Mood disorders Flashcards
State the 3 types of mood disorder
- Depressive disorder
- Single
- Recurrent episodes - Bipolar disorder
- Mania
- Hypomania
- Mixed - Persistent mood disorder
- Cyclothymia (mixed hypomanic and depressive symptoms, does not reach threshold for bipolar)
- Dysthymia (milder form of depression, not meeting threshold)
State the 3 core symptoms of depression
- Continuous low mood for at least 2 weeks
- Low energy
- Anhedonia (lack of interest / enjoyment)
State some somatic symptoms of depression
- Diurnal variation of mood
- Sleep changes (early morning wake cycle)
- Appetite change (typically reduced)
- Weight change (typically loss)
- Psychomotor retardation
- Loss of libido
State some cognitive symptoms of depression
- Poor concentration
- Low self esteem
- Guilt / hopelessness
- Hypochondriacal thoughts
- Suicidal thoughts
- Negative thoughts
How is severity of depression diagnosed based on symptoms
Mild if:
- 2 core symptoms
- 2 ‘other’ symptoms
- Able to function
Moderate:
- 2 core symptoms
- 3-4 other symptoms
Severe:
- 3 core symptoms
- 4+ other symptoms
+/- psychotic symptoms
State 2 additional symptoms that can present in psychotic depression and what type they are
- Hallucinations
- Often auditory - Delusions
- Guilt
- Nihilistic
- Persecutory
- Hypochondriacal
List some risk factors for postnatal depression
Mental health related:
- Previous postnatal depression
- Personal history of depression
- Family history of depression
Other:
- Older age
- Single mother
- Unwanted pregnancy
- Poor social support
State the prevalence of moderate-severe depression in the UK and the M:F ratio
Approx. 1 in 6 have moderate-severe depression
M:F ratio 1:2 (twice as many females as males)
State the prevalence of bipolar affective disorder in the UK and the M:F ratio
Approx. 1 in 50 = 2%
Average onset 19 years
Higher in black / minority ethnic groups
Equal M:F ratio (1:1)
State how hypomania differs from mania
Hypomania and mania are both periods of over-active and high energy behaviour
However hypomania is:
- milder in terms of symptoms
- typically lasts for a shorter period
- doesn’t cause severe disruption to their life (but can cause considerable disruption still)
- may have partial insight
- less likely to have delusions
List some symptoms of hypomania
- Mildly elevated mood / irritable mood
- Increased energy
- Reduced need for sleep
- Increased libido
- Increased self esteem / self importance
- Inability to focus on single task / distractible
- Increased sociability / talkativeness / overfamiliarity
List some symptoms of mania
ICD 10 requires 3/9 to be present for diagnosis
- Elevated mood / irritable mood
- Increased energy
- Reduced need for sleep
- Increased libido
- Increased self esteem / self importance
- Distractibility
- Restlessness / psychomotor agitation
Additional for mania:
- Pressure of speech (can’t be interrupted)
- Flight of ideas
- Delusions of grandeur
- Loss of inhibitions
- Reckless behaviour
Explain cyclothymia
Milder form of bipolar disease, not meeting threshold
- Mild periods of elation / depression
- Early onset
- Chronic course
- Common in relatives of bipolar disorder
Explain dysthymia
Milder form of depression, not meeting threshold
- More mild depression
- Chronicly low mood
Explain mixed affective state
Characterised by a mixture of rapid alternation between: hypomanic, manic and depressive symptoms (typically within a few hours)
- Considered a subtype of bipolar disorder
Explain how bipolar disorder is classified
Requires at least one mania (or hypomania) episode, with at least one further episode of mania or depression
Bipolar type 1:
- Manic episode with further manic or depressive episodes
Bipolar type 2:
- Multiple hypomanic episodes (not manic)
- Multiple depressive episodes
ICD-10 requires at least 2 episodes, of which 1 must be manic or hypomanic
List some biological, psychological and social risk factors for depression
Biological:
- Genetic
- Previous depression
- Female gender
- Chronic physical illness
Psychological:
- Personality type
- Poor coping strategies
- View of self and the world
Social:
- Stressful life event
- Adverse childhood experiences
- Poor social support
- Lack of employment
- Poor socioeconomic status
- Housing / poverty
List some biological and environmental causes for bipolar disorder
Biological:
- Genetic
- Endocrine or neurochemical disturbance e.g. disruption of HPA axis
Environmental:
- Adverse life events
- Stressful events
- Loss of loved one
- Postpartum period
- Substance misuse
State general bio-psycho-social management options for depression
Biological:
- Antidepressants
- Adjuvants e.g. antipsychotics or mood stabilisers, anti-anxiolytics
- ECT if severe, life-threatening or resistant
- Physical activity
Psychological:
- Psychotherapies e.g. CBT, interpersonal therapy, counselling, psychodynamic therapy
Social:
- Social support groups
State how bio-psycho-social management options for depression changes for mild-mod depression and severe depression
Biological:
- Generally don’t use SSRIs as first line in mild-mod depression (first line in severe, +/- adjuvants)
- Group physical activity groups in mild-mod
- ECT considered only in severe
Psychological:
- Self-help programmes as first line mild-mod (don’t consider in severe)
