Anne Washington Derry (1927) Oil on canvas

by Laura Wheeler Waring(1887 - 1948)

1st CME

Mood Disorders

Assumption

No dichotomy between mind and body/ mind and brain

René Descartes: Res Cogitans VS Res Extensa

(1596 - 1650)

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)

Engel (1977)

Biopsychosocial model

SocialSocial factorsfactors

Biological Biological

factorsfactors Psychological Psychological

factorsfactors

• 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

Mental Status Examination

Mood Disorders: Prevalence

Disorders

Major Depression

Dysthymia

Bipolar I

Biploar II

MDD (Postpartum)

Prevalence

4.9%

3.2%

0.8%

0.5

13%

Kenian Data

Our data

Depression longer: 18,6 months = 1,5 yearsAssociation 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 (benzo- diazepines,

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

• Less libido

• Somatic complains: persistent pain, strange sensation in the head like warms, insects

• Diziness, fainting, loose of memory

• Paranoid ideas (persecution)

gastrits, headache, backpain

DSM modified criteria for Sub-saharian Africa (Berstchy et al., 1992)

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)

• Behavior and cognition

• Emotion

• Social and cultural factors

• Developmental factors

• Life events

30 % Genetic power

Depression is a sistemic disorder

Mood depression

Mood depression

BIOLOGICAL BASISBIOLOGICAL BASIS

neurotrasmettitorialneurotrasmettitorial

hormonalhormonal

immunologicalimmunological

neurotrophicneurotrophic

5HT - NE- 5HT - NE- DADA

HPA - HPTHPA - HPT

NK - ILNK - IL

BDNF - NGFBDNF - NGF

Major Depression - Treatment

• Farmacotherapy: Antidepressants

• Psychotherapy (Behavioural,Cognitive, interpersonal, dinamic)

• Electroconvulsive therapy (ECT)

• Vagal Nerve Stimulation

Combined!

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

- Trauma or hard life events Sex: + F+ 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 Think you would be better off dead or wish you were dead? NO YES 1

• C2 Want to harm yourself? NO YES 2

• C3 Think about suicide? NO YES 6

• C4 Have a suicide plan? NO YES 10

• C5 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

3 weeks: improving/ 6-8 weeks full therapeutic effect.

1)Amitriptyline 50 mg NOCTE: gold standard

2) Fluoxetine 20 mg OD

Contraindications

Not tollerate side effects

Explain!

Amitriptyline

Start with: 25 mg NOCTE 1/12 **If Severe Depression start with 50 mg:

-25 mg 1° week- 50 mg 2° week

2 weeks

Monitoring acute treatmentPsychological counseling

Light emprouvement

4-6 weeks

Evaluation of response to treatment

Remarkable emprouvement

NO emprouvement

+ 25 mg every week (max: 200 mg)

Change antidepressantRefer Psychiatrist

Long term therapy at least 6-8 months

If problem to review soon

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

FluoxetineStart with: 20 mg die 1/12 *

2 weeks

Monitoring acute treatmentPsychological counseling

Light emprouvement

4-6 weeks

Evaluation of response to treatment

Remarkable emprouvement

NO emprouvement

+ 10 mg every week (max: 40-60 mg)

Change antidepressantRefer Psychiatrist

Long term therapy at least 6-8 months

*Better 10 mg 1° week 20 mg 2° week

Administer in morning or after lunch

Fluoxetine

Contraindication: Pregnancy and breast feeding, Hypersensibility

Bipolar Disorders

• Bipolar I Disorder

• Bipolar II Disorder

• Cyclothymic Disorder

Hypomanic Episode: Diagnostic Criteria

A. A distinct period (at least 4 days) of abnormally and persistently elevated, expansive, or irritable mood. Different from usual non depressed mood.

B. 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 othersE. 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

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

Sex: + MGenetic power: 80%High familiarity

Our data

Major Depressive Episode in Bipolar 2

Controindication: serious liver, kidney, heart disease, history of aplasia, pregnancy

Monitoring after 2 and 6 weeksIf effetictive: long term therapy: at least 2 yearsNot effective: + dosage or add an antidepressant

+ 200 mg every week

hepatic enzyme induction.

Mood Stabilizers

Carbamazepine

Start with: 200 mg NOCTE 1/12 **If Severe Depression start with 400 mg:

-200 mg 1° week- 400 mg 2° week

2 weeks

Monitoring acute treatmentPsychological counseling

Light emprouvement

4-6 weeks

Evaluation of response to treatment

Remarkable emprouvement

NO emprouvement

+ 200 mg every week (max: 800 mg)

- Add an antidepressant- Refer Psychiatrist if no emprouvement

Long term therapy at least 2 years

If problem to review soon

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 rec- ognize

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 youhad 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.)

• ACUTE TREATMENT:

Haloperidol 5-10 mg nocte PO + Carbamazepine 200 mg nocte

• LONG TERM TREATMENT:

Continue only with Carbamazepine (see 2a)

Hypomanic Episode (Bipolar 2 )

Resolution of Hypomanic Episode

(see 2a)

• ACUTE TREATMENT:

Haloperidol 10 mg IM or Chlorpromazine: 150-200 mg IM

POST-ACUTE TREATMENT:

Haloperidol 5-10 mg Nocte PO + Carbamazepine (see 2a)

• LONG TERM TREATMENT:

Carbamazepine (see 2a); if not enough add Haloperidol 5-10 mg Nocte PO

Manic Episode (Bipolar 1 )

Resolution of Manic Episode

Untill patient can not be managed PO

Bipolar 1 Manic Episode

ACUTE:

• Haloperidol 10 mg IM

• Clorpromazine: 150-200 mg IM

LONG TERM:

• Haloperidol 5-10 mg PO nocte

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.” Eduardo Hughes Galeano

Asante sana for your attention

For any suggestion: jean.84@libero.it 0735525429