DEPRESSSION MANIA REVISION NOTES BASIC PSYCHIATRY REVISION NOTES BASED ON LECTURE NOTES AND HIGH YIELD POINTS BASED ON PREVIOUS YEAR QUESTIONS FOR NEET AIIMS PG PREPARATION

1. MOOD DISORDERS
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2. Mood disorders
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3. Mood disorders
• Major depressive disorder
• Bipolar disorder disorder
• Either have both mania & depression /may present with mania
• Hypomania
• Less severe than mania
• Cyclothymia
• Less severe form of bipolar disorder
• Dysthymia
• Less severe & c/c form of major DepressionTONY SCARIA 2010
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4. Rapid cycling
• Picture of mania & depression alternates rapidly with each other with
out a normal intervening period
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5. Mood disorders
Unipolar mood disorders Bipolar disorders
Depression (single episodes or recurrent episodes of
depression alone)
• Mania (recurrent episodes of mania alone)
• Episodes of mania & depression  manic
depressive illness
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6. Depression
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7. depression
• Mc psychiatric disorder after anxiety disorder
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8. depression
• F>>M
• Around middle age
• Divorced and separated persons
• Mc cause of suicide
• Maximum DALY among psychiatric ds
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9. Symptoms of depression (should be present
> 2weeks )
• Sleep
• Insomnia or hypersomnia
• Early morning awakening
• Reduced latency of REM sleep
• Lack of appetite & weight loss
• Decreased energy levels & easy fatigability
• Negative cognitions & poor concentration
• Anhedonia
• Guilt feeling  himself or trivial matters
• Suicidal thoughts
• Depressed mood
• Psychomotor activity retardationTONY SCARIA 2010
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10. • Social withdrawal
• Delusion of nilhilsm
•
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11. Becks cognitive triad of depression
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12. Diagnostic criteria of depression
5 or more symptoms should last for > 2 weeks
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13. Omega sign
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14. Otto veraguth fold
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15. Other features of depression
• Psychotic features
• In severe depression
• Delusions & hallucinations
• Mood congruent / incongruent
• With atypical features
• Hypersomnia /over eating/ weight gain
• With melancholic features  involutional melancholia
• Old age
• Severe anhedonia
• Guilt feelings
• Early morning awakening
• Weight loss
• With catatonic features
• Stupor TONY SCARIA 2010
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16. Symptoms of depression
Mood Thought Cognition Psychomotor activity
• Low & sad
• Social withdrawal
• Anhedonia
• Social withdrawal
• Delusion of nilhilism
• Suicidal ideas
• Hypochondriacal
delusions
• Guilt feeling
• Loss of self esteem
• Poor concentration
• Pseudodementia in
elderly
• Psychomotor
retardation
• Lack of initiative &
energy
Somatic symptoms & biological
disturbances
Psychotic symptoms
• Decrease in appetite
• Terminal insominia Early morning
awakening
• Reduced latency of REM sleep
• Diurnal variation (depression is worse
in the morning )
• May be mood congruent or mood
incongruent 2nd person auditory
hallucination / delusionTONY SCARIA 2010
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17. Types of depression
• Mild
• Moderate
• Severe
• Severe depression + psychotic
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18. Causes of depression
• Hypo / hyperthyroidism
• Hypo / hyper parathyroidism
• cushings ds
• Addisons ds
• Withdrawal of steroids
• Post partum psychosis
• Post MI
• AIDS cancer
• OCD TONY SCARIA 2010
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19. Etiology
• NT disturbances
• Serotonin & NE
• Hormonal disturbances
• Elevated HPA activity
• Hypothyroidism  depression
• Neuroanatomical considerations
• ↓↓ in dorsolateral of prefrontal cortex
• ↑↑in amygdala
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20. TONY SCARIA 2010
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21. Aaron beck cognitive triad of depression
• Negative view of self (idea of worthlessness
• Ideas of helplessness
• Ideas of hopelessness
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22. Diagnostic criteria of depression
Major depressive disorder
5 or more of above symptoms
Minor depressive disorder
Atleast 2 of the above symptoms
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23. Rx
• Pharmacotherapy
• Psychotherapy
• Other somatic rx
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24. Pharmacotherapy
• PTx given in case of
• In c/ depression (>2 years)
• >3 depressive episodes
• Antidepressants exert 3-4 weeks for therapeutic action
• Choice of antidepressant  by s/e profile of drug
• For a period (which ever is longest)
• Of 6 months
• Drn of previous period
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25. Atypical depression
• Hypersomnia
• Increased carbohydrate
craving
• Obesity
• Interpersonal sensitivity
• Leaden paralysis
• Always lying down on bed
• Feeling heaviness of legs
• Rx
• MAOi
(moclobemide/phenelzine
)
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26. Involutional melancholia
• severe depression in which melancholia (Somatic symptoms) occur in
involutional period of life (40-65 years).
