MOOD DISORDERS GENERAL + DEPRESSION Flashcards
What are the different types of manic episodes?
Hypomania
Mania without psychotic symptoms
Mania with psychotic symptoms
What is hypomania?
persistant mild elevation of mood, increased energy and activity, and usually marked feelings of well-being and both physical and mental efficiency. Increased sociability, talkativeness, over-familiarity, increased sexual energy, and a decreased need for sleep are often present but not to the extent that they lead to severe disruption of work or result in social rejection.
Lasts at least 4 days
What is mania?
Mood is elevated out of keeping with the patient’s circumstances and may vary from carefree joviality to almost uncontrollable excitement. Elation is accompanied by increased energy, resulting in overactivity, pressure of speech, and a decreased need for sleep. Attention cannot be sustained, and there is often marked distractibility. Self-esteem is often inflated with grandiose ideas and overconfidence. Loss of normal social inhibitions may result in behaviour that is reckless, foolhardy, or inappropriate to the circumstances, and out of character.
Lasts at least 7 days
What psychotic symptoms may occur with mania?
delusions (usually grandiose)
hallucinations (usually of voices speaking directly to the patient) are present
Pressured or disorganised thoughts and speech
What are mood congruent delusions?
the content of a person’s delusions or hallucinations aligns with the person’s mood state.
What is an example of a mood congruent delusion during a bout of mania?
a person believing they have superpowers or are best friends with a celebrity
What is bipolar defective disorder characterised by?
2 or more episodes in which the patient’s mood and activity levels are significantly disturbed, this disturbance consisting on some occasions of an elevation of mood and increased energy and activity (hypomania or mania) and on others of a lowering of mood and decreased energy and activity (depression). Repeated episodes of hypomania or mania only are classified as bipolar.
How do we describe bipolar affective disorder in its different states?
Current episode hypomanic
Current episode manic without psychotic symptoms
Current episode manic with psychotic symptoms
Current episode mild or moderate depression
Current episode severe depression without psychotic symptoms
Current episode severe depression with psychotic symptoms
Current episode mixed
Currently in remission
How do we diagnose depression?
PHQ2:
During the last month, have you often been bothered by feeling down, depressed, or hopeless?
During the last month, have you often been bothered by having little interest or pleasure in doing things?
If the person answers ‘yes’ to one of the questions and symptoms have been present most days, most of the time, for at least 2 weeks, ask about associated symptoms of depression:
Disturbed sleep
Decreased or increased appetite and/or weight.
Fatigue or loss of energy.
Agitation or slowing down of movements and thoughts.
Poor concentration or indecisiveness.
Feelings of worthlessness or excessive or inappropriate guilt.
Recurrent thoughts of death, recurrent suicidal ideas, or a suicide attempt or specific plan.
Do the PHQ9
How do we determine the severity of the depressive episode?
Mild - 4 symptoms
Moderate 5-6 symptoms
Severe 7+ symptoms
(Depressed mood, loss of interest, reduction in energy, loss of self confidence, feelings of guilt, recurrent thoughts of death, not being able to concentrate, change in psychomotor activity, sleep disturbance, change in appetite and weight)
When can depression present with psychotic symptoms?
In moderate or severe depressive episodes
What psychotic symptoms does severe depression usually cause?
Hallucinations (most common is auditory)
Delusions
Psychomotor agitation or retardation
What is atypical depression?
A specific type of depression in which the symptoms vary from the traditional criteria. One symptom specific to atypical depression is a temporary mood improvement in response to actual or potential positive events (mood reactivity)
What is recurrent depressive disorder?
A disorder characterized by repeated episodes of depression as described for depressive episode, without any history of independent episodes of mood elevation and increased energy (mania).
There may, however, be brief episodes of mild mood elevation and overactivity (hypomania) immediately after a depressive episode, sometimes precipitated by antidepressant treatment.
What category does seasonal depression fall under?
Recurrent depressive disorder
What are the different types of recurrent depressive disorder?
Current episode mild
Current episode moderate
Current episode severe without psychotic symptoms
Current episode severe with psychotic symptoms
Currently in remission
What are the 2 most common persistant mood disorders?
Cyclothymia
Dysthymia
What is Cyclothymia?
A persistent instability of mood involving numerous periods of depression and mild elation, none of which is sufficiently severe or prolonged to justify a diagnosis of bipolar affective disorder or recurrent depressive disorder.
Some patients with cyclothymia eventually develop bipolar affective disorder.
Which group of people is Cyclothymia frequently found in?
in the relatives of patients with bipolar affective disorder
What is dysthymia?
A chronic depression of mood, lasting at least several years, which is not sufficiently severe, or in which individual episodes are not sufficiently prolonged, to justify a diagnosis of severe, moderate, or mild recurrent depressive disorder.
Outline the epidemiology of depression?
4th leading cause of disability worldwide
1/5 will experience it at some point in their life
3rd most frequent reason for consulting a GP
What are the 3 core symptoms of depression?
Persistent low mood
Loss of interests/pleasure
Fatigue/low energy
What are the 3 main options for classification of depressive episodes?
