HCE – Affective Disorders

HCE – Affective Disorders INCIDENCE Commonest psychiatric disorder seen Major depression = 5 % in general population • 3% of population diagnosed/yr by GP • Only 10% of those referred to psychiatrist • Only 1/1000 admitted 10 – 15 % prevalence (in >65s) Incidence increases as more disabled/dependent • 25 – 30 % in residential home (concentration of dependent) • 30 – 35 % in nursing home (or acute medical ward) • 40 – 45 % in post-stroke survivors Approaching 1/3 completed suicides are elderly (only 16% of ppl elderly) IMPORTANCE Untreated it: • shortens life (inc by suicide) • increases health care costs • compounds disability from medical illnesses • is leading cause of suicide among older people Successful treatment has opposite effects and quality of life improves. Most old age depression treated entirely in primary care BUT poor detection and sub-optimal treatment à less effective 1 in 5 GP attenders of all ages have some psychological symptoms. Around 1 in 20 have symptoms, which are likely to respond to treatment. DIAGNOSIS Core symptoms: (2 of 3 required) • Depressed mood sustained for at least two weeks (on most days, much of the time) AND/OR • Loss of interest or pleasure in usual activities (anhedonia) AND/OR • Decreased energy, increased fatigue, diminished activity (in patients who are physically ill this may amount to feelings of fatigue not confined to exertion) Other Symptoms: 1 other required for mild • Suicidal thoughts or behaviour (CC) Cognitive • Loss of confidence or self-esteem (CC) Content • Inappropriate or excessive guilt (CC) Disorder • Feeling of helplessness, hopelessness or worthlessness (CC) • Psychomotor retardation or agitation (B) Biological – most • Sleep disturbance, early morning waking likely to respond to • Reduced appetite with corresponding weight loss (B) medication • Diurnal mood variation (B) • Poor concentration and/or difficulty with memory (CF) Cognitive Form • Avoiding social interactions or going out (Be) Behavioural – if very • Neglect – self care, eating & drinking, children, pets (Be) severe à psychotic • Delusions – mood congruent (sin, poverty, disaster) (Be) depression • Hallucinations – auditory accusatory, olfactory (rot, decay) (Be) • Cotard’s Syndrome – intense nihilistic delusions (world ending, patient dead, organs rotting, loss of possessions) Particular problems in old age depression • Pseudo-dementia = “don’t know” (response to most questions) • 10% suffer delirium – depression increases vulnerability to sedative meds • Paranoid features - à resistance to treatment • Agitation • “masked” depression – easier to miss in elderly, culture of not being a burden CLASSIFICATION Mild & Moderate depression – with/without somatic symptoms Severe depression – psychotic symptoms Also comment if recurrent / single episode MAJOR DEPRESSION (DSM – IV) Pervasive depression of mood or loss of interest, pleasure, motivation, or drive, plus at least four of the following present for at least 2 weeks: • Significant appetite and weight disturbance • Sleep disturbance (decrease or increase) • Fatigue and/or loss of energy • Recurrent thoughts of death or suicide • Lack of concentration • Self-reproach/excessive guilt • Psychomotor retardation/agitation NB: often seen/confused with grief/bereavement (more acute, occurs in waves, should lessen with 1 month & be gone within a year) AEITIOLOGY BIOLOGY Genetics – increased risk of unipolar depression if first degree relative with uni/bipolar Mono-Amine Hypothesis – abnormal mono-amine neurotransmission in the brain (Serotonin, NA, Dopamine) – Supported by effectiveness of antidepressants PSYCHOLOGICAL Errors of thinking (Beck) • Arbitrary inference (conclusion without evidence, or even some evidence against) • Selective abstraction (focus on a single aspect & ignore more important things) • Overgeneralization / Magnification (view / opinion based on a single incident • Personalisation / Minimalisation (relating external events to self when not warranted) Psychoanalytical theory (Freud) Loss & bereavement Self-criticism (was intended for another person, but their death/leaving --> reverses feeling to self) SOCIAL Predisposing (vulnerability) factors • Lack of Confiding relationship / poor social support / Widow(er) • Unemployment • 3+ children <14yrs • Parental loss before adolescence • Poor physical health • Poverty • Living in an institution • Abnormal personality Precipitating Factors • • • Negative life events – (6x increased risk in 6months after) e.g. bereavement, retirement, loss of mobility/health, some meds (all HT meds, any others causing nausea/dizzy/bad SE) Loss event --> depression Threat event --> anxiety RISK FACTORS FOR