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Affective disorders

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  • 1. 1
  • 2. Depression-An under-recognized condition Non- attendance (A) The Epidemiological Catchment Area Study carried out in the USA suggests that approximately one third of people suffering from depression do not seek help or treatment (B) A European survey of 80,000 people also revealed third of people with major depression had not consulted a health-care specialist. Men were less likely to consult a medical specialist than women. Many believed --------They would get better by themselves Some--------------------Too embarrassed to seek help Other reasons why patients don’t consult doctors include: • They may not recognise they have an illness • They may regard their symptoms as appropriate in their circumstances • Many people do not know depression can be treated easily • Misconceptions over treatment Poor recognition • GPs manage about 80 per cent of all mental illness, but evidence suggests that depression is frequently missed in general practice. 1. Half of patients severe depression -----------not recognised at the first consultation. 2. A further 10%------------- Recognised in subsequent consultations. 3. 20%--------------------------Remit during this time. 4. The remaining 20%-------- may remain unrecognised even after six months 5. Recognising difficulty -----------presentations with somatic symptoms - 70% cases - and of depression related to physical disorders 1. Other factors include an aversion on the part of both GPs and patients to talk about psychological problems and inadequate time for consultations 2
  • 3. MAJOR DEPRESSIVE DISORDER OR AFFECTIVE DISORDER( DEPRESSIVE EPISODE) INCIDENCE Male 5-12% Female 10-25% More in females, the ratio 2:1 Age 20-50 years Average 40 years 3
  • 4. Lifetime Prevalence of Various Mood Disorders Mood Disorder Lifetime Prevalence Depressive disorders Major depressive disorder (MDD) 10–25% for women 5–12% for men Recurrent, without full 25–30% of persons with MDD interepisode recovery, superimposed on dysthymic disorder (double depression) • Dysthymic disorder 3–6% Bipolar disorders • Bipolar I disorder 0.4–1.6% • Bipolar II disorder <1% • Bipolar I disorder or bipolar II 5–15% of persons with disorder, with rapid cycling bipolar disorder Cyclothymic disorder 0.4–1.0% 4
  • 5. ICD-10 Criteria for Depressive Episode A. Five (or more) of the following symptoms have been present during the same 2-week period and represent a change from previous functioning; At least one of the symptoms is either (1) depressed mood or (2) loss of interest or pleasure. . (1)Depressed mood most of the day, nearly every day, Either subjective report (e.g., feels sad or empty) or Observation made by others (e.g., appears tearful). Note: in children and adolescents, can be irritable mood. (2) Markedly diminished interest or pleasure in all, or almost all, activities most of the day, nearly every day (as indicated either by subjective account or observation made by others) (3) Significant weight loss when not dieting or Weight gain (e.g., a change of more than 5% of body weight in a month), or Decrease or increase in appetite nearly every day. Note: in children, consider failure to make expected weight gains. (4) Insomnia or hypersomnia nearly every day (5) Psychomotor agitation or retardation nearly every day 5
  • 6. (6) Fatigue or loss of energy nearly every day (7) Feelings of worthlessness or excessive or inappropriate guilt (which may be delusional) nearly every day (8) Diminished ability to think or concentrate, or indecisiveness, nearly every day (either by subjective account or as observed by others) (9) Recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation without a specific plan, or A suicide attempt or a specific plan for committing suicide B. The symptoms do not meet criteria for a mixed episode. C. Significant distress or impairment in social, occupational, or other important areas of functioning. D. Not due to the direct physiological effects of a Substance General medical condition (e.g., hypothyroidism). E. Not better accounted for by bereavement, 6