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27. Agitated depression
• This is a type of severe depression with marked motor restlessness or
agitation. It is either seen alone or along with involutional
melancholia. It is more common after the age of 40 years.
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28. TCA and tetracyclic depressants
• Block SERT (transporters of 5HT & NE)
• Increase levels of 5HT & NE in synapse
• Block H1
• Sedation
• a1 & a2
• Postural hypotension
• Sodium and cardiac sodium channels
• Arrhthmias & seizures
• Anticholinergic symptoms
• Constipation
• Urinary retention  C/I in BPH
• Blurred vision  C/I in glaucoma
• Dry mouth/ delirium /decreased sweatingTONY SCARIA 2010
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29. TONY SCARIA 2010
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30. TCA and tetracyclic depressants
• Amoxapine
• D2 blocking action  EPS
• Impipramine
• For nocturnal enuresis
• Clomipramine
• Fist line in OCD
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31. TCA
• Amitryptilline
• Desipramine
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32. Selective serotonin reuptake inhibitors (SSRI)
• Fist line drug for depression /OCD/Post traumatic stress
disorder/panic disorder/phobias/generalised aniety disorders
• Fluoxetine
• Citalopram
• Escitalopram
• Sertraline
• Paroxetine
• Vilazodone
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33. TONY SCARIA 2010
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34. TONY SCARIA 2010
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35. Down regulation of 5HT1A
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36. S/E of SSRI
• Delayed ejaculation
• Rx of premature ejaculation
• Decreased libido
• Anorgasmia
• Sedation
• Sweating
• Weight gain
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37. Serotonin syndrome
• Concurrent administration of SSRI + MAO inhibitor /L-tryptophan /
Lithium
• ↑↑ plasma serotonin
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38. TONY SCARIA 2010
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39. • Diarrhea
• Restlessness
• Hyperreflexia
• Myoclonus
• Seizures
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40. TONY SCARIA 2010
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41. Rx of serotonin syndrome
• Cyproheptadine
• Supportive care
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42. Serotonin norepinephrine reuptake inhibitor
(SNRI)
• Dual reuptake of inhibitors
• SNRI  HTn in higher dose
• Venlafaxine
• Desvenlafaxine
• Duloxetine
• milnacipran
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43. Monoamine oxidase inhibitor
• MAO A
• Metabolism of serotonin NE & dopamine
• MAO B
• Metabolism of dopamine
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44. Nonspecific MAO inhibitors
• Tranylcypromine
• Phenelzine
• Isocarboxazid
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45. TONY SCARIA 2010
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46. Substances that can cause cheese reaction
contains tyramine  usually destroyed in GIT by
MAO
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47. Nonspecific inhibition of MAO  elevation of
tyramine in blood hypertension= Cheese
reaction
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48. TONY SCARIA 2010
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49. • Rx of cheese reaction
• Phentolamine
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50. Atypical antidepressants
• Trazodone & nefazodone
• SARI (serotonin antagonist & reuptake inhibitors)
• Weak inhibition of serotonin reuptake & strong antagonism @ 5HT2A & 5HT2c
• Trazadone  priapism
• Mirtazapine
• Bupropion
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51. Mirtazapine 
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52. TONY SCARIA 2010
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53. TONY SCARIA 2010
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54. Activates 5HT2 & 5HT3 sedation
no sexual S/E
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55. Bupropion
• Norepinephrine dopamine reuptake inhibitors
• Less sexual S/E or weight gain or sedation
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56. Antidepressant used for smoking cessation 
bupropion
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57. Bupropion  can cause seizures
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58. Tianeptine & amineptine
• Enhance reuptake of serotonin
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59. Psychotherapy for depression
• Cognitive behaviour therapy
• Interpersonal therapy
• Behaviour therapy family therapyTONY SCARIA 2010
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60. • Cognitive behaviour therapy
• Most effective psychotherapeutic technique
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61. • ECT
• Severe depression with suicidal risk
• With stupor
• With psychotic symptoms/refractoriness
• Transcranial magnetic stimulation
• No anaesthesia /nonconvulsive /safe s/e profile
• Vagal N stimulation with an electrode
• Deep brain stimulation
• c/c & intractable
• Sleep deprivation
• Phototherapy  seasonal affective disordersTONY SCARIA 2010
