week 10 - mood disorders Flashcards

Question

MDD stats - prevalence

Answer 1

Prevalence Different studies have presented varying data on prevalence Lifetime risk in community samples: 10% to 25% for women Lifetime risk in community samples: 5% to 12% for men Point-prevalence in adult community sample ---5% to 9% of females, 2% to 3% for males Prevalence appears unrelated to ethnicity, income, education or marital status.

Answer 2

May have onset at any age, mean onset in 20s --Some evidence that age of onset is decreasing Course of Recurrent MDD is variable and idiosyncratic Naturalistic Course - One Year Post-Diagnosis Follow-Up - --40% have symptoms that still meet MDE criteria - --20% have residual symptoms, but do not meet MDE criteria

Answer 3

Relapse Risk After one episode, 60% will experience a second After two episodes, 70% will experience a third After three episodes, 90% will experience a fourth That means that 60% of the 60% (that initially got better) will experience a second episode! So they are not healthy after all

Answer 4

So 63% never get better with management as usual! | potentially

Answer 5

``` Etiology / Formulation Numerous systems are implied in etiology of Major Depressive Disorder. Understanding of mood disorders remains incomplete. - Biological Factors Genetic Factors Dynamic Factors Interpersonal Factors Cognitive Factors Behavioural Factors ``` It is important to remember that each of these factors interacts, and changes in one system can effect changes in others.

Answer 6

The Monoamine Hypothesis of Depression Idea that depression is caused by a deficiency of catecholamines ---Norepinephrine (NE), Serotonin (5HT), Dopamine (DA) ----All effective antidepressants operate on monoamine systems through various mechanisms. ----Drugs that deplete monoamines (e.g. reserpine) have a depressogenic effect See after end of slides for more in depth discussion about the biological factors!

Answer 7

Literature indicates a significant genetic contribution in depression. Genetic factors appear slightly less important in Major Depression, compared with Bipolar Disorder. Those with a first-degree relative with Major Depressive Disorder are at 1.5-3.0 times the normal risk for developing depression. Biological children of depressed parents remain at risk even when reared in a different family. Concordance rate in monozygotic twins is 50% Concordance rate in dizygotic twins is 10-25%

Answer 8

As many as between 2 to 9% of those experiencing depression commit suicide. 30% to 70% of those committing suicide suffer from depression!

Answer 9

Learning Theory / Social Skills Loss of reinforcer effectiveness (Costello, 1972) Also, reduced reinforcers present (e.g., not engaging in rewarding activities anymore!) Briefly stated: Depression is reduced activity and consequently reduced reward and treatment is increasing activity and reward (i.e., behavioural activation)

Answer 10

early experience> dysfuncitonal assumptions>criticalincident> ANTS >symptoms Briefly stated: Depression is automatic negative thoughts and treatment is changing those thoughts and assumptions

Answer 11

``` Depression recognized since antiquity Biblical Examples --King Saul (I Samuel 16, 14-23) The suicide of Ajax in Homer’s Iliad Hippocrates description of Melancholia and Mania (400BC) Further examples throughout history ``` DSM-I Psychoneurotic Disorders / Affective Reactions Manic Depressive Reaction Depressive Reaction Psychotic Depressive Reaction

Answer 12

DSM-III and DSM-III-R conceptualization of “Affective Disorders” --Relationship to Anxiety Disorders Bipolar mood disorders also recognized historically - Hippocrates (400BC) description of Mania. - Bonet (1686) description of Maniaco-Melancholicus - Falret (1854) description of Folie Circulaire - Kahlbaum (1882) first use of term Cyclothymia - Kraepelin (1899) description of Manic-Depression

Answer 13

Chronic Where full criteria for a MDE are met continuously for >2yrs With Catatonic Features Where the clinical picture is dominated by two of the following -Motoric immobility / Catalepsy / Stupor -Excessive motor activity -Extreme negativism or mutism -Peculiarities of voluntary movement as evidenced by -posturing, stereotypies, mannerisms or prominent grimacing. -Echolalia or echopraxia

Answer 14

With Melancholic Features Either Loss of pleasure in all / almost all activities Lack of reactivity to normally pleasurable stimuli Three or more of the following-- Distinctly depressed mood Diurnal mood variation, depression worse in morning Early morning awakening Marked psychomotor agitation or retardation Significant loss of appetite or weight loss Excessive or inappropriate guilt

Answer 15

With Atypical Features - Mood remains reactive - Two or more of the following - -Significant weight gain or increase in appetite - -Hypersomnia - --Leaden paralysis - -Long-standing pattern of sensitivity to interpersonal rejection leading to significant social impairment. With Postpartum Onset --Onset of the MDE is within four weeks postpartum

Answer 16

With Interepisode Recovery When full remission is attained between the two most recent MDEs Without Interepisode Recovery When full remission is not attained between the two most recent mood episodes With Seasonal Pattern There is a regular temporal relationship between MDE onset and a time of year. --Two episodes conform to this pattern with none outside this pattern in the last two years --Seasonally related episodes outnumber non-seasonally related episodes.