  • 7. Somatic syndrome Some depressive symptoms are widely regarded as having special clinical significance and are here called "somatic." (Terms such as biological, vital, melancholic, or endogenomorphic are used for this syndrome in other classifications.) (1) Marked loss of interest or pleasure in activities that are normally pleasurable; (2) Lack of emotional reactions to events or activities that normally produce an emotional response; (3) Waking in the morning 2 hours or more before the usual time; (4) Depression worse in the morning; (5) Objective evidence of marked psychomotor retardation or agitation (remarked on or reported by other people); (6) Marked loss of appetite; (7) Weight loss (5% or more of body weight in the past month); (8) Marked loss of libido. 7
  • 8. Criteria for Seasonal Pattern With seasonal pattern can be applied to:- Major depressive episodes in bipolar I disorder, bipolar II disorder, or Major depressive disorder, recurrent) A. There has been a regular temporal relationship between the onset of and a particular time of the year (e.g., regular appearance of the major depressive episode in the fall or winter) B. Full remissions (or a change from depression to mania or hypomania) also occur at a characteristic time of the year (e.g., depression disappears in the spring). C. In the last 2 years, two major depressive episodes have occurred that demonstrate the temporal seasonal relationships defined in criteria A and B, and no non seasonal major depressive episodes have occurred during that same period. D. Seasonal major depressive episodes (as described above) substantially outnumber any non seasonal major depressive episodes that may have occurred over the individual's lifetime. 8
  • 9. • Recurrent depressive disorder, current episode mild Without somatic syndrome With somatic syndrome • Recurrent depressive disorder, current episode moderate Without somatic syndrome With somatic syndrome • Recurrent depressive disorder, current episode without psychotic symptoms • Recurrent depressive disorder, current episode severe with psychotic symptoms With mood-congruent psychotic symptoms With mood-incongruent psychotic symptoms • Recurrent depressive disorder, currently in remission • Other recurrent depressive disorders • Recurrent depressive disorder, unspecified • Persistent mood [affective] disorders 9
  • 10. Diagnostic Criteria for Dysthymic Disorder A Depressed mood for most of the day, for more days than not, for at least 2 years. B. Presence, while depressed, of two (or more) of the following: (1) Poor appetite or overeating (2) Insomnia or hypersomnia (3) Low energy or fatigue (4) Low self-esteem (5) Poor concentration or difficulty making decisions (6) Feelings of hopelessness C. Never without symptoms for more than two months during the last 2-year period D. No major depressive episode has been present during the first 2 years of the disturbance (1 year for children and adolescent Early onset------------Before 21 years of age Late onset-------------21 years or older 10
  • 11. ICD-10 Diagnostic Criteria for Adjustment Disorders A. Onset of symptoms must occur within 1 month of exposure to an identifiable psychosocial stressor, not of an unusual or catastrophic type. . Symptoms may be variable in both form and severity. The predominant feature of the symptoms may be further specified as:- Brief depressive reaction A transient mild depressive state of a duration not exceeding 1 month. Prolonged depressive reaction A mild depressive state occurring in response to a prolonged exposure to a stressful situation but of a duration not exceeding 2 years. Mixed anxiety and depressive reaction Both anxiety and depressive symptoms are prominent, but at levels no greater than those specified for mixed anxiety and depressive disorder or other mixed anxiety disorders. 11
  • 12. Bipolar affective disorder Episodes are demarcated by a switch to an episode of opposite or mixed polarity Bipolar affective disorder, current episode hypomanic A. The current episode meets the criteria for hypomania. B. There has been at least one other affective episode in the past, meeting the criteria for hypomanic or manic episode, depressive episode, or mixed affective episode. Bipolar affective disorder, current episode manic without psychotic symptoms The current episode meets the criteria for mania without psychotic symptoms. . Bipolar affective disorder, current episode manic with psychotic symptoms The current episode meets the criteria for mania without psychotic symptoms. • . With mood-congruent psychotic symptoms • With mood-incongruent psychotic symptoms Bipolar affective disorder, current episode moderate or mild depression A. The current episode meets the criteria for a depressive episode of either mild or moderate severity. 