Pschiatry - Affective Disorders 1/2

Question 1

Depression?

Aims?

Answer 1

Depression

• Mild, moderate, severe
• Recurrent, chronic (dysthymia), atypical

Postnatal depression

Seasonal affective disorder

Bipolar affective disorder

• Type 1 Vs type 2 / mania Vs hypomania
• Rapid cycling

Cyclothymia

Question 2

Depression?

Answer 2

•Most common psychiatric disorder

•Currently ranked third most prevalent moderate and severe disabling condition globally (WHO)

•Often goes undiagnosed and untreated

•50% of suicides linked to depressive disorder being a major factor

•Associated with many chronic physical health conditions

•Associated with high rates of comorbid alcohol and substance misuse

•More than 80% of patients managed and treated in primary care. Secondary care = much more severe disease

Question 3

Depression?

Answer 3

• Negative affect (low mood) and/or absence of positive affect (loss of interest and pleasure in most activities)
• Usually accompanied by an assortment of emotional, cognitive, physical and behavioural symptoms

Classification:

• NICE uses DSM-IV classification
• To diagnose major depression, this requires at least one of the core symptoms:
• Persistent sadness or low mood nearly every day
• Loss of interests or pleasure in most activities
• Plus some of the following symptoms:
• Fatigue or loss of energy
• Worthlessness, excessive or inappropriate guilt
• Recurrent thoughts of death, suicidal thoughts, or actual suicide attempts
• Diminished ability to think/concentrate or increased indecision
• Psychomotor agitation or retardation
• Insomnia/hypersomnia
• Changes in appetite and/or weight loss

Question 4

Diagnosing Depression?

Answer 4

• Symptoms persistent for at least two weeks, causing clinically significant distress and impairment
• Subthreshold depressive symptoms - < 5 symptoms
• Mild depression - > 5 symptoms. only minor functional impairment
• Moderate depression - symptoms or functional impairment between ‘mild’ and ‘severe‘
• Severe depression - most symptoms present, symptoms markedly interfere with normal function +/- psychotic symptoms.

Normal sadness exists Vs clinically significant depression

Question 5

Depression?

DSM-V?

Answer 5

DSM-V updated 2013:

• Persistent depressive disorder - chronic major depressive disorder and dysthymia
• Removal of the major depression bereavement
• New category of mixed anxiety/depressive disorder

Question 6

Depression?

Risk Factors?

Answer 6

• Genetic
• Gender: 1 in 4 women, 1 in 10 men
• Childhood experiences
• Personality traits
• Social circumstances
• Chronic physical illness increases the risk of depression.
• Significant physical illnesses causing disability or pain.
• Past history of depression
• Other mental health problems e.g. dementia
• African-Caribbean, Asian, refugee and asylum seeker communities

Aetiology not yet full understood for depression – biopsychosocial model, neurobiological factors

Question 7

Depression?

Screening?

Answer 7

•NICE: At-risk groups - individuals with a depression history or a chronic health problem + associated functional impairment:

•

•During the past month, have you:

ØFelt low, depressed or hopeless?

ØHad little interest or pleasure in doing things?

• Affirmative answer to either question = further evaluation BUT a negative response does not exclude depression
• Self-report symptom scales are widely used and include:

ØThe Patient Health Questionnaire (PHQ-9)

ØThe Hospital Anxiety and Depression (HAD) Scale

ØBeck’s Depression Inventory

Question 8

Depresion?

Differential Diagnosis?

Answer 8

• Consider other psychiatric disorders
• Bereavement: Depressive symptoms begin within 2-3 weeks of a death (uncomplicated bereavement and major depression share many symptoms but active suicidal thoughts, psychotic symptoms and profound guilt are rare with uncomplicated bereavement).
• Organic cause
• Neurological
• Endocrine
• Substance misuse
• Medications that may cause depressed mood e.g. methyldopa, propranolol, BZD, progesterone contraceptives

Question 9

Depression?

Investigations?

Answer 9

• Not always necessary to perform all the below tests, use clinical judgement when ruling out organic causes
• FBC, ESR, B12/folate, U&Es, LFTs, TFTs, blood glucose, calcium
• Magnesium levels, HIV or syphilis serology, or drug screening
• MRI / CT brain for atypical presentations or ?intracranial lesion e.g. unexplained headache / personality change
• Seek specialist advice as appropriate

Question 10

Derpression?

Management?

Answer 10

•Improving Access to Psychological Therapies (IAPT)

NICE: Treatment of mild-to-moderate depression

• Consider watchful waiting, 2-week follow-up
• Consider one or more low-intensity psychosocial interventions:
• Guided self-help based on CBT principles - book prescription schemes / Internet resources
• Computerised CBT
• Relaxation therapy
• Brief psychological interventions (6-8 sessions)
• Antidepressants not initially but can be considered in particular situations

Question 11

Depression?

Management?

