Mood disorders Flashcards
epidemiology
depression: F>M (2x);
10-20% gen pop lifetime prevalence; 5% (1/4 major depression; 10% of cases referred (2o care), 0.1% Ax
bipolar: lifetime risk 1%; M=F; average age 21y
more stats in notes
depression - aetiology
biological: genetics (40%; more with more severe); illness, substances, hormones (postnatal), brain changes
- brain: frontal lobe, limbic, neuroplasticity, NT (low NA/5HT/DA)
psych: negative thoughts, PDT, learned helplessness
social: stressors, isolation, breavement/loss, childhood (e.g. abuse), social adversity
depression - prognosis
50-60% recover, 10-25% chronic (>2y)
recurrence: 85% lifetime risk; 25%
depression - Dx criteria
add least 2 core symptoms
more than 2 weeks
depression - features
‘DEPRESSION’;
Core: persistent low mood; anhedonia (interest/enjoyment), anergia
cognitive: concentration, memory, motivation; self-esteem, confidence, worthless; guilt, hopeless, helpless; DSH/SI
biological: sleep (EMW, insomnia/hypersomnia, repeated waking), appetite and weight (?carbs); somatisation; diurnal (AM worse); psychomotor; libido; blunted affect
mania - Dx criteria
elevated/irritable mood >1/52 and 3+ of:
- decreased sleep
- grandiosity/self esteem
- pressured speech
- flight of ideas
- distractible
- psychomotor agitation/goal-directed activity
- risky/disinhibited behaviour
mania - features
> 1/52 or Ax needed
elevated/irritable mood; labile;
increased energy, decreased sleep
disinhibition, libido, grandiosity, risky behaviour
distractible, flight of ideas, rapid thinking
impaired function
DSH/SI stats
depression 5-15% suicide; BAD 10%; schiz 4-10%
alcohol 15%
SI: leading CoD 15-44 (esp. M); hanging (M), poison (F)
peaks in spring, economic depression, prominent media coverage
DSH: F>M (2x); divorced>single>widow>married
2/3
DSH/SI - RF
fixed: male, young/old, LGBTQ, prisoner, unemployment, occupations, socioeco class, immigrant/refugee, poor support/isolation
clinical: psych/physical illness (90% of psych; 25% already known); substances; PMH (DSH 50%; 100x), FHx; stressors
DSH/SI - immediate Mx
history: before during after (intent, discovery, final acts); current MSE/plans, protective factors
Risk + MSE; ?IP/MHA
reduce access, support, modify RFs (illness, social function, crisis planning)
acute mania Mx
environment: ?Ax; less stimulating, control/structure, delay decisions
check current meds and dose/compliance: ?increase dose, ?combo (APD/MS)
bio: stop ADD, start APD (olanz best); mood stabiliser (L/V); ?BZD
psychsocial: education
BPS Mx
history/collateral, ?MHA/MCA, levels, ?tranq
location and team: CRHT, EIP, IP, CMHT
investigations
BPS approach
follow-up
risk assessment
coping mechs: alcohol and drugs;deterioration
SI/DSH/neglect; dependents
reputation, disinhibtion/impulse control, grandiosity, exhaustion
risk from others: aggravation
elderly: comorbidity, access, bereavement, support, suicide
*DSH >65yo = Ax (intention)
adjustment reaction
reaction to stressors
onset
bereavement?
phases of grief
grief counselling: facilitate progression
psychotic depression
delusions: mood congruent; nihilistic, worthless, guilt, ill health, poverty, imminent disaster, may be persecutory
hallucinations: olfactory (rotting), auditory (2nd person; defamatory/accusatory)
depression severity
number of symptoms and functional impact: subthreshold 20: severe; ADD + PT
Low mood DDx
organic: delirium, dementia, SOL, substances, hypothyroid, anaemia, metabolic, hyperCa, infection, meds, pain
psych: depression, dysthymia, BAD, cyclothymia, anxiety, psychosis, PD, adjustment, ED, schizoaffective
Hypomania features
> 4 days
mildly elevated/irritable; distractible, ?labile
increased energy, increased libido, decreased sleep
risk taking, sociable, over-familiartity
psychosis in mania
10% have FRS
delusions: mood congruent; self-esteem/ideation; grandiose; irritability and suspicious (can be persecutory)
hallucinations: less common, mood congruent 2nd person auditory
patterns of mood
recurrent depression: repeated dips; otherwise normal variation
dysthymia: >2y persistent low mood, not depression
double depression: dysthymia + depression
BAD: >2 episodes, at least one manic
cyclothymia: >2y of increased variation but subthreshold
rapid cycling: >4 episodes per year
barriers to presentation
masking physical illness; physical priority
communication/time/rapport
clinician awareness
substance abuse, comorbid MH
subtle mania Sx, not seen as an issue to patients, lack of insight
NT functions
low NA: energy, motivation, attention, memory
low 5HT: mood, sleep, food cravings
low DA: anhedonia, cravings, compulsive behaviour
cortisol: stress; excess = toxic to hippocampus
Bipolar - aetiology
biological: genetic (70%), FDR 7x, substances
psychological: PDT, negative thoughts
social: stressors, interpersonal conflict
BAD - prognosis
usually 8-10 episodes in life in untreated; depp > mania (freq/duration/severity)
90% further episodes after mania (4in10y)
no cure; Rx reduces intensity and frequency; 30% residual abnormal mood in between episodes
suicide 10%
relapse: compliance, stressors, circadian rhythm, substances, childbirth, natural
high mood DDx
organic: delirium, dementia, steroids, DA-agonists, substances, hyperthyroid, metabolic, SOL, seizure
psych: BAD, isolated manic episode, cyclothymia, schizophrenia/affective, PD, depression,
Depression stepped care
I: all known/suspected cases; monitor, education, self-help, lifestyle
II: mild/mod; 1o; low intensity PT (incl. MF); ?meds
III: mod/severe/fail; 1o; meds and/or high intensity PT (CBT, IPT); ?2o referral
IV: severe complex/Life-threatening; 2o, combo, ?ECT, ?IP (risk)
depression referral
significant risk uncertain diagnosis ?psychotic depression treatment resistant (2x ADD) complex presentation e.g. comorbidities
depression Mx
biological: ADDs; augmentation (lithium, atypical APD, T3); ECT
psychological: education, self-help, CBT, IPT, mindfulness
social: lifestyle, hobbies etc.
follow-up: 2/52; drug effect/compliance at 2-4 weeks;
- no effect: ?increase dose, ?switch
- some effect: continue another 2-4 weeks
BAD Mx
bio: mood stabiliser (L/V/C/L); APD (O/Q); ?SSRI /Q (risk of mania if no MS); ?ECT
psych: education; CBT, FIT (EE)
social: usual headings
f/u: 72h IP, 1/52 d/c, 2-4 weeks for 3/12 (relapse risk)
relapse PPx: APD + MS >2y (5y if relapse); avoid ADD; psychosocial
other: annual r/v; contraception
assessment
timing, onset, duration of each episode
triggers and stressors
full range of depression Sx
any manic episodes
other symptoms/differentials incl. DH/substances
functional assessment, coping, personality, support
Mania vs. hypomania
Mania: impact on function, marked change in sleep/(sex) energy, risky behaviour, flight of ideas, grandiosity; 1 week duration
hypomania: less severe mood/sleep/energy, less risky, may have pressured speech but usually no flight of ideas; 4 days duration
psychotic is always mania
