Mood Disorders Flashcards
When do most mental disorders start
50% start before age 14
Mood disorders and anxiety common
What is anhedonia
Loss of enjoyment or pleasure
Seen in depression
What is psychomotor retardation
Slowing of thoughts and/or movement
Can be subjective or objective
How is sleep often affected in depression
Early morning wakening is very common
Classified as waking at least 2 hours before the expected/normal time
Often struggle to get to sleep
What is a stupor
Absence of function such as action or speech
People will often stop eating and looking after themselves
How would appearance and behaviour someone with depression
Reduced facial expression Brow is classically ‘furrowed’ Reduced eye contact Limited gesturing Hard to build rapport
How is speech affected in depression
Reduced rate and volume Speech in monotonous Lowered in pitch Limited content - short answers Longer time between end of question and them answering - speech latency
What is mood
A prolonged prevailing state or disposition
As described by the patient - subjective
How does affect present in depression
Depressed and low
Reduced range of affect - ow throughout
Limited reactivity
May report emotional paralysis
How is thought affected in depression
Form is normal
May be slower than normal
Content is often negative - guilt, failure etc
Delusions of guilt, nihilism, disease can occur
Suicidal thoughts are common
How is perception affected in depression
Not common to be disordered - not delusion or hallucination
Just become more self-conscious and may think people are judging them
What type of hallucination can be seen in depression
Almost always auditory
Second person and derogatory - ‘you are a bad person’
Negative thoughts take on a voice
Not very common
How is cognition affected by depression
Cognition is often slowed
May complain of poor memory - pseudodementia
Often inattentive and lose track of conversation/stories/films
How is insight affected by depression
Insight is usually preserved - people are aware of their symptoms
However, some don’t recognise that it is an illness and not their fault (believe it is due to weakness
Which guidelines are used to classify mental disorders
ICD-10 - used in the UK
DSM-5 - USA
What are the different categories of mood disorders
DSM-5 = major depressive disorder, persistent depressive disorder
ICD-10 = mania, bipolar disorder, depressive disorder and dysthymia
How are depressive disorders further classified
Mild
Moderate
Severe
Major depressive disorder from DSM-5 only corresponds to moderate and severe depressive disorder in ICD-10
How do you separate depression from normal low mood
Depression will be clearly abnormal for the patient
Must persist - for weeks
Will interfere with normal function to a significant degree
May have significant physical, psychomotor and psychological changes
What are the general criteria for diagnosing depression
Depressive episode should last at least 2 weeks
No hypomanic or manic symptoms at any point in the individuals life
What are the core features of depression
Depressed mood - to an abnormal degree and present most of the day for at least 2 weeks
Loss of interest or pleasure in activities
Decreased energy
Very egocentric - about them
List some additional symptoms of depression
Loss of confidence or self-esteem Unreasonable guilt Suicidal thoughts or behaviour Struggling to concentrate Change in psychomotor activity - either agitated or retardation Sleep disturbance Change in appetite
How can you assess the severity of depression
Rating scales exist - Hamilton scale, MADRS, Becks Depression Inventory
ICD-10 rates it based on number of symptoms
What constitutes a moderate depressive episode in ICD-10
Two core symptoms + four others, to give a total of at least six
Doesn’t matter which symptoms
What constitutes a severe depressive episode in ICD-10
All 3 core symptoms + 5 others, to give a total of at least eight
Doesn’t matter which symptoms
Which subcategory of depression is seen in the majority of primary care cases
Mild depression
Very common and often transient (gets better on its own with support)
What are the symptoms of a somatic syndrome
Loss of interest and pleasure Lack of emotional reaction Early wakening Depression worse in the morning Psychomotor retardation or agitation Loss of appetite Weight loss - 5% of body weight or more Loss of libido
Need at least 4 of these
What are the symptoms of atypical depression
Mood reactivity - mood lifts in response to positive events
Weight gain or increased appetite
Hypersomnia
Leaden paralysis - heavy arms/legs