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62. Resistant depression
• 10-20 %
• Depression a/w Personality ds /substance abuse /anemia /TB/DM
• May have white matter intensities
• Augmentation strategy is used
• Combination of antidepressants
• Small dose Li+ antidepressant
• Thyroxine+ Anti depressant
• ECT + antidepressant
• Antipsychotic + antidepressant
• Light therapy
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63. Mania
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64. Mania
• Triad of mania
• Elated mood
• Pressure of speech
• Increased psychomotor activity
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65. TONY SCARIA 2010
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66. CF of mania
Mood Thought & speech Psychomotor activity Psychotic features
• Elated mood
• Irritability
• Pressure of speech
• Flight of ideas
• Delusion of grandeur
• Distractability
• High self esteem
• Increased 
restlessness
• Goal directed activity
• Religious & spiritual
contents
Mania
• Increased sexual drive
• Decreased need for sleep
• Spending excessive money
• Absent insight TONY SCARIA 2010
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67. Bipolar disorder
• Recurrent episodes of mania and depression
• Mania alone
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68. Bipolar disorder type I Bipolar disorder type II
• Episodes of mania & major depression with
euthymia in between
• Mania alone
• Mania + hypomania
• Mania + hypomania + depression
• Hypomania + major depression
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69. TONY SCARIA 2010
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70. TONY SCARIA 2010
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71. TONY SCARIA 2010
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72. Type III bipolar disorder
• Antidepressant induced bipolar
• Patient with depression on intake of antidepressant develops mania
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73. Symptoms should last atleast 7 days
• Elevated mood
• Increased self esteem or grandiosity
• Decreased need for sleep
• Over talkativeness
• Flight of ideas
• Inability to concentrate  distractility
• Increase involvement in activities that have painful consequences
• Increase involvement in gola directed activitiesTONY SCARIA 2010
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74. Etiology
• Neuro transmitters
• Increased levels of dopamine
• Genetic
• 18 q
• 22q
• 21q
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75. Rx of BPD
• Mood stabilsers
• Li
• Valproate
• Carbamazepine
• Oxcarbazepine
• Lamotrigene
• BZD
• Lorazepam & clonazepam in ac mania
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76. Rx of BPD
• Manic phase
• Li is the DOC
• Depressive phase
• Lamotrigene + Li
• Prophylaxis
• Li
• Valproate
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77. TONY SCARIA 2010
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78. Persistent mood disorder
• Symptoms for more than 2 years in adults
• In children & young adolescent 1 yr
Dysthymia Cyclothymia c/c major depression
Depressed mood for > 2
years
Episodes of hypomania &
depression not enough to
meet the criteria of BPD
Depression for > 2 years
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79. Dysthymia diagnostic criteria
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80. Double depression
• Patient with cyclothymia
develops major depression
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81. Rx of BPD
Rx of acute mania Rx of bipolar depression
• Lithium
• valproate
• Carbamazepine
• Atypical & typical antipsychotics
• Benzodiazepines
Maintenance treatment /prophylactic Rx of BPD
• Li
• Carbamazepine
• Valproate
• Other drugs  topiramate /lamotrigine /atypical antipsychotics (aripiprazole olanzapine)
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82. • Somatic therpaies
• Used in Rx resistant depression
Ablative limbic Sx Vagal Nerve
stimulation
Transcranial
magnetic
stimulation
Deep brain
stimulation
• Anterior
cingulotomy
• Anterior
capsulotomy
• Subcaudate
tractotomy
• Limbic
leucotomy
• Left vagus is
used
• Right vagus is
not used as it
supplies heart
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83. Hypomania
• Symptoms slr to mania
• Duration is 4 days only
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84. Rapid cycling
• 4 or more episodes of depression and or mania or hypomania occur
per year
• With either less than 2 weeks of normal mood b/w episodes or switch directly
from one pole to another with out intervening normal period
RF for rapid cycling  prone for rapid cycling
• Female gender
• Hypothyroidism
• Alcoholism
• Antidepressants with out mood stabilisers
• Bipolar type II
• Cyclothymia TONY SCARIA 2010
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85. Rapid cyclers
• DOC  valproate
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86. Li
• Prototypical mood stabiliser
• Act in 1- 2 weeks
• Not metabolised  get excreted unchanged through kidney
• Indications
• Cluster head ache
• neutropenia
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87. Li
• treatment of
• a/c manic episode in patient of BPD
• MDP (manic depressive psychosis)bipolar depression.