Answer 17

A distinct period of persistently elevated, expansive or irritable mood, lasting >4days, that is clearly different from normal non-depressed mood. Clear change in functioning from normal character when asymptomatic. Change in mood disturbance is objectively observable. Symptoms do not cause marked impairment in functioning, and psychotic features are absent. Three or more of the following are present Inflated self-esteem Decreased need for sleep Pressure of speech Flight of ideas / Racing thoughts Distractibility Increased goal-directed activity Increase in pleasant activity with potential for harm

Answer 18

Typically sudden onset, with rapid escalation of symptoms over 24-48 hours Episodes may last weeks to months Hypomanic episodes tend to have more abrupt onset and cessation of symptoms than MDEs Hypomanic episodes tend to be shorter in duration than MDEs 5-15% of Hypomanic Episodes will evolve into a full Manic Episode.

Answer 19

Receptor Based Hypotheses of Depression Almost all antidepressants effect a decrease in the post-synaptic sensitivity of B-adrenergic and serotonergic-type II receptors This down-regulation that occurs with treatment is consistent with the treatment response times seen in antidepressants. Similar down-regulation is seen as a result of atypical antidepressant (e.g mianserin) treatment, and electroconvulsive therapy.

Answer 20

Neuroendocrine Dysfunction Unlikely to be root cause of mood dysfunction, but indicators of other underlying pathology No neuroendocrine markers are perfectly sensitive or specific to presence of depression. Adrenal Axis - -Depressive symptoms are correlated with hypersecretion of cortisol. - -Dexamethasone Suppression Test (DST) - Approximately 50% of depressed patients show abnormal cortisol suppression in response to dexamethasone administration.

Answer 21

Neuroendocrine Dysfunction Thyroid Axis -Abnormal thyroid regulation with depression -About 33% of depressed patients with normal thyroid function may show abnormal (reduced TSH) responses to thyrotropin-releasing hormone. Growth Hormone Depressed patients may show reduced nocturnal release of growth hormone. Other neuroendocrine markers exists e.g. Reduced nocturnal melatonin release

Answer 22

Learned Helplessness/Hopelessness (Seligman) -People prone to depression expect that they are helpless to control aversive outcomes, and behave accordingly. Theory reformulated in light of some inconsistent findings to one of attributions of causes of events ---Internal, stable, global attributions re negative events “I failed the Abnormal Psych exam because I am stupid (internal), I will always fail/be stupid (stable) at everything (global)” --External, unstable, specific attributions re positive events “I only passed the Abnormal Psych exam because Sally helped me (external). It doesn’t mean I will always (unstable) pass everything (specific)”

Answer 23

Depressed mood, most of the day, more days than not, for at least two years. When depressed, two or more of the following: ``` Poor appetite or overeating Insomnia or hypersomnia Low energy or fatigue Low self-esteem Poor concentration or difficulty in making decisions Feelings of hopelessness ``` The above symptoms have never been absent for more than two months No Major Depressive Episode has been present during the first two years of mood disturbance No history of manic or hypomanic episodes

Answer 24

``` Specifiers With Atypical Features See previous slide for Major Depressive Disorder Early Onset Onset is before age 21 Late Onset Onset is after age 21 ```

Answer 25

Major Depressive Disorder - -Chronic versus generally episodic course - -“Double-depression” - ----Major Depressive Disorder superimposed on Dysthymic Disorder Mood Disorder Due to a General Medical Condition Substance Induced Mood Disorder Personality Disorder

Answer 26

Statistics Gender Differences Equally common in male and female children In adulthood, women 2-3 times more likely to be diagnosed as males Family Pattern Increased prevalence of DD when a first degree relative had MDD Increased prevalence of DD and MDD when a first degree relative has DD Prevalence Lifetime prevalence rates: 6% Point prevalence rate: 3% Course Typically early, insidious onset, with chronic course

Answer 27

Relationship to other disorders remains unclear (e.g. Major Depressive Disorder, Borderline Personality Disorder, etc.) Some have suggested that while the symptoms of DD and MDD may be similar, they may be due to different underlying pathology. -Differences in response to Dexamethasone Suppression Test. -But both show abnormalities (decreased latency, increased intensity) to that seen in Major Depression. Psychosocial models for Dysthymic Disorder are similar to those for major depressive disorder

Answer 28

Prognosis has been generally regarded as poor in comparison with Major Depression. -Early studies suggested recovery in only 10 to 15 percent of patients one-year after diagnosis. -Some emerging evidence for effectiveness of cognitive and behavioural interventions, as well as IPT. Treatment - Pharmacological Treatment regimes generally follow that of Major Depressive Disorder ---SSRIs, Tricyclics, MAOIs, venlafaxine

Answer 29

Severe recurrent temper outbursts that are grossly out of proportion Outbursts are inconsistent with developmental level Outbursts occur on average 3+ times per week Persistent irritable or angry mood, even between outbursts Duration of 12 months, with no periods of >3 months asymptomatic Occurring in at least 2 settings

Answer 30

Substance use/abuse is associated with increased frequency of hospitalisation and poorer prognosis. Onset after 40 is rare and other Differential Diagnoses should be considered. Mixed Episodes are much more common in adolescents and young adults than older adults

Answer 31

