Mood Disorders Book Flashcards
How is mood described?
Subjectively in own words.
Objectively as euthymic, dysthymic or elated.
What is a mood disorder?
Affective disorder
Impaired ADLs.
Distorted, excessive and inappropriate moods for a sustained period
What is the difference between primary and secondary mood disorders?
Primary doesn’t result as a cause of another psychiatric disorder I.e. unipolar depression or bipolar disorder.
Secondary is as a result of a psychiatric condition
What are the types of secondary mood disorders?
Physical disorder I.e. cushings, addisons, hypothyroidism etc
Psychiatric disorder I.e. schizophrenia, dementia, alcoholism
Drug induced I.e. beta blockers, corticosteroids, digoxin etc
What is a depressive disorder?
Low mood >2wks
Lack of energy
Anhedonia
What is the pathophysiology of depression?
Monoamine hypothesis
Due to lack of serotonin, noradrenaline and dopamine.
Overactivity of the HPA
Personality type, poor stress control mechanism, stressful life events, chronic health problems, poverty, unemployment, divorce.
What are the RF for depression?
FF, AA PP, SS
Female Family Hx Alcohol Adverse events Past depression Physical co-morbidities Low social support Low socioeconomic status
What are the clinical features of depressive disorder?
DEAD SWAMP
Depressed mood Energy loss Anhedonia Death thoughts (suicide) Sleep disturbance (EMW- waking up 2hrs earlier than premorbidly) Worthlessness/guilt Appetite or weight change Mentation (reduced concentration) Psychomotor retardation (slow movement and speech) Low libido
Usually have diurnal variation in mood I.e. low mood is more pronounced in the morning.
Can also get negative thoughts (Becks triad- of oneself, of the world, of the future)
Psychotic depression- hallucinations (usually 2nd person auditory), delusions (nihilistic, guilt, poverty, hypochondriac, persecutory)
How is depression classified?
Mild- 2 core + 2 other
Moderate- 2 core + 4 other
Severe- 3 core + >/=4 others
Severe depression with psychosis- 3 core + >/=4 other + psychosis
How is depression diagnosed and investigated?
Explore core symptoms I.e. how has your mood been over the last two weeks?
Explore the cognitive symptoms I.e. how do you see things unfolding in the future?
Explore the biological symptoms I.e. do you find your mood particularly worse at certain times of the day?
Investigations are only useful when ruling out organic causes.
Diagnostic questionnaire I.e. PHQ-9, HADS and Becks depression inventory
Blood tests- FBC (anaemia), TFTs (hypothyroidism), U+Es, LFTs, Ca (biochemical cause), glucose (diabetes can cause lack of energy)
MRI/CT if atypical presentation I.e. sudden personality change.
What are the differential diagnosis of depression?
Other mood disorders I.e. bipolar affective disorder,
Secondary to physical condition I.e. hypothyroidism
Secondary to psychoactive substance abuse
Secondary to psychotic disorder i.e. dementia, eating disorders, personality disorder etc.
Normal bereavement
What is the biopsychosocial management of depression?
Biological-
Anti-depressants
Adjuvants I.e. antipsychotics
ECT
Psychological-
Psychotherapists
Self-help programmes
Physical activity
Social-
Social support groups
What are the types of psychotherapies used to manage depression?
CBT- allows people to identify and tackle negative thoughts.
IPT- identify and solve relationship problems
Behavioural activation- encourages development of positive behaviours and activities usually avoided.
Counselling- explore problems and symptoms
Psychodynamic therapy- explore and understand difficulties which may have occurred in the patients life, starting from childhood.
How is mild-moderate depression managed?
Watchful waiting- reassess in 2wks.
Antidepressants- not recommended in mild depression unless- episode has lasted a long time, has had previous moderate-severe depression, other management is not effective, the depression complicates the care of other physical health problems.
Self help programmes- works with a healthcare professional, through self help manuals.
Computerised CBT
Physical activity programmes
Psychotherapies
How is moderate to severe depression managed?
Suicide risk assessment
Psychiatry referral if high suicide risk, severe depression, recurrent depression, unresponsive to initial therapy.
Can implement Mental Health Act if necessary
Antidepressants-
SSRIs I.e. citalopram are first line. Also fluoxetine, sertraline
Others include TCAs, SNRIs and MAOIs (MAOIs only prescribed by specialists)
Adjuvants I.e. lithium, antipsychotics
Psychotherapy- CBT, IPT
Social support- either engaging in community activities the patient is avoiding or attending social support groups
ECT- indicated as an acute treatment of severe depression which is life threatening, if rapid response is required, if depression with psychotic features, if severe psychomotor retardation or stupor, if failure of other treatment.
What is bipolar affective disorder?
Chronic episodic mood disorder characterised by at least one episode of mania (or hypomania) and a further episode of depression or mania.
If at presentation there has only been episodes of mania, this is still considered bipolar as eventually all cases of mania develop depression.
ICD 10- need 2 episodes of mood disturbance, one of which must be mania/hypomania.
What is the pathophysiology of bipolar affective disorder?
