Mood disorders Flashcards
What is Mood?
A pervasive and sustained emotion (feeling) that influences a person’s behavior and colours their perception of being in the world.
Why is it important to assess for depression?
> Significant impact on individual and society.
Affects relationships, employment, future.
Peak incidence 30 y/o – NB time in career, life partner, etc.
Lifetime prevalence of 10%; average duration of 3/12; episodic course
Which biological factors can cause MDD?
- Biological Factors:
-The monoamines (noradrenalin, serotonin, dopamine most implicated in MDD).
-Not a simple deficit.
-Drugs that ↑ these neurotransmitters treat MDD.
-Immunological disturbance.
-HPA overactivity is common but not diagnostic.
-Thyroid axis activity changes may play a role, as well as second messenger systems, growth hormone, and prolactin.
What genetic factors cause MDD(Major depressive disorder)?
Genetic factors
-Mood disorders are heritable but only ↑ the risk.
-Concordance in monozygotic twins is 70-90%, and in dizygotic twins it is 16-35%.
- MDD and bipolar disorder may have similar causative genes.
What psychosocial factors cause MDD?
-Life events and environmental stressors
-Personality factors
How do you diagnose MDD?
Diagnostic and Statistical Manual 5 TR criteria – main method of diagnosis.
-Mnemonic to remember the 9 criteria: M SIGE CAPS (Mood, Sleep, Interest, Guilt, Energy, Concentration, Appetite, PSM agitation/retardation, suicidality)
-Must meet at least 5 criteria, at least one of which being MOOD or INTEREST (screening tool)
TIPS:
-Ask questions without sounding like ticking off a checklist.
-Try to understand the person’s experience.
-Use open and closed-ended questions, empathic and validating statements, and summarizing statements for clarification and correction.
-Be non-judgmental.
Sibu, 28 y/o woman, 1st year registrar.
Presented with few weeks hx fatigue, inability to keep up with peers at work. Wonders if something physically wrong with her vs MDD.
Broke up with long-term boyfriend few months ago
Referred to you by GP as psychiatry intern.
What questions would you ask Sibu?
Screen for commonly comorbid conditions and possible other diagnoses e.g., manic/hypomanic episodes, anxiety, eating disorders, substance-use (OTC, prescribed, illicit)
You gather a Hx and MSE from Sibu:Started 2 months ago – tired and sad at end of the day, didn’t want to do anything except eat and sleep. Thought she was missing her ex, but now feels terrible. Can barely get out of bed; can’t focus at work. Used to love seeing patients, now feels like never will be a good doctor. Doesn’t want to die but sees no hope for the future.
MSE: kempt, poor EC, dysphoric, preoccupied with failures. What is the course and prognosis of MDD?
-Mood disorders tend to have long courses and individuals tend to have relapses.
-Untreated major depressive episodes last around 6 – 13 months and treated episodes about 3 months.
-As individuals have more and more episodes, the time between episodes tends to decrease and the severity of each episode tends to worsen.
What is the next step after taking Hx?
-Rule out medical and psychiatric conditions that can mimic MDD, e.g.,
-Hypothyroidism, MS, OSA
Substances – stimulant withdrawal, ETOH
-Bipolar illness/other depressive disorders (adjustment disorder, persistent depressive disorder)
-Grief/bereavement/normal sadness
MEDICAL, SUBSTANCES, PSYCHIATRIC, NORMAL
-MEDICAL: can cause psychosocially or pathophysiologically (MDD a diagnosis of exclusion)
-Take a psychiatric, medical, and family history.
-Conduct a thorough physical examination.
What investigations can you do to help you rule out other causes of depression other than MDD?
-TSH (if Sx of hypothyroidism)
-FBC (if Sx of low energy or anaemia)
-B12 and folate
-Baseline electrolytes to ensure no abnormalities
-Urine toxicology
-Others as appropriate (syphilis serology, HIV, CTB, EEG etc.)
How does substance use relate to MDD?
- Substance use or withdrawal can cause, exacerbate, or be used in response to MDD.
-Do the Sx of MDD predate or persist beyond acute intoxication or withdrawal?
-Are the Sx more significant than would be expected for the type and quantity of substances used?
