- Spectrum of disorders ranging from depression through to mania
- Patients who suffer attacks of both have bipolar disorder
Aetiology
- Physical
- Genetic - monozygotic twin concordance 30-60%
- Neurotransmitter imbalance - downregulation of 5HT receptors in depression
- Hormonal
- Cortisol (Cushing's syndrome induces depression and corticosteroids alter mood, moreover hypercortisolaemia occurs in patients with depression)
- Oral contraceptives/ pregnancy/ premenstrual
- CNS abnormalities - brain MRI/PET studies show:
- Increased ventricular volume, frontal lobe atrophy and altered blood flow
- Volume reduction in the hippocampus
- Psychological
- Maternal deprivation
- Learned helplessness
- Social
- Stressful life events e.g. divorce, unemployment
- Sexual abuse in childhood
Clinical features
Depression
- Mood
- Depressed
- Miserable
- Unhappy
- Talk
- Slow
- Impoverished
- Monotonous
- Energy
- Reduced
- Apathetic/lethargic
- Ideation
- Feelings of
- Futility
- Guilt
- Self-reproach
- Unworthiness
- Hypochondriasis
- Worrying
- Suicidal thoughts
- Delusions of guilt
- Nihilism
- Persecution
- Cognition
- Impaired learning
- Pseudodementia if elderly
- Physical
- Early waking
- Poor appetite
- Weight loss
- Constipation
- Loss of libido
- Erectile dysfunction
- Fatigue
- Body aches and pains
- Behaviour
- Poverty of movement/expression
- Retardation/agitation
- Hallucinations
- Auditory
- Hostile
- Critical
Mania
- Mood
- Elevated
- Labile
- Irritable
- Talk
- Fast
- Pressurised
- Flight of ideas
- Energy
- Excessive
- Ideation
- Grandiose
- Self-confident
- Delusions of
- Wealth
- Power
- Influence
- Religious significance
- Persecutory delusions
- Cognition
- Disturbance of registration of memories
- Physical
- Insomnia
- Weight loss
- Behaviour
- Disinhibition
- Increased sexual interest
- Hallucination
- Excessive drinking/spending
- Fleeting auditory
- Occasionally visual
Can range from severe life-threatening disease to minor forms
Differential diagnosis
- Mania
- Drug-induced psychosis
- Amphetamines/ecstasy/cocaine
- Long term cannabis use
- Steroids
- Acute schizophrenia
- Hyperthyroidism/Cushing's syndrome
- Depression
- Malignancy
- Hypothyroidism/hyperparathyroidism
- Cushing's syndrome
- Neurological diseases (multiple sclerosis, Parkinson's)
- Cerebral ischaemia or tumour
- Heart failure
- Porphyria
- Drugs
- Steroids
- Psychiatric disorders
- Schizophrenia
- Alcohol/drug (e.g. amphetamines) misuse or withdrawal
- Borderline personality disorder
- Dementia
- Normal bereavement reaction
- Onset
- Immediately after loss
- Duration
- Weeks
- Pattern
- Slow acceptance and adjustment
- Grief
- Expressed openly
- Guilt
- Mild regret in early stage
- Morbid grief reaction
- Onset
- Delayed for weeks/months
- Duration
- Months/years
- Pattern
- Denial of loss and refusal to accept implications
- Grief
- Expressed with difficulty
- Guilt
- Marked guilt often present
Management
- Physical
- Stop depressing drugs including alcohol
- Regular exercise (good for mild/moderate depression)
- Depression
- Drugs - choice depends on side-effects and safety
- Serotonin reuptake inhibitors, e.g. fluoxetine
- Tricyclic antidepressants (TCAs), e.g. amytriptyline
- New generation antidepressants e.g. venlafaxine - serotonin and noradrenaline receptor blocker, mirtazapine increases both noradrenaline and selective serotonin transmission noradrenaline reuptake inhibitors, e.g. reboxetine
- Monoamine oxidase inhibitors, e.g. phenelzine - used 2nd line
- Electroconvulsive therapy (ECT)
- Used in life-threatening depression
- Mania
- Acute attacks
- Lithium
- Neuroleptic drugs for severe hyperactivity e.g. haloperidol
- Prophylaxis
- Lithium
- Regular check on drug levels (narrow therapeutic window)
- Regular check on renal function (renal excretion)
- Regular check on thyroid function
- Carbamazepine
- Valproate
- Psychological
- Psychotherapy
- Cognitive/behavioural therapy
- Social
- Assistance with social problems
- Group support
- Stress management
- Family/carer support
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