mood disorders Flashcards
Core symptoms of depression (present for 2weeks, most days)
Low mood Anhedonia Reduced energy (anergia)
Additional symptoms of depression (2 weeks)
Reduced concentration Reduced self-esteem Ideas of guilt and unworthiness Pessimism about the future Ideas/Acts of self-harm/suicide
Disturbed sleep
Disturbed appetite
Somatic symptoms of depression (overlaps with DSM5)
Markedly reduced appetite
Weight loss (>5% of normal body weight in 1 month)
Early morning wakening (at least 2 hours before usual time)
Diurnal variation in mood (depression worse in the morning, improving through the day)
Psychomotor retardation/agitation
Loss of libido
Marked anhedonia
Lack of emotional reactivity
What is depression with psychosis?
In severe cases of depression!
Delusions:
Content congruent with low mood
Worthlessness, guilt, ill health, poverty, imminent disaster
Nihilistic delusions - belief that the self, part of the self, part of the body, other persons, or the whole world has ceased to exist
Persecutory delusions can also occur
Hallucinations:
2nd person auditory - eg. accusatory
Olfaction - eg. filth, rotting flesh
What are important risks for suicide in depression
Self-harm
Hopelessness
What is the suicide rate in depression?
5-15% completed suicide
What is ICD 10
Used to classify depression into mild, moderate and severe
What is a mild depressive episode according to ICD 10
At least 2 or 3 core symptoms
With additional symptoms overall at least 4 symptoms
With or without somatic syndrome
What is a moderate depressive episode according to ICD 10
At least 2 or 3 core symptoms
With additional symptoms overall at east 6 symptoms
With or without somatic syndrome
What is a severe depressive episode according to ICD 10
ALL 3 CORE symptoms
Plus additional symptoms giving at least 8 overall
What is a severe depressive episode with psychotic symptoms according to ICD 10
ALL3 CORE symptoms
Plus additional symptoms giving at least 8 overall
PLUS
delusions, hallucinations or depressive stupor (speechless and motionless for an extended period)
Psychiatric differentials for mood symptoms
Schizophrenia
Anxiety disorder
Eating disorder
Dementia
Organic differentials for mood symptoms
Multiple sclerosis Parkinsons CVA Head injury Cerebral tumours
Cushing’s/Addison’s disease
Iatrogenic - L-Dopa, opiates
When are patients managed in hospital rather than Community (GP)
Severe depression
First line treatment unsuccessfull
Levels or risk escalating
Community mental health team or Crisis team may be indicated
Epidemiology of depression
M:F = 1:2
Lifetime prevalence of depressive symptoms is 10-20%
Point prevalence of major depressive illnessis 5%
What is the aetiology of depression
Biological: substance misuse, genetics, serious illness, hormonal changes
Psychological: negative thoughts, learned helplessness
Social: life events, social isolation, bereavement, loss, childhood abuse, social adversity
Prognosis of depression
50-60% will recover within a year
Chronic depression (more than 2 years) occurs in 10-25%
5-15% will die by suicide
RELAPSE is a PROBLEM:
75% will have one relapse in the next 10 years
Investigations for physical causes of mood disorders
CRP or ESR for infection
Vit B12 and folate for deficiencies
Urine drug screen
EEG - if epileptic focus or intracranial pahology suspected
Brain CT and MRI
EEG
List the social interventions in mood disorders
Support with regard to education, training, employment
Carer support
Community psychiatry nurse (CPN) and outpatient appointments to monitor symptoms, mood, mental state (for severe depression)
Support with regards to housing and benefits
Work around social inclusion
List the psychological treatments of depression
CBT
Interpersonal therapy
Psychoeducation (empower to know about disease)
Self-help materials
List the biological treatments of depression
1st line SSRIs
In treatment resistant depression, augmentation with:
2nd generation antipsychotics
Lithium
Triiodothyronine
Electroconvulsive Therapy (ECT)
STEP 1 of management of depression (suspected presentation)
Assess Active monitoring Psychoeducation Computerized CBT Sleep hygiene Guided self-help
STEP 2 of management of depression (mild-moderate)
PRIMARY CARE
Low-intensity psychological interventions (such as self-help)
Medication -SSRIs such as citalopram, sertraline, fluoxetine, paroxetine
STEP 3 of management of depression (moderate-severe) or treatment resistant
PRIMARY CARE
Medication
High-intensity psych interventions (individual CBT and IPT)
Consider referring ot secondary care
STEP 4of management of depression (severe complex depression, life-threatening, severe self-neglect)
SECONDARY care
Medication - here, other agents might be considered, including drugs like: venlafaxine (SNRI) mirtazapine (NASSA) imipramine (TCA) phenelzine (MAOI)
adjunctive medications: such as antipsychotics or lithium
High-intensity psychological interventions
ECT
Crisis Resolution and Home Treatment (CRHT)
Multidisciplinary (MDT) approach
Inpatient care
How long should pharmacotherapy be continued for after recovery from a single episode of depression
6 months to reduce risk of relapse
How long should pharmacotherapy be continued for after recovery from recurrent depression
2 years
Epidemiological risk factors for suicide
Male of any age (although younger females more
likely to self-harm)
Being lesbian, gay, bisexual, or transgender (particularly
younger people)
Prisoners (especially remand)
Being unmarried (single, widowed, divorced)
Unemployment
Working in certain occupations (farmer, vet, nurse,
doctor)
Low socioeconomic status
Living alone, social isolation
Clinical risk factors for suicide
Clinical factors:
Psychiatric illness or personality disorder (see Fig. 6.2)
Previous self-harm
Alcohol dependence
Physical illness (especially debilitating, chronically
painful, or terminal conditions)
Family history of depression, alcohol dependence or
suicide
Recent adverse life-events (especially bereavement)
Management of self-harm
Initial assessment of physical health, mental state, safeguarding, social circumstances and risk of repetition/suicide
Comprehensive psychosocial assessment
Monitor accordingly
Self-harmers are 66x more likely to die by suicide
Factors predicting repetition of self-harm
No. of previous episodes
Personality disorder
History of violence
Alcohol misuse/dependence
Being unmarried
Which factors indicate suicidal intent?
