Mood disorders

Depression

• 2-5% of population at any time
• Diagnosis
  • Need 2 of 3 of:
    • Depressed mood, most of the day, most days, largely uninfluenced by external circumstances
    • Markedly diminished interest or pleasure in all, or almost all, activities, most of the day, nearly all day
    • Loss of energy or fatigue, nearly every day
  • Severe depression has all 3 of above
  • Other clinical signs include:
    • Loss of confidence or self-esteem
    • Unreasonable self-reproach or excessive inappropriate guilt, nearly every day
    • Recurrent thoughts of death or suicide or any suicidal behaviour
    • Diminished ability to think or concentrate or indecisiveness, nearly every day
    • Psychomotor agitation or retardation nearly every day
    • Insomnia or hypersonmnia, nearly every day
    • Change in appetite

Depression

• Brief depressive reaction (adjustment disorder) is an alternative differential in the case of a precipitating life event, however, if depression criteria met, this diagnosis can still be made

Depression

• Only a minority of people suffering depression are on active treatment
• Age of first onset is typically third decade
• M:F = 1:2
• After one episode, 80% chance of recurrence
• Recurrent depression typically involves four episodes in a lifetime
• 50% recover within 6 months, 30% symptomatic for more than a year and 12% for more than 5 years

Depression Variants

• Melancholic (somatic) depression
  • Severe mood symptoms, marked physiological dysfunction and significant psychomotor agitation or retardation
  • Need 4 of 8:
    • Marked loss of interest
    • Lack of emotional reactions
    • Waking in the morning 2 hours or more before usual time
    • Depression worse in morning
    • Objective evidence of psychomotor retardation or agitation
    • Marked loss of appetite
    • Marked loss of libido

Depression Variants

• Psychotic depression
  • Often severe depression +- somatic/melancholic syndrome
• Depression in the elderly
  • Assess in similar manner
  • Physical symptoms may be confused with medical illness
  • 10% of those over 65 suffer from depression
  • Often present with exacerbation of chronic illness
  • Carefully assess any medically trivial overdose
  • Underdiagnosed in men and ethnic minorities
  • Often thought of as normal part of ageing
  • Pseudo-dementia with apparent change in cognitive function
    • Usually recent and relatively abrupt change in concentration and memory
    • Usually show great awareness that memory difficulty exist and show considerable anxiety around this

DDx

• Brief depressive reaction
  • Does not meet major depression criteria after life event
  • Social work and brief psychotherapy can be helpful in crisis setting
• Grief reaction
  • If >6 months or severe, consider depression
  • Symptoms suggestive of depression include lowering self-esteem, persistent thoughts of death/suicide, markedly impaired concentration and psychomotor retardation
• Bipolar depression
  • Distinction rests purely on previous episode of mania
  • Lifelong disorder with recurrent episodes and needs specialised pharmacological and psychological therapy

DDx

• Organic mood disorders
  • Hypothyroidism
  • Hypercalcaemia
  • Pernicious anaemia
  • Pancreatic cancer
  • Lung cancer
  • Stroke
  • Alzheimers

DDx

• Organic mood disorders
  • Parkinson’s
  • Vascular dementia
  • Huntington’s disease
  • AIDS
  • CNS tumour
  • MS
  • Neurosyphilis
  • Brucellosis

DDx

• Medications associated with depression
  • Interferon
  • Isotretinoin
  • Methyldopa
  • Benzodiazepines
  • Beta-blockers
  • Ditigalis
  • OCP
  • Corticosteroids

Mood disorder due to substance use

• Alcohol use strongly associated but difficult to tease out
• Often self-medicating

Depressive stupor, catatonia, hysterical stupor

• Depressive stupor
  • Mute but alert and lacking spontaneous bodily movement
  • DDx includes locked in syndrome
• Catatonic schizophrenia
  • Waxy flexibility, echopraxia and bizarre posturing/grimacing
  • Very rare
• Hysterical stupor
  • Well preceding abrupt apparent paralysis and mutism
  • Usually markedly stressful event leading to this

Dysthymia

• Chronic form of depression with lack of enjoyment and pessimism not meeting full depression criteria
• Often begins in early adult life and persistent
• 3% of population

Anxiety

• Panic disorder (recurrent panic attacks)
• Generalised anxiety disorder (persistent worrying, muscular tension and autonomic symptoms)
• OCD
• Phobic disorders
  • Social phobia
  • Agoraphobia
• May all form part of depressive episode
• Must identify those with suicidal thoughts as warrant inpatient care vs. the rest who can be managed in community

Personality disorder

• Enduring patterns of behaviour, especially interpersonal, well outisde sanctioned societal norms and associated with subjective distress or conflict with others
• Must be persistent, relatively inflexible and present since young age

Antisocial personality disorder

• Long-term disregard for societal rules with chequered employment history, broken relationships and often violent/criminal issues
• Often present with acute brief depression following poor behaviour with helplessness and suicidality
• Need to clarify if superimposed depression and suicide risk
• Inpatient care difficult as often fails to follow ward rules and expectations

Borderline personality disorder

• Persistent severely immature interpersonal behaviour, impulsivity and recklessness
• Splitting and blaming others for own feelings and behaviours
• Abrupt breaches in relationships, alcohol and other drug abuse and self-harm
• Often chronic feelings of emptiness, loneliness and suicidal ideation
• Need to assess depressive symptoms on presentation as 50% have co-diagnosis

Borderline personality disorder

• Strongest indicators
  • Recurrent suicidal threats or acts of self-injury
  • Strong preoccupation with expected rejection and abandonment
• Feel they need to be constantly connected to someone who they believe really cares for them
  • Unrealistic expectations and constant need for validation leads to perceived rejection and breakdown of positive relationships
• Switch between them being ‘the good person let down by others’ to ’the bad person who doesn’t deserve to live’
• 8-10% completed suicide rate
• Men tend to suffer substance abuse and women eating disorders

Treatment

• SSRI’s first-line limited by sexual dysfunction
• Mirtazapine if difficulty sleeping (but adds weight)
• Venlafaxine alternative
• Reboxetine and moclobemide useful alternatives
• TCA’s and irreversible MAO’s usually avoided
• All antidepressants more effective than placebo in symptom reduction
• No antidepressant better than another
• Spontaneous remission at 12 weeks is average without therapy
• Psychotic depression respond better to combination antidepressant and antipsychotic

Psychotherapy

• CBT usually first-line with focus on reversing social isolation, scheduled relaxation and incentives for helpful behaviours
  • Cognitive restructuring to systemically explore unhelpful thought patterns
• IPT may be helpful to manage interpersonal relationships contributing to issue
• Both of proven benefit vs. pill placebo
• As effective as medication for mild-moderate depression
• For severe depression, psychotherapy alone is not as good as medication alone or both together

Somatoform disorders

• Somatisation disorder
  • Communication of psychological stress as physical complaints
  • Usually multiple symptoms
  • Red flags
    • Dysmenorrhoea
    • Globus hystericus
    • Vomiting
    • SOB
    • Burning genitals
    • Painful extremities
    • Amnesia for hours or days

Somatoform disorders

• Conversion disorder
  • Sudden and dramatic single symptoms e.g. pseudoseizure, coma, syncope, paralysis
• Pain disorder
• Hypochondriasis
  • Disproportionate symptoms to demonstrable organic disease

Last Updated on October 7, 2020 by Andrew Crofton