SUICIDE (IN ELDERLY) • Older men • Widow/er status • Living alone • Chronic physical ill health • Particularly painful ill health • Alcohol abuse (also seen in young) • Depressive episode • Seen GP in last month • Discharged from hospital in last week MANAGEMENT OF DEPRESSIVE DISORDER • Monitor the risk of self-harm. • Educate patient (& carers) about depression and involve in treatment decisions. • Treat whole person – co-existing physical disorder; attention to sensory deficits and other handicaps; signpost patient to appropriate social care agencies; review medication to withdraw those unnecessary. • Prompt referral of patients requiring specialist mental health services Biological • Antidepressants (tailored to individual) • If resistant --> augmentation / ECT Psychological • Minor / adjustment problems --> counciling / self help groups • CBT to target negative thoughts & dysfunctional beliefs Social • Rehab after prolonged hospitalisation • OT, Day hospital, home help, MOW, social skills training, • Support carers WHEN TO REFER FOR SPECIALIST ADVICE • When the diagnosis in doubt (for example, is this dementia?) • When depression is severe, as evidenced by; o Psychotic depression o Severe risk to health because of failure to eat or drink (few reserves) o Suicide risk • Complex therapy is indicated (for example in cases with medical co-morbidity) • When first-time therapy fails (although primary care physicians may wish to pursue a second course of an antidepressant from a different class) MANIA • • • Hypomania Mania w/o psychosis Mania with psychosis • NB: Bipolar = describes the course of the illness. The occurance of both depression and hypo/mania in a patient. Must specify which the current episode is Increased mood Increased quantity & speed of physical & mental activity HYPOMANIA – symptoms DO NOT affect daily functioning • Persistent mildly elevated mood (or irritable/boorish) for minimum 4 days • Disordered attention / concentration • Increased energy & activity • Increased sociability, talkativeness, over familiar, increased sexual energy • Decreased need for sleep • Mild overspending / recklessness (due to poor insight & judgement) • Perceptual disorders may be present MANIA WITHOUT PSYCHOSIS • More severe form of hypomania • Disruption to work & social activities • Loss of insight --> risk of harm to self or others • • • Elevated mood, expansive, irritable for minimum 1 week (or require admission) + at least 3 of the following (4 if mood irritable) o increased activity or physical restlessness o increased talkativeness (‘pressure of speech’) o flight of ideas or subjective experience of thoughts racing o loss of normal social inhibitions, resulting in behaviour that is inappropriate o decreased need for sleep o inflated self-esteem or grandiosity o distractibility or constant changes in activity or plans o foolhardy or reckless behaviour whose risks individual does not recognize, eg. spending sprees, foolish enterprises, reckless driving o marked sexual energy or sexual indiscretions With NO psychotic features (hallucinations or delusions) NOT due to psychotic drugs MANIA WITH PSYCHOTIS • Mood congruent psychosis • Grandiose delusions – famous, important, special powers • Increased self esteem • Can be delusion of persecution if irritable • Can --> incomprehensible with pressure of speech and flight of ideas • Hallucinations – auditory, voice confirms delusion DIFFERENTIALS FOR MANIA/HYPOMANIA Cyclothymia – 2 yr history of subthreshold hypomania & depressive episodes, usually responds to mood stabilisers Schizophrenia / Schizoaffective disorder Organic Psychosis (drug (e.g. amphetamine, steroid), CVA, Frontal lobe pathology, HIV) 2o Mania – iatrogenic. Over treatment of depressive episode in bipolar --> mania BIPOLAR DISORDER • 2 episodes of affective disorder (of opposite types) • Complete recovery between episodes • As progresses --> increased frequency of depression with shorter remission • M=F • 1st attack usually 15-25yrs • Mania lasts 2 weeks – 1 month, Depression lasts 3-6 months o • Strong genetic links (12% risk to 1 relatives), confirmed by twin/adoption studies • Episodes can be precipitated by life events and acute stress MANAGEMENT Acute Mania – antipsychotics + benzodiazepines f.b. mood stabiliser Lithium = Prophylaxis bec mood stabiliser Sodium Valproate preferred for rapid cycling disorder & mixed affective state Carbemazepine = 3rd line if other 2 not tolerated. 65% response The difference between grief and depressive disorder. The prevalence of depression in old age. What predisposes to it. Symptomatology in old age. Particular problems seen in old age depression. The problems of under recognition and under treatment.