Fifth year Psychiatry Lecture
11th and 12th Oct. 2015 Dr Sami Adil Al-BadriMood Disorders (Part 2)
Case 2: a 79-year-old man is brought to the emergency department by his family for being mute since 2 days. The family tells you that since 3 weeks the patient has had frequent crying episodes and complained of a decrease in energy. He has lost at least 6 kilograms in the 3 weeks and for the past 2 days has refused to eat anything at all. Three days ago the patient told his family that he was “sorry for all the pain and suffering I have caused you” and that “it would be better if I were not around any more.” The patient has hypertension and he is on treatment.
Discuss: more history taking, physical exam., dx., ddx., tr., prognosis.
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Investigations:
There are no specific tests for depression. Investigations focus on the exclusion of treatable causes (see above), or other secondary problems (e.g. loss of appetite, alcohol misuse).
Standard tests FBC, ESR, B12/folate, U&Es, LFTs, TFTs, glucose, Ca2+
Focused investigations (if indicated by history or physical signs):
CT/MRI, EEG, LP (VDRL, Lyme antibody, cell count, chemistry, protein electrophoresis)
Dexamethasone suppression test (Cushing's disease)
ACTH stimulation test (Addison's disease)
Urine toxicology (to diagnose drug abuse like Cannabis or Opiates)
Antinuclear antibody
Syphilis serology
HIV testing
Course and prognosis:
Duration of one episode is usually: 6 mths – one year
The majority will have recurrence.
Suicide attempts are common but completed suicide is seen in about 4%.
Death rate is higher than the general population is due to the neglect of health and due to suicide.
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Management and treatment
Initial assessment
History and MSE (MSE= Mental State Examination) to search for the symptoms.
Physical examination: to exclude the differential diagnoses.
Baseline investigations.
Hospital admission
Risk of suicide
Risk of harm to others
Significant self-neglect (esp. weight loss)
Psychotic symptoms
Initiation of ECT
Lack of social supports
Treating depressive illness
Antidepressant drugs are effective in around 65% of patients. Mild depression tends to improve on placebo so that the difference between antidepressant use and placebo effect is very small, or at times, absent. Severe depression (e.g. melancholic) do not improve on placebo and the response to the drugs is better than in the mild forms.
All antidepressant drugs have a delayed effect. They take about two weeks to start to show the benefit. We must tell the patient about this delay and about the need to continue taking medication. No antidepressant is more efficacious or faster to act than another.
For mild- moderate episodes or where antidepressants are contraindicated (e.g. recent MI) Cognitive Behavioral Therapy (CBT) or other psychotherapies are indicated.
CBT is time-limited, and structured. Dysfunctional thought patterns are modified through verbal and action-oriented procedures.
CBT or other psychotherapy are not effective alone in severe or psychotic depression. The combination of psychological approaches and pharmacotherapy may be synergistic, but in severe cases treatment is almost exclusively pharmacological or physical (e.g. ECT).
In depression with psychotic features ECT is first choice and we must add to the antidepressants treatment an antipsychotic . In depression with catatonic features ECT and benzodiazepines are first choice.
Choosing an antidepressant
The decision about which antidepressant to choose will depend upon:Patient factors: Age, sex, comorbid physical illness (cardiac, renal, liver, neurological), previous response to antidepressants.
Symptomatology: Sedative agent for insomaniac patients, lack of energy/hypersomnia (more adrenergic/stimulatory agent), OCD symptoms (clomipramine/SSRI), risk of suicide (avoid TCAs).
Adequate trial
Generally an adequate trial of an antidepressant is defined as at least 6 wks of the highest tolerated dose (up to BNF maximum).
If there are intolerable side effects, switch to another antidepressant.
Maintenance therapy: continue the effective treatment for 6 mths to 1 yr after remission in first episode and for at least 5 yrs in recurrent episodes.New therapies under research: vagal nerve stimulation, trancranial magnatic stimulation.
