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MOOD DISORDERS
part 1
1
What's with this MOOD???
Temperament
Depressive
Hyperthymic
Holiday blues
Cyclothymic
elation,
Irritable-explosive
fight into death,
superhuman
actions...
Anniversary reaction
normal adjustment
adjustment disorder
Premenstrual Tension
Disorder/Premenstrual
Dysphoric Mood
Changes
mental disorders
Maternity blues
2
Grief due to:
to death,
divorce, romantic
disappointment,
leaving familiar
environments, forced
emigration, or
civilian
catastrophes.
General classification of mood
(affective) disorders
ICD – 10
F30
F31
F32
F33
F34
F38
F39
Manic episode
Bipolar affective disorder
Depressive episode
Recurrent depressive disorder
Persistent mood (affective) disorders
Other mood (affective) disorders
Unspecified mood (affective) disorder
3
Other ICD-10 codes
F06.3 Organic affective disorders
F1x.54/55 Affective epizodes due to usage of
psychoactive substances
F20.4 Post-schizophrenic depression
F25 Schizoaffective disorders
F41.2 Anxiety-depression mix disorders
F43.2 Adjustment depression disorder (short and
prolonged depression reaction)
4
•
F30 Manic episode
F33 Recurrent depressive disorder
•
(F30.0) Hypomania
(F33.0) Recurrent depressive disorder, current episode mild
•
(F30.1) Mania without psychotic symptoms
(F33.1) Recurrent depressive disorder, current episode moderate
•
(F30.2) Mania with psychotic symptoms
•
(F30.8) Other manic episodes
•
(F30.9) Manic episode, unspecified
•
•
F31 Bipolar affective disorder
(F31.0) Bipolar affective disorder, current episode hypomanic
(F31.1) Bipolar affective disorder, current episode manic without
psychotic symptoms
•
(F31.2) Bipolar affective disorder, current episode manic with
psychotic symptoms
•
(F31.3) Bipolar affective disorder, current episode mild or
moderate depression
•
(F31.4) Bipolar affective disorder, current episode severe
depression without psychotic symptoms
•
(F31.5) Bipolar affective disorder, current episode severe
depression with psychotic symptoms
•
•
(F31.6) Bipolar affective disorder, current episode mixed
•
(F31.7) Bipolar affective disorder, currently in remission
•
(F31.8) Other bipolar affective disorders
•
(F31.9) Bipolar affective disorder, unspecified
•
- Bipolar II disorder
•
- Recurrent manic episodes NOS
•
(F33.3) Recurrent depressive disorder, current episode severe with
psychotic symptoms
(F33.4) Recurrent depressive disorder, currently in remission
(F33.8) Other recurrent depressive disorders
(F33.9) Recurrent depressive disorder, unspecified
F34Persistent mood (affective) disorders
(F34.0) Cyclothymia
(F34.1) Dysthymia
(F34.8) Other persistent mood (affective) disorders
(F34.9) Persistent mood (affective) disorder, unspecified
F38 Other mood (affective) disorders
(F38.0) Other single mood (affective) disorders
- Mixed affective episode
(F38.1) Other recurrent mood (affective) disorders
- Recurrent brief depressive episodes
(F38.8) Other specified mood (affective) disorders
F39 Unspecified mood (affective) disorder
F32Depressive episode
•
(F32.0) Mild depressive episode
•
(F32.1) Moderate depressive episode
•
(F32.2) Severe depressive episode without psychotic symptoms
•
(F32.3) Severe depressive episode with psychotic symptoms
•
(F32.8) Other depressive episodes
•
- Atypical depression
•
- Single episodes of "masked" depression NOS
•
(F33.2) Recurrent depressive disorder, current episode severe
without psychotic symptoms
(F32.9) Depressive episode, unspecified
International Statistical
Classification of Diseases and
Related Health Problems
10th Revision
5
A way of mood disorder patients to
the psychiatric care (1)
Mood disorder patients
in family doctors’ care
100
Diagnosis of mood disorders by the family
doctor
All family
doctors’ patients
200
Decision to visit the family doctor
Population
1000
6
A way of mood disorder patients to
the psychiatric care (2)
Patients in psychiatric
care - inpatients
1
Decision of hospitalisation
Patients in psychiatric
care - outpatients
10
Decision of psychiatric consultation
Family doctors patients
with mood disorders
100
7
Causes of mental health problems
Neuroanatomy
Genetics
MENTAL DISORDER
Brain damages
Environment
But also: psychological causes (such as unhelpful behavioral
patterns/coping skills, ineffective emotional skills, life stresses,
past traumas), medical conditions, unhealthy lifestyle, even
nutrient deficiencies or imbalances.
