Mood Disorders Flashcards
Key Symptoms of Depression
- Persistently Low Mood
- Anhedonia
- Anergia
Associated Symptoms of Depression
- Concentration Reduced
- Self Esteem Reduced
- Guilt and Worthlessness
- Hopeless about future
- Appetite Diminished
- Suicidal Thoughts
- Sleep Disturbance
Classification of Depressive Disorders
Mild (≥2A + 2B),
Moderate (≥2A + 3B),
Severe (All 3A + ≥2B)
Most days, most of the time, for 2/52
Associated somatic symptoms of depression
Psychomotor Retardation, Agitation, Loss of Libido,
Constipation and Amenorrhoea
Dysthymia
– Longstanding mild depressive symptoms; Often associated with other psychiatric
illness or physical illness; Can co-occur with Depression ‘Double Depression’
Psychotic depression
Severe spectrum of disease; Delusional intense worry and perceived faults; May be associated with Cotard’s syndrome and Derogatory Auditory Hallucinations
o High Suicide Risk; Depressive Stupor might occur (Severe Psychomotor Retardation)
o Depressive Stupor risks fatality from dehydration; Treated with Em ECT
o Needs to be distinguished from other Psychotic Disorders; Distinguishing features
include Mood Congruity of Delusions and Hallucinations
Atypical Depression
Increased Sleep, Appetite and Phobic Anxiety; Responds better to MAOI
Mixed Anxiety and Depressive Disorder
Termed if symptoms of either to not meet criteria
for diagnosis of either mood or anxiety disorder
Organic Mood Disorder
Anaemia, Hypothyroidism, Addison’s, Cushing’s, Hypercal, DM, Pituitary, Ca and CNS tumour, Epilepsy, SLE, MS, Stroke, TBI, Vit D and B Deficiency
Epidemiology of Depression
Common; 2F>M; 15% Lifetime risk; Mean late 20yrs onset; Positive Family Hx; Moderate Heritability of about 40%; More so if early onset
o Predisposition of Depressive Disorder
and Anxiety Disorders but Bipolar Disorder predisposition is separate
Biological Aetiology of Depression
Genetics, Organic Mood Disorder,
Neurochemical Changes
o Hypofunction of Monoamine systems (5-HT, NA) and HPA axis
o Negative bias in Emotional Processing might involve failure of FP regulation of
processes in Amygdala
o Focal Lesions of Subcortical WM on MRI – Late onset depression and Poor prognosis;
Other structural changes include Glial reduction in PFC and Hippocampal Atrophy;
Unknown if Causal, Consequential or Coincidence
Psychological and Social Aetiology of Depression
Childhood, Abnormal Cognition, Learned Helplessness, Personality
o Cognitive Theory – Tendency to think negatively of self, future and the world
o Neuroticism – Personality attributes of Anxiety, Obsessions and Poor Stress Coping
o Adverse Experiences in Childhood, Recent Life Events and Lack of Social Support
Management of Mild Depression
Mild Depression without previous episodes – Often self-limiting; Antidepressants may not be
indicated; Information, Advice and Self Help to Problem Solving
o Sleep Hygiene (Timing, Activities prior, Environment, Physical Exercise)
o Drug treatment if previous episodes of ≥Mod depression that responds to treatment
• Consider: Ideas, Concerns, Expectations; Suicide Ideation, Psychotic Symptoms, disabling
symptoms, Past DH, Past History of Mania, Cardiac Disease (avoid TCA with recent MI);
Management of Moderate Depression
Drug Treatment is First-line for ≥Mod depression; >70% respond to Antidepressants, although
only 30% might respond to first-line drugs
o Monitor emergent Suicide Ideation which can occur with mood improvement;
Especially in younger people; No evidence for increased suicide
o After recovery, continue at same dose for at least 6-9/12; Dose is tapered off over
several weeks to Reduce Risk of Relapse (by >50%) and Withdrawal
Medication counselling, Psychosocial Support; Ensure Drug is at adequate dose, good adherence and sufficiently long duration
SSRIs
o SSRIs are safer and more tolerable than TCAs; 4 – 6 weeks before Improvement; 6 – 8 weeks therapeutic trial; First-line Antidepressants are Setraline and Citalopram
▪ SE: Nausea, Anxiety/Agitation, Drowsiness, Insomnia, Sexual Dysfunction;
Consider Gastroprotection if on NSAID in older peoples
Sedating Antidepressants
o Paroxetine and Fluvoxamine – Sedating Antidepressants; Useful if insomnia; NB:
Paroxetine is associated with weight gain; Fluoxetine – Strongly Activating;
Antidepressants with fewer sexual SE
