MEDI3004 MENTAL HEALTH ROTATION -YEAR 3 MBBS. Topic 2 - Mood and Adjustment Disorders.docx

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Associate Professor Jane Turner

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MOOD AND ADJUSTMENT DISORDERS  Defined by the presence of mood episodes  Represent a combination of symptoms comprising a predominant mood state that is abnormal in quality or duration Medical workup of mood disorder TYPES  Routine  Depressive o Physical exam o Major depressive disorder o FBC o Dysthymic disorder o Thyroid function test  Bipolar disorder o Electrolytes o Bipolar I disorder o Urinalysis o Bipolar II disorder o Urine drug screen o Cyclothymic disorder  Additional  Secondary o Neuro consult o General medical condition o CXR o Substances o ECG o Medications o CT scan Category Examples Vascular Cardiomyopathy, Congestive heart failure, myocardial infarct, cerebrovascular accident Infectious Encephalitis, meningitis, hepatitis, pneumonia, TC, syphillus Neoplastic Pnacreatic cancer, carcinoid, pheochromocytoma Degenerative Huntington’s, multiple sclerosis, tuberous sclerosis, vascular dementia, Alzheimer’s Intoxication Antihypertensives, antiparkinsonism, hormones, steroids, antituberculous, interferon, antineoplastic medications, vitamin deficiencies (Wernicke’s, beriberi, pellagra, pernicious anaemia) Congenitla - Autoimmune SLE, polyarteritis nodosa Traumatic - Endocrine/ Hypothyroidism, hyperthyroidism, hypopituitarism, SIADH, porphyria, Wilson’s, Metabolic diabetes DEPRESSION  Also known as unipolar affective disorder  Reactive depression: clearly associated with stressful life-events  Endogenous depression: shows familial pattern, unrelated to external stresses. CLASSIFICATION  Major Depressive disorder (MDD) o Melancholia o Catatonic Depression o Atypical depression o Seasonal affective disorder o Postpartum Depression  Dysthymic disorder  Bipolar disorders  Adjustment disorder with depressed mood  Mood disorders secondary to illness and medications CLINICAL FEATURES DSM IV Major Depressive Episode DSM IV Criteria for Major Depressive Episode > 2 weeks duration, at least 4 of: A. >5 of the following symptoms have been present during the same 2 week period and represent a Sleep disturbance change from previous functioning; at least one of the Anhedonia symptoms is either (1) depressed mood or (2) loss of interest or pleasure (anhedonia) Dysphoria Appetite/weight change  depressed mood most of the day, nearly Fatigue every day, as indicated by either subjective Agitation report or observation made by others Concentration difficulty  markedly diminished interest or pleasure Esteem and excessive guilt in all, or almost all, activities most of the day, nearly every day Suicidal ideation  significant weight loss when not dieting or weight gain, or decrease or increase in Other Possible Symptoms appetite nearly every day  Panic attacks  insomnia or hypersomnia nearly every day  Diurnal mood changes (worse  psychomotor agitation or retardation mood in the morning) nearly every day  Loss of libido  fatigue or loss of energy nearly every day  Delusions or hallucinations  feelings of worthlessness or excessive or  Pseudodementia (sx of dementia, inappropriate guilt (which may be caused by depression) delusional) nearly every day (not merely self-reproach or guilt about being sick)  Behavioural disorders (shoplifting, skipping school)  diminished ability to think or concentrate, or indecisiveness, nearly every day  recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation without a specific plan, or a suicidal attempt of a specific plan for committing suicide B. The symptoms do not meet criteria for a mixed episode C. The symptoms cause clinically significant distress or impairment in social, occupational or other important areas of functioning D. The symptoms are not due to the direct physiological effects of a substance of a general medical condition E. The symptoms are not better accounted for by bereavement the symptoms persist for longer than 2 months symptoms are characterized by marked functional impairment morbid preoccupation with worthlessness, suicidal ideation, psychotic symptoms or psychomotor retardation  Anhedonia: Inability to feel pleasure in acts which normally are pleasurable  Dysphoria: A state of unease or generalized dissatisfaction with life DDX  Anxiety disorder  Dysthymia  Bipolar disorder  Delirium  Substance use disorders  Organic conditions o Hypothyroidism o Cushing’s ETIOLOGY Risk Factors  Genetic  Female gender  Age 20-50  