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Mood Disorders Flashcards

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1
Q

What is mood?

A

Refers to patient’s sustained, experienced emotional state

Subjective - in patient’s own words, or objective as dysthymic (low) euthymic (normal) or elated

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2
Q

What is affect?

A

Transient flow of emotion in response to a particular stimulus

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3
Q

What is a mood disorder?

A

Affective disorder

Any condition characterised by distorted, excessive or inappropriate moods or emotions for a sustained period of time

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4
Q

What is the ICD-10 classification of affective disorders?

A

Manic episode - hypomania, mania without psychotic symptoms or with them.
Bipolar affective disorder
Depressive episode
Recurrent depressive disorder
Persistent mood disorders - cyclothymia, dysthymia
Other mood disorders
Unspecified mood disorders

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5
Q

What is the classification of a mood disorder?

A

Primary - does not result from another medical or psychiatric condition. Either unipolar or bipolar

Secondary - results from another condition

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6
Q

What are causes of secondary mood disorders?

A

Physical e.g. anaemia, hypothyroidism, malignancy, MS
Psychiatric - schizophrenia, alcoholism, dementia, personality disorder
Drug-induced - corticosteroids, digoxin, antiepileptic drugs, antidepressants can induce mania

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7
Q

What is depressive disorder?

A

Affective mood disorder
Characterised by a persistent low mood, loss of pleasure and/or lack of energy
Accompanied by emotional, cognitive and biological symptoms

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8
Q

What is the monoamine hypothesis?

A

That a deficiency of monoamines; NA, serotonin and dopamine causes depression.
Overactivity of the hypothalamic pituitary adrenal axis has also been linked to depression.

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9
Q

What are the risk factors for depression?

A 
Bio:
- Low monoamines
- Being female
- Chronic health problem
Psycho
- Personality type
- Poor coping strategies
- Mental health co-morbidities
Social:
- Poor support network
- Stressful events
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10
Q

What is beck’s triad for depression?

A

Negative views about the world
Negative views about oneself
Negative views about the future

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11
Q

What are the core symptoms of depression?

A

Low mood
Lack of energy
Anhedonia - no pleasure in normally pleasurable activities

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12
Q

What are the other symptoms of depression?

A

Cognitive:

  • Suicidal ideation
  • Guilt/worthlessness
  • Lack of concentration

Biological:

  • Diurnal mood variation
  • Loss of appetite
  • Early morning wakening
  • Loss of libido
  • Psychomotor retardation

Psychotic:

  • 2nd person auditory hallucinations
  • Persecutory, nihilistic, guilt, hypochondriacal delusions
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13
Q

How long must symptoms be present for before considering a diagnosis of depression?

A

> 2 weeks

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14
Q

What are the DSM-IV (NICE guidelines) stages of depression?

A

Subthreshold: <5 symptoms
Mild: 5 symptoms with minimal functional impairment, 2 core, 2 other
Moderate: Somewhere between mild and severe, 2 core +3-4 other symptoms
Severe: Most symptoms with significant impairment
With psychosis - 3 core +>4 other and psychosis

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15
Q

What differentials would you consider for depression?

A

Functional - bipolar, schizophrenia, seasonal affective disorder

Organic - drug use, dementia, hypothyroidism

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16
Q

How is subthreshold and mild depression managed?

A

Watchful waiting with monitoring and sleep hygiene advice

Low intensity therapy: Self help, computerised CBT, group physical activity class

Group based CBT

Antidepressants if:

  • > 2 years
  • Past episode of severe
  • Physical health complications
  • Failure of other interventions
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17
Q

How is moderate-severe depression managed?

A

Suicide risk assessment
Psychiatry referral indicated if suicide risk is high, depression severe, recurrent depression or unresponsive to treatment

SSRI are first line e.g. citalopram
Other anti-depressants include tricyclic, SNRIs or monoamine oxidase inhibitors prescribed only by specialists
Should be continued for 6 months after resolution of first episode or 2 years after second

High intensity therapy: CBT, IPT, behavioural activation

ECT

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18
Q

When is ECT used in depression?

A

Life threatening
Psychotic
Severe psychomotor retardation
Failure of other therapies

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19
Q

What are predisposing factors for depression?

A

Female gender
Neurochemical inbalance
Physical comorbidities
Past history of depression

Personality type
Poor coping strategies
Other mental health problems
Stressful life events
Lack of social support
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20
Q

What are the precipitating factors to depression?

A 
Poor compliance with meds
Corticosteroids
Acute stressful life events
Unemployment
Poverty
Divorce
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21
Q

What are the perpetuating factors to depression?

A

Chronic health problems e.g. diabetes, COPD, CF
Poor insight, negative thoughts - Beck’s triad
Alcohol and substance misuse
Poor social support and social status

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22
Q

What is the mnemonic for risk factors of depression?