Mood Disorders: Bipolar Disorder
Concept
Before 20th century all mental illnesses were regarded as one condition.Kraeplin--- differentiated two types of insanity, 1. Deteriorating (Dementia Praecox=Schizophrenia) and 2. Periodic (Manic-Depressive Insanity).
Treponema pallidum was identified and syphilis discovered
Treponema pallidum was found in the CSF of some of the patients who have manic-like symptoms (biological explanation became more accepted)
Lithium discovered to have anti-manic properties (the fact that a drug treat mania only, but not schizophrenia or major depression, means that mania is a separate illness).
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Many creative people were found to have bipolar disorder and spoke publically about it to decrease the stigma and to educate the people about it.
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Clinical Features:
Classically, periods of prolonged and profound depression alternate with periods of excessive elevated and/or irritable mood, known as mania. Between these highs (mania) and lows (depression), patients usually experience periods of full remission.
The symptoms of mania: characteristically include a decreased need to sleep (feels rested after only 3 hours of sleep), flight of ideas (subjective feeling that the thoughts are racing), pressured speech (the patient doesn't stay in the same subject but jump from subject to another, sometimes with clang association which also occur in schizophrenia), increased activity (sometimes this activity is beyond the body limit: example a manic patient walks in the summer under the sun for many hours till he develop hypotension, feet ulcers and fainting), indiscriminate غير مميِّز، غير مقيَّد behavior without regard for consequences (e.g. buying many useless things that are beyond the patients financial abilities, they usually buy vividly colored clothes or fancy cars, or many fancy electric devices not needed like e.g. a woman buying five refrigerators at the same time, or a young man buying ten fancy high priced mobile phones, inappropriate sexual behavior and disinhibition is common), grandiosity (in grandiosity there is inflated self esteem and this can reach a delusional degree like for example when the patient believes that he has special powers e.g. healing powers, or the belief that he can fly and he may jump from a high building), and distractibility (i.e. attention too easily drawn to unimportant or irrelevant external stimuli). In severe cases there may be severe thought disturbance and even psychotic symptoms.
Types:
Bipolar I: manic episodes and depressive episode, or manic episodes only.Bipolar II: hypomanic episodes and depressive episodes.
Cyclothymia: less severe, more chronic.
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Diagnostic criteria of mania (DSM-IV criteria):
Elevated mood with 3 or more of these 7 for one week
The mnemonic: DIGFAST
Distractibility
Indiscretion طيش or Inhibition lost
Grandiosity
Flight of Ideas
Activity increased
Sleep decreased
Talkativeness
N.B. in every diagnostic criteria in psychiatry add these two points at the end: (i) not caused by the direct physiological effect of a substance (e.g. drug or alcohol) or a general medical condition; (ii) causes significant distress or impairment of function.
Diagnostic criteria of hypomania is the same of the criteria of mania but not severe enough to interfere with social or occupational functioning, do not require admission to the hospital, and do not include psychotic symptoms.
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Epidemiology :
Lifetime prevalence 1%
No sex difference
Age: mean 21yrs.
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Aetiology
Genetic 1st-degree relatives are 7x more likely to develop the condition than general population.
Children of a parent with bipolar disorder have an increased chance of developing a psychiatric disorder (genetic liability appears shared for schizophrenia, schizoaffective, and bipolar affective disorder).
MZ concordance rate is higher than DZ concordance rate.
Neurotransmitters NA, DA, 5HT, and glutamine have all been implicated.
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Differential diagnosis
Schizophrenia, schizoaffective disorder, delusional disorder, other psychotic disorders
ADHD/conduct disorder
Alcohol or drug misuse (e.g. stimulants, hallucinogens, opiates)
Physical illness (e.g. hyper/hypothyroidism, Cushing's syndrome, SLE, MS, head injury, brain tumors, epilepsy, HIV and other encephalopathies, neurosyphilis)
Other antidepressant treatment or drug-related causes
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Investigations: as for depression
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Course and prognosis
There is often a 5-10yr interval between age at onset of illness and age at first treatment or first admission to hospital. Untreated patients may have more than 10 episodes in a lifetime, and that the duration and period of time between episodes stabilises after the 4th or 5th episode.