8
Nature vs Nurture
(genetic – environment interactions)
Schizophrenia and
Affective disorders
Alcohol and
Substance
dependance
35 %
environment
50 %
environment
65 %
genes
50 %
genes
Cardno et al, 1999
Merikangas et al, 1997
Anxiety disorders
70 %
environment
30 %
genes
Hettema et al, 1998
9
The stress – vulnerability model
GENES
NEUROANATOMY
VULNERABILITY
ENVIRONMENT
ST
RE
SS
ST
RE
SS
PSYCHOL
OGICAL
FACTOR
DISORDER
10
DEPRESSION
“I didn’t want my picture taken because I was going to cry. I
didn’t know why I was going to cry, but I knew that if
anybody spoke to me or looked at me too closely the tears
would fly out of my eyes and the sobs would fly out of my
throat and I’d cry for a week. I could feel the tears brimming
and sloshing in me like water in a glass that is unsteady and
too full.”
― Sylvia Plath
11
Statistics and epidemiology
WHO – depression 4th on the list of the most urgent health
problems worldwide.
Major Depressive Disorder among adults:
–
Average age of onset falls between 20 and 40 years
–
Lifetime prevalence: aproxim 16,5 % of population; 10-25%
for women, 5-12% for men
–
An estimated 120 million people worldwide suffer from
depression (E. Olson, 2001)
–
Demographic risk factors: age (initial onset is most common
among young adults); socioeconomic status (people
lower down the socioeconomic ladder are at greater risk
than those who are better off); marital status (people who
are separated or divorced have higher rates than married
or never-married people).
12
Depression may be concomitant
with somatic deseases
Disease:
Percentage:
Endocrinological diseases............………...20 - 30%
Diabetes…………………………………….. up to 10%
Viral infections.........…………………………….<10%
Neoplasms...…………………………………..20 - 40%
Cardiovascular diseases……………………15 - 25%
Kidney diseases…………………………....up to 20%
Hepatic diseases……………………………up to 15%
Blood-serum diseases………………….….up to 20%
CNS diseases... ……………………………..up to 60%
Chronic pain.....……………………………...up to 50%
13
Medicines that may cause
depression
Hypertension drugs
Calcium channel antagonists
Corticosteroids
Gestagens
Anti-parkinson drugs
Psychotropic drugs
Anti-neoplasmatic drugs
14
Different grounds, similar symptoms
●
Reactive (triggered by an event)
vs. Endogenous (comin from
within)
●
Typical (melancholic) vs. Atypical
depression
● Primary vs. Secondary
Some organic causes of depression
NEUROLOGICAL: Stroke, Alzheimer's disease/dementia,
Parkinson's disease, Huntington's disease, multiple sclerosis,
epilepsy, intracranial tumourus
ENDOCRINE: Cushin's syndrome, Addison's disease,
hypothyroidism, hyperparathyroidism
METABOLIC: Iron deficiency, vitamin B12/ folate deficiency,
hypercalcaemia, hypomagnesaemia
INFECTIVE: Influenza, infectious mononucleois, hepatitis, HIV/AIDS
DRUGS: L-dopa, steroids, beta blockers, digoxin, cocaine,
amphetamines, alcohol
NEOPLASTIC: Non-metastatic effects of carcinoma
DSM IV criteria for Major Depressive Episode
A. Five (or more) of the following symptoms have
been present during the same 2-week period
and represent a change from previous
functioning; at least one of the symptoms is
either (1) depressed mood or (2) loss of
interest or pleasure.
