Mood Disorders - Lecture Flashcards
Types of mood disorder
- Depressive disorder - single or recurrent episodes
- Bipolar disorder - mania, hypomania, mixed - likely to recurr
- Persistent mood disorder - cyclothymia, dysthymia
Types of symptoms of depression
- Core
- Biological (somatic)
- Cognitive symptoms
Cluster groups of depressive episode - ICD-11 criteria
- Affective cluster
- Cognitive-behavioural cluster
- Neurovegetive cluster
Core symptoms depression
- Continious low mood for at least 2 weeks
- Lack energy
- Lack enjoyment/interest
Affective cluster - ICD-11
- Depressed mood reported or as observed (tearful, defeated appearance) - must be for 2 weeks at least
- Markedly diminished interest or pleasure in activities esp those normally found to be enjoyable to individual - can include reduced sexual desire - anhedonia
Cognitive behavioural cluster symptoms ICD-11
- Reduced ability to concentrate and sustain attention
- Beliefs of low self worth or excessive/inappropriate guilt
- Hopelessness
- Recurrent thoughts of death (not just fear of dying) or recurrent suicidal ideation
Always ask re self harm and suicide
Neurovegetivive cluster symptoms - ICD-11
- Significantly disrupted sleep (under 25 seem to sleep more when disrupted)
- Significant change appetite - eat more (under 25) or less
- Psychomotor agitation or retardation - difficult to converse, struggle to go to toilet
- Reduced energy, fatigue or marked tiredness
Diagnosis of depression criteria
- Concurrent presence of at least 5 symptoms occurring most of the day, nearly every day for a period of at least 2 weeks
- At least one symptom from affective cluster
- Assessment of presence or absence of symptoms should be made relative to typical functioning of individual - eg in their role, look at it in context of their job etc
*ICD needs two from lack energy, anhedonia and low mood and another 2 symptoms for diagnosis
Mild depression - ICD-11
- None symptoms present to intense degree
- Distressed by symptoms and has some difficulty continuing to function
- No psychotic symptoms
- ICD 10 says two-three symptoms
Moderate depressive episode - ICD-11
- Several symptoms present to marked degree or large number of symptoms of lesser severity
- Considerable difficulty functioning in multiple domains - struggle to work etc
- Delusions, hallucinations with psychotic symptoms
- ICD 10 says 4 or more symptoms and does not include psychotic symptoms
Severe depressive episode
- Many or most symptoms marked degree or smaller number and manifest as intense degree
- Serious difficulty continuing to function in most domains
- Delusions/hallucinations
- ICD10 says can be with or without psychotic symptoms, suicidal thoughts and acts are common
Post-natal depression
- 10-15% of women usually within 1-2 months post partum but can appear later in some women
- Thought content may include worries about babys health or her ability to cope with the baby
RF for post-natal depression
- Personal or FH depression
- Older age
- Single mother
- Unwanted pregnancy
- Poor social support
- Previous PND
Epidemiology of depression
- 2nd ranked global burden of disease
- 2-3x more common if chronic physical health problems
- More common females (1:2)
Symptoms of mania
- Elevated/expansive/irritable mood - 1 week
- Increased energy/activity (inc agitation)
- Grandiosity/increased self esteem
- Pressure of speech
- Flight of ideas/racing thoughts - jumping around different ideas
- Distractable - can’t pay attention
- Reduced need for sleep
- Increased libido
- Social inhibitions lost - can be insulting
- Psychotic symptoms - Grandiose delusions eg they are the king
Symptoms of hypomania
- Mildly elevated, expansive or irritable mood
- Increased energy/activity
- Increased self esteem
- Sociability, talkativeness, over-familiarity
- Increased sex drive
- Reduced need for sleep
- Difficulty in focusing on one task alone
People like their hypomania state - productive and happy
What are PMD? - persistent mood disorders
Do not fit criteria for disorders - milder
Cyclothymia
- Mild periods of elation/depression
- Early onset/chronic course
- Common in relatives of BAD
Dysthymia
- Chronic low mood not fulfilling criteria of depression
What is mixed episode or mixed affectuve state?
