Mood Disorders and Clinical Depression

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Questions and Answers

Which factors are typically assessed when classifying mood disorders?

Past psychiatric treatments and family composition

Personal history and social environment

Severity and presence of physical features (correct)

Presence of suicidal thoughts and criminal behavior

What defines clinical depression in contrast to normal sadness?

Presence of physical health symptoms only

Intensity and impairment in daily activities (correct)

Duration of sadness over several weeks

Occurrence during specific seasons only

Which statement accurately describes the epidemiology of major depression?

It affects only young adults worldwide.

Women and men are equally likely to be affected.

It is one of the leading causes of disability. (correct)

Prevalence decreases with age.

What are some contributing factors to the aetiology of depression?

Biopsychosocial influences including brain changes Signup and view all the answers

What is a common risk associated with severe depressive cases?

Risk of suicide Signup and view all the answers

What distinguishes major depression from bipolar disorder?

Major depression typically does not involve manic episodes. Signup and view all the answers

What is defined as the subjective emotional state of an individual?

Mood Signup and view all the answers

Which factor is part of the epidemiology and aetiology of affective disorders?

Genetic predisposition Signup and view all the answers

What is a key responsibility of healthcare providers regarding treatment strategies for depression?

To advise patients on treatment implementation. Signup and view all the answers

What is an aspect of mood disorders as defined in psychiatric terms?

They include illnesses with abnormally high or low moods. Signup and view all the answers

What is a key symptom required for diagnosing depression?

Low mood or loss of interest/pleasure Signup and view all the answers

Which type of antidepressants work by preventing amine reuptake?

Tricyclic antidepressants Signup and view all the answers

What neurotransmitter is specifically mentioned in relation to the amine deficiency theory of depression?

Serotonin Signup and view all the answers

Which of the following scales is NOT used for diagnosing depression?

Hamilton Anxiety Scale (HAS) Signup and view all the answers

What is true about the biochemical markers for depression?

They are not reliable or established. Signup and view all the answers

What is the maximum score one can achieve on the PHQ-9 questionnaire?

27 Signup and view all the answers

According to current NICE guidelines, what is the first step a healthcare professional should take when assessing for depression?

Inquire about feelings of hopelessness or lack of interest Signup and view all the answers

What is a requirement for diagnosing Major Depression according to DSM-5?

At least 5 out of 9 symptoms during the same 2-week period, including one core symptom Signup and view all the answers

Which of the following statements accurately compares DSM-5 and ICD-11 criteria for depression?

Both require at least one core symptom nearly every day Signup and view all the answers

What indicates a hypomanic episode according to the definitions provided?

Symptoms of mania that do not severely impair social functioning Signup and view all the answers

Study Notes

PM3PY2: Depression & Bipolar Disorder

This session covers mental health disorders, including associated suicide risk.
The session is being recorded.
For more information about learning capture, see the Learning Capture Student Essentials at https://bit.ly/yujaessentials.
Contact your session lead if you have any concerns.

Learning Outcomes

Students will be able to understand depression and distinguish between types, including severity (e.g., major depression vs. bipolar disorder).
Students will be able to summarise the epidemiology and aetiology of affective disorders.
Students will be able to explain treatment strategies, limitations, side effects, and risks for different types of depressive disorders.
Students will be able to discuss how healthcare professionals (HCPs) can advise patients about treatment options and implementation.
The session connects with other PM3PY2 CNS & Mental Health topics (epilepsy, schizophrenia) and an upcoming workshop with Lee Karim (refer to relevant workbooks).

Mood and Affect

Depression and mania are mood disorders (affective disorders).
Affect: an objective description of a person's emotional behavior.
Mood: an individual's prevailing subjective emotional state.
Mood disorders encompass illnesses with abnormally high or low mood (e.g., mania and depression).
Mood disorders include depression, bipolar disorder, dysthymia (subthreshold depression), and cyclothymia.
Mood disorders often have similarities and comorbidity with anxiety.

Classifying Mood/Affective Disorders

Severity of depression is a key factor.
Physical (somatic/biological) features and the presence or absence of psychotic features are considered.
Course (duration and recurrence) and the presence/absence of intervening manic phases are assessed.
UK uses ICD-11/DSM-5 for diagnosis.

What is Depression?

Depressed mood is a normal part of life.
Sadness and melancholy are normal responses to daily events and resolve spontaneously.
Defining clinical depression involves understanding normal responses to situations.
Symptoms of depression can be emotional, behavioral, physical, and thought-based.

Depression: Epidemiology

Depression is a considerable factor in psychiatric morbidity.
Many people experience depressive episodes.
Recurrence is a common feature for some individuals.
Over 20% of those experiencing an episode will develop chronic depression.
Major depression affects about 5% of the global adult population.
Depression a leading cause of disability.
Women are more likely to experience depression compared to men.
Prevalence tends to increase with age.
Depression often co-occurs with other mental health issues.
Suicide risk is a significant concern, particularly in severe cases.