(1) depressed mood most of the day, nearly every
day, as indicated by either subjective report (eg.
feels sad or empty) or observation made by
others (eg. appears tearful). Note: in children
and adolescents, can be irritable mood.
(2) markedly diminished interest or pleasure in
all, or almost all, activities most of the day,
nearly every day (as indicated either by
subjective account or observation made by
others)
(3) significant weight loss when not dieting or
weight gain (eg, a change of more than 5% of
body weight in a month), or decrease or
increase in appetite nearly every day. Note: in
children, consider failure to make expected
weight gains.
(4) insomnia or hypersomnia nearly every day
(5) psychomotor agitation or retardation nearly
every day (observable by others, not merely
subjective feelings of restlessness or being
slowed down)
(6) fatigue or loss of energy nearly every day
(7) feelings of worthlessness or excessive or
inappropriate guilt (which may be delusional)
nearly
every day (not merely self-reproach or guilt about
being sick)
(8) diminished ability to think or concentrate, or
indecisiveness, nearly every day (either by
subjective account or as observed by others)
(9) recurrent thoughts of death (not just fear of
dying), recurrent suicidal ideation without a
specific plan, or a suicide attempt or a specific
plan for committing suicide
B. The symptoms do not meet criteria for a Mixed
Episode.
C. The symptoms cause clinically significant distress
or impairment in social, occupational, or other
important areas of functioning.
D. The symptoms are not due to the direct
physiological effects of a substance (e.g., a drug
of abuse, a medication) or a general medical
condition (e.g., hypothyroidism).
E. The symptoms are not better accounted for by
Bereavement, i.e., after the loss of a loved one,
the symptoms persist for longer than 2 months
or are characterized by marked functional
impairment, morbid preoccupation with
worthlessness, suicidal ideation, psychotic
symptoms, or psychomotor retardation.
17
Clusters of symptoms in depression
●
Vegetative
●
●
●
Impulse
control
Cognitive
Physical
(somatic)
●
Behavioural
18
Symptomes suggesting diagnosis of
depression
Appearance:
Complains:
Mimical facial expression
Constant feeling of being tired
Voice and statements
Reluctance to everyday work,
Movements and body position
Complains:,,nothing makes me
happy”, ,,I don’t care about
anything”, feeling guilty
Complains:
Feeling of internal tension,
restlessness, anxiety
Isolation from friends
Interrupted sleeping, early waking-up
Bad frame of mind in the mornings
Lack of life satisfaction, aversion
to life, feeling hopeless,
thoughts of death
Worse memory, difficulties of
attention’s concentration by
reading and TV watching
Lost of appetite, lost of weight
Many somatic complains
19
Why 50% of cases are not diagnosed?
Patient
●
Physician
●
Short time of consultation
●
Existing oppinions
●
●
●
Concentration on somatic
symptoms
●
●
Concentration on somatic disorders
Stigmatisation of psychiatric
disorders and patients
Difficulties in recognizing
depression symptoms
Overlooking of depression in those
known to have a physical illness
Blaming depression on
circumstances, regarding it as
‘understandable’.
20
Diagnosis & screening methods
Diagnosis methods: anamnesis, diagnostic criteria
according to ICD-10, structured interview (i.e. MINI)
Self-reported scales:

Young Mania Rating Scale (YMRS)
Beck scale (depression)

Zung scale (depression)

Interview with physician:
Hamilton scale (HAMD)

Montgomery and Asberg scale (MADRS)

21
F 32 Depressive episode
Depressive episode
G1. The depressive episode should last for at least 2 weeks.
