Mood Disorders Flashcards
Core symptoms of depression
Continuous low mood for at least 2 weeks
Lack of energy
Lack of enjoyment/interest (anhedonia)
Somatic symptoms of depression
Sleep changes - early morning waking, insomnia Appetite and weight changes Diurnal variation of mood Psychomotor retardation/agitation Loss of libido
Cognitive symptoms of depression
Low self esteem Guilt/self blame Hopelessness Hypochondriacal thoughts Poor concentration/attention Suicidal thoughts
Severity of depression
Mild - 2 core + 2 others
Moderate - 2 core + 3/4 others
Severe - 3 core + at least 4 others
- can also have severe with psychotic symptoms
Features of postnatal depression
1-2 months postpartum
Usual symptoms of depression
- worries about baby’s health or ability to cope with baby
Risk factors for postnatal depression
PHx or FHx of depression Older age Single mother Unwanted pregnancy Poor social support Previous PND
Symptoms of hypomania
Several of following features with considerable interference with work/social activity for at least several days
- mildly elevated, expansive or irritable mood
- increased energy/activity
- increased self esteem
- sociability, talkativeness, over familiarity
- increased sex drive
- reduced need for sleep
- difficulty focussing on one task alone
Symptoms of mania
Elevated/expansive/irritable mood (at least 1 week) Can occur with or without psychotic symptoms Increased energy/activity Grandiosity/increased self-esteem Pressure of speech Flight of ideas/racing thoughts Distractible Reduced need for sleep Increased libido Social inhibitions lost Psychotic symptoms
Define bipolar affective disorder
Alternating periods of abnormal mood elevation and depression associated with change or impairment in functioning
- manic episode
- hypomanic episode
- depressive episode
- mixed episode
Types of persistent mood disorders
Cyclothymia - mild periods of elation/depression - early onset/chronic course - common in relative of BPD Dysthymia - chronic low mood not fulfilling the criteria of depression
Define cyclothymia
Period of at least 2 years of instability of mood involving several periods of both depression and hypomania with or without intervening periods of normal mood
Define dysthymia
Period of at least 2 years of contestant or constantly recurring depression mood
- intervening periods of normal mood rarely last longer than a few weeks
- no episodes of hypomania
Define mixed affective episode
Episode characterised by mixture or rapid alternation of hypomanic, manic and depressive symptoms
- usually within a few hours
ICD 10 classification of bipolar disorder
Requires at least 2 episodes
- one of which must be hypomanic, manic or mixed episode
Differential diagnosis of mood disorders
Normal fluctuations in mood Adjustments disorders/bereavement PTSD Dementia and other brain disorders Personality disorders Anxiety disorders
Causes of mood disorders
Biological - genetic - brain illness - physical illness Psychological - childhood experiences - view of yourself and the world - personality traits Social - work, housing, finance - relationships/support
Treatment of mood disorders
Biological
- pharmacological
- ECT - electroconvulsive therapy
- rTMS - repetitive transcranial magnetic stimulation
- tDCS - transcranial direct current stimulation
Pharmacological treatment of depression
Antidepressants - SSRIs - SNRIs - TCAs - NASSAs - MAOIs - Melatonin receptor agonist - NRI - SARI Mood stabilisers - Lithium - Valproate - Carbamazepine - Lamotrigine Combination therapies
Features of monoamine hypothesis
Neurotransmitter change seen depression
- in particular nor-adrenaline and serotonin
Indications for ECT
Severe depressive illness - where other treatments not affective Life-threatening illness Prolonged and severe manic episode Catatonia High suicide risk Stupor Severe psychomotor retardation
Features of pharmacological treatment of bipolar disorder
Mood stabilisers
Antipsychotics
- avoid antidepressants
Psychological treatment of mood disorders
Psychoeducation - about illness, relapse signatures, medication CBT IPT Psychodynamic Mindfulness
Social interventions for mood disorders
Targeted interventions - family - housing - finance - employment General coping strategies - importance of regular structured activities
Define mood
Patient’s sustained, experienced emotional state over a period of time
Define affect
Transient flow of emotion in response to a particular stimulus
Define mood disorder
Condition characterised by distorted, excessive or inappropriate moods or emotions for a sustained period of time
ICD-10 types of mood disorders