Depression: Aetiology

Depression's cause is complex and multifactorial, involving a biopsychosocial model.
Brain regional changes are relevant.
Genes and environment play important roles in mood and depression.
Family history, temperament, and personality are associated with depression.
Medical conditions, medications, and substance misuse are considerations.
Biochemical factors such as neurotransmitter imbalances and disruptions are associated with depressive disorders.

Monoamine Neurotransmission

Key neurotransmitters involved in mood regulation are norepinephrine (or noradrenaline), serotonin, and dopamine.
These neurotransmitters influence mood, energy levels, memory, and other functions.

Diagnosis of Depression

DSM-V and ICD-11 are used for diagnoses.
Patients must exhibit key symptoms (e.g., low mood/loss of interest) for at least two weeks.
Questionnaires like BDI-II, PHQ-9, and HADS aid assessment, evaluating symptom severity and general functioning (valid in primary care).
Hamilton Depression Rating Scale (HAMD) also used.

Diagnosis of Depression: NICE Guidance

Healthcare professionals (HCPs) should be aware of potential depression, especially in individuals with a history of depression, chronic illnesses affecting functional ability,
Questions to gauge symptoms include if a patient has frequently felt down, depressed or hopeless, or has had little interest in activities in last month.
Use validated diagnostic tools like ICD-11 or DSM-5.
Depression questionnaires (HADS, BDI-II, and PHQ-9) can assist in tandem.

ICD-11 and DSM-5 Comparison

Both systems categorize depressive symptoms.
Each system defines various symptom levels (mild, moderate, severe, sub-threshold)
(Note: Please see slide 11 for specific details on ICD-11 and DSM-5 symptom differences)

Severity of Depression: Previous Guidance

Based on DSM-IV and ICD-10, severity levels are defined.
Sub-threshold, Mild, Moderate, and Severe are categories according to criteria in slide 12.

Severity of Depression: Current Guidance

In 2022, guidance was updated and is based on the PHQ-9 scale.
(Note: Please see slide 13 for specific details on PHQ-9 criteria)

Treatment Types

Treatment usually involves a multidisciplinary approach.
Treatment options include pharmacological, psychosocial, and psychological approaches.
Factors guiding treatment selection include urgency, efficacy, prior history, psychosis, contraindications, and cost.

Depression: Stepped Care Model

NICE Stepped Care Model (2009, CG90) and the matched care model (2022, NG222) provide frameworks for depression management.
These models guide treatment intensity based on severity and complexity of the disorder.
Options include increasing intensities from mild interventions to combined treatments, multi-professional care, or inpatient care in cases of severe or complex depression.

Depression: Matched Care Model

Updated NICE guidelines (NG222) continue to offer guidance to support step wise interventions for managing depression.
These guidelines are currently applicable and support the delivery and monitoring of treatments.

Treatment Options: Less Severe Depression

Options, in recommended order, encompass individual guided self-help in the initial step.
Subsequent options include group cognitive behavioral therapy (CBT), group behavioral activation (BA), individual CBT, individual BA, group exercise, group mindfulness/meditation, interpersonal psychotherapy (IPT), or counselling.
Finally, short-term psychodynamic psychotherapy is another possibility.

Treatment Options: More Severe Depression

Treatment options, in recommended order, for more severe depression include combined individual CBT and antidepressant medication.
Other options also include individual CBT, individual behavioral activation (BA), antidepressant medication, individual problem-solving, counselling, short-term psychodynamic psychotherapy (STPP), interpersonal psychotherapy (IPT), guided self-help, or exercise.

Treating Depression: Antidepressants

Monoamine oxidase inhibitors (MAOIs) and selective serotonin reuptake inhibitors (SSRIs) are types of antidepressants.
Other classes include SNRIs and tricyclic antidepressants (TCAs).
The choice of antidepressant is often determined by symptom profile, and considerations like side effects, or contraindications
Antidepressants often modulate the effects of serotonin receptors and other neurotransmitters.

Antidepressants: Inhibitors of monoamine reuptake

Tricyclic antidepressants (TCAs) were used before SSRIs. Examples of TCAs include imipramine and clomipramine. TCAs act as non-selective inhibitors of noradrenaline and serotonin. Side effects are generally more severe than SSRIs
SSRIs (selective serotonin reuptake inhibitors) are widely used. Examples include sertraline, fluoxetine, paroxetine, and citalopram. SSRIs act selectively on serotonin. Side effects tend to be less pronounced than TCAs
SNRIs (serotonin-norepinephrine reuptake inhibitors) increase both serotonin and norepinephrine. Examples are venlafaxine and duloxetine
There are specific considerations for choosing between these classes and monitoring their side effects

Pharmacological Therapy

SSRI's are typically first-line treatment.
SNRIs, tricyclic antidepressants (TCAs), monoamine oxidase inhibitors (MAOIs), noradrenergic and specific serotonergic antidepressants (NaSSAs), serotonin modulators and stimulators (SMSs), and noradrenaline reuptake inhibitors (NRIs) are alternative approaches.

