Mood Disorders

Question 1

What’s the lifetime risk of depression? Which populations are most at risk?

Answer 1

• 15-20% lifetime risk, 4% in the last month, 50% recurrent
• More common in women, men suicide more.
• More severe depression is more heritable

Question 2

What are the DSM criteria for diagnosis of major depressive disorder?

Answer 2

• 5+ of the following have been present during the same two week period and represent a change from previous function. Must include one of bold symptoms
  
  • Depressed mood most of the day, nearly every day
  • Markedly diminished interest or pleasure in almost all activities almost all of the time (anhedonia)
  • Significant unintentional weight loss (change by 5% in a month) or change in appetite
  • Insomnia or hypersomnia nearly every day
  • Psychomotor agitation or retardation nearly every day. Observed by others
  • Fatigue or loss of energy nearly every day
  • Feelings of worthlessness or excessive/inappropriate guilt nearly every day
  • Diminished ability to think or concentrate/indecisiveness nearly every day
  • Recurrent thoughts of death of suicidal ideation/attempt +/- plan
• Clinically significant distress or impairment in socio/occupational functioning
• Not due to GMC or better explained by other MH condition
• Never been manic or hypomanic

Question 3

What are some of the neurobiological symptoms patients with major depressive disorder might experience?

Answer 3

• Insomnia and early morning awakening
• Anorexia and weight loss
• Psychomotor retardation
• Impaired concentration
• Working memory deficits
• Decreased libido

Question 4

What are some of the cognitive symptoms a patient with major depressive disorder might experience?

Answer 4

• Anxiety, helplessness, worthlessness (dangerous symptom), social withdrawal, depersonalisation, guilt (cultural dimension to this), shame, rage, nihilism, hopelessness
• Suicidal ideation
  
  • Linked factors: severity, insomnia, weight/appetite loss, worthlessness, hopelessness, guilt, thoughts of death, impulsion, aggression

Question 5

In patients with major depressive disorder beginning treatment, which symptoms tend to resolve earliest? Why does this matter?

Answer 5

• On treatment, biological symptoms improve faster than cognitive symptoms. As amotivation passes, suicidal ideation may remain, and at this stage patients can be very dangerous to themselves

Question 6

What proportion of mothers develop post-partum depression?

Answer 6

• 10% of mothers, 1/2 severe

Question 7

Which medical conditions are most commonly associated with major depressive disorder? What drugs are associated with it?

Answer 7

• Hypothyroidism, MS, Cushing’s, HIV, paraneoplastic syndrome, stroke, basal ganglia diseases
• Propranolol, corticosteroids, GABAergics, chemotherapy, interferons

Question 8

What are the key features distinguishing grief from depression?

Answer 8

• Less early morning awakening, diurnal variation, psychomotor retardation. Grief normally resolves in less than 3 months

Question 9

What are some of the aspects you might consider with a patient to manage their depression?

Answer 9

• Education about illness and course, prognosis, treatment
• Lifestyle: exercise (sleep, diet, alcohol reduction)
• Psychotherapy
  
  • Problem solving therapy
  • CBT
  • Interpersonal therapy
• Medication
  
  • SSRI/SNRI/mirtazepine
  • Agomelatine/moclobemide/reboxetine
  • TCAs/mianserin/MAOIs

Question 10

What are some risk factors for the development of bipolar disorder?

Answer 10

• Genetics, head injury, organic injury (older), AIDS, childbirth

Question 11

What are the DSM criteria for a manic episode?

Answer 11

• 1+week of abnormally elevated/expansive/irritable mood and persistently increased goal-directed activity or energy
• 3+ of the following symptoms (4+ if mood is only irritable)
  
  • Inflated self-esteem or grandiosity
  • Decreased need for sleep
  • More talkative than usual
  • Flights of ideas or subjective experience that thoughts are racing
  • Distractibility
  • Increase in goal-directed activity or psychomotor agitation
  • Excessive involvement in activities that have a high potential for painful consequences
• Mood disturbance is sufficiently severe to interfere with normal function, necessitate hospitalisation, or there are psychotic features
• Not due to a GMC or substance

Question 12

What is the difference between a manic episode and a hypomanic episode?

Answer 12

• The disturbance in mood and function is observable by others BUT
• The episode is not severe enough to cause marked impairment in function or to require hospitalisation. No psychotic features

Question 13

What is the difference between bipolar disorder 1 and 2?

Answer 13

• Bipolar I
  
  • Criteria have been met for at least one manic episode
  • Not better explained by another mental illness
• Bipolar II
  
  • Criteria have been met for at least one hypomanic episode and at least one major depressive episode
  • There has never been a manic episode
  • Not better explained by another mental illness
  • Depressive episode or the unpredictability caused by cycling causes impairment in function

Question 14

What is cyclothymic disorder?

Answer 14

• 2 years with periods close to but not meeting MD and hypomanic criteria
• These symptoms have never been absent for > 2 months
• Criteria for MDE, hypomanic or manic episode never met
• Not better explained by another mental illness, GMC, and function is impaired

Question 15

What proportion of patients with cancer may become depressed?

Answer 15

33%

Question 16

List some protective factors against development of depressive disorder

Answer 16

• 1 good interpersonal relationship
• Higher IQ
• Confiding other (uphold self-esteem during adversity)
• Employment and financial independence

Question 17

How long should pharmacological treatment for a first episode of depresion last and at what dose?

Answer 17

• Full dose 6-12 weeks
• Maintain for 6-12 months post-recovery

Question 18

What proportion of illness time are patients with bipolar disorder depressed rather than manic?

Answer 18

• 3 times more!

Question 19

What are the broad treatment principles for patients with bipolar disorder in acute mania or acute depression?

Answer 19

• Acute mania
  
  • Antipsychotics e.g. olanzapine/risperidone
  • Second-line - other anti-psychotics, lithium
  • Third-line - combination e.g. antipsychotic and lithium
  • ECT
• Acute depression
  
  • Antidepressant AND prophylactic bipolar drug (as antidepressants alone may induce mania or rapid cycling)

Question 20

Describe maintenance therapy for a patient with bipolar disorder

Answer 20

• Education
• Manage exercise, physical health
• Enlist help of family, GP
• Psychotherapy
• Pharmacological options
  
  • Lithium - most evidence based (care with kidney, heart, thyroid effects)
  • Second generation anti-psychotics