Mood Disorders Flashcards
Clinical presentation of depression (core)
- Low mood, varies little day to day, unresponsive to circumstances
=reduced range of affect, monotonous voice, minimal facial expression
=diurnal variation may be present, mood worse in mornings - Reduced interest and loss of pleasure in almost all activities that were formerly enjoyed (anhedonia)
- Increased fatigability on minimal exertion (anergia)
-At least 2 weeks of daily
Clinical presentation of depression (other symptoms)
-Biological (somatic, assumed to occur in absence of external environmental cause):
=Early morning wakening (at least 2 hours earlier than usual, impossible to get back to sleep)
=Depression worse in morning (diurnal variation)
=Loss of appetite with weight loss (5% body weight in last month)
=Psychomotor retardation or agitation (slow monotonous speech, long pauses, muteness, bunted affect/ fidgeting, pacing rubbing or scratching)
=Loss of libido
-Cognitive:
=Reduced concentration and memory
=Poor self-esteem
=Guilt
=Hopelessness
=Suicide or self-harm
-Psychotic:
=Delusions (mood-congruent, guilt, worthlessness ill-health, poverty, nihilism, persecution), hallucinations (derogatory)
=Depressive stupor (unipolar, schizophrenia, BPAD)
Questions for depression
-Any history of depression and coexisting mental health or physical disorders
-Any history of mood elevation
-Any past experience of, and response to, previous treatments
-Personal strengths and resources, including supportive relationships
-Difficulties with previous and current interpersonal relationships
-Current lifestyle (diet, physical activity, sleep)
-Any recent or past experiences of stressful or traumatic life events (redundancy, divorce, bereavement, trauma)
-Living conditions , drug (prescribed or illicit) and alcohol use, debt, employment situation, loneliness, social isolation
RISK ASSESSMENT
Sub-types of depression
-Depressive episode
-Recurrent depressive disorder
=80% of those who suffer one depressive episode will have further episodes (lifetime average 5)
=Diagnosed upon 2nd episode
-Dysthymia
=Chronically depressed mood (at least 2yrs)
=Seldom severe enough to satisfy depressive episode criteria
=Common onset in early adulthood
=Onset in later life associated with bereavement or other serious stressor
=patients may develop a depressive episode on a baseline mood of dysthymia (so called ‘double depression’)
-Bipolar affective disorder
=cyclothymia if instability of mood involves only mild elation and mild depression
What is a depressive episode?
Symptoms should be present for at least 2 weeks
At least two of the following core symptoms:
-Depressed mood
-Loss of interest and enjoyment
-Reduced energy or increased fatigability
AND…
Some of the following:
-Disturbed sleep
-Diminished appetite
-Psychomotor retardation or agitation
-Reduced concentration and attention
-Reduced self-esteem and self-confidence
-Ideas of guilt
-Bleak and pessimistic views of the future
-Ideas or acts of self-harm or suicide
Severity
-Mild: Some difficulty in continuing with normal activities
-Moderate: Considerable difficulty in continuing normal activities but still able to function in some domains
-Severe: Unable to continue normal activities
-Severe with psychotic symptoms: In cases with delusions or hallucinations
Epidemiology of mood disorders
-Recurrent depressive disorder
=Lifetime risk 10-25% (women), 5-12% (men)
=Onset late 20s
=2:1 F:M
-Bipolar affective disorder
=1% risk
=20 years
=Equal incidence
-Cyclothymia
=0.5-1%
=Adolescence, early adulthood
=Equal incidence
-Dysthymia
=3-6%
=Childhood, adolescence, early adulthood
=2-3:1 F:M
Pathophysiology of depression
-Genetics – 40-50% heritability (multiple variants of weak effect)
-Early life experiences
=Parental separation
=Neglect, physical and sexual abuse
=Maternal postnatal depression indifferent early upbringing
=Foetal and environmental stressors effect of neuroendocrine system
-Personality
=‘Neuroticism’ (anxious, moody, shy, easily stressed)
=Personality disorders (borderline, obsessive-compulsive)
=Pre-morbid traits/temperaments
-Acute stress (e.g. bereavement, relationship breakdown, redundancy)
-Chronic stress (e.g. poor social support, working from home, raising young children, chronic pain, chronic illness)
-Neurobiology (abnormal brain structure and function)
=Regions involved in emotional regulation
=Neurotransmitter pathways
Differential diagnosis of low mood
-Mood disorders
=Depressive episode
=Recurrent depressive disorder
=Dysthymia
=Bipolar affective disorder
=Cyclothymia, SAD
-Schizoaffective disorder
-Reactive
=Acute stress reaction
=Adjustment disorder (adaption to significant life change or stressful event)
=Normal or abnormal bereavement reaction
-Secondary to a general medical condition (intracranial, extracranial)
-Secondary to psychoactive substance use (including alcohol)!!!
-Secondary to other psychiatric disorders
=Psychotic disorders
=Anxiety disorders!!!
=Adjustment disorder (including bereavement)
=Eating disorders
=Personality disorders!!
