Chap 5 - Depressive Disorders & Bipolar & Related

Question 1

Depressive and manic disorders have certain common characteristics:

Answer 1

▪ Periodicity: Acute episodes, single or recurrent.
▪ Return to normal after the acute phase. In other words, return to a previous level of functioning.

Question 2

How does this group of disorders differ from schizophrenia?

Answer 2

This is in contrast to schizophrenia, where the course of illness is usually chronic and progressive

Question 3

Define mood

Answer 3

A persistent emotion that colours the individual’s entire attitude. The mood may be normal, depressed, or elevated (euphoric)

Question 4

Depressive episode

Answer 4

Persistent depressed mood (for at least two weeks), plus other symptoms such as impaired concentration, insomnia, weight loss.

Question 5

Euphoria

Answer 5

An abnormally elevated mood.

Question 6

Manic episode:

Answer 6

Abnormally elevated mood plus overactivity, insomnia, etc.

Question 7

Mood disorder

Answer 7

A pattern of mood episodes, for example one or more manic episodes and/or one or more major depressive episodes.

Question 8

Depressive disorder define

Answer 8

One or more depressive episodes without a history of manic (or hypomanic) episodes

Question 9

Name the different depressive disorders

Answer 9

a) Major depressive disorder (MDD): Recurrent depressive episodes

b) Persistent depressive disorder (dysthymia): Depressive mood most of the time for at least two years, but not meeting criteria for a major depressive episode

c) Premenstrual dysphoric disorder: Affective lability, irritability and other mood symptoms are present in the majority of menstrual cycles. The symptoms must be present in the final week before the onset of menses and become minimal or absent in the week postmenses.

d) Disruptive mood dysregulation disorder

e) Substance/medication-induced depressive disorder

f) Depressive disorder due to another medical condition

g) Other specified depressive disorder

h) Unspecified depressive disorder

Question 10

Bipolar disorders define what they are

Answer 10

The essential characteristic is one or more manic (or hypomanic) episodes.

Question 11

Name the different Bipolar Disorders

Answer 11

a) Bipolar I disorder: One or more manic (or hypomanic) episodes with or without one or more
major depressive episode.

b) Bipolar II disorder: One or more hypomanic episodes together with major depressive
episodes.

c) Cyclothymic disorder or cyclothymia: Frequent hypomanic episodes plus frequent episodes
with depressive symptoms that do not meet criteria for major depressive episode.

d) Substance/medication-induced bipolar and related disorder

e) Bipolar and related disorder due to another medical condition

f) Other specified bipolar and related disorder

g) Unspecified bipolar and related disorder

Question 12

Diagnostic criteria for manic episode

Answer 12

1. A distinct period of abnormally and persistently elevated, expansive or irritable mood as
   well as a marked increase in activity or energy levels.
2. During the period of disordered mood the following symptoms may appear:
   a) Inflated self-esteem or grandiosity.
   b) Decreased need for sleep, e.g. feeling wide-awake after 3 hours of sleep.
   c) More talkative than usual, or an urge to keep on talking.
   d) Flight of ideas, or the subjective experience that thoughts are racing.
   e) Distractibility.
   f) Increase in goal directed activity, e.g. on social, professional or sexual levels, or
   psychomotor agitation (anxious restlessness).
   g) Excessive involvement in activities that have a high potential for painful consequences,
   e.g. excessive buying, sexual indiscretions, poor business decisions.
3. The mood disorder is severe enough to cause a significant impairment in social and
   occupational functioning, or to warrant hospitalisation to protect the patient or the
   community, or there are psychotic features.
4. Symptoms are not due to substances or to another medical condition.

The DSM‑5 requires symptoms to be present for at least 7 days in order to diagnose a
manic episode, and 4 days to diagnose a hypomanic episode.

Question 13

Hypomania

Answer 13

a milder degree of mania
A hypomanic episode does not include criterion C,
i.e. it does not require impairment in functioning
hypomania may be a period of increased creativity and/or productivity

The DSM‑5 requires symptoms to be present for at least 7 days in order to diagnose a
manic episode, and 4 days to diagnose a hypomanic episode.

Question 14

Age of onset of depressive & bipolar

Answer 14

Usually in the teens to early twenties

Question 15

Course of disorder

Answer 15

Sudden onset, worsening over the course of days. A manic episode usually lasts days
to months, and is usually of shorter duration than major depressive episodes.

Question 16

Precipitating factors

Answer 16

▪▪ Psychosocial stressors (divorce, bereavement, etc.).
▪▪ The post-partum period.
▪▪ Antidepressant medications.
▪▪ Electroconvulsive treatment (this may cause a switch from a depressive phase into a manic
episode in a patient with a bipolar disorder).