Long standing interpersonal rejection - social or occupational impairment
What is Cotard’s syndrome
Type of psychotic depression
Common in the elderly
Nihilistic delusions that they are dead or organs have died
What is seen in psychotic depression
Paranoid delusions
Often hypochondriacal
Think people are out to get them or that they are dying
How is chronic depression defined in DSM-5
Full criteria for a Major Depressive Episode have been met continuously for at least the past 2 years
Describe the pattern of depression
Symptoms begin Respond to treatment Remission - may stay here Can relapse Go into recovery Can recur
What are the treatment phases for depression
Acute - up to 12 weeks
Continuation - 4-9 months
Maintenance - over a year
Which sex commits suicide more often
Men
Are mood disorders usually recurrent
Yes
Usually have recurrent episodes
May be seen as a chronic illness
How is bipolar disorder classified
DSM-5 - by course/pattern
- Bipolar 1 and 2
ICD-10 - by episode severity
- hypomania
- mania with or without psychotic features
What is bipolar 1 disorder
The classic form of bipolar
Has met the criteria for mania and had previous depressive/hypomanic episodes
Highly disabling manic episodes and episodes of major depression
What is bipolar 2 disorder
More common form
Only have the hypomanic and depressive episodes
Haven’t met the criteria for mania
What is bipolar 3
Pseudo-unipolar
Only have hypomanic episodes after use of anti-depressants
What are the specifiers for bipolar in DSM-5
A list of extra symptoms that helps to further classify the disorder
Includes: anxiety, psychotic features, rapid cycling etc
How is bipolar disorder classified in ICD-10
A disorder characterized by two or more
episodes in which the patient’s mood and activity levels are significantly disturbed
On some occasions this is mania or hypomania and others depression
Repeated episodes of hypomania or mania only are classified as bipolar.
When is a diagnosis of depression changed to bipolar
On the first episode of hypomania or mania on a background of recurrent depression
What is hypomania
A mood disturbance that is below mania
Still and elevated mood state
Very subjective distinction and depends on the patients normal
How does a hypomanic episode present
Elevated mood or irritability to an abnormal degree Interferes with normal function At least 3 of the following symptoms: Increased activity or physical restlessness Increased talkativeness Difficulty concentrating Decreased need for sleep Increased sexual energy Mild spending sprees Irresponsible behaviours
How long does hypomania need to last to be confirmed
AT least 4 days
How long does mania need to last to be confirmed
At least a week
Unless hospitalised
How does a manic episode present
Predominantly elevated mood (expansive or irritable_ which is definitely abnormal for at least a week
Interferes with normal function
Three of the following symptoms:
Increased activity or physical restlessness
Increased talkativeness
Flight of ideas or racing thoughts
Loss of normal social inhibition - leads to inappropriate behaviour
Decreased need for sleep
Inflated self-esteem
Distractibility or constant changes in activity or plans;
Behaviour which is foolhardy or reckless
Marked sexual energy
What is pressure of speech
Very fast speech where they are saying loads
Racing thoughts
Often change topics rapidly
What sort of risk taking behaviour is seen in manic episodes
Spending sprees
Foolish business ideas - will invest lots in it
Reckless driving
Starting fights
Risky sexual behaviour - one night stands etc
Which type of episode can lead to hospitalisation - hypomania or mania
Mania
How might a manic/hypomanic episode affect appearance/behaviour in the MSE
Bright clothes
Distractibility
Loss of normal social inhibitions / overfamiliarity
How might a manic/hypomanic episode affect speech in the MSE
Increased talkativeness - hard to interrupt
Punning and clanging
How might a manic/hypomanic episode affect thought in the MSE
Increased flow (lots of thoughts)
Flight of ideas & loosening of associations
Grandiosity - believe they have a gift or great new idea
What psychotic symptoms can be seen in bipolar disorder
Delusions or hallucinations
The commonest examples are grandiose delusions , self- referential, erotic or persecutory content
What is the lifetime prevalence of bipolar disorder
1-4% Bipolar 1 (the 'classic' type) only makes up 1/3 of cases
When does bipolar disorder usually start
Usually late teens or early 20s
Earlier than depression
Recurrent depression in late teens may be more likely to have some form of bipolar rather than depression