=Neurodevelopmental disorders (autism or attention deficit hyperactivity disorder)
=Delirium/dementia
Assessment of depression
-History
=Core symptoms (mood, pleasure, energy and fatigability)
=Biological (worse in mornings, waking, slowed up or restless, sex drive), cognitive (how do you see things turning out in the future, do you ever feel life is not worth living, concentration on fav TV) and psychotic symptoms (hear, smell, feel body is healthy)
=Red flags = self-harm, suicidality, mania
=Hospital Anxiety and Depression (HAD) scale and Patient Health Questionnaire (PHQ-9)
-Examination
=Observations and general examination
=Neurological examination
=Endocrine system examination
-Investigations
=FBC, U&E, LFT, TFT, Ca (check for alcohol in cell volume, hyponatraemia in antidepressants, hypothyroidism in lithium)
=If indicated: CRP (Infection inflammation), B12 and folate, urine drug screen, ECG, EEG, CT
Aims of investigation
-Exclude medical or substance-related causes
-Establish baseline before administering treatment
-Assess renal and liver functioning which may affect elimination of medications
-Screen for physical consequences of neglect(e.g. malnutrition)
Management of depression
-All patients: sleep hygiene, regular physical activity, alcohol and substance misuse, diet
-Mild depression/ persistent sub-threshold symptoms, minimal functional impairment: psychosocial intervention (low intensity), self-help CBT, structured group physical activity
-Moderate/ severe/ mild to marked functional impairment (>16 PHQ-9 score)= psychosocial intervention (high intensity), individual CBT, individual IPT AND antidepressant medication
The Stepped Care Model for depression management
- GP, practice nurse. Recognition through assessment
- Primary care team and mental health worker. Mild depression= watchful waiting, guided self-help, computerised CBT, exercise, brief psychological interventions
- Same, moderate or severe depression= medication, psychological interventions, social support
- Mental health specialists, including crisis teams. Treatment resistant, recurrent, atypical and psychotic depression, significant risk= medication, complex psychological interventions, combined treatments
- Inpatient care, crisis team. Risk to life, severe self-neglect, psychotic, detention under MHA?= medication combined treatments, ECT
Antidepressant choice
-1st line: SSRIs (fewest side effects)
=Sertraline
=Paroxetine
=Citalopram
=Fluoxetine
-Factors:
=Side effects (sedation good or bad, match to lifestyle)
=Previous good response
=Risk for overdose (SSRI safer than TCA)
=Severity of depression (TCA affect noradrenaline and serotonin so preferable in severe depression requiring hospital)
=Atypical depression (hypersomnia overeating, anxiety- MAOIs)
=Comorbid physical health (SSRI worsen hyponatraemia, NSAID, warfarin, heparin, triptan, TCA not in MI or arrhythmia)
=Comorbid mental health (OCD prefer high dose SSRI or clomipramine)
Management options when antidepressant does not work
No response to treatment dose prescribed for 6-8 weeks
=Confirm concordance.
=Confirm duration of treatment and dose (at least 4 weeks at minimum therapeutic dose, longer periods may be required in older adults).
=Reassess the diagnosis: Is depression the cause of their low mood? Are they using alcohol or substances? Do they have a different psychiatric disorder? Is there an ongoing psychosocial stressor?
=Consider psychological therapy, if this is not already in place.
=Increase the dose of the current antidepressant (e.g. increasing fluoxetine from 20 mg to 40 mg).
=Change to another selective serotonin reuptake inhibitor (SSRI; e.g. from fluoxetine to sertraline).
=If trialled two SSRIs, or not appropriate to do so: change to another antidepressant from a different class (e.g. from sertraline (SSRI) to venlafaxine (selective serotonin-norepinephrine reuptake inhibitor) or mirtazapine).
=If adequately trialled at least two antidepressants, consider augmenting the current antidepressant with lithium or another antidepressant, for example, mirtazapine (usually done by a psychiatrist). Antipsychotics can also be used as augmenting agents in treatment-resistant depression. There are many other options.
=Consider electroconvulsive therapy if criteria met
Antidepressant withdrawal symptoms
-Unsteadiness, vertigo or dizziness
-Altered sensations (for example, electric shock sensations)
-Altered feelings (for example, irritability, anxiety, low mood tearfulness, panic attacks, irrational fears, confusion, or very rarely suicidal thoughts)
-Restlessness or agitation
-Problems sleeping
-Sweating
-Abdominal symptoms (for example, nausea)
-Palpitations, tiredness, headaches, and aches in joints and muscles
-withdrawal symptoms can be mild, may appear within a few days of reducing or stopping antidepressant medication, and usually go away within 1 to 2 weeks
-withdrawal can sometimes be more difficult, with symptoms lasting longer (in some cases several weeks, and occasionally several months)
-withdrawal symptoms can sometimes be severe, particularly if the antidepressant medication is stopped suddenly.
Switching antidepressants
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
Switching from a SSRI to a tricyclic antidepressant (TCA)
cross-tapering is recommend (the current drug dose is reduced slowly, whilst the dose of the new drug is increased slowly)
- an exceptions is fluoxetine which should be withdrawn prior to TCAs being started
Switching from citalopram, escitalopram, sertraline, or paroxetine to venlafaxine
cross-taper cautiously. Start venlafaxine 37.5 mg daily and increase very slowly
Switching from fluoxetine to venlafaxine
withdraw and then start venlafaxine at 37.5 mg each day and increase very slowly