Pharmacological Options: Examples

Specific examples of SSRIs (sertraline, citalopram, escitalopram, fluoxetine, paroxetine) offer details on dosages and recommended increases, with minimum time intervals.
Venlafaxine and duloxetine (SNRIs) also provided.

Pharmacological Options: Examples 2

NaSSAs, TCAs, SARIs, SMSs, and NRIs are examples of alternative approaches with associated side-effects and usage cautions.

Electroconvulsive Therapy (ECT)

ECT, while used, has a still unclear mechanistic understanding.
It is associated with neuronal death and is utilized in severe depressive or psychotic episodes, especially severe cases where suicide is a significant risk.
Ketamine and esketamine, with rapid action, are newer options for treatment-resistant depression.

Treatment Strategy: New Guidance

Treatment strategy evolves. Recognition, assessment, and monitoring are core steps.
Non-pharmacological interventions are crucial.
Less severe cases prioritize least intrusive methods, while more severe conditions consider combined approaches.
Patient input plays a vital role in treatment selection, matching to their needs and experience.

Treatment Strategy 2

In severe conditions or with personality disorders, referral to secondary care specialized services is recommended.

Patient Advice and Care (if Prescribed Antidepressants)

Patients need careful preparation for antidepressant initiation.
They should understand the delayed onset of effects, potential side effects, interactions, and the importance of adherence to the prescribed regimen.
Following-up with their doctor in the initial stages and continuing thereafter is crucial for monitoring side effects and ensuring the treatment is effective.

Mania and Bipolar Disorder

Mania is characterized by elevated mood, excitement, and hyperactivity.
Bipolar disorder includes periods of mania and depression.
Depressive episodes typically last longer than manic episodes.
The duration of manic or depressive episodes is a key element in the diagnosis.

Bipolar Disorder Identification

Mania and hypomania are identified by particular symptoms.
Mixed episodes encompass a combination of manic/hypomanic and depressive symptoms, typically alternating rapidly.
Detection involves identifying symptoms of mania, hypomania, or depressive states, and noting a history of these in the past.

Management of BPD

Aims of treatment include controlling manic and depressive attacks.
Mood stabilization, either through drugs like lithium or sodium valproate or other antipsychotic medications, remains crucial.
Other treatments, like other anticonvulsants, atypical antipsychotics, or benzodiazepines, can also augment care for manic phases.
The treatment of BPD is complex and requires care by clinicians experienced in mental health management.

Treatments for Mania and BPD 1

Lithium is a key treatment for acute mania or bipolar disorder and should be closely monitored by clinicians
Antipsychotics are also used for managing mania.
Anti-epileptic drugs, similar to lithium, are also valuable therapeutic modalities.

Treatments for Mania and BPD 2

Antipsychotics (atypical) like olanzapine, quetiapine, risperidone, and haloperidol, are frequently used and may prevent future episodes.
Anti-epileptic drugs, such as valproate, lamotrigine, and carbamazepine, are often effective for mood stabilizing in bipolar disorder.

Learning Outcomes - Recap

These learning objectives cover the crucial elements for understanding and treating depression and bipolar disorders.

Reference Material

The reading list is structured to cover the relevant topics.
Refer to the list for the specific books, chapters, and sections relevant to the content on neurological disorders and mental healthcare.

Mechanisms of Action ADs

Different classes of antidepressants (SSRIs, SNRIs, etc.) target various neurotransmitters.
Understanding these mechanisms can help predict potential side effects.
This includes details on relevant receptors (SERT, NET, etc.), specific drug examples (fluoxetine, sertraline, venlafaxine, duloxetine, mirtazapine, trazodone, etc.)

Mechanisms of Action: Typical and Atypical Antipsychotics

Detailed mechanisms of action are outlined, emphasizing the difference between typical (e.g., haloperidol) and atypical (e.g., olanzapine) antipsychotic drugs.
These mechanisms elucidate how drugs like haloperidol and olanzapine affect crucial neurotransmitter receptors in the brain, with emphasis on the dopamine-related actions in haloperidol and more extensive and potentially wider acting receptor involvement with olanzapine.
Various other critical neurotransmitters and their mechanisms of action are covered.

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Description

Test your knowledge on mood disorders, including the classification of clinical depression and factors affecting its epidemiology and aetiology. Understand the distinctions between major depression and other mood disorders, and learn about treatment strategies and key symptoms related to depression.