- Computerised CBT, with psychotherapies down the line in mild-mod (straight to more personalised psychotherapies)
Social:
- Social support groups same for both
- Consider psychiatry referral / MHA in severe
Explain the monoamine hypothesis
States that a deficiency of monoamines (NA, serotonin and dopamine) causes depression
- Supported by antidepressants cause an increase in concentration of these neurotransmitters in the synaptic cleft
- This then improve the clinical features of depression
State some drugs from the following categories that can be used in the pharmacological management of depression
- Antidepressants (types not names)
- Mood stabilisers (names)
Antidepressants:
- SSRIs
- SNRIs
- TCAs
- MAOIs
- Noradrenaline and specific serotonergic antidepressants (NASSAs)
Mood stabilisers:
- Lithium
- Sodium valproate
- Carbamazepine
- Lamotrigine
Briefly outline how ECT works (as if explaining to a patient)
- Treatment involves sending an electric current through the brain
- Causes a brief surge of electrical activity within your brain (seizure)
Aim is to relieve severe symptoms of some mental health problems
List some indications for electroconvulsive therapy (ECT) in mood disorders
- Severe treatment-resistant depressive illness
- Life threatening illness
- Prolonged / severe manic episodes
- Catatonia (abnormal movements) / stupor / severe psychomotor retardation
List some side effects for electroconvulsive therapy (ECT)
Most common (similar to after natural epileptic attack):
- Confusion
- Headache
- Body aches
- Memory loss (short term and long term)
- General anaesthetic risks e.g. MI, arrhythmias, malignant hyperthermia, broken teeth etc.
Suggested the prognosis of depression
80% have further depressive episode
10% severe unremitting depression
Suggest some factors that may indicate a poor prognosis for bipolar disorder
- Early onset (young at first episode)
- Severe symptoms
- Late treatment intervention
- Cognitive deficits
Explain how you diagnose someone with bipolar / how long should each symptom be present for (mania and hypomania)
Exclude organic causes (but depending on presenting symptoms):
- Physical examination including neurological examination / CT head
- Baseline bloods
- HIV
- Toxicology screen
Referral to specialist team:
Bipolar disorder should be considered when there is evidence of:
- Mania (at least 7 days)
- Hypomania (at least 4 days)
- Depression with a history of manic or hypomanic episodes
State the normal range of lithium
Ideally between 0.6 - 0.8 mmol/L
- Minimum effective level = 0.4mmol/L
- Up to 1.0mmol/L may be
used in treating acute mania - Toxic effects reliably occur above 1.5mmol/L
State some symptoms and signs of lithium toxicity
- Diarrhoea
- Vomiting
- Muscle weakness / lethargy / drowsiness
- Dizziness
- Tinnitus / blurred vision
- Coarse tremor of the extremities and jaw
- Dysarthria
State some routine investigations that can be done for individuals presenting with mood disturbances (depression or mania)
- FBC for anaemia
- Thyroid function tests for hypothyroidism
- U&Es for calcium levels
- Toxicology screen (substance misuse)
- Sleep studies (sleep apnoea)
Consider CT/MRI if atypical presentation or unexplained symptoms e.g. headache
State bio-psycho-social management options for bipolar affective disorder
Biological:
- Mood stabilisers e.g. Lithium (sodium valproate 2nd line)
- Antipsychotics
- Benzodiazepines
- ECT if severe, uncontrolled mania
Psychological:
- Psychoeducation and calming activities
- Cognitive-Behavioral Therapy (CBT) or Interpersonal therapy
Social:
- Social support groups
- Self help groups
State the management options for an acute manic episode
First-line: antipsychotic e.g. Risperidone, Olanzapine or Quetiapine (Haloperidol is also effective) - have a rapid onset of action compared to mood stabilisers
- Mood stabilisers can be added as second line e.g. Lithium or Sodium Valproate
- Benzodiazepines can be added if agitation and poor sleep
- Rapid tranquilisation may be required with Haloperidol or Lorazepam
Consider admission to psychiatric unit
State the management options for an acute depressive bipolar episode
- Atypical antipsychotics e.g. Olanzapine or Quetiapine
- Mood stabilisers can be used e.g. Lamotrigine or Lithium
**Avoid antidepressants (risk of causing mania)
State tests that need to be done prior to initiating Lithium
- U&Es to check renal function (for Lithium excretion)
- Thyroid function levels
- Pregnancy test
- Baseline ECG
State the number of hours after Lithium dose should levels be tested
Blood test 12 hours after Lithium has been taken
List some complications of depression
- Suicide (4 Xs higher than without depression)
- Substance misuse & alcohol use problems
- Persistent of symptoms over 2 years
- Recurrence of depressive episodes (majority will have future episodes)
- Reduced quality of life / strained relationships
- Unemployment / homelessness
- Antidepressant side effects e.g. sexual dysfunction, risk of self-harm, weight gain, hyponatraemia and agitation
List some complications of bipolar disorder
- Suicide
- Risk of death by general medical conditions e.g. CVS disease
- Side effects of antipsychotic drugs e.g. metabolic effects, weight gain and extrapyramidal symptoms
- Negative drift down socioeconomic ladder
