Psychiatry - Mood disorders

Question 1

What is the ICD-10 criteria for depression?

Answer 1

3 core symptoms, at least 2 of which should be present every day for at least 2 weeks:

• low mood
• anhedonia (= loss of enjoyment in formerly pleasurable activities)
• decreased energy or increased fatiguability

Question 2

What determines the severity of a depressive episode?

Answer 2

Depressive episodes are described as mild, moderate or severe. They depend on:

• number of symptoms present (core + additional)
• severity of the symptoms
• degree of associated distress
• interference with daily activities

Question 3

Other than core symptoms, give some additional symptoms of depression

Answer 3

• reduced concentration and attention
• disturbed sleep and/or appetite
• reduced self esteem
• ideas of guilt and worthlessness
• thoughts of hopelessness

Question 4

If a depressive episode has psychotic features how should it be classified?

Answer 4

Any depressive episode associated with psychotic features (i.e. first rank symptoms) is automatically classed as severe.

Question 5

What is a unipolar mood disorder?

Answer 5

This is a mood disorder characterised by recurrent depressive episodes only.

cf. bipolar mood disorders if there is a history of at least one manic or hypomanic episode

Question 6

Thought content in depressed patients

Answer 6

Clinical features of depression include thought content, biological symptoms, altered motor activity, cognition, psychotic features etc.

Thought content in depression often includes negative, pessimistic thoughts about:

• the self (low self esteem)
• the world
• the future

These 3 subjects are referred to as Beck’s cognitive triad. There may also be feelings of worthlessness and thoughts about self harm (risk assessment important)

Question 7

Biological symptoms of depression

Answer 7

Biological symptoms refer to reduced sleep, appetite and libido. These may be particularly prominent in older people, who less often complain of disturbed mood.

There is often a sleep pattern of early waking (more than 2 hours before usual) and maximal lowering of mood in the morning (diurnal variation).

Poor appetite may be associated with weight loss.

Question 8

Psychotic features in depression

Answer 8

Psychotic features may occur in depression (and bipolar). First rank symptoms are usually mood congruent.

Delusions are usually nihilistic (e.g. a belief that one is dead, has lost all ones assets or ones body is rotting), hypochondriacal, concerning illness or death.

When hallucinations occur, they are usually auditory, in the second person and accusing, condemning or urging the individual to commit suicide.

Question 9

What is atypical depression?

Answer 9

This is a form of depression that most often occurs during adolescence. It features initial anxiety related insomnia, subsequent oversleeping, increases appetite and a relatively bright and reactive mood.

Question 10

What are the differential diagnoses to consider in depression?

Answer 10

• normal sadness, particularly in the context of bereavement or severe physical illness
• psychotic depression should be differentiated from schizophrenia on the basis of thought content (mood congruent first rank symptoms) and the time sequence in which symptoms develop
• Alcohol or drug withdrawal
• Depressive retardation may be difficult to distinguish from the flat (unreactive) affect of chronic schizophrenia

Question 11

Epidemiology of depression

Answer 11

Lifetime risk is 10-20%, with rates almost doubled in women.
First onset is typically in the third decade (cf. bipolar disorder which is earlier).
Depression is strongly associated with low SES.

Question 12

What is the aetiology of depression?

Answer 12

Twin and adoption studies show that there is a genetic component to depression, but this is less prominent for unipolar than bipolar depression.

Current theories suggest a gene-environment interaction - i.e. a genetic predisposition to depression if exposed to adverse life events or social circumstances. These include:

• parental loss, stress, abuse in childhood
• alcohol/ drug abuse (depression is often comorbid)
• severe physical illness, some medications (e.g. steroids, isotretinoin)
• life event (e.g. bereavement), deprivation, adversity, unemployment, lack of a confiding relationship

Question 13

What is the final common pathway in the aetiology of depression?

Answer 13

Gene-environment interactions suggest that the final common pathway in depression is decreased brain derived neurotropic factor (BDNF) that promotes neurogenesis.

This is caused by increased cortisol (hypercortisolaemia) and decreased central synaptic monoamine levels (i.e. noradrenaline and 5-HT).

Reduced BDNF may be particularly important in the limbic system and prefrontal cortex.

Question 14

What is the management of mild depression?

Answer 14

Most cases of depression can be managed in primary care. Psychiatric referral is only indicated if suicide risk is high, or the depression is severe, unresponsive to treatment, bipolar or recurrant.

For mild depression:

• self help groups
• structured physical activity groups
• guided self help groups
• behavioural couples therapy

NB - antidepressants are not indicated for mild depression

Question 15

How should moderate depression (and mild depression not responding to treatment) be managed?

Answer 15

Psychological therapy should be given with antidepressants for moderate or severe depression. These can have a 60-70% response rate, but often fail because of inadequate dosage, duration or adherence.

So:

• add antidepressant
• individual CBT
• interpersonal therapy

Question 16

Treatment for severe cases of depression

Answer 16

Remember that multiple factors determine the severity of a depressive episodes (esp. number of core + additional symptoms).