1. Without somatic syndrome 2. With somatic syndrome Bipolar affective disorder, current episode severe depression without psychotic symptoms Bipolar affective disorder, current episode severe depression with psychotic symptoms 1. With mood-incongruent psychotic symptoms 2. With mood-congruent psychotic symptoms Bipolar affective disorder, current episode mixed . Both manic and depressive symptoms must be prominent most of the time during a period of at least 2 weeks. Bipolar affective disorder, currently in remission The current state does not meet the criteria for depressive or manic episode of any severity or for any other mood [affective] disorder (possibly because of treatment to reduce the risk of 12
  • 13. M A N I A D E P R E S S I O N Normal State 13
  • 14. BIPOLAR AFFECTIVE DISORDERS M A N I A D E P R E S S I O N NORMALSTATE 14
  • 15. ICD-10 Diagnostic Criteria for Mood [Affective] Disorders Manic episode .Mania without psychotic symptoms A. Mood must be predominantly elevated, expansive, or irritable, Change must be prominent and sustained for at least 1 week (unless it is severe enough to require hospital admission). B. At least three of the following signs must be present (four if the mood is merely irritable), leading to severe interference with personal functioning in daily living: (1) increased activity or physical restlessness; (2) increased talkativeness ("pressure of speech"); (3) flight of ideas or the subjective experience of thoughts racing; (4) loss of normal social inhibitions, resulting in behavior that is inappropriate to the circumstances; (5) decreased need for sleep; (6) inflated self-esteem or grandiosity; (7) distractibility or constant changes in activity or plans; (8) behavior that is foolhardy or reckless e.g., spending sprees, foolish enterprises, reckless driving; (9) Marked sexual energy or sexual indiscretions. C. There are no hallucinations or delusions, although perceptual disorders may occur D.The episode is not attributable to psychoactive substance use or to any organic mental disorder. 15
  • 16. Mania with psychotic symptoms . Delusions or hallucinations are present, The commonest examples are those with grandiose, self- referential, erotic, or persecutory content. . Congruent with the mood: With mood-congruent psychotic symptoms Example: - Grandiose delusions or voices telling the individual that he or she has superhuman powers) With mood-incongruent psychotic symptoms Example: -voices speaking to the individual about affectively neutral topics, or delusions of reference or persecution) 16
  • 17. Hypomania A. The mood is elevated or irritable to a degree that is definitely abnormal for The individual concerned and Sustained for at least 4 consecutive days. B. At least three of the following signs must be present, leading to some interference with personal functioning in daily living: (1) Increased activity or physical restlessness; (2) Increased talkativeness; (3) Distractibility or difficulty in concentration; (4) Decreased need for sleep; (5) Increased sexual energy; (6) Mild overspending, or other types of reckless or irresponsible behavior; (7) Increased sociability or overfamiliarity. 17
  • 18. Table 14.6-7. DSM-IV Criteria for Manic Episode A. A distinct period of abnormally and persistently elevated, expansive, or irritable mood, lasting at least 1 week (or any duration if hospitalization is necessary). B. During the period of mood disturbance, three (or more) of the following symptoms have persisted (1) inflated self-esteem or grandiosity (2) decreased need for sleep (e.g., feels rested after only 3 hours of sleep) (3) more talkative than usual or pressure to keep talking (4) flight of ideas or subjective experience that thoughts are racing (5) distractibility (i.e., attention too easily drawn to unimportant or irrelevant external stimuli) (6) increase in goal-directed activity (either socially, at work or school, or sexually) or psychomotor agitation (7) excessive involvement in pleasurable activities that have a high potential for painful consequences (e.g., engaging in