Mood Disorders Flashcards
Categorising Mood Disorders
Unipolar Disorders-One side of the mood spectrum
Bipolar Disorder e.g. mania, bipolar disorder, cyclothymia
Symptoms of Depression
Depressed mood Negative Thinking Lack of enjoyment Reduced energy Slowness
Symptoms of Mania
Overactivity
Elevated mood
Self important ideas
Aetiology of Depression
Genetic component with family clustering
Neurobiological theories:
Monoamine hypothesis-deficiency in serotonin, NA and dopamine, Endocrine abnormalities-Hypothyroidism, HPA dysfunction, blunted cortisol response to stress
Immunological theories-Increased cytokines leading to HPA dysfunction
Psycho-social theories include parental deprivation, recent life events, learned helplessness, cognitive dysfunction and psycho-analytical theory (anger turned inwards)
3 Core Symptoms
3 Cardinal Symptoms:
Depressed mood
Loss of interest and enjoyment (anhedonia)
Reduced energy levels, easy fatigability, diminished activity and tiredness
Must be present for at least 2 weeks
Not secondary to an external factor like medications, bereavement
Causes significant distress and impairment
Cognitive Symptoms
Reduced concentration and attention Reduced self-esteem and self-confidence Ideas of guilt and unworthiness Pessimism Ideas or acts of self harm and/or suicide
Biological Symptoms
Loss of interest
Lack of emotional reactivity
Disturbed sleep, generally with early morning awakening
Diurnal variation, with symptoms worst in the morning
Objective evidence of psychomotor retardation
Poor appetite and weight loss
Loss of libido
Classification of Depressive Disorders
Mild-2 cardinal plus 2 others, total 4, usually able to continue ordinary work
Moderate-2 cardinal plus four others, total 5/6, considerable difficulty in carrying out social, work or domestic activities
Severe without psychosis-All 3 core plus 5+ others, unlikely to continue social, work or domestic activities, suicide risk high
Severe with psychotic symptoms-All 3 core plus 5+ others, unlikely to continue social, work or domestic activities, suicide risk high, delusions, hallucinations or depressive stupor. Delusions are mood congruent e.g. sin, poverty, imminent disaster
Clinical Variants of Depression
- Agitated depression, this is depression with some features of mania e.g. impulsiveness
- Depressive stupor, this is psychomotor retardation to the point of apparent coma
- Atypical depression e.g. overeating, oversleeping, pronounced anxiety, variable mood
Recurrent depressive disorder
severe relapsing-remitting form of depression, and is commonest in the 5th decade
- Individual episodes last 3 – 12 months with complete recovery in between. The interval between episodes becomes gradually shorter with age
- Some patients may develop a chronic unremitting course
Investigations in Depression
In addition to focussed questioning on mood, it is useful to use a standardised rating scale as a baseline prior to any management plans
- Beck Depression Inventory (BDI) may be used, this is a 21 question test assessing how the patient has been feeling over the course of the past week
Investigations in depression are focussed on excluding treatable causes of the symptoms, and secondary problems e.g. malnutrition, alcohol misuse
- FBC, ESR, B12/folate, U&Es, LFTs, TFTs, glucose, and calcium studies
- Where indicated there can be urine toxicology, syphilis serology, dexamethasone suppression test for Cushing’s, and short synacthen test for Addison’s
Management In Depression
Managed using a biopsychosocial model
Medication have a greater effect on more severe disease, not effective in mild cases
Psychological treatments in depression include the following:
Counselling
Psycho-education
CBT-Breakdown of unhelpful thoughts, emotions and behaviours
Interpersonal therapy
Attendance at day hospitals
Social Factors: Address
Housing
Finance
Employment
Support networks
Respite care and voluntary organisations can be helpful in this
Biological Treatments
Work to increase the function of monoamines
SSRIs-First line e.g. fluoxetine
SNRIs-Venlafaxine, duloxetine, used in resistant disease
Mirtazipine-a2 receptor antagonist
TCAs-Amitriptyline
MAOi e.g. phenelzine
SSRIs Side Effects
Side Effects:
GI Upset, sweating, insomnia, weight gain, decreased seizure threshold, sexual dysfunction
Hyponatremia-rare
Lag period of 4-6 weeks before effects are seen
Mirtazapine
Side Effects
Sedation
Weight gain
TCAs
Side Effects:
Dry mouth, constipation, blurred vision, sedation, postural hypotension, sexual dysfunction, arrhythmias, GI upset, tremor
High risk in overdose and cardiac disease
MAOi
Rarely used, usually in atypical cases
Side Effects:
Hypertensive crisis to tyramine containing foods, toxicity in overdose, and complex interactions with other medications
Starting Antidepressants
SSRIs are first-line mediations (normally fluoxetine or sertraline) in moderate to severe depression.