G2. There have been no hypomanic or manic symptoms
sufficient to meet the criteria for hypomanic or manic episode
(F30.-) at any time in the individual's life.
G3. Most commonly used exclusion clause. The episode is not
attributable to psychoactive substance use (F10- F19) or to
any organic mental disorder (in the sense of F00-F09).
22
F 32 Depressive episode
Somatic syndrome (...)
To qualify for the somatic syndrome, four of the following symptoms should be
present:
(1) marked loss of interest or pleasure in activities that are normally pleasurable;
(2) lack of emotional reactions to events or activities that normally produce an emotional
response;
(3) waking in the morning 2 hours or more before the usual time;
(4) depression worse in the morning;
(5) objective evidence of marked psychomotor retardation or agitation (remarked on or
reported by other people);
(6) marked loss of appetite;
(7) weight loss (5% or more of body weight in the past month);
(8) marked loss of libido.
23
In The ICD-10 Classification of Mental and Behavioural Disorders: Clnical descriptions and diagnostic guidelines, the presence or absence of the somatic
syndrome is not specified for severe depressive episode, since it is presumed to be present in most cases. For research purposes, however, it may be
advisable to allow for the coding of the absence of the somatic syndrome in severe depressive episode.
F32.0 Mild depressive episode
A. The general criteria for depressive episode (F32) must be met.
B. At least two of the following three symptoms must be present:
(1) depressed mood to a degree that is definitely abnormal for the individual,
present for most of the day and almost every day, largely uninfluenced by
circumstances, and sustained for at least 2 weeks.
(2) loss of interest or pleasure in activities that are normally pleasurable;
(3) decreased energy or increased fatiguability.
C. An additional symptom or symptoms from the following list should be
present, to give a total of at least four:
(1) loss of confidence and self-esteem;
(2) unreasonable feelings of self-reproach or excessive and inappropriate
guilt;
(3) recurrent thoughts of death or suicide, or any suicidal 24
behaviour;
F32.0 Mild depressive episode
(4) complaints or evidence of diminished ability to think or concentrate, such
as indecisiveness or vacillation;
(5) change in psychomotor activity, with agitation or retardation (either
subjective or objective);
(6) sleep disturbance of any type;
(7) change in appetite (decrease or increase) with corresponding weight
change). (...)
F32.00 Without somatic syndrome
F32.01 With somatic syndrome
* In some cases, anxiety, distress, and motor agitation may be more prominent than
the depression
* Masked depression by irritability, excessive consumption of alcohol, histrionic
behaviour, pre-existing phobic or obsessional symptoms, hypochondriacal
preoccupations.
25
F32.1 Moderate depressive episode
A. The general criteria for depressive episode (F32) must be met.
B. At least two of the three symptoms listed for F32.0, criterion B, must be
present.
C. Additional symptoms from F32.0, criterion C, must be present, to give a
total of at least six . (...)
F32.10 Without somatic syndrome
F32.11 With somatic syndrome
26
F32.2 Severe d.e. without psychotic
symptoms
Note: If important symptoms such as agitation or retardation are marked, the
patient may be unwilling or unable to describe many symptoms in detail.
An overall grading of severe episode may still be justified in such a case.
A. The general criteria for depressive episode (F32) must be met.
B. All three of the symptoms in criterion B, F32.0, must be present.
C. Additional symptoms from F32.0, criterion C, must be present, to give a
total of at least eight.
D. There must be no hallucinations, delusions, or depressive stupor.
27
F32.3 Severe d.e. with psychotic
symptoms
A. The general criteria for depressive episode (F32) must be met.
B. The criteria for severe depressive episode without psychotic symptoms
(F32.2) must be met with the exception of criterion D.
C. The criteria for schizophrenia (F20.-) or schizoaffective disorder,
depressive type (F25.1) are not met.