Is there a familial link in bipolar disorder
YES - strong genetic component
Family history often leads to an earlier onset and more severe case
If someone over the age of 60 presents for the first time with bipolar symptoms what must you consider
An underlying organic cause
Onset of bipolar itself at this age is very rare
Which other disorders often occur alongside bipolar
Anxiety disorders Alcohol and drug abuse Personality disorders Eating disorders Schizoaffective disorder Schizophrenia
Which other disorder does bipolar share a lot of genetic factors with
Schizophrenia
Is there a single gene that causes bipolar disorder
Nope
Multiple genes each with a very small effect
Also lots of complex interaction between genes and environment
What are subsyndromal symptoms
Symptoms which occur even when mood is stable - euthymic
Often it is concentration issue
Which phase are people with bipolar experience most of the time
Majority is asymptomatic
Next most common is the depressive episodes
Which mood disturbance is most common in bipolar - depression or mania
Depression
List some predictors of poor outcomes in adolescent mood disorders
Early-onset Low socioeconomic status Subsyndromal mood symptoms Long duration of illness Rapid mood fluctuation Mixed presentations Psychosis Comorbid disorders Family psychopathology
Describe suicide risk in mood disorders
Suicide risk is increased in all mental disorders
- 15% of those with depression will commit suicide
However, bipolar disorder carries a further increased risk
What is the function of the appetitive system
To mediate seeking and approach behaviours
Includes pleasure
This is the reward system
What areas of the brain are involved in the appetitive system
The ascending dopamine system Mesolimbic and cortical projections Amygdala Anterior cingulate Orbitofrontal cortex
What is the function of the aversive system
The function is to promote survival in event of threat (fear/ pain
What areas of the brain are involved in the aversive system
ascending serotonin systems NA / CRF / peptide transmitters Central nucleus of amygdala Hippocampus Ventroanterior and medial Hypothalamus Periaqueductal grey matter
Describe the neurobiological basis of depression
It is an altered sensitivity/accuracy of the brain systems evaluating rewards and cues that predict reward from the environment
Describe the neurobiological basis of anxiety
It is an altered sensitivity / accuracy of brain systems evaluating threat and cues predicting threat within the environment
List life/ neurobiological factors that can impact mood disorders
Abnormal brain development Genetic and developmental effects Endocrine/Metabolic causes Adverse life events Psychological resilience/ or lack of Cultural aspects
Which neurotransmitters may contribute to depression if there is a deficit of them
Serotonin - basis of lots of treatments Norepinephrine Dopamine GABA BDNF Somatostatin
Which neurotransmitters may contribute to depression if there is an excess of them
Acetylcholine (toxic)
Substance P
Corticotrophin Releasing Hormone - this is a stress hormone
How is serotonin affected in depression and other mood disorders
There is a decrease in receptor binding through the cortical and subcortical regions
There is a reduction in reuptake sites
Responses usually carried out by serotonin are blunted
How is norepinephrine affected in depression and other mood disorders
Decrease neurotransmission leading to anergia, anhedonia and decreased libido
How is dopamine affected in depression and other mood disorders
Hypofunction of the system may be the underlying mechanism of loss of pleasure/interest in depression
How is GABA affected in depression and other mood disorders
Principal neurotransmitter mediating neural inhibitionReductions in GABA observed in plasma and CSFGABA receptors upregulated by antidepressants
How is the hypothalamic-pituitary axis affected in depression and other mood disorders
It is upregulated
There is also a down regulation of negative feedback controls
Corticotrophin-releasing factor is hypersecreted from the hypothalamus and induces the release of ACTH from the pituitary
The ACTH causes cortisol to be released from the adrenal glands which has many effects
Negative feedback is impaired so there is continual activation and an excess of cortisol
Receptors become desensitised and there’s increased activity of pro-inflammatory mediators and a disturbance of neurotransmitter transmission
How do adverse childhood events affect the norepinephrine system