Types of substance:
-Prescription drugs: Long list, especially interferon, steroids, clonidine, methyldopa
-Roaccutane, varenicline – mixed evidence
-COC, beta-blockers likely not associated
-Alcohol-use, stimulant withdrawal.
What would differentiate MDD from a normal reaction to grief/ negative event?
Grief/bereavement – symptoms overlap but unlikely to suffer from worthlessness, guilt, or hopelessness unless related to the loss specifically.
-Be careful not to over or under-diagnose.
-The goal is to treat symptoms, not take feelings away.
How do you treat MDD?
-Use a biopsychosociocultural approach –management will depend on resources available where practicing.
-Rule out (or in) acute suicidality.
-Specify if mild, moderate or severe MDD (subjective – number and severity of symptoms and degree of impact on life and functioning).
-Sibu: finds Sx distressing but has been mostly able to cope at work = mild.
What types of psychotherapies could help you manage MDD?
- CBT(Cognitive behavioural therapy).
- IPT( Interpersonal therapy)
- Mindfulness-based CBT.
What are the benefits of using CBT to manage MDD?
- Standardized therapy: aims to correct cognitive distortions.
- Logical analysis and reinterpretation of automatic thoughts.
- Group or individual therapy.
- Good evidence for it.
What are the benefits of using interpersonal therapy(IPT) to treat MDD?
- Problem-focused.
- Current relationships and interpersonal events that contribute to and maintain depression are addressed.
What are the benefits of using Mindfulness-based CBT?
- Traditional CBT methods+ mindfulness and meditation.
- Mindfulness: Focus on awareness of all incoming thoughts/feelings.
- Accepting them without attaching judgment.
- Best for the maintenance.
You gather a Hx and MSE from Sibu: Started 2 months ago – tired and sad at end of the day, didn’t want to do anything except eat and sleep. Thought she was missing her ex, but now feels terrible. Can barely get out of bed; can’t focus at work. Used to love seeing patients, now feels like never will be a good doctor. Doesn’t want to die, but sees no hope for the future
-MSE: kempt, poor EC, dysphoric, preoccupied with failures
How would you manage Sibu?
-Sibu has mild depression and relatively preserved functioning, so you propose psychology monotherapy.
-Because of her negative cognitions and cognitive distortions, you recommend CBT for her, which she is happy to try.
-There is a long waiting list for CBT in your area, so Sibu asks if she can try medication for now.
When is admission indicated in MDD?
Clear indications for admission are:
- Suicidality
- Homicidality
- Inability to care for self (food/shelter)
- The need for diagnostic clarity
5.A history of rapidly progressive symptoms and poor social support.
How do you pharmacologically manage MDD?
- Indicated in moderate-severe depression or mild depression in certain circumstances (E.G Patient preference, no access to therapy, poor response to therapy).
- Group of antidepressants:
- SSRIs: Fluoxetine, Citalopram, Escitalopram, Sertraline.
-SNRIs: Venlafaxine & Duloxetine.
-Atypical agents: Mirtazapine & Bupropion.
-TCAs & Tetracyclics: Amitriptyline, Nortriptyline, Imipramine & Mianserin.
-Serotonin modulators: Trazodone & Vortioxetine.
MAOIs: Phenelzine & Selegiline.
What adverse effects do SSRIs have?
Serious life-threatening (but uncommon):
- Serotonin Syndrome
Cluster of life-threatening Sx caused by significantly elevated serotonin (agitation, anxiety, restlessness, disorientation, diaphoresis, pyrexia, tachycardia, N/V, tremor, rigidity, hyperreflexia, myoclonus, dilated pupils, dry mm, flushed skin, etc.)
Can occur with SSRIs only, but usually only occurs when co-administered with another serotonergic agent e.g., SSRIs + MAOIs, or 2 x SSRIs - Suicidality
-ADs do not increase the risk of completed suicide but may increase the risk of the development or worsening of suicidal thoughts and behaviors in children, adolescents and young adults up to 24 years old.
-Black box warning of such
– important to counsel younger individuals.
But remember: one of the biggest causes of suicide is MDD and ADs are currently one of the most effective ways to treat MDD.
What side-effects do SSRIs have?
