Mood Disorders Flashcards
was there a big increase in depression post pandemic?
yes
what is the epidemiology of depression?
common, 1 in 20 per year
occurs 2x as often in women as it does in men
onset typically in mid-late 20s for all ages races, socioeconomic and ethnic groups
what is the prevalence of depression in primary care?
6-8% but diagnosis if missed in up to 50% of cases
outline the morbidity of depression
3rd most common disorder so high
but this is not reflected in the amount of services available
what are mood disorders?
pathological change of mood state - mania/depression
outline depression
depressed mood - diurnal variation
anhedonia (diminished interest)
anergia (lack of energy)
outline the symptoms of depression
-appetite and weight loss
-sleep disturbance
-psychomotor agitation/retardation
-reduced concentration and cognitive impairment
-feelings of worthlessness/guilt
-recurrent thoughts of deaths/suicide
what do the symptoms need to be to warrant a diagnosis?
present for most of the time on most days for at least 2 weeks
the symptoms are a change from previous functioning
no identifiable organic cause - like a normal reaction to the death of a loved one, or superimposed on schizophrenia
how does the ICD10 classify depression?
key symptoms (2+) :
- persistent low mood
- loss of interest/pleasure
- fatigue
then assess:
- disturbed sleep
- poor concentration
- low self confidence
- poor/increased appetite
- suicidal thoughts
- guilt
how does the DSM 5 classify depression?
5+ of the following over a 2 week period:
- depressed mood
- diminished interest or pleasure in activities
- weight loss or increase appetite
- insomnia/hypersomnia
- psychomotor agitation/retardation
- recurrent thoughts of suicide
why is diagnosis of depression quite challenging?
there are quite a few different symptoms and 3 types of classification of symptom clusters
what are the different categorisations of depression?
bipolar-unipolar
melancholic-non-melancholic
enodgenous-reactive
typical-atypical
psychotic-non-psychotic
what did the STAR*D study show?
study to show depression is not a consistent syndrome
they found 1013 unique symptom profiles
most common symptoms only accounted for 2% of cases
what type of symptoms do some people with MDD (major depressive disorder) experience ?
some have increase in negative emotions, others have LOSS of positive emotions
what are some negative mood states associated with ‘distress’ in MDD
fear, anxiety, irritability, loneliness, guilt, disgust, hostility, pessimism
what are some positive mood states associated with decreased well-being in MDD
pleasure, happiness, interest, motivation, energy, enthusiasm, alertness, self-confidence
what do most drugs targeting depression not do?
bring back the positive emotions
outline psychotic symptoms
delusions:
- false fixed beliefs which persist despite evidence against them
- usually ‘mood congruent’
- poverty, nihilistic, persecution, guilt
outline hallucinations
sensory experience in absence of an external/objective sensory correlate
occur in any sensory modality
second person auditory hallucination most common (talking to person ‘you are worthless, kill yourself’
what % of depressed patients commit suicide?
10-15%
what is the aetiology of depression?
genetic - greater incidence in 1st degree relatives, twins, enivronmental influences
monoamine hypothesis
neuroendocrine dysfunction
neurodevelopmental
inflammatory theories
very complex - NO SINGLE CAUSE
what types of antidepressants are there?
SSRI (fluoxetine, sertraline)
NRIs (reboxetine) NDRIs (bupropion)
SNRIs (venlafaxine)
TCAs (amitriptyline)
MAOIs (phenelzine)
what is the guide for antidepressants?
first line treatment for moderate/severe MDD or depression that has persisted for 2 yrs
mild depression = psychological treatment is better
NOT first line treatment for short-duration sub-threshold depression
how do you choose an appropriate antidepressant?
match drug to patient
choose drug better tolerated and safer in overdose like SSRI
TCA used if first line drug has failed
some people are hopeless and think none of them will work - need to guide people in this choice
what are some special factors to consider when prescribing an antidepressant?
-patient preference
- comorbid psychiatric disorders
-previous treatment response
-tolerability and adverse effect of previous drug
-likely side effects
-overdose
-interaction of current medicine
what is the duration of trialing antidepressant treatment?
if there is not significant improvement after 2-4 weeks, it reduces the probability of a sustained response
after 4 weeks if response is adequate, continue treatment for another 4, if there isnt, undertake next step treatment
what does the delayed onset of action of antidepressants mean?
it is not clear when to change dose or change drug
what also needs to be addressed alongside treatment?
social factors which are maintaining the depression - help patient address these
- symptoms may prevail if this is not adressed
what % of people respond to medication?