Depressive episode
Bipolar affective disorder
Recurrent (unipolar) depressive disorder
What are the 2 whooley questions/PHQ2 used to screen for depression in primary care?
During the last month have you often been bothered by feeling down, depressed or hopeless?
During the last month have you often been bothered by having little interest or pleasure in doing things?
What are the known risk factors of depression?
Female sex.
Older age.
PHx of depression.
Personal, social, or environmental factors, such as relationship issues or breakdown, bereavement, stress, poverty, unemployment, homelessness, social isolation, or past history of child maltreatment.
Postpartum period.
FHx of depressive illness or suicide.
History of other mental health conditions and/or substance misuse.
Other chronic physical health conditions associated with functional impairment
Outline how a FHx of depression is a risk factor for depression?
first-degree relatives of a person with a ‘major’ depressive episode have a three-fold increased risk of depression
Hereditability is 40-70%
What chronic physical illnesses increase your risk of depression?
Diabetes mellitus, COPD, CVD, chronic pain syndromes, epilepsy, stroke disease
What is the monoamine theory of depression?
Depression is due to a shortage of noradrenaline, serotonin and potentially dopamine.
What evidence supports the monoamine theory of depression?
Pt with low levels of serotonin metabolite were found to be more likely to have committed suicide
drugs that deplete monoamines can cause depression
TCAs and MAOIs increase monoamines and are known to treat depression
What evidence does not support the monoamine theory of depression?
it takes 2-3 weeks for antidepressant drugs to effectively treat depression but if the monoamine theory is true then depression should decrease as levels of neurotransmitters rise - shold not have a delayed therapeutic effect onset
What are the somatic symptoms of depression?
sleep disturbance, appetite disturbance, and fatigue or loss of energy.
What proportion of those with depression report multiple unexplained physical symptoms?
50%
What brain changes have been seen with bipolar?
Enlarged cerebral ventricles on CT scan
How do we treat depression conservatively?
Education
Lifestyle changes e.g. sleep hygiene, diet, exercise, substance use
Improve physical health
Problem solving e.g. sorting out debt and divorces
How do we treat mild depression?
Watch and wait for 2 weeks
Lifestyle changes
Group exercise
Self help - books, online CBT, self help groups
How do we treat mild to moderate depression?
Talking therapies e.g. CBT, counselling, behavioural activation, interpersonal psychotherapy
How do we treat moderate to severe depression?
Antidepressant medication and talking therapy (combination therapy)
Or individual CBT orBA
Or individual medication
What is CBT?
Based on the cognitive model - it focuses on identifying and changing negative through patterns and behaviours that can contribute to depression
What are the ‘levels’ of CBT?
Self help materials
Assisted self help e.g. computerised CBT
Specific CBT interventions
Formulation driven CBT (1:1 weekly sessions)
Which patients are likely to be good candidates for CBT?
Can recognize and capture thoughts in different situations
Can recognize and differentiate emotions
Accepts personal responsibility to change
Understands cognitive model
Can form good therapeutic relationship
Onset of problems is recent (e.g. within 6 months)
Can stay focussed ‘on task’
Doesn’t use defence mechanisms
Optimistic about outcome
Problems are not very severe
Whats the CBT model of depression?
Underlying beliefs centre around being helpless or unloveable because of early experiences
Trigger events typically involve loss or ‘failure’
This produces negative cognitions about self/ future/world which reinforce underlying beliefs, and affect mood and behaviour
These negative thoughts are maintained by distorted information processing (e.g. overgeneralization, personalization, selective abstraction)
Whats the evidence base for CBT?
CBT is highly effective compared to controls and shows equivalence to medication except in severe cases
What is behavioural activation therapy?
Therapy aiming to increase a pt’s engagement in positive rewarding activities
It’s based on the ideas that depression is maintained by a lack of positive reinforcement
What is counselling?
Individual sessions delivered by a practitioner with therapy-specific training and competence.
Usually consists of 12-16 regular sessions
Focus is on emotional processing and finding emotional meaning, to help people find their own solutions and develop coping mechanisms.
Provides empathic listening, facilitated emotional exploration and encouragement.
Collaborative use of emotion focused activities to increase self-awareness, to help people gain greater understanding of themselves, their relationships, and their responses to others, but not specific advice to change behaviour.
Who is counselling suitable for?
May be useful for people with psychosocial, relationship or employment problems contributing to their depression.
May suit people who do not like talking about their depression in a group.
What is psychodynamic psychotherapy?
Therapy thataims to resolve unconscious conflitcts and early childhood experiences that may underlie depression
What is interpersonal psychotherapy?
a talking treatment that helps people with depression identify and address problems in their relationships with family, partners and friends.
This is based on the idea thta depression can be exacerbated bu issues in interpersonal relationships
Why do we choose SSRIs first line?
all antidepressants have a similar efficacy for the treatment of depression so we choose SSRIs as they are better tolerated as have less side effects and are safer in overdose
During the first few weeks of treatment with antidepressants, how is the pt likely to feel?
increased potential for agitation, anxiety, and suicidal ideation.