o Bupropion and Mirtazapine have fewer sexual SE
Considerations with Antidepressants
Avoid Antidepressants in Pregnancy and Breastfeeding; Avoid ETOH when on TCA or MAOI;
Cannabis, Amphetamines, Cocaine, Heroin and Ketamine interact with TCA; Avoid driving and
heavy machinery if SE cause drowsiness and blurred vision
Examples of SSRIs
Setraline (=Zoloft)
Citalopram
Paroxetine
Fluoxetine (=Prozac)
Examples of TCAs
Amitriptyline
Desipramine
Imipramine
Example of SNRIs
Venlafaxine
Duloxetine
Milnacipran
Atypical Antidepressants
Mirtazapine
Bupropion
Trazodone
Esketamine
Psychological Therapies in Depressive Disorders
• Useful if patient choice in Mild-Moderate Depression; Mindedness (Ability and Willingness to
think about Psychological matters), Engagement in Therapy and Homework tasks
• CBT and CCBT – Improves outcomes when combined with antidepressants
• Interpersonal, Problem-Solving, Psychodynamic Therapy, Behavioural Couples Therapy
Non-response to First-Line Therapy
• Up to 2/3rds do not respond; Check Antidepressant taken as prescribed, Increase to
Maximum Tolerated/Recommended Dose
• Consider Perpetuating factors e.g. Endocrine, Marital Issues, ETOH XS
• Consider switching to SNRI (Duloxetine, Venlafaxine) or other SSRI; Add-on therapy includes Lithium (for Severe Depression), Mirtazapine (Sedative effect), Atypical Antipsychotic
(Olanzapine, Quetiapine), Psychological Therapies
• Psychiatric Referral – No response to treatment, Risk to self or others, second opinion required, Specialist therapies or severe depression necessitating admission or ECT
Antidepressant Overdose
If present within 1hr; Gastric Lavage and Charcoal might be beneficial
SSRI Overdose
Enhanced Central Serotoninergic Neurotransmission; Elimination Half-life
24hrs; Citalopram and Escitalopram can cause QT prolongation and risk of Torsades
o Seizures in <4% of patients; Managed with Benzodiazepines (E.g. Lorazepam,
Diazepam, Midazolam)
o Serotonin Toxicity typically mild and only 20% of patients; Higher risk if co-ingested
with other Serotoninergic agents
Aggressive Cooling, Intubation, Ventilation,
Neuromuscular Paralysis might be required
for severe toxicity
Serotonin Toxicity
▪ Fever, Mental State changes (Agitation), Autonomic Instability (Diaphoresis),
Neuromuscular Changes (Tremor, Hyperreflexia, Clonus, Hypertonia)
▪ Cyproheptadine (Antihistamine with Antiserotinergic effects), Olanzapine,
Chlorpromazine)
TCA Overdose
Anticholinergic, Inhibition of
Catecholamine Release, Alpha Adrenergic Blockade
and Sodium Channel Blockade (Cardiac and CNS)
o Reduced GCS – Intubation and Hyperventilation to raise pH
o IV Bicarbonate Bolus to raise pH; Aim >7.5; Raised serum pH increases proportion of
un-ionised drug; Increases drug distribution throughout body
▪ Increased sodium overcomes sodium channel blockade
Stages of Grief
stages of Shock/Disbelief, Pre-occupation (Includes Anger, Tearfulness, Low Mood, Social
Withdrawal and Somatic Symptoms similar to Depression), Acceptance and Resolution (Which
may take months to start and months to complete)
o Recurrence of grief common around anniversaries (Anniversary reactions)
o Bereavement Counselling and Support (E.g. Hopeagain; Cruse 0808 808 1677)
Absent Grief
No outward signs, or beginning a few weeks later
Prolonged Grief
Prominent symptoms 6 – 12 months later; Actively consider Depressive Disorder
and need for treatment
Excessive Grief
Intensively unusually great; Might reflect relationship to deceased, Personality of
patient or underlying Depressive Disorder
Bipolar Disorder
Relapsing Remitting condition; periods of Elated mood
(Mania/Hypomania) and Depressed mood; Presence of
Elated mood alone is sufficient for diagnosis
Manic Symptoms
A (Predominantly Elevated mood, Expansive or Irritable and Definitely Abnormal for the individual concerned) + ≥3 or 4 B (Loss of Social
Inhibition, Talkativeness, Flight-of-Ideas/Racing
Thoughts, Inflated Self-Esteem/Grandiosity,
Distractibility, Activity/Restlessness, Risky Behaviour without Insight, Decreased Need for Sleep, Libido)
Hypomania
Happiness and Zest for life in excess of normalcy; Variable degree of functional
impairment; Daily routine may be maintained with less need for sleep and more nocturnal;
Subjectively more productive but tasks might be rarely done well or completed