Manic episode Bipolar affective disorder Depressive episode Recurrent depressive disorder Persistent mood disorders
Types of mood disorders
Primary
- does not result from another medical or psychiatric condition
Secondary
- results from another medical or psychiatric condition
Define depressive disorder
Affective mood disorder characterised by persistent low mood, loss of pleasure and/or lack of energy accompanied by emotional, cognitive and biological symptoms
Monoamine hypothesis for depression
Deficiency of monoamines (noradrenaline, serotonin and dopamine) causes depression
Over-activity of HPA axis
Predisposing factors for depressive disorder
Biological - Female gender (2:1) - Postnatal period - Genetics - family history - Neurochemical: ↓ serotonin, ↓ noradrenaline, ↓ dopamine - Endocrine: ↑ activity of HPA axis - Physical co-morbidities - Past history of depression Psychological - Personality type - Failure of effective stress control mechanisms - Poor coping strategies - Other mental health co-morbidities (e.g. dementia) Social - Stressful life - Lack of social support - Asylum seeker and referee population
Precipitating factors for depression
Biological - Poor compliance with medication - Corticosteroids Psychological - Acute stressful life events - personal injury, loss of loved one, bankruptcy Social - Unemployment - Poverty - Divorce
Perpetuating factors for depression
Biological - Chronic health problems - diabetes, COPD, CCF, chronic pain Psychological - Poor insight - Negative thoughts about self, the world and future Social - Alcohol and substance misuse - Poor social support - Low social status
Investigations for depression
Diagnostic questionnaire - PHQ-9
Bloods - FBC, TFTs, U+Es, LFTs, calcium levels, glucose
Imaging - MRI or CT scan
Other depressive disorders
Recurrent depressive disorder
Seasonal affective disorder - depressive episodes recurring annually at same time of year
Masked depression - depressed mood not particularly prominent
Atypical depression - mild-moderate depression with reversal of symptoms
Dysthymia - depressive state for at least 2 years which does not meet criteria for mild depression
Cyclothymia - chronic mood fluctuations over at least a 2 year period with episodes of elation and depression which are insufficient to meet criteria for hypomanic or depressive disorder
Management of depression
Biological - antidepressants - adjuvants - antipsychotics - ECT Psychological - psychotherapies - self-help programmes - physical activity Social - social support groups
Treatment of mild-moderate depression
Watchful waiting - reassess in 2 weeks Antidepressants - not 1st line unless - lasted long time - past history of moderate-severe depression - failure of other interventions - depression complicates care of other physical health problems Self-help programmes CBT Physical activity programme Psychotherapies
Management of moderate-severe dpression
Suicide risk assessment Psychiatry referral - high suicide risk - severe depression - recurrent depression - unresponsive to initial treatment Mental health act Antidepressant - 1st line = SSRIs Adjuvants - lithium or antipsychotics Psychotherapy Social support ECT - acute treatment of severe life-threatening depression - rapid response required - psychotic features - severe psychomotor retardation - failure of other treatments
ICD-10 criteria for mania
3/9 symptoms present
- grandiosity/inflated self-esteem
- decreased sleep
- pressure of speech
- flight of ideas
- distractibility
- psychomotor agitation
- reckless behaviour
- loss of social inhibitions
- marked sexual energy
ICD-10 criteria for bipolar
At least 2 episodes in which a person’s mood and activity levels are significantly disturbed
- one of which must be mania or hypomania
Investigations for bipolar
Self-rating scales - mood disorder questionnaire
Blood tests - FBC, TFTs, U+Es, LFTs, glucose, calcium
Urine drug test
CT head - space occupying lesions
Management of bipolar
Full risk assessment
Ask about driving
Mental health act - hospitalisation required if
- reckless behaviour causing risk to patient or others
- significant psychotic symptoms
- impaired judgement
- psychomotor symptoms
For bipolar depression offer CBT
ECT - severe uncontrolled mania
Mood stabilisers, benzodiazepines, antipsychotics
Pharmacological management of bipolar
First line = antipsychotics - olanzapine, risperidone, quetiapine
Mood stabilisers - lithium
Benzodiazepines
Rapid tranquilisation - haloperidol or lorazepam
Antidepressants for depressive episode
Long term management = lithium
- consider valproate
