Mood disorders Flashcards
two questions screen for depression
‘During the last month, have you often been bothered by feeling down, depressed or hopeless?’
‘During the last month, have you often been bothered by having little interest or pleasure in doing things?’
screening tool depression, how work
Patient Health Questionnaire (PHQ-9)
asks patients ‘over the last 2 weeks, how often have you been bothered by any of the following problems?’
9 items which can then be scored 0-3
includes items asking about thoughts of self-harm
less severe - <16
more severe - same or >16
criteria to grade depression
DSM-IV
criteria grades depression how work
- Depressed mood most of the day, nearly every day
- Markedly diminished interest or pleasure in all, or almost all, activities most of the day, nearly every day
- Significant weight loss or weight gain when not dieting or decrease or increase in appetite nearly every day
- Insomnia or hypersomnia nearly every day
- Psychomotor agitation or retardation nearly every day
- Fatigue or loss of energy nearly every day
- Feelings of worthlessness or excessive or inappropriate guilt nearly every day
- Diminished ability to think or concentrate, or indecisiveness nearly every day
- Recurrent thoughts of death, recurrent suicidal ideation without a specific plan, or a suicide attempt or a specific plan for committing suicide
MILD - >5 for diagnosis (otherwise subthreshold)
MOD
SEV -> most sx, interfere with functioning, with or without psychosis
anhedonia
lack of interest/enjoyment
sx depression
core, somatic, cognitive
core - lack of energy, anhedonia
somatic - loss of libido, early morning waking, diurnal variation of mood, agitation
cognitive - low self esteem , guilt, suicidal, hypochondral
psychotic depression
hallucinations - usually auditory
delusions - hypochondrical, guilt, nihilstic, persecutory
delusions
not based on reality, or individual’s cultural or religious background
less severe management depression
less severe - avoid antidepressant meds unless person’s preference
1st line -> guided self help, CBT, BA, individual CBT, BA, group exercises, mindfulness, IPT, SSRI, counselling, STPP (most ->least)
more severe management depression
1st line - individual CBT + antidepressant
then individual BA, individual problem solving, counselling, STPP, IPT, guided self help, group exercise
switching antidepressants guidlines
Switching from citalopram, escitalopram, sertraline, or paroxetine to another SSRI
the first SSRI should be withdrawn* before the alternative SSRI is started
Switching from fluoxetine to another SSRI
withdraw then leave a gap of 4-7 days (as it has a long half-life) before starting a low-dose of the alternative SSRI
depression over dementia
short history, rapid onset
biological symptoms e.g. weight loss, sleep disturbance
patient worried about poor memory
reluctant to take tests, disappointed with results
mini-mental test score: variable
global memory loss (dementia characteristically causes recent memory loss)
prevalence depression
lifetime prevalence 10-20%
depression risk factors
female
chronic physical health conditions
sx of hypomania
interference for at least several days ->
- mildly elevated mood
- increased energy
- increased self esteem
- sociabke, talkative
- increased sex drive
- reduce need for sleep
- difficulty in focussing on one task alone
sx of mania
- elevated mood
- increased energy, agitated
- gradiosity
- pressure of speech (not make sense)
- flight of ideas
- distractible
- reduced need for sleep
- increased libido
- social inhibitions lost
- psychotic sx
mania v hypomania
mania - at least 7 days, severe functional impairment, require hospitalisation, psychotic sx
hypomania - lesser version, <7 days, high functioning, no psychotic sx or hospitalisation
BPD ddx
-> cyclothymia - mild episodes of elation/depression
early onset, chronic course
common in relatives of BPD
-> emotionaly unstable personality disorder
depression ddx
dysthymia - chronic low mood, not fulfil criteria of depression
define mixed affective state
mixture or rapid alternation of hypomanic, manic and depressive sx
bipolar disorder define
chronic mental health disorder characterised by periods of mania/hypomania alongside episodes of depression
