Mood Disorders Flashcards
Define unipolar affective disorder
Patients suffer from depressive episodes alone, although they are commonly recurrent.
Define bipolar affective disorder
Patients suffer bouts of both depression and mania. Although mania can rarely occur by itself without depressive mood swings (thus being ‘unipolar’), it is far more commonly found in association with depressive swings, even if sometimes it takes several years for the first depressive illness to appear
What is depression?
Condition where symptoms of unhappiness become qualitatively different and pervasive or interfere with normal functioning.
Is depression more common in men or women?
women
General Criteria for diagnosis of depression?
A. The depressive episode should last at least 2 weeks
B. There have been no hypomanic or manic symptoms sufficient to meet the criteria for hypomanic or manic episode at any time in the individual’s life
Core and Additional Features needed for diagnosis of depressive episode?
CORE: (need 2/3)
1) depressed mood
2) loss of interest or pleasure
3) decreased energy
ADDITIONAL: (need at least 1, total to make 4)
1) Loss of confidence
2) guilt
3) suicidal ideas or behaviours
4) poor concentration
5) agitation/ retardation
6) sleep disturbance
7) changes in appetite
Define dysthymia?
Mild or moderate depressive illness that lasts intermittently for 2 years or more
Explain what psychotic depression is?
Occurs in some with severe depression where thinking becomes psychotic
Usually hallucinations with theme of depression e.g. voices saying they are a failure
Nihilistic delusions can occur where it is believed by the patient that a part of them is dead or decomposed or annihilated or they don’t exist entirely as a human being (called Cotard syndrome)
List some clinical features of depression?
Mood: Depressed, miserable or irritable
Talk: Impoverished, slow, monotonous
Energy: Reduced, lethargic, lacking motivation
Ideas: Feelings of futility, guilt, self-reproach, unworthiness, hypochondriacal preoccupations, worrying, suicidal thoughts, delusions of guilt, nihilism and persecution
Cognition: Impaired learning, pseudodementia in elderly patients
Physical: Insomnia (especially early waking), poor appetite and weight loss, constipation, loss of libido, erectile dysfunction, bodily pains
Behaviour: Retardation or agitation, poverty of movement and expression
Hallucinations: Auditory – often hostile, critical
Explain the difference between the two main classifications of bipolar disorder?
Bipolar I
– Has to have met criteria for mania, although previous episodes may have been hypomanic and/or depressive
– Represents the ‘classic’ form of manic-depressive psychosis in the last century
Bipolar II
– Current or past hypomanic episode and current or
past depressive episode
– Has never met criteria for manic episode
– Represents the most common form of illness
- not a milder form, still a large amount of disability
A single episode of hypomania or mania even if the patient hasn’t been depressed is ________
bipolar (mania doesn’t occur as a unipolar disorder)
The first episode of hypomania or mania on a background of recurrent depression means that _________
the diagnosis is bipolar disorder and not depression anymore
Define what is meant by hypomania?
A level of disturbance below mania
What is the criteria for a hypomanic episode?
A. The mood is elevated or irritable to a degree that is definitely abnormal for the individual concerned and sustained for at least 4 consecutive days
B. At least three of the following signs must be present, leading to some interference with personal functioning in daily living:
- increased activity or physical restlessness;
- increased talkativeness;
- difficulty in concentration or distractibility;
- decreased need for sleep;
- increased sexual energy;
- mild spending sprees, or other types of reckless or irresponsible behaviour;
What is the criteria for a manic episode?
A. Mood must be predominantly elevated, expansive or irritable, and definitely abnormal for the individual concerned. The mood change must be prominent and sustained for at least 1 week (unless it is severe enough to require hospital admission)
B. At least three of the following signs must be present (four if the mood is merely irritable), leading to severe interference with personal functioning in daily living
- Increased activity or physical restlessness;
- Increased talkativeness (‘pressure of speech’);
- Flight of ideas or the subjective experience of thoughts racing;
- Loss of normal social inhibitions resulting in behaviour which is inappropriate to the circumstances;
- Decreased need for sleep;
- Inflated self-esteem or grandiosity;
- Distractibility or constant changes in activity or plans;
- Behaviour which is foolhardy or reckless and whose risks the subject does not recognize e.g. spending sprees, foolish enterprises, reckless driving;
- Marked sexual energy or sexual indiscretions.
Length of manic episode vs hypomanic episode?
hypomanic: at least 4 consecutive days
manic: mood change must be prominent and sustained for at least a week (unless severe enough to require hospital admission)
Prevalence of bipolar disorder?
1-4%
Mean age of onset of bipolar disorder? How does this compare to depression?
age 21, this is earlier than depression
Is bipolar more common in men or women?
it is equally common
Is there genetic factors in bipolar?
yes there is strong evidence of genetic factors, multiple genes each with small effects
Patients with bipolar 1 and 2 typically spend about _______ of the time with syndromal mood disturbance
50%
In both types of bipolar what is the most common mood disturbance?
depression
Compared to bipolar 2, bipolar 1 has slightly higher percentage time spent in ____
mania or hypomania
In bipolar disorder explain subsyndromal symptoms?
These are symptoms of depressed or elated mood that don’t necessarily meet criteria for a depressive or manic episode but can still be very disabling
Explain what the monoamine hypothesis is?
