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
3. Mood disorders
ā¢ Major depressive disorder
ā¢ Bipolar disorder disorder
ā¢ Either have both mania & depression /may present with mania
ā¢ Hypomania
ā¢ Less severe than mania
ā¢ Cyclothymia
ā¢ Less severe form of bipolar disorder
ā¢ Dysthymia
ā¢ Less severe & c/c form of major DepressionTONY SCARIA 2010
KMC
4. Rapid cycling
ā¢ Picture of mania & depression alternates rapidly with each other with
out a normal intervening period
TONY SCARIA 2010
KMC
5. Mood disorders
Unipolar mood disorders Bipolar disorders
Depression (single episodes or recurrent episodes of
depression alone)
ā¢ Mania (recurrent episodes of mania alone)
ā¢ Episodes of mania & depression ļ manic
depressive illness
TONY SCARIA 2010
KMC
8. depression
ā¢ F>>M
ā¢ Around middle age
ā¢ Divorced and separated persons
ā¢ Mc cause of suicide
ā¢ Maximum DALY among psychiatric ds
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9. Symptoms of depression (should be present
> 2weeks )
ā¢ Sleep
ā¢ Insomnia or hypersomnia
ā¢ Early morning awakening
ā¢ Reduced latency of REM sleep
ā¢ Lack of appetite & weight loss
ā¢ Decreased energy levels & easy fatigability
ā¢ Negative cognitions & poor concentration
ā¢ Anhedonia
ā¢ Guilt feeling ļ himself or trivial matters
ā¢ Suicidal thoughts
ā¢ Depressed mood
ā¢ Psychomotor activity retardationTONY SCARIA 2010
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15. Other features of depression
ā¢ Psychotic features
ā¢ In severe depression
ā¢ Delusions & hallucinations
ā¢ Mood congruent / incongruent
ā¢ With atypical features
ā¢ Hypersomnia /over eating/ weight gain
ā¢ With melancholic features ļ involutional melancholia
ā¢ Old age
ā¢ Severe anhedonia
ā¢ Guilt feelings
ā¢ Early morning awakening
ā¢ Weight loss
ā¢ With catatonic features
ā¢ Stupor TONY SCARIA 2010
KMC
16. Symptoms of depression
Mood Thought Cognition Psychomotor activity
ā¢ Low & sad
ā¢ Social withdrawal
ā¢ Anhedonia
ā¢ Social withdrawal
ā¢ Delusion of nilhilism
ā¢ Suicidal ideas
ā¢ Hypochondriacal
delusions
ā¢ Guilt feeling
ā¢ Loss of self esteem
ā¢ Poor concentration
ā¢ Pseudodementia in
elderly
ā¢ Psychomotor
retardation
ā¢ Lack of initiative &
energy
Somatic symptoms & biological
disturbances
Psychotic symptoms
ā¢ Decrease in appetite
ā¢ Terminal insominia Early morning
awakening
ā¢ Reduced latency of REM sleep
ā¢ Diurnal variation (depression is worse
in the morning )
ā¢ May be mood congruent or mood
incongruent 2nd person auditory
hallucination / delusionTONY SCARIA 2010
KMC
17. Types of depression
ā¢ Mild
ā¢ Moderate
ā¢ Severe
ā¢ Severe depression + psychotic
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18. Causes of depression
ā¢ Hypo / hyperthyroidism
ā¢ Hypo / hyper parathyroidism
ā¢ cushings ds
ā¢ Addisons ds
ā¢ Withdrawal of steroids
ā¢ Post partum psychosis
ā¢ Post MI
ā¢ AIDS cancer
ā¢ OCD TONY SCARIA 2010
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19. Etiology
ā¢ NT disturbances
ā¢ Serotonin & NE
ā¢ Hormonal disturbances
ā¢ Elevated HPA activity
ā¢ Hypothyroidism ļ depression
ā¢ Neuroanatomical considerations
ā¢ āā in dorsolateral of prefrontal cortex
ā¢ āāin amygdala
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21. Aaron beck ļ cognitive triad of depression
ā¢ Negative view of self (idea of worthlessness
ā¢ Ideas of helplessness
ā¢ 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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24. Pharmacotherapy
ā¢ PTx given in case of
ā¢ In c/ depression (>2 years)
ā¢ >3 depressive episodes
ā¢ Antidepressants exert 3-4 weeks for therapeutic action
ā¢ Choice of antidepressant ļ by s/e profile of drug
ā¢ For a period (which ever is longest)
ā¢ Of 6 months
ā¢ Drn of previous period
TONY SCARIA 2010
KMC
25. Atypical depression
ā¢ Hypersomnia
ā¢ Increased carbohydrate
craving
ā¢ Obesity
ā¢ Interpersonal sensitivity
ā¢ Leaden paralysis
ā¢ Always lying down on bed
ā¢ Feeling heaviness of legs
ā¢ Rx
ā¢ MAOi
(moclobemide/phenelzine
)
TONY SCARIA 2010
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26. Involutional melancholia
ā¢ severe depression in which melancholia (Somatic symptoms) occur in
involutional period of life (40-65 years).
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27. Agitated depression
ā¢ 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.
