Mood Disorders Flashcards
In mood disorders there is a persistent disturbance of mood sufficiently severe to cause impairment in activities of daily living. This alteration in mood is beyond the fluctuation we all experience. Normal mood (euthymia) can be lowered (depression) or elevated (mania).
What are examples of mood disorders in the ICD-10 classification?
- Manic episode
- Bipolar affective disorder
- Depressive episode
- Recurrent depressive episode
- Persistent mood disorders
Depression is a mental state characterised by persistent low mood, loss of interest and enjoyment in everyday activities, neurovegatitive disturbance, and reduced energy, causing varying levels of social and occupational dysfunction.
What are the risk factors for depression?
- non-modifiable → age, female, post-natal status, personal or family history
- modifiable → drugs (steroids, propranolol), co-existing med conditions (diabetes)
What are differentials for depression?
-
Organic disease (many different organic diseases may present w/ depression):
- Haematological → anaemia (IDA, B12), polycythaemia
- Neurological → CVA, SLE, Parkinson’s disease
- Iatrogenic → oral contraceptives, steroids
- Adjustment disorder → unpleasant but mild affective symptoms following a life event, but symptoms do not reach severity required to diagnose depression
- Grief → symptoms more consistent w/ depression include appropriate guilt regarding actions surrounding a death
- Substance misuse
What are the varying features distinguishing between depression and grief?
What is the epidemiology of depression?
- depressive disorders very common + among leading causes of disability worldwide
- prevalence of major depression is between 5-10% of people seen in primary care settings
- about 20% of adults will be affected by a mood disorder needing treatment at some point in their life
- women are affected twice as often as men
What is the aetiology behind mood disorders?
- Genetic → Mood disorders often run in families, but rather than single gene for depression (or BPAD), a combo of genes may predispose to developing mood disorders. There is an overlap between inheritance of BPAD and depression
- Childhood life events (depression) → Associated w/ later depression eg. childhood abuse, criticism, parental loss. No childhood precipitants identified in BPAD
- Factors in adults (depression) → Unemployment, lack of a confiding relationship, lower SEC, social isolation
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Life events → An excess of life events may occur in the 3months before depressive episode. Negative life events associated w/ depression. All forms of life event may precipitate mania, although as disease evolves over time, environmental triggers become less important.
- eg. spouse death, divorce, marital separation, jail term, death of close relative
What are the core clinical features of depression?
- constant low mood
- lack of energy
- anhedonia
(At least 2) Symptoms must have been present for at least 2 weeks to meet diagnostic criteria
Somatic symptoms are symptoms that relate to the physical body. In other words, they are not symptoms of the mind.
What are the somatic symptoms of depression?
- psychomotor retardation
- poor sleep, EMW
- diurnal variation in mood (worse in morning)
- lack of energy + fatigue
- loss of appetite
- weight loss
- loss of libido
- constipation
- amenorrhoea
What two questions can be used to screen for depression?
- ‘During the last month, have you often been bothered by feeling down, depressed or hopeless?’
- ‘During the last month, have you often been bothered by having little interest or pleasure in doing things?’
‘Yes’ -> prompt more in-depth assessment
What are the tools to assess the degree of depression?
- HAD scale → consists of 14 Qs, 7 for anxiey + 7 for depression, each item scored 0-3, produces score /21 for both anxiety + depression, severity 8-10 = borderline, 11+ = case, pts should be encouraged to answer Qs quickly
- PHQ-9 → asks pts ‘over last 2 weeks, how often have you been bothered by any of the following problems?’, 9 tems scored 0-3, includes item about self-harm, 15-19 = moderate depression, 20-27 = severe depression
What are the features of mild depression?
- main complaint feeling stressed + tired
- anxiety symptoms commonly co-exist
- suicidal thoughts may occur but self-harm rare
- mood is responsive (ie will be happy if they hear good news)
- patient will be able to work, but will become more tired than usual and concentration is impaired
Severe depression mimics moderate depression but just amplified.
What are the features of moderate depression?
- mood is subjectively + objectively depressed
- somatic symptoms (eg. early morning awakening)
- anhedonia
- lack of energy
- negative cognitions → focus on unpleasant memories, failings, disappointments
- psychomotor retardation
- sense of hopelessness
- suicidal thoughts or acts of self-harm
- social withdrawal + anxiety
What are features of psychotic depression?
- worries + perceived misdemeanours become delusional in intensity
- pt may believe they are dead - Cotard syndrome
- pts may experience auditory hallucinations → commonly persecutory, saying person is worthless
Psychotherapy is effective for mild depression and can be effective in combination with drugs. Its efficacy in severe depression may be limited due to the severity of the disease, e.g. inability of the patient to concentrate.
What are the ‘low-intensity psychosocial interventions’ for depression?
Alternative is group-based CBT:
- be based on a model such as ‘coping with depression’
- be delivered by 2 trained + competent practitioners
- consist of 10-12 meetings of 8-10 participants
- typically take place over 12-16wks incl follow-up
For pts with chronic physical health problems NICE also recommend considering a group-based peer support programme - focus on sharing experiences + feelings associated with having a chronic physical health problem. They consist of typically 1 session per week over 8-12 weeks.
General measures for depression include sleep hygeine and active monitoring for people who do want an intervention.
When should drug treatment be used?
Don’t routinely use but consider them for:
- past history of moderate or severe depression
- initial presentation of subthreshold depressive symptoms that have been present for a long period (typically at least 2 years)
- subthreshold depressive symptoms or mild depression that persists after other interventions
- if a pt has a chronic physical health problem and mild depression complications the care of the physical health problem
Anti-depressants increase the overall level of monoamines at the synapse by either decreasing reuptake or breakdown. Over time, the serotonin and central beta-adrenergic receptors become downregulated, which is thought to account for the 4-6 week delay in its effects.
What are the pharmacological options for depression?
- SSRIs → citalopram + fluoxetine (<- esp in children) preferred
- citalopram can prolong QT interval, max daily dose is 40mg
- if on warfarin/heparin → avoid SSRIs + consider mirtazapine
- triptans → avoid SSRIs
- review antidepressants after 2 weeks
- continue treatment for at least 6 months after remission as this reduces risk of relapse
- when stopping SSRI dose should be gradually reduced over 4wk period
Serotonin syndrome (SS) is a group of symptoms that may occur with the use of certain serotonergicmedications or drugs. Causes include MAOs, SSRIs, ecstasy and amphetamines.
What are the features and management of serotonin syndrome?
- neuromuscular excitation (hyperreflexia, myoclonus, rigidity)
- autonomic nervous system excitation (hyperthermia)
- altered mental state
Rx → supportive (IV fluids), benzodiazepines, serotonin antagonists in severe cases eg. cyprohetadine, chlorpromazine
