Mood disorders.txt

mixed affective episode

1%

20-30s

m=f

• high class
• urban

• 1. biological:
• less need for sleep (not assoc with fatigue)
• increased energy (spending, risky business)
• increased interest in sex (disinhibition)
• general: psychomotor excitation
• 2. cognitive:
• self esteem, grandiose
• poor concentration, easily distractible
• accelerated thinking: flight of ideas, pressured speech
• impaired judgement and insight
• 3. psychotic
• thought form disorder: circumstantiality (lots of detail eventually to the point), tangentiality (never to the point),
• thought content disorder: secondary delusions (grandiose and persecutory) - mood congruent,
• abnormal perceptions: auditory hallucinations (2nd person) and sensory distortions (hyperacusis or visual hyperaesthesia)

• in mania there has to be 1 week duration of symptoms
• COMPLETE DISRUPTION OF WORK AND SOCIAL LIFE (whereas in hypomania it is not complete)

• MOOD DISORDERS: hypomania, mania, depression (after AD or ECT) or agitated depression
• SECONDARY TO GENERAL MEDICAL CONDITIONS: brain tumour, infarct, infection, cushiness disease, huntington's disease, hyperthyroid, MS, temporal lobe epilepsy
• PSYCHOACTIVE SUBSTANCE USE: amphetamines, antidep, cocaine, steroids, hallucinogens
• PSYCHOTIC DISORDERS: schizoaffective disorder (may be similar to mania with psychosis, but delusions are mood INCONGRUENT), schizophrenia
• PERSONALITY DISORDERS
• DELIRIUM OR DEMENTIA

• RISK ASSESSMENT: where what who treat (OP, CC, IP)
• 1. mood stabilisers: lithium, anti-convulsants (sodium valproate, carbamazapine, lamotrigine)
• 2. anti psychotic: olanzapine
• 3. prophylaxis: if had 2 episodes
• 4. depression: anti-depressants (but may cause secondary mania) use SSRI with mood stabiliser

as a chemical salt - carbonate or citrate, sulphate

• small so cross BBB into CNS
• interacts with receptors to decrease noradrenaline release and increase serotonin synthesis

• 1. establish diagnosis
• 2. discuss need for prolonged treatment
• 3. renal and thyroid function, weight
• 4. pregnancy test (Ebsteins heart defect)
• 5. tell patient must use contraception if on Lithium as don't want to accidentally have baby then its got defect

• 600-800mg nocte
• then can gradually increase dose

after 5-7 days from first starting

0.5-1.0 mmol/l

• 1. reduce the risk of manic episodes by 30-40%
• 2. reduce the length and severity of manic episodes

• 1. monitor mood - mood diary?
• 2. adherence or concordance with treatment?
• 3. any SE from lithium
• 4. Li level every 3 months (note every time change dose of Li, check after a week)
• 4. Renal function every 6 months
• 5. Thyroid function every 12 months
• 6. Discontinue Li slowly - otherwise risk of manic relapse

• thirst- polydipsia
• polyuria
• metallic taste
• GI disturbance
• sedation
• mild tremor

above 1.3mmol/l

• worsened SE
• N&V

• disorientation
• dysarthria
• convulsions
• coma
• severe bloody diarrhoea

• cardiac effect
• pulmonary complications

• elderly
• also as many on diuretics which dehydrates

• enhances the actions of GABA
• may have effects on membrane excitability

• 1. treatment resistant mania or depression
• 2. treatment resistant schizophrenia
• 3. adjunct to lithium in prophylaxis of BPAD
• 4. rapid-cycling BPAD: multiple episodes >4/year

• CNS: headache, drowsiness, diplopia
• Liver: elevation of GGT, hepatitis, cholestatic jaundice
• Other GI: N&V
• Blood dyscrasias
• Skin rashes
• Teratogenic effects - folate deficiency (spina bifida, anencephalcy)

• hepatic enzyme inducer
• so induces metabolism of:
• anticoagulants, AD, AP, OCCP, Steroids

• inhibit GABA transaminase
• inhibit calcium channel current
• increase GABA binding in hippocampus
• reduce action of NA at alpha2 receptors
• inhibit formation of protein kinase C

• 1. refractory mania
• 2. rapid cycling BPAD
• 3. may have benefit in prophylaxis
• 4. epilepsy
• NB: most effective in non-psychotic patients
• may have benefit in prophylaxis

• WHAT
• weight gain
• hepatotoxicity
• alopecia
• tremor, teratogenic
• N&V

• stabilise sodium channels
• inhibits glutamate release

• it is an anti-depressant in bipolar depression
• (mood stabiliser)

• rash
• GI problems
• CNS problems

• tardive dyskinesia
• neuroleptic malignant syndrome (medical emergency)

• acute dystonia: torticollis
• spasm of any muscle group esp head and neck
• akathesia: inner disccomfort and restlessness
• signs of parkinsons disease
• tardive dyskinesia: repetitive, involuntary, purposeless actions eg lip smacking, grimacing, tongue protrusion. tardive=slow onset

• 1. bipolar prodromes: recognise early signs and symptoms
• 2. life events monitoring, diary
• 3. regulate social and sleep routines (disruption of circadian rhythms)
• 4. structured short term problem-focused therapies eg cognitive to develop new coping skills
• teach to reject negative thoughts

sexual dysfunction especially in men

• sedative
• weight gain

4 months

6-12 months

10-15%

• remissions are shorter
• episodes more severe

depression more common and longer

women

• 4 or more episodes per year
• women more

• young age onset
• more severe symptoms
• co-morbid: Personality disorder
• Co-morbid substance misuse
• treatment avoidance

• worthlessness\
• guilt
• ill health
• poverty
• nihilistic delusions: pt believe something important has ceased to exist eg family no longer exists, bowel disintegrated

• severe depression
• slowing of movement
• poverty of speech
• motionless
• mute

negative patterns of thinking about the present, future, past and the world.