Question 17

Differential diagnosis for manic episode

Answer 17

a) Substance-induced manic disorder, e.g. amphetamine, steroid use or abuse.
b) Manic disorder due to another medical condition.
NB: Delirium with excitement (e.g. due to epilepsy) may present in exactly the same manner
as a manic episode.
c) Attention deficit/ hyperactivity disorder in children

Question 18

Diagnostic criteria for a major depressive episode

Answer 18

b) Decreased interest and pleasure in all or almost all activities.
c) Significant loss of appetite or loss of weight, or increased appetite and weight gain.
d) Insomnia or hypersomnia, almost every day.
e) Psychomotor agitation or retardation.
f) Tiredness, listlessness.
g) Feelings of worthlessness, self-reproach, guilt feelings.
h) Concentration impairment.
i) Recurrent thoughts of death, suicidal ideas or suicidal gestures.

Question 19

Functional shift in depression

Answer 19

a) Loss of appetite.
b) Loss of weight.
c) Diurnal mood swing (the patient usually feels worse in the morning, and the depressed mood
improves slightly as the day progresses).
d) Terminal insomnia, or early morning waking (this is a specific disorder of the sleep pattern
and is associated with specific electro-physiological changes in sleep architecture).
e) Decreased libido.

Question 20

Anatomical dysfunction leading to functional shift in depression.

Answer 20

depression of both the meso-limbic (emotive part) and hypothalamic
(physiological aspects) system

Question 21

psychomotor changes in depression

Answer 21

psychomotor retardation, or agitation (restless anxiety)

Question 22

Major depressive disorder (MDD)

Answer 22

disorder of recurrent major depressive episodes,
without manic or hypomanic symptoms.
(WHO) have indicated that major depression is becoming the most important cause of disability worldwide

Question 23

Major depressive disorder is sub-classified as follows

Answer 23

▪▪ Single episode
▪▪ Recurrent
▪▪ Mild
▪▪ Moderate
▪▪ Severe
▪▪ With psychosis
▪▪ Without psychosis
▪▪ With melancholia
▪▪ With mixed features

Question 24

Gender distribution in MDD

Answer 24

The disorder occurs twice as frequently in women than in men 2:1

Question 25

The following masks of depression are of importance

Answer 25

1. Children: Major depression usually does not present with typical symptoms in children 2. Elderly: Major depression in the elderly may often be confused with dementia. 3. Somatisation 4. Agitation 5. Chronic Fatigue

Question 26

What is the most NB cause of completed suicide?

Answer 26

MDD Depression wow surprise

Question 27

Etiology of MDD

Answer 27

1. Genetic 2. Biochemical: the neurotransmitters serotonin and noradrenaline are involved in the pathogenesis of major depression “amine-hypothesis” proposes that there is a relative lack of these two substances in the limbic-hypothalamic areas of the brain 3. Endocrinological: hypercortisolemia

Question 28

Difference between BPMD type 1 and 2

Answer 28

Bipolar I disorder: at least one previous manic episode. Bipolar II disorder: at least one hypomanic episode, together with one or more major depressive episodes.

Question 29

Aetiology of Bipolar

Answer 29

Genetic !

Question 30

rapid cycling

Answer 30

the manic episodes in BPMD occur very frequently, with almost no “normal” or symptom-free periods in between. This condition is known as “rapid cycling”

Question 31

Cyclothymic disorder definition

Answer 31

The essential characteristic here is a chronic mood disorder of at least two years duration (one year for children and adolescents) with frequent periods of hypomania and frequent periods of depressed mood (or a loss of interest and pleasure) that do not meet criteria for either a manic episode or a major depressive episode. there must be a period of two years where the patient was not free of either hypomanic or depressive symptoms for longer than a two-month period.

Question 32

Persistent depressive disorder list the features

Answer 32

a) In the form of depressed mood for most of the time (most of the day and more days than not) for at least two years (1 year for children and adolescents). b) Some of the following symptoms may be present in addition to the depressed mood. -- Loss of appetite or excessive appetite -- Insomnia or hypersomnia -- Tiredness and reduced energy -- Poor concentration -- Difficulty in making decisions -- Feelings of hopelessness and helplessness -- Decreased self-confidence c) Never symptom free for longer than two months over a period of two years. d) No indication of a major depressive episode during the first two years. e) No previous manic or hypomanic episodes. f) Not superimposed on a chronic psychotic condition (e.g. schizophrenia, delusional disorder). g) No indication of a another medical condition or substance-induced disorder that could cause or perpetuate the disorder

Question 33

dysthymia

Answer 33

Another word for Persistent depressive disorder

Question 34

Typical symptoms of persistent depressive disorder

Answer 34

-- Loss of appetite or excessive appetite -- Insomnia or hypersomnia -- Tiredness and reduced energy -- Poor concentration -- Difficulty in making decisions -- Feelings of hopelessness and helplessness -- Decreased self-confidence

Question 35

Criteria for hospitalization

Answer 35

a) when the depression is of a severe degree b) where there is a high risk of suicide c) when severe medication side-effects occur d) in cases where electroconvulsive treatment is applied e) when the patient’s support systems are inadequate f) further special investigations are required, or g) other associated psychiatric or physical disorders that require hospitalisation are present.