o Concentration impaired, Distractibility is usual; Might be irritable; Might progress to
Mania, especially if past Hx
o Patients with Elated mood never going beyond Hypomania characterised as Bipolar-II
Mania
Substantial impairment of Occupational and Social functioning; Disordered Speech
and Thought; Congruent, Grandiose Psychotic symptoms including Auditory Hallucinations
o Patients with at least one Manic episode characterised as Bipolar-I
Mixed Affective State
Manic and Depressive symptoms which co-exist within a day; May be
triggered by Antidepressants in patients with tendency to Bipolar Disorder
Cyclothymia
Mild, Chronic Bipolar variation of mood; Patients might have increased risk of
developing Manic episode following Antidepressant treatment
Epidemiology of Bipolar
1% Lifetime risk; M=F, Early 20yrs; 10% risk of BPD if FH BPD; 15% risk of Depressive Disorder
Aetiology of Bipolar
Strongly heritable (80%); FH of Bipolar Disorder increased risk of both Bipolar and Unipolar Depressive Disorder; No childhood risk factor known, although life events can precipitate
Neurobiological abnormalities similar to Depressive Disorder, with differences in
abnormalities of Emotional Processing
Other causes of Bipolar Disorder
Drug induced Mania should be considered, esp young with no FH; If first presenting in middle age, consider Cerebrovascular Disease, Tumours, Medication SE
o Amphetamine use, Antidepressants, Dopaminergic (L-DOPA, Bromocriptine), Isoniazid
Management of Bipolar Disorder
• Full Psychiatric Clerking, Corroborative History, Risk Assessment; Ensure patient is in calm
environment with reduced stimulation; Advice not to make any important decisions
Management of Mania/Hypomania
Mania/Hypomania, or Mixed Episodes: Stop Antidepressants, Offer Antipsychotics
(Haloperidol, Olanzapine, Quetiapine, Risperidone)
o Check Lithium level if already on to assess adherence
o Consider adding Lithium; If not tolerable, Consider Valporate
o ECT for severe mania that is not response to drug treatment
Management of Bipolar Depression
Psychotherapy – CBT, IPT, BCT (In line with guidelines for Depressive
Disorder) or Pharmacotherapy – Fluoxetine + Olanzapine dual therapy, or Quetiapine or
Lamotrigine alone depending on preference and previous response
o If already on Lithium, consider add-on either dual F+O therapy, or just Olanzapine or
Lamotrigine alone (Lithium not with Quetiapine)
o Antidepressants alone are less effective, and can precipitate Mood Destabilisation
and Manic episodes
o If Severe – Antipsychotics, Admission and ECT might be necessary
Prevention of Relapse
Patients should understand their own illness and recognise signs of
Mood instability; Long-term Monitoring
o Long-term Pharmacotherapy to prevent relapse: Lithium first-line; Add-on Valporate;
If Lithium not tolerated, use Valporate, Olanzapine or Quetiapine (if effective
previously during acute episodes)
▪ Typically, not offered until patient has at least 2 episodes, with at least one
being Manic/Hypomanic; Current trend towards starting after one serious
episode especially if FH Bipolar Disorder
▪ Lithium reduces risk of Manic and Depressive Relapse by 40 – 50%; Should
not be initiated unless intend to continue for at least 2yrs
o CBT or Family Therapy might be useful in preventing relapse
o Relapse might be heralded by non-specific symptoms e.g. Developing Insomnia,
Increased Energy); Short-course of Antipsychotics or Valporate may successfully treat
Starting Antipsychotics
Weight/BMI, HR/BP, FBG/HbA1c, Blood Lipids prior to starting
Antipsychotics; ± ECG
Starting Lithium
Weight/BMI, FBCs, U/Es, Ca, TFT, ECG if cardiac RF;
o Measure Li 1 week after starting and 1 week after every dose changes until dose stable; Aim for 0.6 – 0.8mmol/L for first-time onto Lithium
o Consider 0.8 – 1mmol/L trial for 6/12 if had relapse on Li on the past, or symptomatic
o Seek medical attention if D+V or acutely ill; Ensure fluid intake; Avoid in Pregnancy
Antipsychotics
Typical: Haloperidol
Atypical: Olanzapine, Quetiapine,
Risperidone
SE of Antipsychotics
Extrapyramidal SE
Hyperprolactinaemia
Sedation, Weight gain, Hyperglycaemia,
Anticholinergic SE
Mood Stabilisers
Lithium Salts
Valporate, Lamotrigine,
Carbamazepine,
SE of Lithium
GI symptoms, Metallic Taste,
Tremor, Thirst/Polyuria/Oedema; Severe
GI, Neuromuscular Signs