epidemiology BPD
late teens
2%
M=F
2 types of bipolar
type I disorder: mania and depression (most common)
type II disorder: hypomania and depression
ICD classification bipolar
> 2 episodes, one of which must be hypomanic, manic or mixed episode
BPD management
psychological interventions
lithium - 1st line
episode of mania/hypomania - consider stopping antidepressant if on one, start antipsychotic - olanzapine, haloperidol
episodes of depression - talking therapies, fluoxetine
BPD co-morbidites
2-3x increased risk of DM, CVD, COPD
BPD primary care referral
hypomania - routine referral to CMHT
mania or severe depression - urgent referral
electroconvulsive therapy indication
severe depression that is treatment resistant - most common
prolonged, severe manic episode
high suicide risk
caratonia
stupor
psychmotor retardation
short and long term side effects electroconvulsive therapy
headache
nausea
short term memory impairment
memory loss of events prior to ECT
cardiac arrhythmia
some patients report impaired memory
ECT mechanism
electric current through brain to trigger epileptic seizure
rTMS
repetitive transcranial magentic stimulation - repetitive pulses of magnetic energy at a fixed frequency
tDCS
transcranial direct current stimulation = constant low strength current
avoid BPD
antidepressants
BPD prognosis
80% relapse after first episode within 5-7 years
esp if severe episodes or early onset
nature of ECT
small dose of electric current to induct seizures
under anaesthetic and given muscle relaxant - propofol and suxamethonium
frontotemporal region
uni or bilateral
cerebral blood flow increases, hormone changes
neurotransmitter hypothesis - balancing chemical changes in mental illness. increase serotinergic and noradrenergic
unsure tho
monitor Hamilton Depression Rating Scale and Montreal Cognitive Assessment before and after ECT
indications ECT
severe depression
catatonia
mania
schizophrenia
s/e ECT
memory loss, confusion, headache, status epilepticus, stroke, PE, broken teeth, body aches
risks of anaesthesia - Mi, arrthymias, aspiration pneumonia, nausea
c/i ECT
raised ICP, cerebral aneurysm - absolute
MI within 3 mths
unstable angina
acute resp infection
pregnancy
unstable fractures
etc
grief reaction
denial
anger
bargaining
depression
acceptance
atypical grief reaction
delayed grief: sometimes said to occur when more than 2 weeks passes before grieving begins
prolonged grief: difficult to define. Normal grief reactions may take up to and beyond 12 months
insomnia define
difficulty initiating or maintaining sleep, or early-morning awakening that leads to dissatisfaction with sleep quantity or quality. This is despite adequate time and opportunity for sleep and results in impaired daytime functioning.
chronic insomnia criteria
at least 3 nights per week for 3 months or longer
sx of insomnia
decreased daytime functioning, decreased periods of sleep (delayed sleep onset or awakening in the night) or increased accidents due to poor concentration
insomnia risk fx
Female gender
Increased age
Lower educational attainment
Unemployment
Economic inactivity
Widowed, divorced, or separated status
Alcohol and substance abuse
Stimulant usage
Medications such as corticosteroids
Poor sleep hygiene
Chronic pain
Chronic illness: patients with illnesses such as diabetes, CAD, hypertension, heart failure, BPH and COPD have a higher prevalence of insomnia than the general population.
Psychiatric illness: anxiety and depression are highly correlated with insomnia. People with manic episodes or PTSD will also complain of extended periods of sleeplessness.
insomnia investigations
sleep diaries and actigraphy
polysomnography
management insomnia
identify causes
advise driving advice
sleep hygeine
only consider hypontics if daytime impairment severe (zopiclone)
seasonal affective disorder
escribes depression which occurs predominately around the winter months. SAD should be treated the same way as depression, therefore as per the NICE guidelines for mild depression, you would begin with psychological therapies and follow up with the patient in 2 weeks to ensure that there has been no deterioration. Following this an SSRI can be given if needed.