Less serious (but common):
-Headache (transient)
-Increased activation/anxiety (transient)
-LOA, GIT upset (transient)
-Sexual dysfunction (usually resolves with AD withdrawal)
-QTc prolongation (improves with AD withdrawal)
- Hyponatraemia (improves with AD withdrawal)
-Bleeding (improves with AD withdrawal)
-Abrupt discontinuation can cause discontinuation effects
»Counsel patients not to abruptly discontinue antidepressants.
SSRIs are mostly used now in the public sector. What other Anti-depressants can be used with fewer side effects?
- Bupropion: fewer sexual side-effects, caution if eating disorder/seizure disorder, activating (so can cause anxiety and insomnia).
- Mirtazapine: fewer sexual side effects, sedating and increases appetite so good if Sx of insomnia and LOA, but can cause weight gain.
Sibu has some questions:
How long does an antidepressant take to work?
How long must she take it for?
What if she has a poor response? What next?
Antidepressants take 2-4 weeks or longer to impact mood; but some efficacy (e.g., improved energy levels) should be evident after 1-2 weeks.
Once symptoms resolved, antidepressants must be continued for 6-12 months, or 2 years + if multiple episodes.
Poor response options (do one thing at a time!):
1. Optimize does (increase)
2. Switch to another antidepressant
3. Combine/augment (add another AD/add a different Rx)
What initial monitoring is required in managing MDD?
- Those newly on ADs should be reviewed after 1 – 2 weeks and then 2 – 4 weekly for early response, S/Es and adherence.
- Always enquire specifically about these three factors. - Further monitoring depends on case complexity, medical/psychiatric comorbidity, suicide/other risk, depression severity, and degree of functional impairment.
-Always watch for a manic switch.
Sibu has some questions:
What is the likelihood that an antidepressant will work?
- The STAR * D trial showed that 28% of individuals achieve complete remission after the first AD.
- An additional 25% of the remaining individuals achieve remission after the second trial (i.e., 53% in remission after 2 x sequential AD trials).
- Thereafter, switching vs augmenting didn’t really change the likelihood of remission (a further +/- 18%).
- The more trials needed, the less likely to achieve remission (about 10.3% at the 4th trial).
- There is no way to predict who will respond at what point.
What will you tell Sibu?
What drug will you choose for her?
- Discuss common and serious side effects/adverse effects.
- Will need to take the medication for 2-4 weeks or longer before she experiences a change in her mood.
3.She will need regular follow-up after starting the AD; more regularly if any suicidality.
-Most SSRIs and SNRIs have similar efficacy; SSRIs tend to be better tolerated.
Therefore, you decide together that citalopram 20mg will be an appropriate agent to start.
What are neurostimulation Therapies?
The use of electrical currents or magnetic fields applied to the brain to cause stimulation of the neurons.
Include:
-Electroconvulsive therapy (ECT).
-Repetitive transcranial magnetic stimulation (rTMS).
-Deep brain stimulation (DBS).
-Vagal nerve stimulation (VNS).
What is ECT(Electroconvulsive therapy)?
- Application of electrical current to the brain to induce a therapeutic seizure.
-Use of informed consent (if capacity), and anaesthesia and muscle relaxant medication to prevent a motor seizure.
-Indications: highly effective in MDD – 80-90% remission; 50-60% remission in treatment-resistance + it works quickly.
- The main side effects are antero- and retrograde amnesia, nausea and headache.
-Therefore, reserved for life-threatening depression (psychotic depression, suicidality, catatonia/unable to care for self), those with a prior good response to ECT/patient preference, and treatment-resistant depression.
What is rTMS(Repetitive transcranial magnetic stimulation ?
-Uses a magnetic field to induce electrical currents in the brain.
-Main difference to ECT – can target specific brain regions, does not cause memory impairment, does not require anesthetic.
-But: not as effective as ECT (25-30% response rate)
As it is better tolerated but less effective than ECT, it is second-line for treatment-resistant MDD
Would you use Deep brain stimulation(DBS) & Vagal nerve stimulation(VNS) to manage MDD?
DBS is invasive, requires surgery.
Both are experimental still and rarely used.
Complimentary and alternative medications (CAMs): healthy diet, exercise, and sleep schedule should be encouraged in all individuals.
What is the main difference between Bipolar & Bipolar 2?