These events can produce an overactive response that persists into adulthood
This means that in stressful situations these people may deplete their NE which can lead to depression
How can you assess if treatment of a mood disorder is working
Proper mood monitoring
Scoring systems for mood can be used
Ask patients what their goals are for feeling better and then check if they are achieving this
What is the IDS-30
Common scale used for assessing mood
30 questions – very detailed
Takes time so some may struggle to complete it
or someone who struggles with reading may find it hard
Good for someone with treatment resistant depression
What is the QIDS
Common scale used for assessing mood
Shorter version of the IDS-30
Focuses more on the biological symptoms - sleep, appetite, concentration etc
What is the Hospital Anxiety and Depression Scale
Common scale used for assessing mood
14 item list that the patient rates themselves
Easy and quick to complete
What is the MADRS
Montgomery-Asberg Rating Scale
Common scale used for assessing mood
More objective test
It is a 10 item list completed by an observer
Good if patient lacks insight or is too unwell to complete it themselves
What is the prescribing trend for antidepressants
Number being prescribed is increasing
Are antidepressants more or less effective than placebo
MORE
All antidepressants tested were more effective than placebo
What is lithium used for
Maintenance treatment in bipolar
It is a mood stabiliser
How is treatment length of antidepressants related to relapse rate
The longer you take them for the greater the relative reduction in relapse
Treatment effect persists for at least 36 months
If an SSRI doesn’t work you must try another class of anti-depressant - true or false
FALSE
One SSRI may work even if another hasn’t
Should try 2 drugs from that class before switching
What is the most commonly used class of antidepressants
SSRIs
What are the ‘top 4’ SSRIs
Escitalopram - probably the best
Sertraline
Mirtazapine
Venlafaxine - more adverse effects
What are the benefits of sertraline
Well established SSRI
Good cardiac safety - good for the elderly
Easy dose titration
What are the benefits of mirtazapine
Promotes sleep and appetite and weight gain
Good if the patient is struggling with this
What should you do if antidepressant therapy doesn’t work
Check compliance
Check diagnosis – could they be bipolar? Have dementia?
Rule out substance misuse or physical illness
Address any other predisposing, precipitating and prolonging factors
Then either increase dose, swap drug or combine with another
How long should you try an antidepressant before deciding it doesn’t work
Must try for 4-6 weeks before deciding to change – takes time to work
Also gives side effects time to pass - usually transient
When should you review a patient after starting antidepressants
After 1-2 weeks
Assess side effects
After 4-6 weeks to check efficacy
How long should someone stay on antidepressants for
First episode- continue antidepressant for at least 6 months after full recovery without reducing dose
Second episode or more- continue antidepressant for at least 1-2 years after full recovery without reducing dose
If someone has had 3-4 episodes it might be time to take it for life
How should you manage a hypomanic/manic phase
Maximise antimanic dose if already on maintenance treatment
Antidepressants should be discontinued
Combination therapy may be required
Hospital admission likely to be required if mania
Should you prescribe anti-depressants in bipolar
Not without an antimanic drug as well
They should be avoided in those with recent manic/hypomanic episodes or a history of rapid cycling
Which drugs can be used in acute mania
Antipsychotic is first line treatment- olanzapine, quetiapine or risperidone
Other options- lithium, valproate, carbamazepine
Benzodiazepines can be used for acute symptoms control
What are the side effects or risks with taking lithium
Narrow therapeutic range so must be monitored - regular ECG and U&Es
Can damage the heart, kidney and brain if too high a dose
Can cause hypoparathyroidism - monitor calcium
GI side effects most common – N&V, diarrhoea (usually settles)
Can exacerbate skin conditions – psoriasis
Can cause a tremor
What are the signs of lithium toxicity
Dizziness
Nausea
Worsening tremor
Should inform patients of these so that they can present early for treatment
Which antidepressants can cause cognition issues
Tricyclics
Which common drugs cannot be used alongside lithium
ACEi
NSAIDs
How is ECT administered
Put under general anaesthetic and give them a muscle relaxant