- Mixture or rapid alternation (within few hours) of hypomanic, manic and depressive episodes
- Have to have had episode before
Bipolar I vs II
- Bipolar I - 1 or more manic episodes or mixed episodes +/- 1 or more depressive episodes
- Bipolar II - 1 or more depressive episodes with at least 1 hypomanic episodes
- ICD needs at least 2 epidosed, one must be hypomanic, manix or mixed
Bipolar epidemiology
- Median onset 25years
- Male=female
- 1-2%
- Suicide rate more 20x normal population
Differentials for mood disorders
- Normal fluctuations
- Adjustement disorder/bereavement, PTSD
- Dementia or other brain disorder
- Personality disorder
- Anxiety disorders
Causes of mood disorders - biological
- Genetic
- Brain illness
- Physical illness
Causes of mood disorder - psychological
- Childhood experiences
- View of yourself and the world
- Personality traits - particular people, very ordered and control
Causes of mood disorders - social
- Work
- Housing
- Finance
- Relationships/support
Types of treatments for mood disorders
- Biological
- Psychological
- Social
80% depressive disorders managed primary care
Bipolar managed secondary care - will be normal in between episodes - good as anyone
Biological treatments for mood disorders
- Pharmacological
- Electroconvulsive therapy
- rTMS
- tDCS
- DBS
- Vagus nerve stimulation
Monoamine hypothesis
- Neurotransmitter changes in depression in particular NA and serotonin
- At synaptic cleft
Pharmacological examples
- Selective serotonin reuptake inhibitors - eg sertraline, fluoxetine - most common first line
- SNRI eg duloxetine
- Tricyclic antidepressants - amitryptiline prevent uptake, dangerous with overdose as affect lots, used for pain
- NASSAs - eg Mirtazapine - sedative and quick to act, works on autoreceptors (Noradrenaline and specific serotonergic antidepressants)
- Monoamine oxidase inhibitors - prevents breakdown of serotonin
- Melatonin receptor agonist - not used often, hepatotoxic
- Noradrenaline reuptake inhibitors
- SARI
- Mood stabilisers - lithium (worry re thyroids and kidney, check therapeutic index), valproate (not used for reporoductive age women and men under 55), carbamazapine, lamotrigine
Monitoring with lithium
- Narrow TI - 0.4-1 mmol/L
- When testing, do sample 12 hrs after dose
- Do weekly initially and after each dose change weekly until stable level
- Once stable level, check every 3 months
- Can’t be used with certain drugs
Need to do TFTs and U&E every 6 months
ECT
- Elective current through brain - alter neurone activity triggers an epileptic seizure
Indications for ECT
Psychotic depression
Catatonia
Severe depression refractory to medication
rTMS
- Repetitive transcranial magnetic stimulation
- Involves electromagnetic coil against head which sends repetitive pulses of magnetic energy at fixed frequency
- Improves neurotransmission, neuroplasticity and serotonin/noradrenaline in dorsolateral pre-frontal cortex (limbic system)
tDCS
- Transcranial direct current stimulation uses small battery operated stimulator to deliver constant low strength current through 2 electrodes placed on head
- Neuroplasticity, neurotransmission and neurotransmitters
Vagus nerve stimulation
- Pacemaker device implanted attached to stimulating wire along vagus nerve
- Travels up neck to brain where connects to areas to regulate mood
Deep brain stimulation
- Electrodes directly onto brain
Psychological treatment for mood disorders
- Psychoeducation - illness, relapses, medication
- CBT
- IPT
- Psychodynamic
- Mindfulness
Social interventions for mood disorders
- Assess for gambling relating harms - signpost to self referral service, GamCare
- Mind charity UK
- Mental health cafes
- VitaMinds self referral
- LAMP - independent advocates in leicester
- Life Links leicester - MH support
Depression prognosis
- First episode - continue AD for at least 6-12 month
- Multiple episodes - continuye them for much longer
- 80% further episode
- 10% severe, unremitting depression
Bipolar prognosis
Poor prognosis suggested by:
* Severe episodes
* Early onset
* Cognitive deficits
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* Treatment more effective earlier in illness
* 80% relapse after first episode within 5-7 years
