Dr. Cindy PY Chiu

Specialist-in-PsychiatryMBBS (HK)

MRCPSYCH (UK) FHKCPSYCH

FHKAM (PSYCHIATRY)DIP MED (CUHK)

GRAD DIP CHILD P.S. (MONASH)

13 May 2016

Psychological reaction in adaptation to new

circumstances

Life changes – life events

Reaction is understandably related to the

stressful experience, and in proportion

Individual characteristics taken into account

at least one stressor

Symptoms begin soon after the change

Starts within three months, usually within

one month (ICD-10 criteria)

Social and occupational decline

Symptoms resolution within 6 months upon

removal/ resolution of stressor

A quantified measure of life events

Higher score -> “higher” stress

Life event score

Death of a spouse 100

Divorce 73

Marital separation 65

Imprisonment 63

Death of a close

family member63

Personal injury or

illness53

Marriage 50

Dismissal from work 47

Marital reconciliation 45

Retirement 45

Change in health of family

member44

Pregnancy 40

Sexual difficulties 39

Gain a new family member 39

Business readjustment 39

Change in financial state 38

Death of a close friend 37

Change to different line of

work36

Change in frequency of

arguments35

Major mortgage 32

Foreclosure of

mortgage or loan30

Change in

responsibilities at

work

29

Child leaving home 29

Trouble with in-laws 29

Outstanding personal

achievement28

Spouse starts or stops

work26

Begin or end school 26

Change in living

conditions25

Trouble with boss 23

Change in working

hours or conditions20

Change in residence 20

Change in schools 20

Change in recreation 19

Change in social

activities18

Minor mortgage or loan 17

Vacation 13

Christmas 12

Minor violation of law 11

Depressive reaction

Mixed anxiety and depressive reaction

Predominant disturbance of other emotions

Predominant disturbance of conduct

Mixed disturbance of emotions and conduct

Experienced or witnessed extreme stressors (life-threatening scenarios)

Response is intense, prolonged and sometimes delayed

Hyperarousal

Intrusions

Avoidance

Hyperarousal

Persistent anxiety

Insomnia

Irritability

Poor concnetration

hypervigilance

Intrusions

Flashbacks (intrusive imagery)

Recurrent Nightmares

Difficulty in recalling the stressful event at will

Depressive symptoms

Avoidance

Avoidance of the reminders of the event

Detachment

Emotional numbness

Social isolation, withdrawal

Diminished interest in activities

Other symptoms

Guilt (amongst survivors)

Maladaptive coping eg alcohol and substance

abuse

Increased suicide rate, divorce rate

Anyone but not everyone exposed to the

same extreme stressor develop PTSD

Proximity to the stressful situation, length of

exposure

Not limited to Victims, but also firefighters,

rescue workers, health professionals, army,

volunteers, reporters etc

Personality factors – non expressive

Maladaptive coping

History of previous trauma

Mania

Hypomania

Euthymia

Mild to moderate depression

Severe depression

Depressed mood – melancholic, miserable. note diurnal variation, usu. worse in mornings

Pessimistic thoughts

Depressive cognition : past (self reproach, guilt, focusing on unhappy past

events),

present (useless, worthless, hypochondriacal)

Future (hopelessness, pessimism, apprehension, nihilism, life not worth living beware of SUICIDAL IDEATION)

Beck’s cognitive triad (Beck et al 1976) Self (e.g. I am useless and undeserving)

World (e.g. Everyone thinks I am a failure, my children do not respect me, people laugh at me)

Future (e.g. I am doomed, I will lose everything)

Lack of enjoyment – no enjoyment in usual

pleasurable activities

Reduced energy – finds tasks effortful, easily

fatiguable, lethargy, anhedonia

Social withdrawal

Slowness – psychomotor retardation

Agitation and irritability

Cognitive symptoms – poor memory,

decreased concentration or perseverance

Sleep disturbance

Unrefreshed sleep

Early morning wakening – > 2 hours earlier than

usual, lying in bed with pessimistic thoughts,

does not want to get up to face the day

Diurnal variation

Waking in the night, difficulty falling asleep

Some patients may have excessive sleep

Decreased appetite

Not wanting to eat, not hungry

Finds food tasteless, picking at food

Some may have excessive eating and/or binging

Weight loss (>10%)

Loss of libido

Constipation

Amenorrhea (women)

Psychotic symptoms

Delusions – mood congruent (worthlessness,

guilt, persecutory) or mood incongruent

Cotard’s syndrome – nihilistic delusions

hallucinations

Elevated mood –excessive cheerfulness, euphoria, elation, infectious gaiety

Lability of mood

Increased activity –restlessness, physically exhausted

Expansive ideas –grandiosity (can be delusional), recklessness, overspending)