This states that depression results from a functional deficit of monoamine transmitters in particular serotonin (5-HT) and noradrenaline
This was based off the evidence that drugs that deplete stores of monoamines e.g. reserpine can induce low mood
Also CSF from depressed patients have reduced levels of monoamines or metabolites
Most drugs that treat depression act to increase monoaminergic transmission
But it’s NOT that simple, these are just parts of the complex pathway that are modifiable
Give some examples of SSRIs?
fluoxetine, citalopram, sertraline, paroxetine
Fluoxetine, citalopram, sertraline, paroxetine are examples of?
selective serotonin reuptake inhibitors
MOA of SSRIs?
selectively inhibit reuptake of serotonin (5-HT) from the synaptic cleft
What are some common side effects of SSRIs?
nausea, headache, worsened anxiety, transient increase in self harm in adolescents and young people, sweating, vivid dreams, sexual dysfunction, hyponaetremia (in elderly), discontinuation effects
List some examples of tricyclic antidepressants?
imipramine, dosulepin, amitriptyline, lofepramine
MOA of tricyclic antidepressants?
Block the uptake of monoamines serotonin and noradrenaline into presynaptic terminals equally
Common side effects of tricyclic antidepressants?
Most are due to anticholinergic effects > blurred vision, dry mouth, constipation, urinary retention, sedation, weight gain, postural hypotension, tachycardia, arrhythmias, cardiotoxic in overdose
In comparison to SSRIs, tricyclic antidepressants are relatively ________
dangerous
Are monoamine oxidase inhibitors used commonly?
no, they are rarely used now due to side effect profile
MOA of monoamine oxidase inhibitors?
monoamine oxidase usually breaks down monoamines such as serotonin and NA so inhibition increases levels of these transmitters
List two examples of monoamine oxidase inhibitors?
phenelzine (irreversible) or moclobemide (reversible)
Common side effects of monoamine oxidase inhibitors?
irreversible inhibitors cause a deadly reaction with cheese, they potentiate the actions of some other drugs e.g. barbiturates by decreasing their metabolism, insomnia,, postural hypotension, peripheral oedema
Give an example of a noradrenaline reuptake inhibitor?
reboxetine
Reboxetine is an example of ______
noradrenaline reuptake inhibitor
Mechanism of action of noradrenaline reuptake inhibitor?
selectively inhibits the reuptake of NA from the synaptic cleft
List some clinical uses of antidepressants?
moderate to severe depression dysthymia generalised anxiety disorder panic disorder, OCD, PTSD premenstrual dysphoric disorder bulimia nervosa neuropathic pain
What are venlafaxine and duloxetine examples of?
other monoamine uptake inhibitors that aren’t SSRIs, tricyclic or NRIs
MOA off venlafaxine and duloxetine?
block reuptake of monoamines noradrenaline and serotonin into presynaptic terminals
Side effects of venlafaxine and duloxetine?
similar to SSRIs, they lack major receptor blocking actions e.g. anticholinergic so more limited range of side effects compared to tricyclics
List some categories of antidepressants?
SSRIs NRIs tricyclics other monoamine uptake inhibitors monoamine oxidase inhibitors
In bipolar acute mania or hypomania is treated with?
if they are on a mood stabiliser, dose should be optimised
if not they should be treated with a 2nd generation antipsychotic e.g. quetiapine, risperidone, olanzapine
What are the two main agents used as mood stabilisers in bipolar disorder?
lithium and valproic acid
MOA of lithium?
not really known
Side effects of lithium?
dry mouth, strange taste, polydipsia, polyuria, tremor, hypothyroidism, long term reduced renal function, nephrogenic diabetes insipidus, weight gain
Signs of lithium toxicity?
vomiting, diarrhoea, ataxia, coarse tremor, drowsiness, altered consciousness, convulsions, coma
What anticonvulsants can also be used as mood stabilisers?
valproic acid, lamotrigine, carbamazepine
MOA of anticonvulsants as mood stabalisers?
very unclear
Valproate is ______
teratogenic!
Side effects of valproate and carbamazepine?
drowsiness, ataxia, cardiovascular side effects, induction of liver enzymes
Lamotrigine has a small risk of _____
steven johnson syndrome
Provide an overview of treatment of depressive disorders?
Education on diagnosis (knowing why they feel distress may help) Severe may need admitted Psychotherapy Antidepressants ECT
What has mild to moderate depression been shown to respond well to?
talking therapies (the main one is CBT)
List some types of talking therapies?
CBT behavioural activation therapy CBASP acceptance and commitment therapy pyschoeducation
When is medication for depression used?
In moderate and severe depression
Describe what antidepressants work best?
Little evidence that one works better than others, all to do with the patient. Escitalopram is probably the best all round SSRI. Setraline is well established, has good cardiac safety profile and allows easy dose titration.
Describe how long antidepressants should be given after a first episode?
antidepressant should be confined for 6 months after full recovery without reducing the dose
Describe how long antidepressants should be given after a second episode or more?
antidepressant should be continued for 1-2 years after full recovery without reducing the dose
When is electroconvulsive therapy the treatment of choice?
in severe life threatening depressive illness, particularly when psychotic symptoms are present
Principles of treating acute mania?
discontinue antidepressant, maximise anti manic dose if patient on maintenance treatment (e.g. lithium or sodium valproate) if mania may need admission to hospital
Principles of treating acute bipolar depression?
Antidepressants should not be prescribed without an anti manic drug, avoid antidepressants in those with recent hypomanic or manic episode or history of rapid cycling, SSRIs particularly fluoxetine is preferable to other classes. Antipsychotics such as quetiapine is 1st line, other e.g. olanzapine also used. An antidepressant may be used alongside an antipsychotic.
Principles of maintenance therapy in bipolar disorder?
Lithium is gold standard
other options= lamotrigine if primarily depression or valproate if primarily manic
psychoeducation is also important