Pass current through the brain to cause a seizure for around 20 seconds
Monitor with an EEG to time the seizure and tells you when it stops
Usually given 2x per week as an inpatient
can be acute treatment or maintenance
What is ECT
Electroconvulsive therapy
Used in the treatment of severe depression or bipolar
Induces seizures
What are the contraindications to ECT
Recent MI - within 3 months Recent cerebrovascular event Intracranial mass lesion Phaechromocytoma Angina, congestive heart failure, severe lung disease and osteoporosis Cant be used in pregnancy
Is ECT safe
Yes
Very tiny risk of mortality from cardiac or pulmonary complications
Risk of not treating is much greater
What are the common side effects of ECT
Short term memory impairment - recovers
gradually
Impaired cognitive function - hard to differentiate from that caused by the depression itself
Is consent needed for ECT
Yes and No
Around 2/3 of patients voluntarily consent to treatment
Need consent if they have capacity - even if detained under the MHA
However some are too ill to have capacity so if second opinion doctor agrees, then ECT can go ahead without consent
What are the 5 areas of the 5 areas model of CBT
Life situations, practical problems and relationships Altered thinking - cognitive Altered feelings Altered physical symptoms Altered behaviour
What is overgeneralising as a thinking error
When you apply rules or outcomes from an isolated incident to all cases
What is dichotomous thinking as a thinking error
All or nothing thinking
Very black and white
What is selective abstraction as a thinking error
When you focus on one negative detail and this colours your entire experience
What is personalisation as a thinking error
When you relate external events to yourself with little or no cause
What is minimisation or magnification as a thinking error
Over or underestimate magnitude of undesirable events
What is arbitrary evidence as a thinking error
Draw a conclusion in context of no evidence or contrary evidence
What is emotional reasoning as a thinking error
I feel bad/guilty/therefore I am bad/have something to feel guilty about
What are predisposing factors of mental illness
Factors that put you at higher risk
Genetics, childhood attachments, childhood trauma or illness
What are precipitating factors of mental illness
Factors which can trigger an episode
Recent trauma/stress, childbirth, big life changes, new medication (tramadol)
What are prolonging factors of mental illness
Factors that impede recovery
Similar to precipitating, stuck in hospital or detained, drinking
What are protective factors of mental illness
Factors which help to prevent episodes or promote recovery
Friends, family, job that they enjoy, meaningful activity
What is behavioural action therapy
Involves meaningful activities and goal setting
The idea is that the more you do with your day the better you feel
What is the Cognitive Behavioural Analysis System of Psychotherapy (CBASP)
Create a timeline of life events - start with personal history and people who have influenced
You rate how the patient makes you feel which gives them an idea of how others perceive them
Situational analysis together – look at situations that make them stressed/angry etc to develop coping
What is acceptance and commitment therapy
You teach patients to accept the negative thoughts and feelings
But they learn to step back and observe them but not actually take them ‘seriously’
Which physical medical disorders may present with mood disturbance
Endocrine - thyroid
Neuro - epilepsy, Huntington’s
What are the mainstays of treatment for altered mood
Psychological or psychotherapy - e.g. CBT
Physical treatments
- antidepressant and other medications
- ECT
- These can be use separately OR in combination.
List drugs commonly used in the treatment of depression
Selective Serotonin Reuptake Inhibitors (SSRI’s)
Tricyclic Antidepressants (TCA)
Monoamine reuptake inhibitors (MAOI’s)
List drugs commonly used in the treatment of bipolar
Mood Stabilisers - lithium, sodium valproate
Atypical Antipsychotics
Antidepressants
List drugs commonly used in the treatment of acute mania
Antipsychotics (atypical and typical)
Mood stabilizers (eg Lithium , Sodium Valproate , Lamotrigine)
Benzodiazepines
ECT
How common are the ‘baby blues’
Affect up to 70% of women after birth
What are the main differences between baby blues and post-natal depression
Baby blues are more common, presents within a few days of delivery and have mild and self-limiting symptoms
PND presents at any time but usually within 6 months, symptoms are more severe, consistent with depression