Neurotransmitter dysfunction:  serotonin, noradrenaline and dopamine activity  FHx of depression, alcohol  Secondary to general medical condition abuse and sociopathy  Psychosocial  Childhood experiences of loss o Psycodynamic (before age 11), abuse, neglect  Recent stressors – illness, o Cognitive o Environmental factors e.g. job loss, diet, financial, legal bereavement, history of abuse  Postpartum <6 months o Co-morbid psychiatric diagnoses e.g. anxiety,  Lack of intimate, confiding substance abuse, mental retardation, dementia, relationships or social eating disorder isolation MAJOR DEPRESSIVE DISORDER Criteria A. presence of a single MDE (vs recurrent, which requires presence of two or more MDEs, to be considered separate episodes, there must be an interval of at least 2 consecutive months in which criteria are nto met for a MDE) B. The MDE is not better accounted for by schizoaffective disorder and is not superimposed on Schizophrenia, Schizophreniform Disorder, Delusional Disorder or Psychotic Disorder nto otherwise specified C. The has never been a manic episode, a mixed episode, or a hypomanic episode. Subtypes Type Features Psychotic  with hallucinations or delusions Chronic  Lasting 2 years of more Catatonic  At least two of motor immobility, excessive motor activity, extreme negativism or mutism, peculiarities of voluntary movement, echolalia or echopraxia Melancholic  Quality of mood is distinctly depressed  Mood is worse in the morning  Early morning waking  Marked weight loss  Excessive guilt  Psychomotor retardation Atypical  Increased sleep  Weight gain  Leaden paralysis  Rejection hypersensitivity Postpartum  Seasonal  Pattern of onset at the same time each year – most often in autumn or winter MANAGEMENT  Medication o Antidepressants  First line: SSRIs, SNRIs and mirtazapine  Assess response to antidepressant after 2-4 weeks. If no response, increase the dose. After 2-4 weeks of higher dose with no reponse, switch to a different drug First-line treatment options Drug Usual initial treatment dose Max daily dose Selective serotonin reuptake inhibitors (SSRIs) citalopram < 65 yo: 20 mg PO, mane < 65 years of age: 40 mg > 65yo: 10 mg PO, mane > 65 years of age: 20 mg escitalopram 10 mg PO mane 20 mg fluoxetine 20 mg PO mane 80 mg fluvoxamine starting dose 50 mg PO nocte 300 mg  100 mg nocte in 5-7 days as tolerated paroxetine 20 mg PO mane 50 mg sertraline starting dose 50 mg PO mane. 200 mg  to 100 mg mane in 5-7 days as tolerated Serotonin and noradrenaline reuptake inhibitors (SNRIs) desvenlafaxine 50 mg PO mane 200 mg duloxetine 60 mg PO mane 120 mg venlafaxine 75 mg PO mane 375 mg Other mirtazapine 15- 30 mg PO nocte 60 mg Second-line treatment options agomelatine (melatonin 25 mg PO nocte 50 mg agaonist) moclobemide (MAOi) 300-450 mg PO 600 mg reboxetine (NRI) 2-4 mg PO bd 10 mg o Lithium o Antipsychotics o Anxiolytics o ECT o Light therapy  Psychological: psychodynamic, interpersonal, CBT, family therapy, group therapy  Social: vocational rehabilitation, social skills, training PROGNOSIS  One year after diagnosis of a MDE without treatment o 40% of individuals still have symptoms that are sufficiently severe to meet criteria for a full MDE o 20% continue to have some symptoms that no longer meet criteria for a MDE o 40% have no mood disorder DYSTHYMIA CRITERIA A. depressed mood for most of the day, for more days than not, as indicated either by subjective account or observation by others for > 2 years. Note in children/adolecents, mood can be irritable and duration must be at least 1 year B. Presence, while depressed, of >2 of the following  Poor appetite or overeating  Insomnia or hypersomnia  Low energy or fatigue  Low self-esteem  Poor concentration or difficulty making decisions  Feelings of hopelessness C. During the 2 year period of the disturbance, the person has never been without the symptoms in criteria A and B for more than 2 months at a time D. No MDE has been present during the first 2 years of the disturbance, i.e. the disturbance is not better accounted for by chronic MDD, or MDD in partial remission E. There has never been a Manic Episode, a Mixed Episode, or a Hypomanic Episode, and criteria have never been met for Cyclothymic Disorder F. The disturbance does not occur exclusively during the course of a chronic psychotic disorder, such as schizophrenia or delusional disorder G. The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning MANAGEMENT  Psychological: principle treatment for dysthymia,
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