unrestrained buying sprees, sexual indiscretions, or foolish business investments) C. The symptoms do not meet criteria for a mixed episode. D. The mood disturbance is sufficiently severe to cause marked impairment in occupational functioning or in usual social activities or relationships with others, or to necessitate hospitalization to prevent harm to self or others, or there are psychotic features. E. The symptoms are not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication, or other treatment) or a general medical condition (e.g., hyperthyroidism). Note: Manic-like episodes that are clearly caused by somatic antidepressant treatment (e.g., medication, electroconvulsive therapy, light therapy) should not count toward a diagnosis of bipolar I disorder. 18
  • 19. BIO-PSYCHO-SOCIAL VIEW BIOLOGICAL SOCIAL PSYCHOLOGICAL •Age •Sex •Neurotransmitters •Hormones •Genetic •Brain structure •Family Stability •Social Support •Sex •Nurture •Place of living •Minority class •Social & religious values •Stress •Nurture •Cognitions •Personality •Painful childhood •Psychoanalysis AETIOLOGY OF DEPRESSION 19
  • 20. . Medical Conditions Physiologically Associated With Affective Disorders Endocrine Disorders • Hypothyroidism • Hyperthyroidism • Parathyroid disorders • Cushing's syndrome Neurologic Disorders • Cerebrovascular accidents • Central nervous system (CNS) lesions • Neurosyphilis • Multiple sclerosis • Neurosarcoidosis • CNS vasculitis • HIV-associated CNS pathology Other Disorders • Vitamin deficiencies (e.g, folate and vitamin B12) • Anemia • Hypoxia • End-stage renal disease • Systemic lupus erythematosus and other connective tissue diseases • Occult malignancy (eg, pancreatic cancer) 20
  • 21. Differentiating Characteristics of Bipolar and Unipolar Depressions Bipolar Unipolar History of mania or hypomania Yes No (definitional) Temperament/personality Cyclothymic/extroverted Dysthymic/introverted Sex ratio Equal More women than men Age of onset Teens, 20s, and 30s 30s, 40s, 50s Postpartum episodes More common Less common Onset of episode Often abrupt More insidious Number of episodes Numerous Fewer Duration of episode 3 to 6 months 3 to 12 months Psychomotor activity Retardation > agitation Agitation > retardation Sleep Hypersomnia > insomnia Insomnia > hypersomnia Family history Bipolar disorder Yes ± Unipolar disorder Yes Yes Alcoholism ± Yes Pharmacological response Cyclic antidepressants Induce hypomania-mania ± Lithium carbonate Acute antidepressant effects Ineffective 21
  • 22. Basic principles of prescribing in depression • Discuss with the patient: - 1) Choice of drug and 2) utility/availability of other, non-pharmacological treatments • Discuss with the patient likely outcomes. e.g. Gradual relief from depressive symptoms over several weeks • Prescribe a dose of antidepressant (after titration, if necessary) that is likely effective • Continue treatment for at least 4—6 months after resolution of symptoms • Withdraw antidepressants gradually; Always inform patients of the risk and nature of discontinuation symptoms Treatment of affective illness Depression 22
  • 23. •Episode: A period lasting longer than 2 weeks (as defined by the DSM-IV-R) during which the patient is consistently within the fully symptomatic range of a sufficient number of symptoms to meet syndromal criteria for the disorder. •Partial remission: A period during which an improvement of sufficient magnitude is observed that the individual is no longer fully symptomatic •Response: The point at which a partial remission begins. A response, unlike a partial remission, does require treatment and thus implies that the cause of the change in the patient's condition is known, which may not be a valid assumption. •Full remission: A relatively brief period during which an improvement of sufficient magnitude is observed that the individual is asymptomatic •Recovery: A remission that lasts for a specified period of time. Relapse: A return of symptoms satisfying the full syndrome criteria for an episode that occurs during the period of partial or full remission, but before recovery as defined above. A relapse signals a need for treatment intervention or modification of ongoing treatment. •Recurrence: The appearance of a new episode of major depressive disorder occurring during a recovery. Definitions of terms related to the course of depression 23