Environmental-
Post exams
Stressful life events
Loss of loved ones
Biological-
Neurochemical- increase in monoamines
Endocrine- increase in cortisol, aldosterone, thyroid
Genetic
What are the RF for developing bipolar affective disorder?
Aggressive Spenders
Age- early 20s
Anxiety disorders
After depression
Stressing life events
Strong FHx
Substance misuse
Higher in black and ethnic minorities
What are the clinical features of bipolar?
Mix of manic and depressive symptoms.
Refer to depression notes for depressive.
Manic- I DIG FASTER. Irritability Distractibility/disinhibition (sexual, spending, social) Insight impaired/increased libido Grandiose hallucinations Flight of ideas Appetite/activity increased Sleep decreased Talkative I.e. pressured speech Elevated mood/energy increased Reduced concentration/reckless I.e. spending, behaviours
How is mania classified?
Hypomania-
Mild elevated mood >/=4 days
Partial insight
Symptoms of mania to a lesser extent than true mania
Interference with work and social life BUT not severe disruption
Mania without psychosis-
Greater extent than hypomania
Symptoms present for >1wk with complete disruption to work and social life
May have grandiose ideas, spend excessively, sexual disinhibition and reduced sleep leading to exhaustion.
Mania with psychosis-
Severely elevated/suspicious mood
Psychotic features I.e. grandiose/persecutory delusions, auditory hallucinations which are congruent to mood.
Patient may show aggression.
How is bipolar affective disorder classified?
Bipolar 1- periods of severe mood episodes from mania to depression.
Bipolar 2- milder form of mood elevation I.e. milder hypomania and severe depression.
Bipolar 3- >4 mood swings in 12 months without an asymptomatic intervention period. Poor prognosis.
How is bipolar affective disorder investigated?
Take a good history, asking questions related to the clinical symptoms of bipolar.
Self rating scales- Mood Disorder Questionnaire
Bloods- FBC (routine), TFTs (hyper/hypothyroidism), LFTs (need baseline hepatic function in starting lithium), glucose, Ca (biochemical disturbances)
Urine drug test- illicit drug use
CT head- rule out SOL.
What are the differential diagnosis for bipolar affective disorder?
Mood disorders I.e. hypomania, mania, mixed mood, cyclothymia
Psychotic disorders I.e. schizophrenia, schizoaffective disorder
Secondary to medical condition I.e. Cushings, hyper/hypothyroidism, stroke, cerebral tumour
Drug related I.e. amphetamines, cocaine, acute drug withdrawal and corticosteroid side effect.
Personality disorder I.e. histrionic, emotionally unstable
How is bipolar affective disorder managed?
Need to do a risk assessment- risk to self or others, DVLA.
Can use MHA to detain patient if they are aggressive or risk to self.
Hospitalise a patient if they present a risk to self/others, if they have psychotic symptoms, if they have impaired judgement or if there is psychomotor agitation.
Biopsychosocial model- Biological- Mood stabilisers I.e. Lithium Benzodiazepines I.e. lorazepam Antipsychotics ECT- only if severe uncontrolled mania
Psychological-
Psychoeducation
CBT (high intensity psychobiological intervention)
Social-
Social support groups
Self-help groups
Encouraging calming activities
CALMER Consider hospitalisation/CBT Antipsychotics (atypical) Lorazepam Mood stabilisers ECT Risk Assessment
How is an acute manic/mixed episode of bipolar affective disorder managed?
First line- Antipsychotics I.e. olanzapine, risperidone or quetiapine, (haloperidol also affective). These work faster at stabilising mood than lithium so are used in the first instance or severe mania. If one antipsychotics ineffective, prescribe another antipsychotic.
Second line- mood stabilisers I.e. Lithium, (if not tolerated then sodium valproate), can be used as an add on treatment.
Benzodiazepines can be used to aid sleep and reduce agitation
Rapid tranquillisation can be achieved by haloperidol and/or lorazepam.
How is a bipolar depressive episode managed?
Atypical antipsychotics i.e olanzapine + fluoxetine, olanzapine alone or quetiapine alone.
Mood stabiliser of choice is lamotrigine, although lithium still effective.
Antidepressants alone are usually avoided. Although patient can present with depression as a main symptom, treating this could induce mania therefore give antidepressants with anti-manic medication.
How is long term bipolar managed?
4wks post acute episode Lithium is given first line to prevent relapse.
If lithium ineffective then consider valproate, olanzapine or quetiapine.
What precautions are in place before lithium prescribing?
Before commencing check U+Es (excreted renaly), TFTs, pregnancy test, baseline ECG.
Lithium has a narrow therapeutic window and so can cause side effects.
Side effects include- polydipsia, polyuria, fine tremor, teratogenicity (1st trimester), impaired renal function, memory problems.
Toxicity (1.5-2.0 mM)- N+V, coarse tremor, ataxia, muscle weakness, apathy.
Severe toxicity (>2.0)- nystagmus, dysarthria, hyperreflexia, oliguria, hypotension, convulsions and coma.
Lithium level should be checked: 12hrs after first dose then Weekly until therapeutic range of 0.5-1mM has been stable for 4wks Once stable check every 3 months U+Es every 6 months TFTs every 12 months
Use lithium and sodium valproate for treating rapid cycling.