For severe depression:

• ECT if poor oral intake, psychosis, or stupor present
• atypical antipsychotics (e.g. aripiprazole, olanzapine, risperidone, quitiapine) if psychotic
• augment antidepressants with lithium or an atypical antipsychotic if depression resistant

Question 17

How long should a patient stay on antidepressants after a depressive episode?

Answer 17

Continuing antidepressants for at least 6 months reduces relapse. In recurrent depression, prophylactic effects have been demonstrated for up to 5 years.

When discontinuing antidepressants, taper slower to avoid withdrawal symptoms.

Question 18

What is the prognosis for depression?

Answer 18

Single episodes of depression usually last several months.

About:

• 20% of patients remain depressed for 2 years or more
• 50% have recurrences, rising to 80% in severe cases

The lifetime suicide risk is 15% in severe depression, but much lower in milder illness.

Predictors of poor outcome include early onset, greater symptom severity and psychiatric or physical comorbidity.

Question 19

What is bipolar disorder?

Answer 19

Also known as manic depression
Involves recurrent episodes of both depression and mania. Recovery between episodes is usually complete and the frequency and pattern of episodes is variable

Question 20

Aetiology of bipolar

Answer 20

Genetic factors have a strong contribution:

• heritability is estimated at 85%
• MZ:DZ = 80:20%
• risk of bipolar illness in a first degree relative of those with bipolar is 8%

Question 21

What risk factors are associated with bipolar disorder?

Answer 21

High SES 
Urban areas 
Ethnic minority groups 
Increased risk of manic episodes in post partum period 
Sleep disturbance caused by shift work
Equally common in men and women

Question 22

Clinical features of hypomania

Answer 22

Persistent elevation in mood (> 3days)
Increased activity and energy
Decreased sleep
Talkative
Overfamiliarity
Increased libido

Question 23

What is the difference between mania and hypomania?

Answer 23

Elevated mood with psychotic symptoms distinguishes mania from hypomania

• delusions are usually congruent (grandiose)
• auditory hallucinations may be present

Mania can occur WITHOUT psychotic symptoms

Question 24

Examination findings in bipolar disorder

Answer 24

Appearance and behaviour: Dress inappropriate/ outlandish, may be neglect of personal hygeine, overfamiliar, flirtatious behaviour, increased psychomotor activity, distractible
Speech: load, pressure of speech, flight of ideas
Emotions: elated but can quickly turn to irritability and anger
Perceptions: auditory hallucinations, often mood congruent
Thoughts: grandiose or persecutory
Insight: poor
Cognition: attention and concentration often impaired

Question 25

What investigations should be performed in bipolar?

Answer 25

Exclude other causes of manic episodes: substance misuse, space occupying lesion, hyperthyroidism, corticosteroids, anabolic androgenic steroids

FBC, U&E, LFTs, Ca, TFTs, glucose, urine drug screen

Question 26

Management of an acute manic episode

Answer 26

Most patients require hospitalisation - use MHA if poor insight

Lithium is mood stabiliser. It takes 3-7 days to take effect, so antipsychotics are required for rapid control of acute behavioural disturbance

BDZ can be used as adjunct

Olanzapine can also be used as mood stabiliser, also has sedating effects

ECT if exhaustion becomes life threatening

Antidepressants can precipitate or aggravate a manic episode, so are stopped

Question 27

When should patients be offered prophylaxis for bipolar and how is this achieved?

Answer 27

One episode of mania at an early age is an indication for prophylactic treatment

Li and sodium valproate are mood stabilisers and are main treatments used to prevent relapse. They help to prevent both depression and mania

Advise women about contraception

Before starting lithium check renal function and TFT. Lithium has a narrow therapeutic range and levels should be checked carefully

Olanzapine can be used for prophylaxis

Carbamazepine and lamotrigine are also effective and may benefit some responder

Question 28

What complications are associated with bipolar disorder?

Answer 28

10% of patients with bipolar commit suicide
Alcohol and substance abuse can complicate the picture
Non compliance with prophylaxis is an important issue

Patients often don’t comply due to the side effects or a prolonged period of well being. Abrupt withdrawal of a mood stabiliser carries a high risk of relapse of mania and/or depression (50% of patients relapse within 5 months if lithium is stopped)

Minority of patients develop rapid cycling of four or more episodes a year

Question 29

What is the prognosis of bipolar disorder?

Answer 29

Most relapses are associated with poor compliance
90% of patients will have at least one recurrence of mania and/or depression within 10 years

Median duration of an untreated manic episode lasts 4 months, depression is slightly longer at 6 months. Usually with time, manic episodes become less frequent, depressive episodes last longer

Question 30

What factors are associated with a poor prognostic outcome for bipolar?

Answer 30

Early onset of illness
Poor compliance
Persistant depressive symptoms 
Severe mania
FHx of non response
Co-morbid personality 
Substance misuse
Rapid cycling (four episodes per year)