Question 36

cornerstone of treatment for depressive episodes

Answer 36

Antidepressants (lol) A) Newer Antidepressants - SSRI - SNRI - Melatonergic - NaSSA - RIMA B) Older Antidepressants Tricyclic antidepressants: ▪▪ Imipramine ▪▪ Amitriptyline ▪▪ Clomipramine Tetracyclic antidepressants: ▪▪ Mianserin

Question 37

Contraindications to Antidepressants

Answer 37

▪▪ Glaucoma ▪▪ Urinary tract obstruction, e.g. prostatism ▪▪ Cardiovascular disorders, especially patients with ventricular arrhythmias.

Question 38

S/E of Antidepressants

Answer 38

Side-effects: ▪▪ Anticholinergic side-effects are particularly important. -- Postural hypotension -- Tachycardia -- Fine tremor of the hands -- Dry mouth -- Constipation -- Visual disorders (disturbances of accommodation) -- Excessive sweating -- Sexual dysfunction -- Sleepiness

Question 39

What is supportive psychotherapy

Answer 39

This form of psychotherapy aims to improve defence mechanisms and stress tolerance in times of illness and stress.

Question 40

Indications for Electroconvulsive Treatment

Answer 40

1. Treatment resistant major depression 2. Major depressive illness with psychosis 3. Severe, immediate risk of suicide 4. Psychomotor stupor 5. Depressive episodes where the patients has stopped eating or drinking and where his/her life is endangered as a consequence 6. Where the patient so chooses 7. Where contra-indications exist for antidepressant medication

Question 41

Risks and side-effects of ECT:

Answer 41

1. Injuries if muscle relaxant is insufficient 2. Memory disturbance

Question 42

Backbone treatment for bipolar mood disorder

Answer 42

Moodstabilizers

Question 43

3 groups of mood stabilizers

Answer 43

A. Lithium **Gold standard for Bipolar B. The anticonvulsant mood-stabilisers: - sodium-valproate - carbamazepine - lamotrigine. C. The antipsychotic-mood stabilisers: - quetiapine - olanzapine - aripiprazole

Question 44

Backbone treatment of mania

Answer 44

combination of an antipsychotic and an antimanic agents

Question 45

The most common side-effects of lithium are:

Answer 45

"LITHIUM" menumonic L - Leukocytosis I - Increased urination (polydipsia) T - Tremors, Thirsty, T-wave flattening H - Hypothyroidism I - Increase in weight U - Upset stomach M - Muscle weakness S - Skin changes (acne, psoriasis exacerbation)

Question 46

Side effects when lithium is at toxic levels

Answer 46

▪▪ Diarrhoea ▪▪ Tremor ▪▪ Abdominal pain ▪▪ Ataxia ▪▪ Clouding of consciousness ▪▪ Hyperreflexia ▪▪ Coma ▪▪ Death

Question 47

What can be used as an alternative to Lithium in treating manic episodes

Answer 47

Sodium Valproate

Question 48

Advantages of sodium valproate

Answer 48

a) no need for blood level monitoring, due to the wide therapeutic index; b) in acute situations, patients can be given a loading dose of up to 30 mg/kg/day for the first two days; c) it is more effective than lithium in patients with mixed pictures, so-called “rapid cycling”, patients

Question 49

Why do all female patients have to take a pregnancy test before being placed on mood stabilizers?

Answer 49

Mood stabilizers are highly teratogenic

Question 50

What do we use to sedate a manic patient while we wait for the mood stabilizers to kick in?

Answer 50

Second generation antipsychotics and or benzodiazepines

Question 51

Why is second generation antipsychotics preferred over first generation?

Answer 51

because of the side-effects associated with the latter compounds, particularly extrapyramidal symptoms, and especially tardive dyskinesia

Question 52

Can we treat bipolar mood disorder with antidepressants alone?

Answer 52

No ! antidepressants without a mood stabiliser must be avoided in this disorder, as it can induce “rapid cycling"

Question 53

mood stabilisers with the best treatment of the depressive phase of bipolar disorder are?

Answer 53

Lamotrigine Lithium Quetiapine Aripiprazole Combination of Olanzapine & Fluoxetine

Question 54

Tricyclic antidepressants and bipolar depression?

Answer 54

Big no