  • 24. Panic Disorder 50%-65% Social Anxiety Disorder 70% OCD 67% PTSD 48% GAD 8%-39% COMORBID MOOD & ANXIETY DISORDERS DEPRESSION 24
  • 25. STRATEGIES FOR TREATMENT When initiating acute-phase treatment, practitioners decide where the patient should be treated (e.g., outpatient, day hospital, or inpatient). Treatment location is dictated by factors such as (1) the imminent risk of suicide, (2) the capacity of the patient to recognize and follow instructions or recommendations (adherence, psychosis), (3) the level of psychosocial resources, (4) the level of psychosocial stressors, and (5) the level of functional impairment. Next, one chooses among the four common acute-phase treatments (A) Medication . (B) The combination of medication and psychotherapy. (C) Electroconvulsive therapy [ECT]). (D) For some, light therapy alone or in combination with medications may also be an option. 25
  • 26. Treatment Plan A treatment plan for depression consists of three distinct phases Phase 1: - Acute treatment, relieves the immediate symptoms of depression. Phase 2, Continuation treatment, preserves the gains achieved initially and protects the patient from sliding back into depression. Phase 3, Maintenance treatment, guards against future episodes. Treatment Phases and Goals Phase Length Treatment goal Acute 6–12 weeks Achieve remission Continuation 16–24 weeks Prevent relapse Maintenance Varies Protect against recurrence Remission = Return to level of symptoms and functioning that existed before illness. Relapse = Re-emergence of significant depressive symptoms. Recurrence = Another major depressive episode.26
  • 27. Relation of Diagnosis to Treatment Selection Diagnosis Treatment Recommendations •Major depressive Episode Medication or time-limited (mild-to-moderate severity) psychotherapies* No maintenance-phase treatment •Major depressive disorder, recurrent Consider maintenance-phase treatment •Major depressive disorder Antipsychotic plus antidepressant with psychotic features medications Electroconvulsive therapy •Major depressive disorder with melancholic Medications essential or severe features •Depression with atypical features Nontricylic drugs preferred Monoamine oxidase inhibitors •Depression with seasonal pattern Light therapy or medications •Dysthymic disorder Medications; time-limited, depression- targeted psychotherapies; or their combination Consider maintenance-phase therapy •Complex or chronic depressions Medication plus psychotherapy‡ Interpersonal psychotherapy, cognitive therapy, or behavior therapy.27
  • 28. Tricyclics and tetracyclics Starting Dose mg/day Usual Dose Mg/day Tertiary amine tricyclics Amitriptyline 25-50 100-300 Clomipramine 25 100-250 Doxepin 25-50 100-300 Imipramine 25-50 100-300 Trimipramine 25-50 100-300 Secondary amine tricyclics Desipramine 25-50 100-300 Nortriptyline 25 50-200 Protriptyline 10 15-60 Tetracyclics Amoxapine 50 100-400 Maprotiline 50 100-22528
  • 29. SSRIsb Citalopram 20 20-60 c Fluoxetine 20 20-60 c Fluvoxamine 50 50-300 c Paroxetine 20 20-60 c Sertraline 50 50-200 c Dopamine-nor epinephrine reuptake inhibitors Bupropionb 150 300 Bupropion, sustained release 150 300 Serotonin-norepinephrine reuptake inhibitors Venlafaxineb 37.5 75-225 Venlafaxine, extended release 37.5 75-225 Serotonin modulators Nefazodone 50 150-300 Trazodone 50 75-300 Nor epinephrine-serotonin modulator Mirtazapine 15 15-45 MAOIs Irreversible, nonselective Phenelzine 15 15-90 Tranylcypromine 10 30-60 Reversible MAOI-A Moclobemide 150 300-600 29
  • 30. MAOI Drug Incompatibilities Generally Contraindicated Hazardous Potentiation Stimulants Weight-reducing or antiappetite drugs; amphetamine, cocaine Decongestants Sinus, hay fever, and cold tablets; nasal sprays or drops; asthma tablets or inhalants, cough preparations (or any products containing ephedrine, phenylephedrine, or phenylpropanolamine Antihypertensives Methyldopa, guanethidine, reserpine Tricyclics Migraine, desipramine, clomipramine MAOIs Tranylcypromine, after other MAOIs Sympathomimetics Dopamine, Metaraminol Amine precursors L-dopa, L-tryptophan Narcotics Meperidine (Demerol) Some Potentiation Possible Opioids Morphine, codeine Sedatives Alcohol, barbiturates, benzodiazepines Local anesthetics containing vasoconstrictors Sympathomimetics Ephedrine, norepinephrine, isoproterenol General anesthetics 30