mood disorders Flashcards
what are the classes of mood disorders and their types
Anxiety:
Affective:
Psychoses:
what are affective disorders and the 2 types
disorders that affects feeling or emotions.
- only depressive symptoms (low mood)
- oscillation between depression and manic symptoms
what are the types of Anxiety disorders
Panic disorder
GAD
OCD
Agoraphobia
List the types of psychosis
Schizophrenia
Schizoaffective
list the types of affective mood disorders
Major Depression
Bipolar Disorder
Dysthymia
what is depression
low mood,
- sadness,
- feelings of worthlessness and guilt
-withdrawal and isolation - changes in sleep and appetite
what is mania
abnormally elevated mood
- intense elation or irritability
- hyperactivity , talkativeness, distractibility
what are the DSM 5 criteria for depression
- depressed mood or loss of interest of pleasure ( anhedonia) for a min of 2 weeks. NOT DUE to normal bereavement such as heartbreak
- Plus any of these 5 symptoms
- Sleep - insomnia
- Interest : in life
- Guilt
- Energy - lethargic
- Concentration
- Appetite : increased or decreased
- Psychomotor retardation
- suicidality
name the emotional symptoms of depression (MAJOR DEPRESSIVE DISORDER MDD)
- sadness
- loss of interest or pleasure
- overwhelmed
- anxiety
- diminished ability to think or concentrate, indecisiveness
- excessive or inappropriate guilt
What are Physical symptoms of depression
- vague aches and pain
- headaches
- sleep disturbances: lack of sleep / too much
- fatigue
- backpain
- change in appetite > weight loss or gain
what is epidemiology of depression
- mdd is twice as common in women than men
» may be due to under diagnosis in men - 16.4% of people (per 100) experience MD, 2.5% dysthymia
what are the somatic consequences of MDD
Mortality
Heart Disease
Cancer
Disability
Diabetes
Cognitive Impairment
Obesity
which gender is depression more common in?
women
Can depression manifest in children?
Yes. shows up as stomach and headaches
Does depression have co-morbidities?
2/3 of those with MDD will also meet criteria for anxiety disorder at some point
What is bipolar disorder?
Usually involve episodes of depression alternating with mania
Mania - States of intense elation or irritability
Mixed episode - Symptoms of both mania and depression in the same week
What is Hypomania?
-Symptoms of mania but less intense
-Doesn’t interfere with functioning
-Hypomania alone is not a DSM diagnostic category
what is the characteristics of hypomania
-Four or more days of elevated mood
What is the DSM-5 criteria for Manic and Hypomanic episodes?
Elevated, expansive, or irritable mood
PLUS 3 of the following (4 if mood is irritable):
- Psychomotor agitation or increase in goal-directed behaviour
- Excessive talking or pressured speech
- Flights of ideas; racing thoughts
- Reduced need for sleep
- Grandiosity or inflated self esteem
- Easily distractible
- Excessive involvement in pleasurable activities with negative consequences
e.g., unprotected sexual activity, spending sprees
Criteria for manic episode specifically?
Symptoms last for 1 week OR require hospitalization
Symptoms cause significant distress or functional impairment
Criteria for hypomanic episode specifically?
Symptoms last at least 4 days
Clear changes in functioning but impairment is not marked
What is Seasonal Affective disorder?
Episodes happen regularly at a particular time of year
Postpartum onset?
Within 4 weeks of giving birth
what is Anhedonia? (Melancholic)
it is the inability to experience pleasure
(depression)
Is there a genetic predisposition for MDD?
Yes.
- MDD clusters within families
- First-degree relatives of patients with MDD have a threefold increased risk of MDD
- Heritability approximately 35%
- Genetic overlap between MDD and other psychiatric disorders (schizophrenia; bipolar disorder).
What depression symptoms does 5HT mediate
Sex
Appetite
Aggression
What depression symptoms does noradrenaline mediate
Concentration
Interest
Motivation
What symptoms does both 5HT and noradrenaline mediate?
Depressed Mood
Anxiety
Irritability
Thought process
Vague aches and pains
what does low levels of NA and 5HT cause?
MDD
What does high levels of NA and low levels of 5HT cause?
Mania
Three main classes of drugs for mood disorders
Tricyclic antidepressants (TCAs)
Selective NA/5HT reuptake inhibitors (SS/NRIs)
Monoamine Oxidase Inhibitors (MAOIs)
What is the aim of antidepressants?
Strategy is to increase extracellular levels of certain neurotransmitters in the brain,
with varying degrees of selectivity for particular neurotransmitter systems
selectivity determines degree of side effects.