Precautions to avoid intervention Planning Leaving a note Use of violent methods Perceived lethality by patient (did you think that it would kill you?)
Investigations for mood disorders
Social: collateral info from GP, community mental health team, family
Consider home visit to assess self-care
Psychological:
Beck Depression Inventory (BDI)
Hospital Anxiety and Depression Scale (HADS)
Action of antidepressants
most inhibit serotonin reuptake or noradrenaline reuptake or both
Side effects of SSRIs
(fluoxetine, citalopram, sertraline, paroxetine)
Nausea Insomnia Apathy/fatigue Diarrhoea Dizziness Sweating
Akathisia
Sexual dysfunction
Paroxetine causes cardiac defects in first trimester
Indications and side effects of TCAs
Amitryptiline, Imipramine, Clomipramine
Toxic in overdose! Anti-muscarinic side effects: Dry mouth Blurred vision Constipation Retention
Sedation Weight gain Dizziness Hypotension Delirium
Indicated in pregnancy! (not teratogenic)
Side effects of SNRIs
2nd or 3rd line treatment
Venlafaxine
Duloxetine
Similar SEs as SSRI with more discontinuation symptoms (headache, distress, depression)
Side effects of MAOI and indications
Phenelzine, Trancypromine
Used in treatment resistant depression and atypical depression
Risk of CHEESE Reaction (tyromine containing foods)
Anti-muscarinic side effects
Indications for ECT
Treatment resistant depression
Life-threatening severe depression
Treatment resistant mania
Catatonia
Contraindications to ECT
Cochlear implant (ABSOLUTE)
Raised ICP History of stroke, MI, aortic aneurysm Uncontrolled arrhythmias DVT Decompensated cardiac failure
Side effects of ECT
Headache
Confusion
Impaired cognitive function
Temporary retro and anterograde amnesia
Some events in previous years can be lost
Indications of antidepressants
Depressive illness Anxiety disorders Neuropathic pain Insomnia Bulimia nervosa Impulsivity Migranies IBS Chronic fatigue syndrome
What is Mirtazapine?
Noradrenaline and specific serotonergic antidepressant (Nassa)
When is Mirtazapine used. Side effects?
May be superior to SSRIs in depression
Reduce anxiety
Combine with other antidepressants if treatment resistant
Sedation and/or weight gain on relatively low doses
Interactions with St John’s Wort
Inducer, leading to loss of therapeutic effect:
Oral contraceptive
Digoxin
Warfarin
HIV protease inhibitor
Anticonvulsants (phenytoin, carbamazepine)
Which antidepressants have the greatest withdrawal effects
paroxetine (SSRI)
venlafaxine (SNRI)
Tapering the dose down over 4 weeks can help reduce the symptoms
Which antidepressants do not cause weight gain?
SSRIs
SNRIs
Which antidepressants cause weight gain?
TCAs
Most caused by NaSSA
Which antidepressant does NOT cause sedation?
SSRIs
Epidemiology of self-harm
Male to female ratio - 1:2
Divorced > Single > Widowed > Married
Two-thirds of people who harm themselves are under 35 years of age
Overdoses and cutting are the most common methods
Factors of self-harm
Predisposing
Precipitating
Perpetuating
Indications for ECT
Treatment-resistant depression
Life-threatening severe depression
Treatment-resistant mania
Catatonia
A patient will typical receive between 4 and 12 sessions in a course of ECT. The sessions usually occur twice per week.
Mechanism of ECT
Modulation of neurotransmitter functioning
Changes in regional blood/activity
Modulation of neuronal connectivity
Alterations of neuronal structures, including hippocampal neurogenesis
How is ECT monitored?
With an EEG
Can see when the seizure has finished