A

FF, AA, PP, SS

Female, family history
Alcohol, adverse events
Psst depression, physical co-morbidities
Social support, SE status

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23
Q

What are the main symptoms of depression mnemonic?

A

DEAD SWAMP

Depressed mood
Energy loss
Anhedonia
Death thoughts

Sleep disturbance
Worthlessness/guilt
Appetite or weight change
Mentation - conc reduced
Psychomotor retardation
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24
Q

What can be extracted from the history when diagnosing depression?

Study These Flashcards
A

Explore core symptoms - mood, still enjoy doing things, feel more tired or worn out
Explore cognitive symptoms - lack of concentration, negative thoughts, suicidal thoughts
Biological symptoms - mood worse at certain times of day, early morning wakening, low or restless, loss of libido

25
What is seen in a MSE in depression?
Appearance - signs of self-neglect, thin, unkempt, tearful Behaviour - poor eye contact, tearful, slow movements and responses Speech - slow, reduced volume and tone Mood - low and depressed Thought - pessimistic, guilty, worthless, helpless, suicidal or delusional Perception - second person auditory derogatory hallucinations Cognition - impaired concentration Insight - usually good
26
What are the investigations for depression?
Diagnostic questionnaires e.g. PHQ-9, HADS, Beck's triad Bloods: FBC (anaemia) TFTs, U&Es, LFTs, calcium Glucose - diabetes can cause anergia Imaging - CT or MRI if presentation or examination is atypical, or features of intracranial lesion
27
What are differentials for depression?
Other mood disorders e.g. bipolar, other depressive disorders Secondary to physical condition e.g. hypothyroid Secondary to psychoactive substance abuse Secondary to other psychiatric disorder e.g. anxiety, adjustment disorder, personality disorder, ED Normal bereavement
28
What are other depressive disorders?
Recurrent depressive disorder - recurrent after first episode Seasonal affective disorder - depressive episodes annually at same time each year, usually the winter Masked depression - depressed mood not particularly prominent, other symptoms e.g. sleep disturbance present Atypical Dysthymia Cyclothymia Baby blues Postnatal depression
29
What is dysthymia?
Depressive state for >2 years which doesn't meet depression criteria
30
What is cyclothymia?
Mood fluctuations for >2 years where elation and depression do not meet criteria
31
What is atypical depression?
Mild-moderate depression with reversal of biological symptoms: e.g. overeating, hypersomnia
32
What is bipolar affective disorder?
Prev known as manic depression Chronic episode mood disorder Characterised by at least one episode of mania or hypomania and further episodes of mania or depression
33
What is the pathophysiology of bipolar affective disorder?
Biological - genetic FH, neurochemical - increase in dopamine and serotonin, endocrine - increase in cortisol, aldosterone, thyroid Environmental - adverse life events, exams, post partum period, loss of loved one
34
What is the epidemiology and risk factors for bipolar?
Mean age onset 19 years Incidence higher in UK in black and minority ethnic groups Male:female is 1:1 AAA, SSS Age in early 20s, anxiety disorders, after depression Strong FH, substance misuse, stressful life events
35
What can the severity of mania in bipolar be divided into?
Hypomania Mania without psychosis Mania with psychosis
36
What are the symptoms of mania?
I DIG FASTER Irritability Distractibility, disinhibited - sexual, social, spending Insight impaired, increased libido Grandiose delusions ``` Flight of ideas Activity/appetite increased Sleep decreased Talkative Elated mood, energy increased Reduced concentration, recklessness - behaviour and spending ```
37
What is seen in hypomania?
Mildly elevated or irritable mood for >4 days Symptoms of mania present to lesser extent than true mania Not severe disruption to life Partial insight may occur
38
What is seen in mania without psychosis?
Symptoms like hypomania but to a greater extent Symptoms last >1 weeks Complete disruption to work or social activities Grandiose and excessive spending could lead to debt Sexual disinhibition Reduced sleep may lead to exhaustion
39
What is seen in mania with psychosis?
Severely elated mood Suspicious mood Addition of psychotic features - grandiose or persecutory delusions, auditory hallucinations Patient may show signs of aggression
40
What is the classification of bipolar?
Bipolar I - periods of severe mood episodes from mania to depression. Bipolar II - milder form of mood elevation, milder episodes of hypomania alternating with severe depression Rapid cycling - more than four mood swings in a 12 month period with no intervening asymptomatic periods, poor prognosis.
41
What is the ICD-10 criteria for mania and bipolar affective disorder?
Mania requires 3/9 symptoms to be present - grandiosity, decreased sleep, pressure of speech, flight of ideas, distractability, psychomotor agitation, reckless behaviour, loss of social inhibitions, marked sexual energy. Bipolar - need at least 2 episodes in which mood and activity significantly disturbed, one of which must be mania or hypomania
