Mood Disorders Flashcards
Clinical presentation of depression (core)
- Low mood, varies little day to day, unresponsive to circumstances (persistent)
=reduced range of affect, monotonous voice, minimal facial expression
=diurnal variation may be present, mood worse in mornings
=characterised by feelings of sadness, emptiness, or hopelessness for the majority of the day, nearly every day - 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)
=Insomnia (difficulty falling asleep or maintaining sleep) or hypersomnia (excessive sleeping)
=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, decision making
=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: adequate social support, aware of sources, self-harm and suicide
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
Medical differentials of depression
-Thyroid Disorders: Hypothyroidism, in particular, can mimic depressive symptoms such as fatigue, weight gain, and mood changes.
-Neurological Disorders: Conditions such as Parkinson’s disease and multiple sclerosis may have depressive symptoms as a feature of the disease or as a reaction to the diagnosis.
-Chronic Pain Syndromes: Depression can be both a cause and a consequence of chronic pain, complicating the clinical picture.
-Nutritional Deficiencies: Particularly deficiencies in vitamin B12, folate, and vitamin D can present with depressive symptoms.
-Endocrine Disorders: Such as Cushing’s syndrome or Addison’s disease, which affect hormone levels and can lead to mood disturbances.
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, severity: 0-7 normal, 8-10 borderline, 11+ case/14) scale and Patient Health Questionnaire (PHQ-9, 9 questions scored 0-3). Less severe depression encompasses subthreshold and mild depression, and more severe depression encompasses moderate and severe depression. Thresholds on validated scales were used in this guideline as an indicator of severity
a score < 16 on the PHQ-9: less severe depression
a score of ≥ 16 on the PHQ-9: severe depression
-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
Major Depressive Disorder (MDD) DSM-5 Criteria
Five (or more) of the following symptoms have been present during the same 2-week period and represent a change from previous functioning; at least one of the symptoms is either (1) depressed mood or (2) loss of interest or pleasure.
Depressed mood most of the day, nearly every day, as indicated by either subjective report (e.g., feels sad, empty, hopeless) or observation made by others (e.g., appears tearful). (Note: In children and adolescents, can be irritable mood.)
Markedly diminished interest or pleasure in all, or almost all, activities most of the day, nearly every day (as indicated by either subjective account or observation).
Significant weight loss when not dieting or weight gain (e.g., a change of more than 5% of body weight in a month), or decrease or increase in appetite nearly every day. (Note: In children, consider failure to make expected weight gain.)
Insomnia or hypersomnia nearly every day.
Psychomotor agitation or retardation nearly every day (observable by others, not merely subjective feelings of restlessness or being slowed down).
Fatigue or loss of energy nearly every day.
Feelings of worthlessness or excessive or inappropriate guilt (which may be delusional) nearly every day (not merely self-reproach or guilt about being sick).
Diminished ability to think or concentrate, or indecisiveness, nearly every day (either by subjective account or as observed by others).
Recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation without a specific plan, or a suicide attempt or a specific plan for committing suicide.
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
Treatment options for depression in order of preference
guided self-help
group cognitive behavioural therapy (CBT)
group behavioural activation (BA)
individual CBT
individual BA
group exercise
group mindfulness and meditation
interpersonal psychotherapy (IPT)
selective serotonin reuptake inhibitors (SSRIs)
counselling
short-term psychodynamic psychotherapy (STPP)
Treatment options for severe depression in order
a combination of individual cognitive behavioural therapy (CBT) and an antidepressant
individual CBT
individual behavioural activation (BA)
antidepressant medication
selective serotonin reuptake inhibitor (SSRI), or
serotonin-norepinephrine reuptake inhibitor (SNRI), or
another antidepressant if indicated based on previous clinical and treatment history
individual problem-solving
counselling
short-term psychodynamic psychotherapy (STPP)
interpersonal psychotherapy (IPT)
guided self-help
group exercise
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