Morbidity/mortality (complications)
Morbidity and mortality rates are high, in terms of lost work, lost productivity, effects on marriage (increased divorce rates) and the family, with completed suicide in 10%.Management and treatment
Initial assessmentHistory and MSE (MSE= Mental State Examination) to search for the symptoms.
Physical examination: to exclude the differential diagnoses.
Baseline investigations.
Acute episodes
Hospital admission
Frequently acute episodes of bipolar disorder are severe enough to require hospital admission (often on a compulsory basis.
Treatment of acute manic episodes
First-line treatment
Lithium remains the first-line treatment for acute mania, with a response rate of around 80%. Note: Up to 2 weeks of treatment may be necessary to reach maximal effectiveness for manic patients. Due to this delayed effect addition of an antipsychotic or a benzodiazepine is usually required.
Antipsychotics (e.g. haloperidol, chlorpromazine) are useful in the rapid control of severely agitated or psychotic patients with bipolar disorder. Despite widespread use, the high frequency of EPSEs has led to caution, particularly because of the risk of TD with long-term treatment, hence "novel" antipsychotics have been advocated and evidence is accumulating for treating acute mania with olanzapine, risperidone, or clozapine.
Benzodiazepines: another approach to reduce the need for antipsychotics is the adjunctive use of benzodiazepines. Clonazepam and lorazepam are the most widely studied compounds.
The fact that lorazepam is well absorbed after intra-muscular injection (unlike other benzodiazepines) has made it particularly useful for some very agitated patients.
ECT has been shown to be one of the best treatment options in acute mania. Current practice reserves ECT for clinical situations where pharmacological treatments may not be possible, such as pregnancy or severe cardiac disease, or when the patient's illness is refractory to drug treatments.
Second-line (Anticonvulsants)
Carbamazepine or its derivative, oxcarbazepine, may be effective, either alone or in combination with lithium or antipsychotics.Valproate may also be effective.
Lamotrigin is proved to help the depression in bipolar patients.
Topiramate has shown some promise in both depressed and manic bipolar patients, with the added benefit of promoting weight loss.
No current evidence for gabapentin.
Treatment of depressive episodes
Same as treatment of depressive disorders but the response rate will be lower to antidepressant and we may need to use lithium or mood stabilisers, and there is a risk of switching to mania. Recent evidence suggests monotherapy with lamotrigine may have utility in the treatment of refractory bipolar depression.Prophylaxis (Maintenance Treatment)
Indications: any patient who has had at least 2 episodes in 5 years.
First-line treatment: lithium remains the first-line choice.Second-line treatments:
Carbamazepine appears to be effective in the long-term treatment of bipolar disorder, with an overall response rate of 63%.Sodium valproate/divalproex , is another choice.
No evidence for gabepentin, topiramate, or lamotrigin use in prophylaxis.
Psychotherapeutic interventionsThese should not be used alone, they are an addition to the treatment and include many types of psychotherapy like CBT, and group therapy.
Support groups: groups of patients and/or their families and/or doctors and nurses and other volunteers. These may provide useful information about bipolar disorder and its treatment. Patients may benefit from hearing the experiences of others, struggling with similar issues. This may help them to see their problems as not being unique, understand the need for medication, and access advice and assistance with other practical issues.
Case Answer:
History taking: any stressor? Neurological causes of mutism (aphasia?) (CVA?) suicide in more detail? psychotic symptoms? Which kind of antihypertensive drug? Previous hx. of similar condition? Previous hx. of mania? Family hx.?
Physical exam.: neurological exam. for CVA, thyroid
Dx. major depressive disorder (MDD)
Ddx.: MDD with psychotic features, Bipolar disorder, Conversion disorder
Tr. Admission to the psychiatric unit, ECT is of first choice with antidepressant drugs
Prognosis: poor since he is male and old. Suicide risk must be assessed seriously.
References: same as those for depressive disorder (part 1)