Bipolar 1 disorder – manic episode(s) (usually also hypomanic and depressive episode(s))
Bipolar 2 disorder – hypomanic and depressive episode(s)
Describe the epidemiology of Bipolar 1 Disorder.
-Lifetime prevalence 0.7 – 1%
-M=F
-Mean age of onset 30s (wide range)
-Commoner in those with a higher SES
-Comorbidity is common and worsens the prognosis
Explain the diagnostic criteria for a manic episode of Bipolar.
- A specific period of persistent and abnormal change in mood (elevated/expansive/irritable) AND increased energy/activity lasting at least ONE WEEK (or any period if hospitalization required)
- During this period, THREE of the following must be present (FOUR if mood is only irritable):
Mneumonic: DIG FAST.
-Distractibility (poor attention)
-Indiscretion (in spending, sexual activity, etc.)
-Grandiosity (inflated self-esteem)
-Flight of ideas (racing thoughts)
-Activity increased (GDA or agitation)
-Sleep need decreased (NOT insomnia)
-Talkativeness increased
Manic episode- Diagnostic criteria 2.
- Symptoms are severe enough to cause marked impairment in functioning, or require hospitalization, or there is psychosis.
- Not due to a substance or another medical condition.
Describe the diagnostic criteria for the hypomanic episode of Bipolar.
- A specific period of persistent and abnormal change in mood (elevated/expansive/irritable) AND increased energy/activity lasting at least FOUR DAYS
- During this period, THREE of the following must be present (FOUR if mood is only irritable):
Mneumonic: DIG FAST.
-Distractibility (poor attention)
-Indiscretion (in spending, sexual activity, etc.)
-Grandiosity (inflated self-esteem)
-Flight of ideas (racing thoughts)
-Activity increased (GDA or agitation)
-Sleep need decreased (NOT insomnia)
-Talkativeness increased
Hypomanic episode-diagnostic criteria 2.
-There is a definite change in functioning for that person.
-The change in mood and functioning is observable by others.
-The episode is NOT severe enough to cause marked impairment in functioning, or require hospitalization.
-If there is psychosis – it is a manic episode.
-The change is not due to substances or another medical condition.
Explain the diagnostic features of Bipolar 1 disorder.
-Characterized by recurrent mood episodes.
-The mood is often described as euphoric, excessively happy, high, excited, fantastic, “up”, “on top of the world”, or else is predominantly irritable (easily angered).
-The mood is often infectious to those around the patient (including the clinician) – a helpful clue.
-Rapid mood shifts often occur (from euphoric to irritable to dysphoric).
-The individual often feels as if he/she can accomplish anything and often engages in multiple overlapping tasks that are rarely completed, often through the night.
-Insight is usually very poor
Explain the course & Prognosis of Bipolar 1 disorder.
-About 75% of bipolar 1 disorders start with a depressive episode.
-Most patients experience both manic and depressive episodes; 10 – 20% experience only manic episodes.
-Manic episodes tend to have a rapid onset (hours to days), but may evolve over a few weeks.
-Untreated manic episodes tend to last about 3 months.
-After an index manic episode, 90% will go on to have a second episode.
-The prognosis is poorer than in MDD – a third of patients will have chronic symptoms and significant social decline.
How do you treat Bipolar mania?
-For acute severe mania: a second-generation antipsychotic or a mood stabiliser or both (preferably).
-SGA options: risperidone, olanzapine, quetiapine, aripiprazole, (haloperidol).
-Mood stabiliser options: lithium, valproate.
-If there is no/a poor response over 1-3 weeks, switch the mood stabilizer or the antipsychotic.
- If no/poor response to 4-6 different treatment combinations, consider ECT or clozapine (either clozapine monotherapy or clozapine + lithium/valproate).
-Treat agitation and lack of sleep with benzodiazepines temporarily, while giving the treatment time to work e.g., clonazepam or lorazepam.
How do you treat Bipolar depression?
-Psychopharmacology is the cornerstone of treatment, often with adjunct psychotherapy.
-Antidepressants are often unhelpful and may cause rapid cycling and/or manic switch.
-First line: quetiapine monotherapy.
-Second line (if no/poor response or poorly tolerated):
Olanzapine + fluoxetine
Valproate
Quetiapine + lithium/valproate
Lithium + valproate/lamotrigine
