Mood disorders Flashcards
What are mood (affective) disorders
Fluctuations in mood severe enough to cause impairment to activities of daily living
What are the 3 characteristic features of depressive disorder
Low mood
Loss of pleasure (anhedonia)
Lack of energy
What are the predisposing factors for depressive disorder
Biological
- Female, postnatal period, genetics, neurochemical (low serotonin/dopamine), increased HPA activity, physical co-morbidity, PMH
Psychological
- Personality type, failure of effective stress control, poor coping strategies, mental health co-morbidities
Social
- Stressful life event, lack of social support, asylum seekers, refugees
What are the precipitating factors for depressive disorder
Biological
- Poor compliance, corticosteroids
Psychological
- Acute stressful life event
Social
- Unemployment, poverty, divorce
What are the perpetuating factors for depressive disorder
Biological
- Chronic health conditions
Psychological
- Poor insight, negative thoughts
Social
- Substance misuse, poor social support, lack of social status
What is the epidemiology of depressive disorder
1 in 20 adults every year
Most common in men in 40s, women in 30s
What are the risk factors for depressive disorder
Female
Family history
Alcohol
Adverse life event
Past history
Physical co-morbidity
Lack of social support
Lack of socioeconomic status
What are the cognitive symptoms of depressive disorder
Lack of concentration
Negative thoughts (about self/world/future)
Excessive guilt
Suicidal ideation
What are the biological symptoms of depressive disorder
Diurnal variation in mood (worse in morning)
Early morning wakening (2 hours before normal)
Loss of libido
Psychomotor retardation
Weight loss
What are the potential psychotic symptoms of depressive disorder
Hallucinations
- Usually 2nd person auditory
Delusions
- Usually hypochondriacal, guilty, nihilistic, persecutory
What is the ICD-10 classification for the severity of depression
Mild
- 2 core + 2 other
Moderate
- 2 core + 3-4 other
Severe
- 3 core + >4 other
Severe depression with psychosis
What investigations are needed in depressive disorder
Diagnostic questionnaires
- PHQ-9, HADS, Beck’s depression inventory
Bloods
- FBC, TFTs, U&Es, LFTs, calcium, glucose
Imaging
- CT/MRI head
What are the differential diagnoses for depressive disorder
Bipolar affective disorder
Seasonal affective disorder
Psychotic disorders
Anxiety disorders
Personality disorders
Eating disorders
Dementia
Hypothyroidism
Substance abuse
Normal bereavement
What is the management for depressive disorder based on the bio-psycho-social model
Biological
- Antidepressants, adjuvants (antipsychotics), ECT
Psychological
- Psychotherapy, self-help programmes, physical activity
Social
- Support groups
What is the management for mild-moderate depression
Watchful waiting (2 weeks)
Antidepressants (not first line)
Self-help programmes
CBT
Physical activity programmes
Psychotherapy
What is the management of moderate-severe depression
Assess suicide risk
Consider implementing mental health act
Antidepressants (SSRIs first line)
Adjuvants (lithium, mood stabilisers)
Psychotherapy
Social support
ECT
How long should antidepressants be taken in moderate-severe depression
6 months after resolution of 1st episode
2 years after resolution of 2nd episode
Long-term for recurrent episodes
What are the indications for ECT
Life-threatening depression
Rapid response needed
Psychotic features
Severe psychomotor retardation
Failure of other treatments
What is bipolar affective disorder
Chronic episodic mood disorder
At least one episode of mania, then an episode of mania/depression
What is the pathophysiology of bipolar affective disorder
Biological
- Genetics, neurochemical (high dopamine/serotonin), endocrine (high cortisol/aldosterone/thyroid function)
HPA axis dysfunction
What are the epidemiological and risk factors for bipolar affective disorder
Lifetime risk 1-3%
Mean age on onset: 19
Black/ethnic minority groups
M=F
Substance misuse
What are the symptoms of bipolar affective disorder
I DIG FASTER
- Irritability
- Distracted/disinhibited
- Impaired insight
- Grandiose delusions
- Flight of ideas
- Appetite increase
- Sleep decreased
- Talkative (pressure of speech)
- Elated mood/energy increase
- Reduced concentration/recklessness
How may the severity of bipolar affective disorder be classified
Hypomania
Mania without psychosis
Mania with psychosis
What is hypomania
Mildly changed mood for >4 days
Mild symptoms of mania
No severe disruption to work/social life
May have partial insight
What is mania without psychosis
Symptoms for >1 week
Very elated mood
Complete disruption to work and social life
May have grandiose ideas
Sexual disinhibition
Reduced sleep
What is mania with psychosis
Severely elated mood
Psychotic features
- Grandiose or persecutory delusions
- Auditory hallucinations
May be aggressive
What are the classifications of bipolar affective disorder
Bipolar 1
- Periods of severe episodes of mania and depression
Bipolar 2
- Milder form of mood elation, severe depression
Bipolar 3
- > 4 mood swings in 12 months
- Poor prognosis
What investigations are needed for bipolar affective disorder
Mood disorder questionnaires
Bloods
- FBC, TFTs, U&Es, LFTs, glucose, calcium
Urine drug test
Consider CT head
What are the differential diagnoses for bipolar affective disorder
Mood disorders
Psychotic disorders
Secondary to medical condition
Drug-related
Personality disorder
What is the management of bipolar affective disorder based on the bio-psycho-social model
Biological
- Mood stabilisers, benzodiazepines, antipsychotics
Psychological
- Psychoeducation, CBT
Social
- Support groups, self-help groups, encourage calming activities, consider driving
Need full risk assessment
ECT (if all else fails)
What is the pharmacological management for an acute manic/mixed episode in bipolar affective disorder
First line
- Antipsychotics (olanzapine, risperidone, quetiapine, haloperidol), can add a second
Mood stabilisers
- Lithium, valproate
Benzodiazepines
- Aid sleep, reduce agitation
Rapid tranquilisation
- Haloperidol, lorazepam
What is the pharmacological management for a depressive episode in bipolar affective disorder
Atypical antipsychotics
- Olanzapine, quetiapine
Mood stabilisers
- Lamotrigine, lithium
Avoid antidepressants
- If used, also give anti-mania medication
What is the long term management for bipolar affective disorder
Lithium
- 1st line for preventing relapses
- Start 4 weeks after episode has resolved
If lithium not working
- Valproate, olanzapine, quetiapine
