1st CME
Mood
Disorders
Anne Washington Derry (1927)
Oil on canvas
by Laura Wheeler Waring(1887 - 1948)
Assumption
No dichotomy between mind and body/ mind and brain
All mental processes, even the most
complex psychological processes,
derive from operations of the brain.
The central tenet of this view is that
what we commonly call mind is a
range of functions carried out by the
brain. (Kandel, 1998)
René Descartes: Res Cogitans VS Res
Extensa
Biopsychosocial model
Engel (1977)
Social
factors
Biological
factors
Psychological
factors
Mental Status Examination
• Appearance (hygiene, dressing)
• Behavior (psychomotor acitivity)
– Cooperation/ Attitude
• Speech (to much, dysartric, disorganized, prosody)
• Thought Process/Form (Circumstantiality, Tangentiality, flight of
ideas, Idiosyncracies, loose of association)
•
•
•
•
•
Thought Content (delusions, obsessions)
Perceptions (illusion, hallucinations)
Mood and Affect
Insight and Judgment
Cognitive Functioning and Sensorium
Mood Disorders: Prevalence
Disorders
Major Depression
Dysthymia
Bipolar I
Biploar II
Prevalence
4.9%
3.2%
0.8%
0.5
MDD (Postpartum)
13%
Kenian Data
Our data
Depression longer: 18,6 months = 1,5 years
Association with gastric pain and headache
Mood Disorders (DSM-IV)
• Depressive Disorders
-Major Depressive Disorder
-Dysthymic Disorder
-Depressive Disorder, Not otherwise specified
• Bipolar Disorders
-Bipolar I Disorder
-Bipolar II Disorder
-cyclothymic Disorder
1) Major
Depressive
Disorder
Diagnostic Criteria for
Major Depressive Episode:
A) 5 of following symptoms, must include one of
first two, occurred almost every day for two
weeks
• Depressed mood
• Pleasure or interest/ Loss
• Appetite
• Sleep disturbance, too much or too little
• Agitation or retardation
• Fatigue
• Feelings of worthlessness or guilt
• Difficulty concentrating or deciding
• Recurrent thoughts of death, suicide
C) Significant distress or impairment in social,
occupational or other important areas of
functioning
D) Exclusion effect of:
- Substance: drugs, medications (benzodiazepines, beta-blockers, narcotics and steroids
- general medical condition (es. Hypothyroidism,
diabetes, cancer)
E) Not better account by a bereavement (only
after 2 months or with marked impairement)
Other sintoms of depression
• Mood irritable
gastrits, headache, backpa
• Less libido
• Somatic complains: persistent pain, strange
sensation in the head like warms, insects
DSM modified criteria for Sub-saharian Africa (Berstchy et al., 1992)
• Diziness, fainting, loose of memory
• Paranoid ideas (persecution)
Major Depressive Disorder
MDD, Single episode
• 1 major depressive
episode
• Absence of mania or
hypomania
MDD, Recurrent
• 2 major depressive
episodes, separated by
at least a 2 month period
with more or less
normal
functioning/mood
Major Depressive Disorder:
Etiological Theories
• Biological (genetic, brain structures,
neurotransmitters)
30 % Genetic power
• Behavior and cognition
• Emotion
• Social and cultural factors
• Developmental factors
• Life events
Depression is a sistemic disorder
Mood
depression
BIOLOGICAL BASIS
5HT - NEDA
neurotrasmettitorial
HPA - HPT
hormonal
NK - IL
immunological
BDNF - NGF
neurotrophic
Major Depression - Treatment
• Farmacotherapy: Antidepressants
• Psychotherapy (Behavioural,Cognitive,
interpersonal, dinamic)
Combined!
• Electroconvulsive therapy (ECT)
• Vagal Nerve Stimulation
Preliminary assessment
Identified patients at risk:
- family or personal history of depression
- multiple medical problems
- unexplained physical symptoms
- chronic pain
- use of medical services that is more frequent
than expected
Sex: + F
- Trauma or hard life events
+ Middle Age
•
Have you been consistently depressed or
down, most of the day, nearly every day, for
the past 2 weeks?
NO YES
• In the past 2 weeks, have you been much less
interested in most things or much less able to
enjoy the things you used to enjoy most of the
time?
NO YES
• Screen for Depression if at least one of this 2 item is code yes
Preliminary assessment
• Exclude organic illness (Hypothyroidism,
diabetes, cancer, neurological disease)
•
•
•
•
Exclude Substance abuse disorder
Medical and psychiatric history
Physical and neurologic examination
Mental status assessment
Ask for suicidality!!!
• C1
were dead?
• C2
• C3
• C4
• C5
Think you would be better off dead or wish you
NO
YES 1
Want to harm yourself?
NO
YES 2
Think about suicide?
NO
YES 6
Have a suicide plan?
NO
YES 10
Attempt suicide?
NO
YES 10
1° steps
•
•
•
•
Information
Empathetic listening
Reassurance
psychological support (e.g. problem solving
counselling)
• referral to relevant social services and
resources in the community.
When to use antidepressants?
•
•
•
•
•
•
•
moderate to severe major depression
functional impairment
Long duration of illness/ Remittent course
Severe somatic complains / concomitant chronic ilness
Alcol or substance abuse
Familiarity for mood disorders
Psychotic sintoms
Antidepressants
Effective in around 60% of patients
Explain!
3 weeks: improving/ 6-8 weeks full therapeutic
effect.