Outline the options for antidepressants?
SSRI
Another SSRI or SNRI
TCAs
MAOIs
Addition of other antidepressant
Use of augmenting agent
How long should antidepressant treatment be tried for. Before considering switching to another antidepressant ?
4 weeks at least (6 in elderly)
How long should you continue using an antidepressant for if it has bought on remission of symptoms?
Continued at full dose for 6 months at least
Long term use of which antidepressants have been linked to an increased risk of developing type 2 diabetes?
SSRIs and TCAs
Outline how serotonin is released into synaptic clefts?
Presynaptic serotonergic neurones use tryptophan to synthesise serotonin (5-Hydroxytryptophan) which is then stored in vesicles. When an action potential reaches the presynaptic membrane, vesicles fuse with the membrane and release serotonin into the synaptic cleft. Serotonin can bind to 5HT2 receptors on the postsynaptic neurone and this causes a new action potential. On the presynaptic membrane there are serotonin reuptake transporters which facilitate the uptake of serotonin.
Outline the moa of SSRIs?
SSRIs bind to serotonin reuptake transporters and inhibit them which increases the serotonin level within the synaptic cleft.
How long do SSRIs take to work? And why?
4-6 weeks before improvements seen
These meds are slow acting as it takes time for serotonin to accumulate within the synaptic cleft.
What can SSRIs treat?
Chronic anxiety
PTSD
OCD
Major depressive disorder
Bulimia nervosa
What are the side effects of SSRIs?
Body weight increase
Anxiety and agitation
Dizziness (+ other anticholinergic side effects e.g. blurred vision and dried mouth)
Serotonin syndrome
Sad tummy (nausea, vomititng, indigestion, diarrhoea, constipation)
Reproductive and sexual dysfunction
Insomnia
What are side effects specific to citalopram?
Arrhythmias due to prolongation of QT interval
What are side effects specific to paroxetine?
Congenital heart defects if taken in pregnancy
Which SSRI drugs inhibit CYP450 and reduce the rate of elimination of other drugs causing, potentially toxic, effects?
Fluoxetine, norfluoxetine and paroxetine
What is serotonin syndrome?
Serotonin accumulation which causes overstimulation of the nervous system. It usually happens when using a combination of SSRIs and other antidepressants that increase serotonin levels.
What are the symptoms of serotonin syndrome?
Shivering
Hyperreflexia and myoclonus (most prominent in lower extremities. Differentiates from NMS which has lead pixie rigidity)
Increased temp (in severe cases)
Vital sign abnormalities (tachypnoea, tachycardia, labile bp)
Encephalopathy (mental state changes, confusion, delirium, agitation)
Restlessness
Sweating
How do we treat serotonin syndrome?
withdrawal of medication and supportive care. In moderate to severe cases we may consider cyproheptadine
Whats the moa of cyproheptadine?
competing with free histamine and serotonin for binding at their respective receptors.
What are the effects of serotonin?
Serotonin plays a key role in such body functions as…
mood - more focused, emotionally stable, happier and calmer
sleep - promotes wakefulness and inhibits REM sleep. Also a precursor to melatonin
digestion - inhibits gastric acid secretion and increases gut motility to facilitate absorption after feeding
Appetite - suppresses appetite
nausea - too much serotonin can cause nausea
wound healing - causes proliferation and migration of fibroblasts
bone health - gut derived serotonin reduces the osteoblast proliferation and thus leads to bone loss and brain derived serotonin decreases sympathetic output and thus favors bone formation
blood clotting - induces constriction of injured blood vessels and enhances platelet aggregation
Inhibitory modulator of sexual desire
How do we get tryptophan in the body?
Through diet e.g. meat, dairy products, eggs and nuts
Why do SSRIs cause anxiety?
Its thought to be because of fluctuating serotonin levels during the early days of treatment
Why do SSRIs cause nausea?
stimulation of 5-HT3 receptors in the vomiting centre, CTZ
Why do SSRIs cause insomnia?
SSRIs regulate sleep-wake cycle
Why do SSRIs cause diarrhoea or constipation?
As they can disrupt the gut motility and gastric acid secretion = disrupts normal functioning of digestive tract
Why do SSRIs cause loss of appetite and weight loss?
Serotonin suppresses appetite
Loss of emotional eating as antidepressant starts to work
Why do SSRIs cause hyponatraemia?
Serotonin causes increase of ADH release = SIADH
Which population is SIADH secondary to SSRI use most likely in?
Why?
Elderly population - more vulnerable to diffiuclties in fluid level regulation
What are symptoms of mild and more severe hyponatraemia?
Mild symptoms include nausea, headache, muscle pain, reduced appetite, confusion.
More severe hyponatraemia can cause fatigue, disorientation, agitation, psychosis and seizures and even coma.
What are the contraindications of SSRIs?
manic phase of bipolar disorder.
poorly controlled epilepsy.
What are contraindications specific to citalopram?
With known QT interval prolongation, or congenital long QT syndrome
Concurrent use of drugs known to prolong the QT interval
What are contraindications specific to sertraline?
severe hepatic impairment