60%
what are the 3 drug treatment options which are ‘next step’ if current treatment doesnt work?
dose increase
switch antidepressants
augmentation/combination treatment
does increasing the dose actually have an effect?
limited evidence supporting the efficacy of increasing dose but it is considered if patient has limited side effects, there has been some improvement
if current antidepressant has possible dose-response e.g venlafaxine
can you switch antidepressant abruptly?
yes unless there is potential drug interaction in which case follow recommended taper/washout period
switch within or between antidepressant classes
is there evidence for difference in efficacy between antidepressants?
there is evidence but the effect size is small
meta analysis shows venlafaxine, and sertraline are better in comparison to second generation antidepressants
what hormone do a lot of the antidepressants target?
serotonin
what is used as adjunctive pharmacotherapy in depression?
antipsychotics
even if person is not psychotic
what are types of psychotherapy used in depression?
CBT
interpersonal therapy (IPT)
supportive psychotherapy
psychodynamic psychotherapy
what social factors need to be addressed in depression?
unemployment
financial difficulty
relationship difficulty
alcohol/illicit substance misuse
what are emergency treatments for depression?
ketamine
psilocybin
prodopaminergic neurones (pramipexole)
what is the lifetime prevalence of depression?
17%
what is the rate of recurrence of depression?
80%
outline bipolar disorder
mood disorder of both mania and depression often with psychotic symptoms
episodes occur one after another separated by intervals of remission (euthymia)
reduction of 9 years in lifespan and 14 years of working
15-20% suicide rate
outline the symptoms associated with mania
elevated/irritable mood
inflated self esteem/grandiosity
decreased need for sleep
more talkative
racing thoughts
distractible
increase in activity/agitation
increased involvement in pleasurable activities
what is the difference between bipolar type 1 and type 2 (according to DSM)
type 1 - mania with/without depression
type 2 - have to have depression as well as mania
how does the ICD10 claffisy bipolar?
mood episode specified as depressed, manic or mixed
severity
presence of psychotic symptoms
what is the epidemiology of bipolar disorder?
common
rates in men and women are equal
90% onset before 30 years old
what is the occurrence of bipolar in primary care?
1-2% of patients have bipolar, diagnosis is often delayed by 5-10 years
what is the burden of symptoms in bipolar disorder?
patients are symptomatic half of their lives, 32% depressed 9% manic
what is the burden of bipolar disorder for a person?
hey lose 9 years of life, 12 years of normal health and 14 years of work activity
what is the aetiology of bipolar
complex and biological arguably
genetic studies show greater incidence in 1st degree relatives and twins.
monoamine hypothesis (5-HT, NA, DA)
environmental influences too
what do family twin and adoption studies show in bipolar
there is not one single gene
complex inheritance patterns
increased risk in 1st degree relatives
more likely to develop in identical twins than not
polygenetic model
what is the neuropathology of bipolar
these studies are in their early days
various temporal lobe, cortical and cytoarchitectural abnormalities - lack of gliosis (more/larger glial cells)
imaging studies inconclusive but show ventricular enlargement, hippocampus damage
what are biological treatments for bipolar disorder?
lithium
anticonvulsants - valproate, carbamazepine
antidepressants (uncertainty over effectiveness)
antipsychotics e.g clozapine
what to do during manic episodes if someone is not already having long-term treatment?
oral administration of dopamine antagonist or valproate/lithium
to promote sleep - GABA modulating drugs
drugs for depressed should be tapered and not used in a manic episode
what do to during acute manic episode for someone taking long term treatment?
ensure highest well-tolerated dose of current treatment
check serum concentration of lithium if thinking of increasing dose - 0.6/0.8mmol/L - higher carry long term risk
what should be considered for manic episodes if there is an inadequate response to first line medication?
combine lithium/valproate with dopamine antagonist
electroconvulsive therapy for those who prefer it/ whos mania is particularly severe
is bipolar treatment limited?
yes there are 6/7 main treatments compared to around 35 for depression
what should be administered in bipolar for acute depressive episodes in people not already taking long-term treatment
antidepressants have not been adequately studied in bipolar - only olanzapine/fluoxetine has specific treatment
antidepressants should be co-prescribed with drug for mania
ECT for those with high suicide risk, psychosis, treatment resistance
what should be administered for bipolar disorder for acute depressive episodes while taking long-term treatment
ensure current treatment is likely to protect person from manic relapse long term
check lithium concentrations are in therpaeutic range
address current stressors
long term prevention is key to treatment