• Prohylaxis of MDP 0.8 mEq
• Cyclothymia
• It has a low toxic : therapeutic ratio.
• therapeutic level of Lithium = 0.8 - 1.2 mEq/L.
• Lithium toxicity
• when serum lithium levels exceed 1.5 to 2 mEq/L. Hence frequent bood tests are
done to monitor the drug levels.
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88. TONY SCARIA 2010
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89. • S/E
• Teratogenic  EBSTEINS ANOMALY
• Tremors  postural  Rx propranolol
• Polyuria diabetes insipidus
• Renal failure
• Hypothyroidism
• Exacerbation of psoriasis
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90. Lithium toxicity
• >1.5mEq
• Excreted changed through kidney
• R/F
• Low sodium diet / dehydration/renal impairement
• Symptoms
• GI symptoms
• Abdominal pain/vomiting
• Neurological
• Coarse tremors/ataxia /dysarthria
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91. • Late signs of Li toxicity
• Impairement of consciousness
• Muscular fasciculations
• Increased deep tendon reflexes
• Convulsions
• Rx
• Stop Li
• Polyethyelene glycol
• Hemodialysis
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92. TONY SCARIA 2010
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93. • Lithium carbonate, sodium valproate and olanzapine are equally
effective in acute mania.
• Lamotrigine is effective in the depressed phase of Bipolar Disorder.
• The response rate to lithium carbonate is 70–80% in acute mania.
Lithium also has a prophylactic effect in prevention of recurrent
mania and, to a lesser extent, in the prevention of recurrent
depression.
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94. Suicide
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95. Suicide
• Depressive disorder /schizophrenia/alcohol dependence /personality
disorders
• Low CSF levels of 5-hydroxyindoleacetic acid (5-HIAA) high risk
• A metabolite of serotonin ( markedly low serotonin)
• Male
• >45 yrs
• Divorced
• Widowed
• Unemployed
• F h/o
• c/c illness TONY SCARIA 2010
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96. TONY SCARIA 2010
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97. Causes of suicide
Psychiatric ds Physical illness Psychosocial factors Biological factors Other risk factors
• Depression 
MC psychiatric
cause
• Alcoholism (2nd
MC)
• Drug / substance
abuse
dependence
• Schizophrenia
10-12 %
commit suicide
• Anorexia
nervosa 10%
• Borderline
personality
disorder 10%
• Cancer
• AIDS
• Multiple sclerosis
• Head trauma
• Love failure
• Marital
difficulties
• Family dispute
• Markedly low
serotonin
• Decreased 5HIAA
in urine &
plasma
• Male sex
• Age > 40
• Single
• Past attempt of
suicide  most
important risk
factor
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98. Family problems  Mc cause
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99. Methods of suicide
• Hanging MC
• Followed by poisoning
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100. Becks cognitive triad of depression
• Hopelessness  MC predisposition for suicide
• Helplessness
• Wortlessness
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101. • Anabolic steroids initially produce mania & their withdrawal produces
depression
• Glucocorticoids & ACTH  depression
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102. Psychiatric disorders in
postpartum period
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103. Post partum psychiatric disorders
Postpartum blues Postpartum depression Postpartum psychosis
40-85 % incidence 8-15 % incidence 0.1-0.2 %
• Depressed affect
• Tearfulness
• Fatigue
• Depressed affect
• Anxiety
• poor concentration
• Mood congruent delusions
• Hallucination
• Thoughts of harming self/ baby
• Supportive
• Followup to assess for
postpartum depression
• CBT & SSRI • Hospitalisation
• Atypical antipsychotics
• ECT
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104. Postpartum blues
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105. Post partum psychosis
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106. TONY SCARIA 2010
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