Examples of Tricyclic Antidepressants
Clomipramine
Amitriptyline
Doxepin
Imipramine
Desipramine
-pramine
Uses of TCAs
Depression
Migraine prophylaxis
Neuropathic pain
Obsessive compulsive disorder (Clomipramine)
Enuresis (lack of bladder control)
Panic disorder
Sleep disorders
Attention deficit / hyperactivity disorder
Preferred uses of TCAs
Depression with
Pain
Fibromyalgia
Migraine
insomnia
Adverse effects of TCAs
- Antagonist activity at mACh receptors, histamine H1 receptors and 𝛼1-adrenoceptors.
- The antagonist activity at mACh receptors results in atropine-like side effects
The antagonist activity at histamine H1 receptors causes weight gain, drowsiness and sedation. - The antagonist activity at 𝛼1-adrenoceptors can produce postural hypotension, syncope in some patients and sedation.
- The incidence of these side effects varies with different TCAs. Therefore, TCAs with excessive sedative properties, such as amitriptyline and doxepin, should be avoided in the elderly, who should be prescribed TCAs with less sedative properties such as imipramine or nortriptyline.
What happens during TCA overdose?
Confusion, convulsions, tachycardia, hypotension, ventricular arrhythmias.
Ventricular arrhythmias - death
Treatment of TCA overdose
- removal of the remaining drug in the stomach
anticonvulsant agent (diazepam) - antiarrhythmic drugs and further cardiac
- support to prevent or treat ventricular arrhythmias.
How long does it take for SSRIs to become effective
- 4–6 weeks before a clinically significant antidepressant effect is observed
- during this time, side effects may dissuade patient compliance - importance of patient counselling by pharmacists.
advantages of SSRIs over TCAs or MAOIs
generally better tolerated
possess less anticholinergic and cardiovascular side effects
low acute toxicity in overdose.
Examples of SSRIs
Fluoxetine (Prozac)
Paroxetine (Paxil)
Sertraline (Zoloft)
Fluvoxamine (Luvox)
Citalopram (Celexa)
Escitalopram (Lexapro)
Uses of SSRIs
Depression
Social phobia
Panic disorder
Obsessive compulsive disorder
Bulimia Nervosa
Post Traumatic Stress Disorder
Pre Menstrual Dysphoric Disorder (Sarafem)
Least preferred use of SSRI
Patients with sexual dysfunction
Patients with nocturnal myoclonus
Patients with consistent agitation
Patients with consistent insomnia
Adverse effects of SSRI
Gastrointestinal
Nausea, vomiting, diarrhoea
Sexual dysfunction
Some anticholinergic side effects, especially with paroxetine
Headache
insomnia
Long-term weight gain
Occasional aggressive and violent behaviours.
Fatigue
Akathisia (an inability to remain still) and dystonic reactions
5HT can reduce DA levels
What are the symptoms associated with discontinuation/withdrawal of SSRI
Usually after prolonged treatment
- dizziness,
- nausea,
- headache,
- fatigue,
- flu-like symptoms,
- agitation,
- impaired concentration,
- paraesthesia
- sensations of electric shocks,
- vivid dreaming
- anxiety.
What causes serotonin syndrome?
- Occurs when several serotonergic drugs combined
- Often involves MAOI’s as one of the drugs
- Other serotonergic drugs implicated:
SSRI’s
TCA’s
Serotonin releasing agents (i.e. MDMA or “ecstasy”)
Dextromethorphan, meperidine, others
What are the symptoms of Serotonin Syndrome ?
- Altered mental status – confusion, agitation
- Autonomic dysfunction – diaphoresis, tachycardia, BP changes, fever
-Neuromusucular abnormalities – clonus
How do you avoid Serotonin Syndrome?
Allow 2 weeks between MAOI and other antidepressant administration
- 5 weeks for fluoxetine
do SSRIs cause suicide?
Yes. major risk factor for suicide in children, adolescents and young adults.
WHY:
Discontinuation or withdrawal symptom with an increased risk of suicidal ideation if dose missed.
Especially SSRIs with short half-lives
What SSRIs increase risk of suicide?
SSRIs with short half-lives
how to avoid suicide risk of SSRIs?
- Avoid SSRIs with short half lives
-SSRIs not to be prescribed in children and young adults (apart from fluoxetine which has a long half-life)
When should SNRIs be given?
4-6 weeks before a clinical effect is observed.
How do SNRIs work?
Selectively inhibit NA transporters and block the reuptake of noradrenaline
Indirectly increase 5-HT release by an action at presynaptic 𝛼1-adrenoceptors on 5-HT neurones.