If these are not effective at 4 weeks, or only partially effective at 6 weeks then the medication should be switched
- Second-line medications are usually a second generic SSRI or venlafaxine/ mirtazapine
- Third-line should be venlafaxine, mirtazapine, or a TCA
- Augmentation of medications can be with lithium, antipsychotics, or combining the above medications
- If the patient has CVD sertraline is best, TCAs and venlafaxine should not be used
Stopping Antidepressants
When stopping antidepressants, reduce the dose gradually over a 4-week period (fluoxetine may be shorter than this). If symptoms re-appear, consider prescribing again at the last dose at which symptoms were controlled
ECT
ECT should be considered in resistant or life threatening symptoms. This is usually 6 – 12 sessions over 3 – 6 weeks, but the need should be reviewed after each session
- ECT requires general anaesthetic and muscle relaxant, this is followed by a brief a pulse of electricity that may be bilateral or unilateral
- Bilateral ECT is more effective but associated with more memory problems. An electrode is placed on each temple
- Unilateral ECT is technically more difficult as one electrode is placed on the back of the head and the other on one temple
- Side effects include short term memory impairment and headache
- ECT requires informed consent, or for inpatients without capacity a second opinion from a mental health act commission doctor
Psychosurgery
Psychosurgery can be used in intractable depression, including cingulotomy and subcaudate tracotomy
Mild Depression Management
Watchful waiting Sleep and anxiety management Structured and supervised exercise Guided self-help Psychological interventions Antidepressants if patient has a history of moderate/severe depression
Moderate/Severe Depression Management
SSRI
Adjunctive treatment for resistant cases
Severe depression: Meds and CBT
Continue medications for 6-9months after first episode
Continue meds for 2 years if more than 2 episodes with functional impairment, restarting the clock at every relapse
Dysthmia
Form of persistent affective disorder, leading to long standing depression of mood that falls just below threshold for clinical depression
Subjective distress and disability, feeling tired and depressed most of the time
SSRIs treatment of choice, best evidence for citalopram and fluoxetine
Long term
May be combined with CBT
Mania Classification
Symptoms must last for at least 1 week
Hypomania-Lesser degree of mania in which symptoms do not lead to severe disruption of work
Mania without psychotic symptoms-Elevated mood out of keeping with circumstances, mood may also be irritable and suspicious
Mania with psychotic symptoms: Most severe form, with delusions and hallucinations, usually mood congruent
Presentation of mania
The cardinal symptoms of mania are as follows
- Elevated, expansive or irritable mood
- Definitely abnormal for the individual concerned
- Sustained for one week
Additional symptoms of mania include
- Increased energy, activity, or physical restlessness
- Talkativeness, pressure of speech, flight of ideas, racing thoughts
- Poor concentration and attention
- Grandiosity, excessive optimism or inflated self-esteem
- Reckless behaviour
- Increased sexual libido, disinhibitions, sexual indiscretions
- Increased sociability, overfamiliarity, inappropriate behaviour
For a diagnosis of mania there must be all cardinal symptoms alongside at least 3 other symptoms
Management of Acute Mania
Acute episodes of mania should be managed in secondary care
- The patient should be prescribed an antipsychotic; those recommended include olanzapine, risperidone, quetiapine and haloperidol
- If the patient is on an antidepressant, consider stopping this
- If the patient is already taking an antipsychotic, consider adding lithium and/or valproate
- If the patient is already taking lithium and an antipsychotic, optimise lithium levels and consider adding valproate
Lithium in Mania
Lithium should be offered first line to all patients with mania. Lithium is a medication with a very narrow therapeutic index and severe side effects, it therefore requires various monitoring regimens. Blood levels of lithium are more important than dose, aiming for 0.6 – 0.8mM or 0.8 – 1mM when symptomatic
- Thyroid and renal function should be checked at baseline and every six months thereafter
- Lithium levels should be checked every 3 months when stable, and every week until stability is achieved
Side Effects of Lithium
- Side effects include hypothyroidism, renal damage, polyuria, tremor, weight gain, cognitive blunting, and teratogenicity.
Interactions of Lithium
There are also significant drug interactions.
Lithium level can be increased by NSAID use, diuretics, dehydration, and low sodium.
Lithium toxicity
Lithium toxicity, which can be fatal
- Diarrhoea and vomiting
- Coarse tremor
- Ataxia and slurring of speech
- Seizure
If lithium is ineffective
If lithium is ineffective, or poorly tolerated, valproate or olanzapine should be considered instead
- Valproate is highly teratogenic and contraindicated in women of childbearing potential
- Side effects include dyspepsia, nausea, weight gain, hair loss, hirsutism, and blood dyscrasias
- Monitor LFTs, FBC and BMI every 6 months
Psychological Interventions in Mania
- Psycho-education for patients and their family
- Insight-oriented therapy, usually indicated once the patient is stabilised
- Supportive psychotherapy
- Relapse identification
- CBT
- Drug education
Bipolar Affective Disorder
Bipolar affective disorder is characterised by two or more periods of hypomania or mania alternating with depression
Bipolar II is less severe than bipolar I, usually with hypomanic rather than manic episodes
Bipolar Depression Management
- If depression is moderate or severe the patient should be offered quetiapine or a combination of fluoxetine and olanzapine
- If the patient is on lithium optimise the levels alongside the above
- If the patient is on valproate optimise the dose alongside the above
- If the patient refuses the above treatment, they should be offered lamotrigine alone
Checks in patients with bipolar
In patient with bipolar disorder there should be physical checks at diagnosis, and annually thereafter. This should include measurement of BP, BMI, and assessment of smoking and alcohol consumption. Other baseline and annual checks include
- FBC, LFTs, U&Es, TFTs, blood glucose, lipid profile
Cyclothymia
Cyclothymia is a persistent instability of mood with numerous periods of mild depression and mild elation. These are not severe or prolonged enough to fulfil the criteria for bipolar affective disorder
- It typically develops in early adult life and has a chronic course
- The mood swings in cyclothymia are unrelated to life events
Pharmacological treatment is not always indicated, but may consist of a low dose of mood stabiliser e.g. lithium 600mg/day
It is thought more beneficial to undertake psychoeducation and insight-oriented psychotherapy to enable the patient to better understand their condition.