D. Either of the following must be present:
(1) delusions or hallucinations, other than those listed as typically
schizophrenic in F20, criterion G1(1)b, c, and d (i.e. delusions other than
those that completely impossible or culturally inappropriate and
hallucinations that are not in the third person or giving a running
commentary); the commonest examples are those with depressive, guilty,
hypochondriacal, nihilistic, self-referential, or persecutory content;
(2) depressive stupor. (...)
28
F32.3 Severe d.e. with psychotic
symptoms
F32.30 With mood-congruent psychotic symptoms
(i.e. delusions of guilt, worthlessness, bodily disease, or impending disaster,
derisive or condemnatory auditory hallucinations)
F32.31 With mood-incongruent psychotic symptoms
(i.e. persecutory or self-referential delusions and hallucinations without an
affective content)
Recovery is usually complete between episodes, but a substantial part of
patients will have a recurrence and about 30% may develop a persistent
depression.
29
Mood congruent delusions
Delusions of:
Guilt
Sinfulness
Worthlessness
Poverty
Failure
Persecution
Terminal somatic illnesses
30
Atypical clinical picture of
depression
Pain masks
Tension headaches, joint pain
Neuralgies
Vegetative and psychosomatic masks
„Pseudo-angina pectoris”
Motoric impairment of gastrointestinal system, spastic states of
bile ducts
Restless legs syndrome
Skin itch
„Pseudo-anorexia”, loss of weight
31
Atypical clinical picture of
depression
Impairment of biological rythym
Insomnia/ hyposomnia
Hypersomnia
Psychopatological masks
Agitation – chronic or acute anxiety
Compulsions
Behavioral masks
Periodical alcohol abuse
Periodical drug abuse
32
F33 Recurrent depressive disorder
F33 Recurrent depressive disorder
G1. There has been at least one previous episode,
episode mild (F32.0), moderate
(F32.1), or severe (F32.2 or F32.3), lasting a minimum of 2 weeks and
separated from the current episode by at least 2 months free from any
significant mood symptoms.
G2. At no time in the past has there been an episode meeting the criteria for
hypomanic or manic episode (F30.-).
G3. Most commonly used exclusion criteria: the episode is not attibutable to
psychoactive substance use (F1) or any organic mental disorder, in the
sense of F0.
It is recommended to specify the predominant type of previous episodes
(mild, moderate, severe, uncertain).
33
Recurrent depressive disorder
The disorder is characterized by repeated episodes of
depression as specified in depressive episode (mild,
moderate, or severe) without any history of independent
episodes of mood elevation and overactivity that fulfill the
criteria of mania.
The age of onset and the severity, duration, and frequency of
the episodes - highly variable.
The first episode occurs later than in bipolar disorder - a mean
age of onset in the fifth decade
Individual episodes last between 3 and 12 months (median
duration about 6 months) but recur less frequently.
34
Recurrent depressive disorder
Recovery is usually complete between episodes
The risk that a patient with recurrent depressive disorder will
have an episode of mania never disappears completely, but a
minority of patients may develop a persistent depression,
mainly in old age.
If a manic episode does occur, the diagnosis should change to
bipolar affective disorder.
35
MANIA
"I feel such creative power in myself that I know for
sure that the time will arrive when, so to speak, I
shall regularly make something good every day. But
very rarely a day passes that I do not make
something, though it is not yet the real thing I want
to make."
(Letter to Theo van Gogh, 9 September 1882)
36
Van Gogh, The Night Cafe, 1888, www.artchive.com
Manic episode
●
●
●
Three degrees of severity are specified here,
sharing the common underlying
characteristics of elevated mood, and an
increase in the quantity and speed of
physical and mental activity.
All the subdivisions of this category should be
used only for a single manic episode.
If previous or subsequent affective episodes
(depressive, manic, or hypomanic), the
disorder should be coded under bipolar
37
affective disorder.