``` Specifiers Use of specifiers is dependent on the current state of the illness (e.g. a person cannot be “In partial remission” if they still meet criteria for a mood episode, etc.) Mild Moderate Severe Severe with Psychotic Features With Catatonic Features With Postpartum Onset ``` ``` In partial remission In full remission Chronic With Melancholic Features With Atypical Features With Full Interepisode Recovery Without Full Interepisode Recovery With Seasonal Pattern ``` With Rapid Cycling

Answer 32

The most recent episode is specified in the diagnosis and DSM-IV-TR coding of the illness Bipolar I Disorder, Single Manic Episode Bipolar I Disorder, Most Recent Episode Hypomanic Bipolar I Disorder, Most Recent Episode Manic Bipolar I Disorder, Most Recent Episode Mixed Bipolar I Disorder, Most Recent Episode Depressed Bipolar I Disorder, Most Recent Episode Unspecified Example 296.53: Bipolar I Disorder, Most Recent Episode Depressed, Severe, With Melancholic Features, Without Full Interepisode Recovery

Answer 33

Numerous drugs are known to be associated with mood symptoms Depressive:-- ``` Cardiac and antihypertensives Sedatives and hypnotics Some Steroids and hormones Stimulants and appetite suppressants Some Analgesics and antiinflammatory drugs Some Antibacterial and antifungal medications Anti-neoplastic medications Illicit drugs Numerous others ```

Answer 34

Diagnosis Two or more years where there have been ‘numerous’ periods with -Hypomanic symptoms -Depressive symptoms not meeting criteria for Major Depressive Episode The person has not been without the symptoms for more than two months during the two year period. No Major Depressive Episode or Mixed Episode has been present during the first two years of the illness Rule out other Axis I disorders, substance use or general medical conditions Impairment of functioning or distress.

Answer 35

``` Differential Diagnosis Other mood disorders --Have full mood episodes been present? General medical conditions Substance use problems Borderline Personality Disorder --What other symptoms are the shifts in mood associated with? ```

Answer 36

Statistics Gender Differences Appears to be equally common in males and females Women may be more likely to present for treatment than men Family Pattern First degree relatives of Cyclothymia patients are at elevated risk for Bipolar I, Bipolar II and Major Depressive Disorder Some increased risk of substance use problems may be evident also Prevalence Lifetime prevalence 0.4 to 1.0% Prevalence in mood disorder clinics of 3.0 to 5.0%

Answer 37

Course Onset is typically in late adolescence or early adulthood Late onset should alert the clinician to differential diagnoses (e.g. general medical conditions) Onset is often insidious and may be part of a characterological vulnerability to mood disorders Course is typically chronic and lifelong 15-50% of Cyclothymia patients will go on to develop Bipolar I or Bipolar II Disorder

Answer 38

``` Specifiers Use of specifiers is dependent on the current state of the illness (e.g. a person cannot be “In partial remission” if they still meet criteria for a mood episode, etc.) Mild Moderate Severe Severe with Psychotic Features With Catatonic Features With Postpartum Onset ``` ``` In partial remission In full remission Chronic With Melancholic Features With Atypical Features With Full Interepisode Recovery Without Full Interepisode Recovery With Seasonal Pattern ``` With Rapid Cycling

Answer 39

Differential Diagnosis Other mood disorders Mood disorder due to a General Medical Condition Substance Induced Mood Disorder Psychotic Disorders Do psychotic symptoms ever occur in the absence of mood features? What other symptoms of the syndromes are present? History of mood symptoms / features Family history

Answer 40

Gender Differences May be more prevalent in women than men In men hypomanic episodes equal or exceed the number of depressed episodes, whereas in women the opposite pattern is evident. Rapid cycling is more common in women than men. Family Pattern First degree relatives of Bipolar II patients show increased prevalence of Bipolar I, Bipolar II, and Major Depression. Prevalence Community lifetime prevalence rates of 0.5%

Answer 41

Course Typical course is chronic and lifelong 60 to 70% of hypomanic episodes occur immediately before or after a Major Depressive Episode. Individuals may show a specific pattern of episodes. Number of episodes in Bipolar II is greater than Recurrent Major Depressive Disorder Interval between episodes reduces with age 5-15% meet criteria for Rapid Cycling (with poor prognosis) Most show full interepisode recovery, but 5-15% experience residual symptoms between episodes Psychotic symptoms do not occur in hypomanic episodes and are less common in the MDEs than for Bipolar I Disorder Over a five year period, 5-15 percent will develop Bipolar I Disorder

Answer 42

Diagnosis Presence (or history) of one or more Major Depressive Episodes. Presence (or history) of one or more Hypomanic Episodes. Never experienced a Manic or Mixed Episode. Symptoms not better accounted for by another Axis I disorder, substance use, or general medical condition Symptoms cause marked impairment in functioning or distress.