1)Amitriptyline 50 mg NOCTE: gold standard
Contraindications
Not tollerate side effects
2) Fluoxetine 20 mg OD
Amitriptyline
Start with:
25 mg NOCTE 1/12 *
2 weeks
If problem
to review
soon
Monitoring acute treatment
Psychological counseling
*If Severe
Depression start
with 50 mg:
-25 mg 1° week
- 50 mg 2° week
4-6 weeks
Evaluation of response to treatment
Remarkable
emprouvement
Long term therapy
at least 6-8 months
Light
emprouvement
NO
emprouvement
+ 25 mg every week
(max: 200 mg)
Change antidepressan
Refer Psychiatrist
Amitriptyline
Contraindication: : Pregnancy and breast feeding, Glaucome,
hyperthyroidism, prostatic hypertrophy, Stenosis pillorica, heart
failure, serious rhythm disturbances, Hypotension, treatment with
thyroid ormons, liver diseases, Dementia.
Inform patients about side effects
- Dosage in elders
Fluoxetine
Start with:
20 mg die 1/12 *
*Better 10 mg 1°
week
20 mg 2° week
2 weeks
Monitoring acute treatment
Psychological counseling
Administer in
morning or after lunch
4-6 weeks
Evaluation of response to treatment
Remarkable
emprouvement
Long term therapy
at least 6-8 months
Light
emprouvement
NO
emprouvement
+ 10 mg every week
(max: 40-60 mg)
Change antidepressan
Refer Psychiatrist
Fluoxetine
Contraindication: Pregnancy and breast feeding, Hypersensibility
Bipolar Disorders
• Bipolar I Disorder
• Bipolar II Disorder
• Cyclothymic Disorder
Hypomanic Episode: Diagnostic
Criteria
A.
B.

•
•
•
•
•
•
A distinct period (at least 4 days) of abnormally and persistently
elevated, expansive, or irritable mood. Different from usual non
depressed mood.
Mood disturbance plus three of the following symptoms (four if the
mood is only irritable):
Inflated self esteem or grandiosity
Decreased need for sleep
More talkative than usual or pressure to keep talking
Flight of ideas, or racing thoughts
Distractibility
Increase in goal directed activity
Excessive involvement in pleasurable activities
C. Unequivocal change in functioning that is uncharacteristic of the person
when is not sintomatic
D. Disturbance in mood and the change in functioning are observable by
others
E. Not organic Disease or substanec
Manic episode: Diagnostic Criteria
• All the criteria of a Hypomanic episode plus:
• Marked impairment (psychotic sintoms,
explosive behaviour, high social-occupational
disfunction, hospitalisation)
Bipolar Disorder
Sex: + M
Genetic power: 80%
High familiarity
Bipolar I
• Alternation of full manic
and depressive episodes
• Average onset is 18 years
• Tends to be chronic
• High risk for suicide
Bipolar II
• Alternation of Major
Depression with hypomania
• Average onset is 22 years
• Tends to be chronic
• 10% progess to full biploar I
disorder
Our data
Major Depressive Episode in Bipolar 2
Mood Stabilizers
+ 200 mg every week
Controindication: serious liver, kidney, heart disease, history of aplasia, pregna
Monitoring after 2 and 6 weeks
If effetictive: long term therapy: at least 2 years
Not effective: + dosage or add an antidepressant
hepatic enzyme induction.
Carbamazepine
Start with:
200 mg NOCTE 1/12 *
2 weeks
If problem
to review
soon
Monitoring acute treatment
Psychological counseling
*If Severe
Depression start
with 400 mg:
-200 mg 1° week
- 400 mg 2° week
4-6 weeks
Evaluation of response to treatment
Remarkable
emprouvement
Long term therapy
at least 2 years
Light
emprouvement
NO
emprouvement
+ 200 mg every week
(max: 800 mg)
- Add an antidepressan
- Refer Psychiatrist
if no emprouvement
Before and during carbamazepine therapy,
monitoring:
• full blood count
• liver and renal function tests
• pregnancy test.
If not feasible
• Regularly medical examination,
• recent medical history that may help recognize symptoms suggesting the development
of blood or renal or hepatic abnormalities.
Questions to do
• Have you ever had a period of time when you were feeling 'up'
or 'high' or ‘hyper’ or so full of energy or full of yourself that
you got into trouble, or that other people thought you were not
your usual self?
Have you ever been persistently irritable, for several days, so
that you
had arguments or verbal or physical fights, or
shouted at people outside your family? Have you or others
noticed that you have been more irritable or over reacted,
compared to other people, even in situations that you felt were
justified?
(Do not consider times when you were intoxicated on drugs or
alcohol.)
Hypomanic Episode (Bipolar 2 )
• ACUTE TREATMENT:
Haloperidol 5-10 mg nocte PO + Carbamazepine 200 mg nocte
(see 2a)
Resolution of Hypomanic Episode
• LONG TERM TREATMENT:
Continue only with Carbamazepine (see 2a)
Manic Episode (Bipolar 1 )
• ACUTE TREATMENT:
Haloperidol 10 mg IM or Chlorpromazine: 150-200 mg IM
Untill patient can not be managed PO
POST-ACUTE TREATMENT:
Haloperidol 5-10 mg Nocte PO + Carbamazepine (see 2a)
Resolution of Manic Episode
• LONG TERM TREATMENT:
Carbamazepine (see 2a); if not enough add Haloperidol 5-10 mg
Nocte PO
Bipolar 1 Manic Episode
ACUTE:
• Haloperidol 10 mg IM
• Clorpromazine: 150-200 mg IM
LONG TERM:
• Haloperidol 5-10 mg PO nocte
Asante sana for your
attention
Utopia lies at the horizon. When I draw nearer by two steps, it
retreats two steps. If I proceed ten steps forward, it swiftly slips ten
steps ahead. No matter how far I go, I can never reach it. What, then,
is the purpose of utopia? It is to cause us to advance.”
For any suggestion: jean.84@libero.i
0735525429
Eduardo Hughes Galeano