Disinhibition- social, sexual

Irritability and agitation –may be violent

Decreased need for sleep

Increased appetite

Overtalkativity – pressure of speech, flight of ideas, loud-spoken

Thought disorder – racing thoughts, punning, clang association

Delusions of persecution and reference, Hallucinations -congruency vs incongruency with mood

Poor insight (often)

Appearance – brightly-coloured clothing, excessively accessorized, inappropriate dress, overfriendly and verbose

Extreme form of psychomotor retardation

Characterized by muteness and motionless

Some may display catatonic motor

disturbances

Rare

Responds to ECT

Depressed mood most of the time for 2 years

at least (1 year for children, can be irritable

rather than depressed in mood)

Functional impairment

Lifetime prevalence 4.4%

F:M = 2:1

Double depression – depressive episode

superimposed on underlying dysthymia

Chronic fluctuating periods of hypomanic and

depressive symptoms for a 2 year period,

absence of symptoms < 2 months

Lifetime risk around: 0.4-1%

Equal amongst both gender

Onset adolescence or early adulthood

15-50% risk of developing into Bipolar

Disorder

ICD-10 DSM-IV

Depressive episode

Mild, Moderate, Severe, Severe

with psychosis

Major depressive episode

Mild, Moderate, Severe, Severe

with psychosis

Other depressive episodes

Atypical depression

Recurrent depressive disorders

Currently mild

Currently moderate

Currently severe

Currently severe with psychosis

In remission

Major depressive disorder

recurrent

Persistent mood disorders

Cyclothymia

Dysthymia

Dysthymic disorder

Other mood disorders

Recurrent brief depression

Depressive disorder NOS

Recurrent brief depression

Role change

Physical change : illness, hormonal changes

Life stage

Childhood Childhood depressive disorders

with behavioral or conduct

presentation

Adolescence Watch for Bipolar Disorder

Prodrome of psychosis

Adult Postpartum depression

Old age Agitated depression

pseudodementia

Symptoms may not be as typical as in adult

depressive picture

Child may have more somatic symptoms,

refuse school, become weepy and clingy

may become more moody, irritable, get into

trouble in school or become socially isolated

Care to avoid over-diagnosis

need to exclude other possibilities e.g. abuse

Depression in Children and

Adolescents

pre-school Typical depressive features (such as negative

thoughts) may not be evident. May present with

irritability, sadness, crying, agitation.

middle

childhood

Miserable, poor motivation, depressed mood may

be more evident in some children. May present

with headaches, abdominal pain, academic

deterioration, irritability, social withdrawal.

adolescence Clinical picture similar to adults, sleep and appetite

changes, negative outlook with feelings of

worthlessness, low self esteem, behavioural and/or

conduct problems, temper outbursts.

Watch out for drug and alcohol use .

27

Clinical picture similar to adult presentation

Presenting problems may include academic

deterioration, strained relationship with

parents, conduct problems, addiction

problems

may precede psychosis (prodromal phase)

initial episode of Bipolar Affective Disorder

often depressive

consistent with the high rate of switching

32% prepubertal depression prepubertal mania

20% depressed adolescents adolescent-onset

mania

2016/5/27Dr. LIU KWONG SUN 29

Post-partum blues Post-partum depression

Up to 50% 10-15%

Short term emotional

disturbances:

- nervousness, low mood

- irritation

- crying bouts

- poor concentration

- not feeling attached towards

baby

- insomnia

Usually occurs 3-5 days

postpartum and last for 1-2

days, then resolve

Symptoms emerge 3 – 14 days

post-partum：- faitgue, anxiety, tension,

miserable

- insomnia, guilty, loss of

confidence and self esteem

-Poor concentration

- feels ineffective as a mother

-Overworries about own and

baby’s health

-Worries about harming baby

-Suicidal tendency

More severe persistent c.f.

postpartum blues

‧role change to mother

‧lack of experience and perceived lack of ability

to care fo child, overwhelming feeling

‧fatigue and lack of sleep after delivery

‧ overly focused on baby, strain with spouse

‧ restricted social activities and feelings of

isolation

‧ loss of status and earnings, low self esteem

‧ anxiety and “failures” related to perfectionism

‧ previous history of depresion, or mood changes

during pregnancy predispose to postpartum

mood disorders

‧ lack of social support‧ conflicts with spouse, family members over baby care‧ stress from postnatal confinement (坐月) conventions ‧ difficulty dividing attention amongst baby and older children ‧ issues regarding helpers‧ change of residence or job after having new baby‧ financial pressure