Answer 11

NICE: Treatment of moderate-to-severe depression:

• Antidepressant medication with high-intensity psychological treatment (CBT or interpersonal therapy (IPT))
• In young people, combining CBT and newer antidepressants may be better in the short term than either therapy alone
• Urgent psychiatric referral may be required
• ECT
• ?Exercise as a treatment
• First-line antidepressant – SSRIs: Selective serotonin reuptake inhibitors

Question 12

Depression?

Monitoring?

Answer 12

• Not at increased risk of suicide - two weeks after initiation of Tx with regular reviews
• Monitor for signs of akathisia, suicidal ideas and increased anxiety and agitation
• At increased risk of suicide or < 30 years old - one week after initiation of Tx
• Regularly review (every 2-4 weeks) in the first three months or until the risk is no longer significant
• High risk of suicide - prescribe a limited quantity of antidepressants plus additional support e.g. frequent contacts with GP / or telephone contacts
• If partial or no response to medication at 2-4 weeks:
• Check adherence and side-effects, consider increasing the dose, consider switching and note ‘wash out times’
• Avoid tricyclic antidepressants or venlafaxine when there is a risk of overdose

Question 13

Dpression?

Treatment Duration?

Answer 13

• Continue for at least six months after remission if Tx was beneficial
• 2 or more depressive episodes recently and experienced significant functional impairment during episodes – continue Tx for 2 years (some may require longer)
• Substantial risk of relapse or residual symptoms – consider referral for either individual CBT or mindfulness-based cognitive therapy
• When stopping antidepressants:
• Reduce doses gradually over a four-week period
• Withdrawal symptoms

Question 14

Depression?

When to Refer?

Answer 14

Urgent referral when actively suicidal

Refer to secondary care if:

• Uncertain diagnosis, including possible bipolar disorder
• Failed response to two or more interventions
• Recurrence of depression <1 year from previous episode
• More persistent suicidal thoughts
• Comorbid substance, physical, or sexual abuse
• Severe psychosocial problems
• Rapid deterioration
• Cognitive impairment

Question 15

Depression?

Com[plications?

Answer 15

• Impaired quality of life and reduced productivity
• Social difficulties are common
• Associated problems, such as anxiety symptoms and substance misuse, may cause further disability
• Increased mortality
• A history of attempted suicide
• High levels of hopelessness
• High ratings of suicidal tendencies
• Depression increases the risk of developing and dying from coronary heart disease

Question 16

Depression?

Prognosis?

Answer 16

The outlook varies with the severity of the condition:

• Mild depression: 6-8 months and spontaneous recovery is likely
• Major depression: ~80% of people who have received psychiatric care for an episode will have at least one more episode in their lifetime, with a median of four episodes

The outcome for those seen in primary care also seems to be poor

Risk factors for increased risk of depression recurrence include:

• ≥3 episodes of major depression
• High prior frequency of recurrence
• An episode in the previous 12 months.
• Residual symptoms during continuation treatment
• Severe episodes – e.g. ‘suicidality’, psychotic features
• Long previous episodes
• Relapse after drug discontinuation
• Poor health overall

Question 17

Catatonia?

Answer 17

• State of apparent unresponsiveness to external stimuli in a patient who appears to be awake
• Not a disease but presentation of a number of different conditions
• It may be an episodic condition with periods of remission and triggered by medication or other changes in circumstances

Question 18

Depression?

Dysthymia?

Answer 18

Dysthymia (ICD-10)

• Chronic, low-grade depressive symptoms
• Long-standing but Hx taking does reveal a time when the person did feel ‘well’
• Double depression
• Clinical features: Depressed mood >2 year, reduced/increased appetite, insomnia/hypersomnnia, reduced energy/fatigue, low self-esteem, poor concentration, difficulties making decisions, thoughts of hopelessness
• Course less severe but more chronic than depression. Low spontaneous remission rates
• Management: Phenelzine (response rates vary 30-70%). Alternatives – SSRI fluoxeteine, sertraline or TCAs. Psychological – evidence lacking – CBT may be useful

Prognosis 10-20% achieve complete remission within a year of Tx. ~25% suffer chronic symptoms

Question 19

Depression?

Postnatal Depression?

Answer 19

Any non-psychotic depressive illness occurring during the first postnatal year

There is no convincing evidence that hormonal changes cause PND

The strongest risk factors appear to be:

• Previous history of mental health problems
• Psychological disturbance during pregnancy
• Poor social support
• Poor relationship with partner
• Baby blues
• Recent major life events

Screening questions:

• Formal assessment tools: PHQ-9, Edinburgh Postnatal Depression Scale or the Generalised Anxiety Disorder Scale (GAD-7)
• Medication – SSRI, TCA, SNRIs

Question 20

Depression?

Seasonal Affective Disorder?

Answer 20

• Depressive episodes that recur annually at the same time each year, usually during the winter months
• 2% of the population in Northern Europe have severe depression resulting from SAD
• In the UK, up to 6% of adults have ‘recurrent major depressive episodes with seasonal pattern’
• The mean age at presentation of SAD is 27 years
• During the reproductive years, it is four times more common in women than in men
• Genetic component
• Management: Advice e.g. working in bright conditions, exercise, self-help programmes, diet, light therapy and antidepressants e.g. fluoxeteine