar be divided into?
Hypomania
Mania without psychosis
Mania with psychosis
What are the symptoms of mania?
I DIG FASTER
Irritability
Distractibility, disinhibited - sexual, social, spending
Insight impaired, increased libido
Grandiose delusions
Flight of ideas Activity/appetite increased Sleep decreased Talkative Elated mood, energy increased Reduced concentration, recklessness - behaviour and spending
What is seen in hypomania?
Mildly elevated or irritable mood for >4 days
Symptoms of mania present to lesser extent than true mania
Not severe disruption to life
Partial insight may occur
What is seen in mania without psychosis?
Symptoms like hypomania but to a greater extent
Symptoms last >1 weeks
Complete disruption to work or social activities
Grandiose and excessive spending could lead to debt
Sexual disinhibition
Reduced sleep may lead to exhaustion
What is seen in mania with psychosis?
Severely elated mood
Suspicious mood
Addition of psychotic features - grandiose or persecutory delusions, auditory hallucinations
Patient may show signs of aggression
What is the classification of bipolar?
Bipolar I - periods of severe mood episodes from mania to depression.
Bipolar II - milder form of mood elevation, milder episodes of hypomania alternating with severe depression
Rapid cycling - more than four mood swings in a 12 month period with no intervening asymptomatic periods, poor prognosis.
What is the ICD-10 criteria for mania and bipolar affective disorder?
Mania requires 3/9 symptoms to be present - grandiosity, decreased sleep, pressure of speech, flight of ideas, distractability, psychomotor agitation, reckless behaviour, loss of social inhibitions, marked sexual energy.
Bipolar - need at least 2 episodes in which mood and activity significantly disturbed, one of which must be mania or hypomania
How does the ICD-10 divide the state of bipolar?
Currently hypomanic Currently manic Currently depressed Mixed disorder In remission
What can be screened for in the history?
Always screen for mania in a depressed patient
How would you describe mood
Ever felt on top of the world
Too much energy compared to those around you
Able to concentrate on routine activities
Need less sleep, but not tired
Interest in sex changed?
New interests or new exciting ideas lately
Special abilities - grandiose
Afraid someone will harm you - persecutory delusions
Ask about family history
Not pressure of speech or flight of ideas
What can be seen on MSE in a bipolar patient? if manic?
Appearance - flamboyant or unusual, heavy makeup, personal neglect if severe
Behaviour - overfamiliar, disinhibited, aggressive, distracted, restless
Speech - loud, pressure of speech, uninteruptable
Mood - elated, euphoric and/or irritable
Thought - optimistic, pressured, flight of ideas, tangeability, grandiose or persecutory delusions
Perception - no hallucination, mood-congruent auditory hallucinations may occur
Cognition - often impaired, fully orientated
Insight - generally very poor
What are the investigations for bipolar?
Self rating scales - mood disorder questionnaire
Bloods - FBC, TFTs, U&Es, LFTs, glucose and calcium
Urine drug test - illicit drugs can cause manic symptoms
CT head to rule out SOL
What are the differentials for bipolar?
Mood disorders e.g. hypomania, mania, cyclothymia
Psychotic disorders
Secondary to medical conditions
Drug related
Personality disorders e.g. histrionic, emotionally unstable
What is a mnemonic for the management of bipolar?
CALMER
Consider hospitalisation Antipsychotics Lorazepam Mood stabilisers e.g. lithium Electroconvulsive therapy Risk assessment
What is the management of bipolar?
BIOLOGICAL
mood stabilisers, benzos, antipsychotics, ECT for severe uncontrolled manias
PSYCHOLOGICAL
Psychoeducation, CBT
SOCIAL
social support groups, self-help groups, encourage calming activities
Full risk assessment incl. suicidal ideation and risk to self
Ask about driving
Mental Health Act
When should patients with an acute episode in bipolar be followed up?
Once a week initially
Then 2-4 weekly for the first few months
When may hospitalisation need to be considered in bipolar disorder?
Reckless behaviour causing risk to others
Significant psychotic symptoms
Impaired judgement
Psychomotor agitation
What is the pharmacological management of an acute manic episode?
First line - offer antipsychotic e.g. elanzapine, resperidone or quetiapine. rapid action of onset.
Mood stabilisers e.g. lithium or valproate second line
Benzos to aid sleep and agitation
Rapid tranquilisation with halloperidol or lorazepam
What is the pharmacological management of bipolar depressive episode?
Atypical antipsychotics e.g. elanzapine combined with fluoxetine, elanzapine alone or quetiapine alone.
Mood stabilisers e.g. lamotrigine
Antidepressants usually avoided as potential to induce mania
What is the long term pharmacological management of BPAD?
4 weeks after acute episode has resolved, lithium should be offered first line to prevent relapses.
If lithium ineffective, consider valproate. Olanzapine or quetiapine alternative options.
What investigations need to be done before treatment with lithium is commenced?
U&Es - lithium has renal excretions
TFTs
Pregnancy status
ECG
What are the side effects of lithium?
Narrow therapeutic window so drug levels need to be closely monitored
Polydipsia, polyuria, fine tremor weight gain, oedema Hypothyroidism Impaired renal function Memory problems Teratogenicity in first trimester
What are signs of lithium toxicity?
1.5-2 mmol/l - N+V, coarse tremor, ataxia, muscle weakness
Severe toxicity - >2mmol: nystagmus, dysarthria, hyperreflexia, oliguria, hypotension, convulsions and coma.
How is the administration of lithium strictly regulated?
Lithium levels measured 12 hours following first dose, then weekly until therapeutic level of 0.5-1mmol has been stable for 4 weeks
Once stable check every 3 months
Measure U&Es every 6 months, TFTs every 12 months
Combination of lithium and sodium valproate for rapid cycling
What is ECT?
Where a generalised seizure without muscular convulsions is electrically induced to manage mental disorders.
Typically 70-120 volts applied externally to patients head, 800 milliamperes of DC passed through brain for 100 milliseconds to 6 seconds duration, temple to temple (bilateral) or front to back (unilateral)
often have treatment twice a week, with few days between each session. On average 9-10 treatments.
What are the risks of ECT?
Short term side effects - headache, aching in muscles and/or jaw, tiredness whilst effects of anaesthetic wear off
Confusion, sickness, nausea
Memory loss, gaps in memory
Some people have reported change in personality, loss of creativity, energy, lack of emotions