Manic episode
●
The onset occurs most commonly between the
ages of 15 and 30 years, but may occur at any
age from late childhood to the seventh or eighth
decade.
38
F30 Manic episode
F30.0 Hypomania
F30.1 Mania without psychotic symptoms
F30.2 Mania with psychotic symptoms
F30.20 With mood-congruent psychotic symptoms
F30.21 With mood-incongruent psychotic symptoms
F30.8 Other manic episodes
F30.9 Manic episode, unspecified
39
Characterised with:
●
●
●
●
Hypomania
Persistent mild elevation of mood, increased energy and activity,
and usually marked feelings of well-being and both physical and
mental efficiency.
Increased sociability, talkativeness, overfamiliarity, increased sexual
energy, and a decreased need for sleep are often present but not
to the extent that they lead to severe disruption of work or result
in social rejection.
Irritability, conceit, and boorish behavior may take the place of the
more usual euphoric sociability.
Concentration and attention may be impaired, thus diminishing the
ability to settle down to work or to relaxation and leisure, but this
may not prevent the appearance of interests in quite new
ventures and activities, or mild over-spending.
The increased activity and restlessness (and often weight loss) must
be distinguished from the same symptoms occurring in
Hyperthyroidism, Anorexia nervosa, Early states of "agitated depression„,
Severe obsessional.
When a short period of hypomania occurs as a prelude to or
aftermath of mania, it is usually not worth specifying 40
the
hypomania separately.
F30.0 Hypomania
A. The mood is elevated or irritable to a degree that is definitely abnormal for
the individual concerned and sustained for at least four consecutive days.
B. At least three of the following must be present, leading to some
interference with personal functioning indaily living:
(1) increased activity or physical restlessness;
(2) increased talkativeness;
(3) difficulty in concentration or distractibility;
(4) decreased need for sleep;
(5) increased sexual energy;
(6) mild spending sprees, or other types of reckless or irresponsible
behaviour;
(7) increased sociability or over-familiarity.
41
F30.0 Hypomania
C. The episode does not meet the criteria for mania (F30.1 and F30.2),
bipolar affective disorder (F31.-), depressive episode (F32.-), cyclothymia
(F34.0) or anorexia nervosa (F50.0).
D. Most commonly used exclusion criteria: the episode is not attributable to
psychoactive substance use (F1) or any organic mental disorder, in the
sense of F0.
- Rarely progresses to manic psychosis; distractibility is uncommon
and insight is preserved.
- There are three patterns of hypomania:
* brief episodes heralding the termination of a retarded depressive episode
(bipolar II disorder),
* cyclic alternation with minidepressions (cyclothymic disorder),
* and an elevated baseline of high mood, activity, and cognition
(hyperthymic)
42
F30.1 Mania without psychotic
symptoms
A. A mood which is predominantly elevated, expansive or irritable and
definitely abnormal for the individual concerned. This mood change must
be prominent and sustained for at least a week (unless it is severe
enough to require hospital admission).
B. At least three of the following must be present (four if the mood is merely
irritable), leading to severe interference with personal functioning in daily
living:
(1) Increased activity or physical restlessness;
(2) Increased talkativeness ('pressure of speech');
(3) Flight of ideas or the subjective experience of thoughts racing;
(4) Loss of normal social inhibitions resulting in behaviour which is
inappropriate to the circumstances;
(5) Decreased need for sleep;
43
F30.01 Mania without psychotic
symptoms
(6) Inflated self-esteem or grandiosity;
(7) Distractibility or constant changes in activity or plans;
(8) Behaviour which is foolhardy or reckless and whose risks the subject
does not recognize e.g. spending sprees, foolish enterprises, reckless
driving;
(9) Marked sexual energy or sexual indiscretions.
C. The absence of hallucinations or delusions, although perceptual disorders
may occur (e.g. Subjective hyperacusis, appreciation of colours as
specially vivid, etc.).
