anne washington derry (1927) oil on canvas by laura wheeler waring(1887 - 1948) 1 st cme mood...
TRANSCRIPT
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%
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
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
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
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
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: [email protected] 0735525429