• hypothyroidism
• cushings
• dementia
• hypoparathyroidism
• medications eg antiHTN or steroids

• women
• unemployed
• low socioeconomic class
• certain occupational groups eg doctors
• single men
• women with children
• chronically physically ill or disabled
• prisoners
• people with other psychiatric disorders or substance misuse

2-4 fold

• genetics
• early environment eg childhood trauma, separation
• divorced parents
• poor relationship with parents
• childhood sexual abuse
• any loss events

• 1. psychodynamic theory: repressed sense of loss and anger turned inwards, excessive dependence on others
• 2. learning theory: seligman - learned helplessness: cannot control the stresses that presented to you - learned passive acceptance
• 3. cognitive theory: negative feelings follow from illogical negative beliefs about self.
• Becks triad: self, future, world. negative interpretation of events

• stress response
• hypothalamic pituitary adrenal axis

• underactivity: frontal and temporal cortices
• overactivity: limbic

15%, highest in first 7 days of leaving hospital

• RISK assessment
• 1. suicide
• 2. self neglect
• 3. self harm
• 4. insight and compliance
• 5. psychotic symptoms
• 6. ongoing stressors
• decide - need inpatient/outpatient or crisis team care??

• minimise adverse life events: finance, house, relationship, work
• contact with key worker - CPN or SW
• admit to day hospital

• social network
• access to help: debt, jobs, relationships
• structured activities
• regular exercise

• antidepressant drugs
• ECT - in an emergency

• 1. TCA: amitriptyline, imipramine
• 2. SSRI: fluoxetine, sertraline, citalopram, paroxetine
• 3. MAOI: phenelzine, moclobemide
• 4. SNRI: venlafaxine
• 5. NASSA: mirtazapine

• anti-depresant
• anti anxiety
• anti obsessive

• agitation
• anxiety
• insomnia
• sexual dysfunction

• nausea
• GI symptoms
• headaches

increase 5HT release

decrease 5HT release

• constpiation
• dry mouth
• blurred vision
• drowsy
• delirium

• hypotension
• dizzi
• drowsy

• weight gain
• sedative - drowsy
• eg mirtazepine (NaSSA)

• 5HT2 actions:
• anxiety (early - will resolve with time)
• agitation (early - will resolve with time)
• insomnia
• sexual dysfunction
• 5HT3 actions:
• GI irritation: N&V (early - will resolve with time)
• headache
• discontinuation effects: body becomes used to having a drug on a receptor, if stop abruptly - body isn't used to not having it, get flu like effects for a week

• anticholinergic:
• dry mouth
• constipation
• urinary retention
• blurred vision
• drowsy
• alpha adrenergic block:
• postural hypotension - dizzi, syncope
• histamine block: wt gain, sedation
• cardiotoxic: long QT, ST elevation, heart block, arrhythmias

• weight gain
• sedation
• so good if skinny and tired!

use ONE antidepressant if possible as they can interact, more SE, harder to remember to take them, £££

• 1. AD are effective on basis of evidence
• 2. NICE: 1st line SSRI (fewer SE, safer than TCA, esp if heart probes)
• 3. warn there are many SE, many are temporary SE eg GI, anxiety will resolve
• 4. not addictive
• 5. delayed therapeutic onset,
• 6. treatment for 6-8 months after recovery
• 7. risk of discontinuation syndrome in some
• ***DOCUMENT THE DISCUSSION***

• 1. dosage
• 2. duration
• 3. adherence
• 4. SE
• consider SWAPPING
• 2nd line: SSRI (citalopram, fluoxetine), mirtazapine, reboxetine or TCA
• 3rd line: venlafaxine
• if still no response:
• lithium augmentation
• ECT

• 1. severe depressive illness including psychotic depression
• 2. catatonia (schizophrenia): immobile, mute
• 3. prolonged or severe manic episode

where rapid symptom relief is required eg not eating or drinking, suicide risk

71-78%

• electric current passed briefly across brain via electrodes
• to produce GENERALISED seizure

mania

increased turnover of NA, DA, 5HT

• headache
• feel muzzy for short period
• short term memory loss both anterograde and retrograde
• possible loss of long term episodic memory

same as GA for minor surgery

severe depression that has failed to repined to treatment trials with 2 or more anti depressant for an adequate time and dose

• 1. any significant medical condition where there is a very high anaesthetic risk
• 2. if had an MI: within 3 months there is an increased risk of arrhythmias
• 3. if had stroke within 3 months - risk of rebelled
• 4. pre-existing brain pathology eg tumour.
• always have to balance these with the patient not eating or drinking due to the depression, so ECT may really be needed.

50-85%

80-90%

continue Rx for 2 years

• for depression?
• psychoeducation (after secured a confiding relationship)
• 1. explain that it is common
• 2. can be treated, will improve
• 3. lifestyle changes help: no alc or drug, more social support, exercise
• 4. clear info about Rx
• 5. sleep hygiene (keep work apart from bedroom, sleep early, horlicks)

• 1. counselling
• 2. problem solving therapy: identify and resolve current life difficulties, good for major depression in primary care and self harm
• 3. supportive psychotherapy: mild depression
• 4. CBT
• 5. interpersonal thearpy (IPT)
• 6. short term psychodynamic psychotherapy

• examines connections between THOUGHTS, EMOTIONS and BEHAVIOURS
• structured approach: homework
• addresses cognitive distortions -eg arbitrary inference (everything focussed on self - all bad things)

• explores ORIGINS of depression in terms of interpersonal lOSSES, role disputes
• deficits in social skills

• patient themselves using CBT approaches
• supportive relationship with GP or keyworker