42
How does the ICD-10 divide the state of bipolar?
``` Currently hypomanic Currently manic Currently depressed Mixed disorder In remission ```
43
What can be screened for in the history?
Always screen for mania in a depressed patient How would you describe mood Ever felt on top of the world Too much energy compared to those around you Able to concentrate on routine activities Need less sleep, but not tired Interest in sex changed? New interests or new exciting ideas lately Special abilities - grandiose Afraid someone will harm you - persecutory delusions Ask about family history Not pressure of speech or flight of ideas
44
What can be seen on MSE in a bipolar patient? if manic?
Appearance - flamboyant or unusual, heavy makeup, personal neglect if severe Behaviour - overfamiliar, disinhibited, aggressive, distracted, restless Speech - loud, pressure of speech, uninteruptable Mood - elated, euphoric and/or irritable Thought - optimistic, pressured, flight of ideas, tangeability, grandiose or persecutory delusions Perception - no hallucination, mood-congruent auditory hallucinations may occur Cognition - often impaired, fully orientated Insight - generally very poor
45
What are the investigations for bipolar?
Self rating scales - mood disorder questionnaire Bloods - FBC, TFTs, U&Es, LFTs, glucose and calcium Urine drug test - illicit drugs can cause manic symptoms CT head to rule out SOL
46
What are the differentials for bipolar?
Mood disorders e.g. hypomania, mania, cyclothymia Psychotic disorders Secondary to medical conditions Drug related Personality disorders e.g. histrionic, emotionally unstable
47
What is a mnemonic for the management of bipolar?
CALMER ``` Consider hospitalisation Antipsychotics Lorazepam Mood stabilisers e.g. lithium Electroconvulsive therapy Risk assessment ```
48
What is the management of bipolar?
BIOLOGICAL mood stabilisers, benzos, antipsychotics, ECT for severe uncontrolled manias PSYCHOLOGICAL Psychoeducation, CBT SOCIAL social support groups, self-help groups, encourage calming activities Full risk assessment incl. suicidal ideation and risk to self Ask about driving Mental Health Act
49
When should patients with an acute episode in bipolar be followed up?
Once a week initially | Then 2-4 weekly for the first few months
50
When may hospitalisation need to be considered in bipolar disorder?
Reckless behaviour causing risk to others Significant psychotic symptoms Impaired judgement Psychomotor agitation
51
What is the pharmacological management of an acute manic episode?
First line - offer antipsychotic e.g. elanzapine, resperidone or quetiapine. rapid action of onset. Mood stabilisers e.g. lithium or valproate second line Benzos to aid sleep and agitation Rapid tranquilisation with halloperidol or lorazepam
52
What is the pharmacological management of bipolar depressive episode?
Atypical antipsychotics e.g. elanzapine combined with fluoxetine, elanzapine alone or quetiapine alone. Mood stabilisers e.g. lamotrigine Antidepressants usually avoided as potential to induce mania
53
What is the long term pharmacological management of BPAD?
4 weeks after acute episode has resolved, lithium should be offered first line to prevent relapses. If lithium ineffective, consider valproate. Olanzapine or quetiapine alternative options.
54
What investigations need to be done before treatment with lithium is commenced?
U&Es - lithium has renal excretions TFTs Pregnancy status ECG
55
What are the side effects of lithium?
Narrow therapeutic window so drug levels need to be closely monitored ``` Polydipsia, polyuria, fine tremor weight gain, oedema Hypothyroidism Impaired renal function Memory problems Teratogenicity in first trimester ```
56
What are signs of lithium toxicity?
1.5-2 mmol/l - N+V, coarse tremor, ataxia, muscle weakness Severe toxicity - >2mmol: nystagmus, dysarthria, hyperreflexia, oliguria, hypotension, convulsions and coma.
57
How is the administration of lithium strictly regulated?
Lithium levels measured 12 hours following first dose, then weekly until therapeutic level of 0.5-1mmol has been stable for 4 weeks Once stable check every 3 months Measure U&Es every 6 months, TFTs every 12 months Combination of lithium and sodium valproate for rapid cycling
58
What is ECT?
Where a generalised seizure without muscular convulsions is electrically induced to manage mental disorders. Typically 70-120 volts applied externally to patients head, 800 milliamperes of DC passed through brain for 100 milliseconds to 6 seconds duration, temple to temple (bilateral) or front to back (unilateral) often have treatment twice a week, with few days between each session. On average 9-10 treatments.
59
What are the risks of ECT?
Short term side effects - headache, aching in muscles and/or jaw, tiredness whilst effects of anaesthetic wear off Confusion, sickness, nausea Memory loss, gaps in memory Some people have reported change in personality, loss of creativity, energy, lack of emotions

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