Main SNRI available in the UK
Reboxetine
Side effect of serotonin and 5HT inhibitors
Similar to SSRI
ME some serotonin and NA reuptake inhibitors
Duloxetine and Venlafaxine
Adverse effects of SNRIs
mild atropine-like effects,
tachycardia,
postural hypotension and
sexual dysfunction.
how do SNRIs work?
Inhibit the reuptake of both 5-HT and NA.
Similar side-effect profile to SSRIs
what is Lithium carbonate used for?
Widely used in the past for first-line therapy but generally superseded by antipsychotics.
Mechanism of action of lithium Carbonate
Main MOA unknown
Affects electrolytes and ion transport (Na+)
Affects release of neurotransmitters (5HT, NA, DA)
Affects second messengers and enzymes that
mediate neurotransmitter function.
what is the onset of action for lithium?
Slow onset of action (6-12 months)
- more useful as prophylaxis therapy than treatment of acute phase.
Indications of Lithium carbonate?
- Prophylaxis and treatment of mania
- Prophylaxis of bipolar disorder (manic-depression)
- Concomitant anti-depressant treatment in patients with
- incomplete response to treatment for depression in bipolar disorder.
-Augmenting agent in treatment resistant depression.
Lithium pharmacology?
small monovalent cation
used therapeutically in its salt form.
Related to sodium functionally
mechanism of action is unclear
What does lithium affect?
Affects electrolytes and ion transport (Na+)
Affects release of neurotransmitters (5HT, NA, DA)
Affects second messengers and enzymes that mediate neurotransmitter function.
what is the pharmacotherapy available for Bipolar Conditions
Antipsychotic drugs (olanzapine; quetiapine; risperidone)
First line treatment (NICE guidelines)
Lithium carbonate
Carbamazepine
Valproate
Benzodiazepines (only for acute treatment)
Trazodone (Serotonin antagonist and reuptake inhibitor) MOA
- antagonist at 5-HT1A and 5-HT2 receptors and inhibits the reuptake of 5-HT.
-Inhibition of 5-HT reuptake will further enhance the postsynaptic effects of 5-HT.
Adverse effects of Trazodone?
its main adverse effects include postural hypotension, sedation and weight gain.
Bupropion (Noradrenergic and dopamine reuptake inhibitors) mechanism of action?
main mechanism of action is to inhibit dopamine and noradrenaline transporters and, thereby, block the reuptake of DA and NA
adverse effects of bupropion?
The main adverse effects of bupropion include
- nausea,
- constipation,
- epigastric distress,
- dry mouth agitation
- insomnia.
More serious, but rare, side effects that can occur are the risk of seizures or the induction of psychosis.
When are monoamine oxidase inhibitors used? (MOAs)
Used in patients with atypical MDD/ anxiety
Examples of MOAs
Phenelzine (Nardil)
Tranylcypromine (Parnate)
Cautions to note with MOAs?
Hypertensive crisis can occur when combined with high tyramine foods or sympathomimetics
Aged cheeses, sour cream, wines, beer, canned or processed meats, fermented foods, coffee, chocolate
Amphetamines, ephedrine, other decongestants
MAOI Side effects?
Atropine-like side effects,
- postural hypotension,
- hyperphagia
- weight gain.
What are the problems with the irreversible MAOIs?
The irreversible MAOIs can cause liver damage, and are contraindicated in patients with hepatic impairments.
What is the most important factor to consider with MAOI use?
The most important factor that limits the use of the MAOIs is their potentially fatal interaction with specific foods types that are rich in certain amines, especially tyramine, such as cheese (with the exception of Cottage cheese), yeast products, processed meats, beef liver, broad beans and beer.
They can interact with the MAOIs to cause a hypertensive crisis.
What are the main indications SSRIs are used for
Depression
Social phobia
Panic disorder
Obsessive compulsive disorder
Bulimia Nervosa
Post Traumatic Stress Disorder
Pre Menstrual Dysphoric Disorder (Sarafem)
In which conditions are SSRIs least preferred
Sexual dysfunction
Nocturnal Myoclonus
Consistent agitation
Consistent insomnia
Main drug under the class of Noradrenaline and Selective Serotonin Antidepressants
MIRTAZAPINE
mechanism of MIRTAZAPINE
antagonist at the presynaptic 𝛼2-adrenoceptors and 5-HT2 and 5-HT3 receptors which increases the release of NA and 5-HT
side effect of Mitrazapine
atropine-like effects, postural hypotension, sedation and weight gain. More rarely, it may cause blood disorders (agranulocytosis)