+

More commonly seen in middle-aged or

elderly persons

Irritation

Motor agitation

Anger

Hypochondrical symptoms

Reversible condition

Decline of cognitive abilities at least partially

accountable by depressive mood

Objective performance on

neuropsychological tests may be better than

the patient’s subjective perception

During testing – may refuse to perform a task

rather than being unable to perform

Depressed mood Anxiety (psychic)

Feelings of guilt Anxiety (somatic)

Suicide Somatic symptoms (GI)

Insomnia: early in the night General somatic symptoms

Insomnia: middle of the night General symptoms (eg loss of

libido, menstrual disturbance)

Insomnia: early hours of the

morning

Hypochondriasis

Work and activities Weight loss (pt report or weekly

measurements

Retardation insight

agitation

Items are rated from 0-6 with regard to the state over the past

week:

Apparent sadness Concentration difficulties

Reported sadness Lassitude

Inner tension Inability to feel

Reduced sleep Pessimistic thoughts

Reduced appetite Suicidal thoughts

Psychotherapy (especially indicated for mild,

recent-onset depression)

Monitoring

guided self help

cognitive behavioural therapy

Antidepressants (recommended for moderate

to severe depression, dysthymia)

Special consideration for children and elderly

patients

Selective serotonin reuptake inhibitors (SSRI)

Serotonin–norepinephrine reuptake inhibitor (SNRI)

Noradrenergic and specific serotonergic antidepressant (NaSSA) (e.g. mirtazapine)

Tricyclic antidepressants (TCAs)

Monoamine oxidase inhibitors (MAOIs)

Melatonergic agonist (agomelatine)

Benzodiazepines

Hypnotics

Bupropion

Act on serotonin reuptake

Citalopram

Fluoxetine

Escitalopram

Paroxetine

Sertraline

Fluvoxamine

Generally well tolerated

Clinical response 2-4 weeks (may be less in some pts)

Beware of drug interaction – some SSRIs are potent inhibitors of cytochrome P450◦ Eg. Fluoxetine (CYP 2D6, CYP 3A4) – increases

levels of antipsychotics, carbamazepine, ciclosporin etc

SE of agitation especially upon initial administration – poorly tolerated in pts with insomnia, significant anxiety, agitation, suicidal ideation

Act on both serotonin and nonepinephrine, though more selective for serotonin reuptake inhibition

Venlafaxine – first SNRI

Desvenlafaxine – active metabolite of venlafaxine

Duloxetine – neuropathic pain

Efficacious in non-responders to SSRI (STAR*D)

Bupropion

Originally developed as an antidepressant for

smoking cessation therapy

NE and dopamine reuptake inhibition

Can be used as monotherapy

Or adjunct in major depression disorder

Less sexual dysfucntion, wt gain

May have agitation, insomnia, seizure

For severe depression: combination of CBT

and antidepressants recommended

For treatment resistant depression:

augmentation with Lithium, antipsychotic,

add second antidepressant

ECT (for severe and treatment resistant

depression)

Open label, pragmatic randomized trial (c.f. RCTs)

N=2876 (attendees of psychiatric/ family practices)

Inclusion criteria: 18-75 yo

Unipolar MDD

HAM –D 14 or above . This includes mildly depressive patients (45-70% of all clinic depressive patients), c.f. the usual RCT entry requirement of 18-22)

Equipoise-stratified randomization strategy : Patient choice taken into account under a 4-level algorithm Sinyor et al .Can J Psychiatry. 2010 Mar;55(3):126-35.

Primary outcome Secondary outcomes

Remission (HAM-D score of 7) Response (50%reduction of

symptoms, clinician and

patient self-report)

Functioning

QoL

Level 1 Flexible doses of Citalopram for

up to 14 weeks

• 12-month naturalistic follow-

up for remitters/responders

• Level 2 for non-reponders/

those who could not tolerate

citalopram

Level 2 •3 augmentation strategies

(Citalopram + bupropion SR,

Citalopram + buspirone,

Citalopram + CBT)

and

•4 switch strategies (bupropion

SR, sertraline, venlafaxine XR,

CBT)

Level 3 •an augmentation strategy

(lithium or T3), or

•a switch strategy (mirtazapine

or nortriptyline)

Level 4 randomized to

• tranylcypromine or

• combination of venlafaxine XR

and mirtazapine

Treatment Remission rate Dicontinuation

rate

Level 1 • Citalopram 28% 26.6%

Level 2 • Bupropion 21.3%

• Venlafaxine XR 24.8%

• Sertraline 17.6%

• + bupropion 29.7%

• + buspirone 30.1%

30.1%

Level 3 • Mirtazapine 12.3%

• Nortriptyline 19.8%

• + Lithium 15.9%

• + T3 24.7%

44.8%

Level 4 • Tranylcypromine 6.9%

• Mirtazapine + venlafaxine

XR 13.7%

60.1%