TONY SCARIA 2010
KMC
28. TCA and tetracyclic depressants
ā¢ Block SERT (transporters of 5HT & NE)
ā¢ Increase levels of 5HT & NE in synapse
ā¢ Block H1
ā¢ Sedation
ā¢ a1 & a2
ā¢ Postural hypotension
ā¢ Sodium and cardiac sodium channels
ā¢ Arrhthmias & seizures
ā¢ Anticholinergic symptoms
ā¢ Constipation
ā¢ Urinary retention ļ C/I in BPH
ā¢ Blurred vision ļ C/I in glaucoma
ā¢ Dry mouth/ delirium /decreased sweatingTONY SCARIA 2010
KMC
68. Bipolar disorder type I Bipolar disorder type II
ā¢ Episodes of mania & major depression with
euthymia in between
ā¢ Mania alone
ā¢ Mania + hypomania
ā¢ Mania + hypomania + depression
ā¢ Hypomania + major depression
TONY SCARIA 2010
KMC
72. Type III bipolar disorder
ā¢ Antidepressant induced bipolar
ā¢ Patient with depression on intake of antidepressant develops mania
TONY SCARIA 2010
KMC
73. Symptoms should last atleast 7 days
ā¢ Elevated mood
ā¢ Increased self esteem or grandiosity
ā¢ Decreased need for sleep
ā¢ Over talkativeness
ā¢ Flight of ideas
ā¢ Inability to concentrate ļ distractility
ā¢ Increase involvement in activities that have painful consequences
ā¢ Increase involvement in gola directed activitiesTONY SCARIA 2010
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78. Persistent mood disorder
ā¢ Symptoms for more than 2 years in adults
ā¢ 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
TONY SCARIA 2010
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81. Rx of BPD
Rx of acute mania Rx of bipolar depression
ā¢ Lithium
ā¢ valproate
ā¢ Carbamazepine
ā¢ Atypical & typical antipsychotics
ā¢ Benzodiazepines
Maintenance treatment /prophylactic Rx of BPD
ā¢ Li
ā¢ Carbamazepine
ā¢ Valproate
ā¢ Other drugs ļ topiramate /lamotrigine /atypical antipsychotics (aripiprazole olanzapine)
TONY SCARIA 2010
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82. ā¢ Somatic therpaies
ā¢ Used in Rx resistant depression
Ablative limbic Sx Vagal Nerve
stimulation
Transcranial
magnetic
stimulation
Deep brain
stimulation
ā¢ Anterior
cingulotomy
ā¢ Anterior
capsulotomy
ā¢ Subcaudate
tractotomy
ā¢ Limbic
leucotomy
ā¢ Left vagus is
used
ā¢ Right vagus is
not used as it
supplies heart
TONY SCARIA 2010
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84. Rapid cycling
ā¢ 4 or more episodes of depression and or mania or hypomania occur
per year
ā¢ 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 ļ prone for rapid cycling
ā¢ Female gender
ā¢ Hypothyroidism
ā¢ Alcoholism
ā¢ Antidepressants with out mood stabilisers
ā¢ Bipolar type II
ā¢ Cyclothymia TONY SCARIA 2010
KMC
86. Li
ā¢ Prototypical mood stabiliser
ā¢ Act in 1- 2 weeks
ā¢ Not metabolised ļ get excreted unchanged through kidney
ā¢ Indications
ā¢ Cluster head ache
ā¢ neutropenia
TONY SCARIA 2010
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87. Li
ā¢ treatment of
ā¢ a/c manic episode in patient of BPD
ā¢ MDP (manic depressive psychosis)ļ bipolar depression.
ā¢ Prohylaxis of MDPļ 0.8 mEq
ā¢ Cyclothymia
ā¢ It has a low toxic : therapeutic ratio.
ā¢ therapeutic level of Lithium = 0.8 - 1.2 mEq/L.
ā¢ Lithium toxicity
ā¢ when serum lithium levels exceed 1.5 to 2 mEq/L. Hence frequent bood tests are
done to monitor the drug levels.
TONY SCARIA 2010
KMC
91. ā¢ Late signs of Li toxicity
ā¢ Impairement of consciousness
ā¢ Muscular fasciculations
ā¢ Increased deep tendon reflexes
ā¢ Convulsions
ā¢ Rx
ā¢ Stop Li
ā¢ Polyethyelene glycol
ā¢ Hemodialysis
TONY SCARIA 2010
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93. ā¢ Lithium carbonate, sodium valproate and olanzapine are equally
effective in acute mania.
ā¢ Lamotrigine is effective in the depressed phase of Bipolar Disorder.
ā¢ The response rate to lithium carbonate is 70ā80% 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.
TONY SCARIA 2010
KMC
97. Causes of suicide
Psychiatric ds Physical illness Psychosocial factors Biological factors Other risk factors
ā¢ Depression ļ
MC psychiatric
cause
ā¢ Alcoholism (2nd
MC)
ā¢ Drug / substance
abuse
dependence
ā¢ Schizophrenia
ļ 10-12 %
commit suicide
ā¢ Anorexia
nervosaļ 10%
ā¢ Borderline
personality
disorderļ 10%
ā¢ Cancer
ā¢ AIDS
ā¢ Multiple sclerosis
ā¢ Head trauma
ā¢ Love failure
ā¢ Marital
difficulties
ā¢ Family dispute
ā¢ Markedly low
serotonin
ā¢ Decreased 5HIAA
in urine &
plasma
ā¢ Male sex
ā¢ Age > 40
ā¢ Single
ā¢ Past attempt of
suicide ļ most
important risk
factor
TONY SCARIA 2010
KMC