D. Mot commonly used exclusion criteria: the episode is not attributable to
psychoactive substance use (F1) or any organic mental disorder, in the
sense of F0.
44
Mania without psychotic symptoms
- Mood is elevated out of keeping with the individual's circumstances
and may vary from carefree joviality to almost uncontrollable
excitement.
- Perceptual disorders may occur, such as the appreciation of colors
as especially vivid (and usually beautiful), a preoccupation with fine
details of surfaces or textures, and subjective hyperacusis.
- The individual may embark on extravagant and impractical schemes,
spend money recklessly, or become aggressive, amorous, or
facetious in inappropriate circumstances.
- In some cases mood is irritable and suspicious rather than elated.
- The onset most commonly between the ages of 15 and 30 years, but
may occur at any age from late childhood to the seventh or eighth
decade.
45
F30.2 Mania with psychotic
symptoms
A. The episode meets the criteria for mania without psychotic symptoms
(F30.1) with exception of criterion C.
B. The episode does not simultaneously meet the criteria for schizophrenia
(F20) or schizo-affective disorder, manic type (F25.0).
C. Delusions or hallucinations are present, other than those listed as typical
schizophrenic in F20 G1.1b, c and d (i.e. delusions other than those that
are completely impossible or culturally inappropriate and hallucinations,
that are not in the third person or giving a running commentary). The
commonest examples are those with grandiose, self-referential, erotic or
persecutory content.
D. Mot commonly used exclusion criteria: the episode is not attributable to
psychoactive substance use (F1) or any organic mental disorder, in the
sense of F0. (...)
46
F30.2 Mania with psychotic
symptoms/other
F30.20 mania with mood congruent psychotic symptoms (such as grandiose
delusions or voices telling the subject that he has superhuman powers)
F30.21 mania with mood incongruent psychotic symptoms (such as voices
speaking to the subject about affectively neutral topics, or delusions of
reference or persecution).
Other:
F30.8 Other manic episodes
F30.9 Manic episode, unspecified
47
Mania with psychotic symptoms
Inflated self-esteem and grandiose
ideas may develop into delusions.
- Irritability and suspiciousness may
develop into delusions of
persecution.
- In severe cases, grandiose or
religious delusions of identity or
role may be prominent.
- Flight of ideas and pressure of
speech may result in the individual
becoming incomprehensible.
- Severe and sustained physical
activity and excitement may result
in aggression or violence
- Neglect of eating, drinking, and
personal hygiene may result in
dangerous states of dehydration
and self-neglect.
- Mood congruent delusions:
Grandiose delusions
Great wealth
Extraordinary abilities or power
Delusions of: exceptional mental
and physical fitness; exceptional
talent; wealth, aristocratic
ancestry; delusions of
assistance; delusions of
reference and persecution
(based on the belief that
enemies are observing or
following them out of jealousy at
their special abilities)
Occur in 75% of all patients with
48
mania
Mania with psychotic symptoms –
differential diagnose
One of the commonest problems is differentiation of this
disorder from schizophrenia.
Difficult to distinguish especially if:
- psychotic symptoms are prominent
- psychotic symptoms are incongruent with the underlying mood
- delusions or hallucinations persist after pharmacotherapy with
neuroleptics, overactivity is gone though
If these symptoms are prominent and persistent, the
diagnosis of schizoaffective disorder is more likely to be
appropriate.
49
Factors:
pharmacologic corticosteroids, L-dopa, bromocriptine,
al
cocain, antidepressants
infectious
influenza, infections of CNS, AIDS,
syphilis
hormonal
hyperthyreosis, Cushing syndrome,
postpartum period
connective
tissue
diseases
neurological
Systemic lupus erythematosus (SLE)
nourishing
vitamin deficiency (B12, folic acid, PP,
B2)
MS, Huntington disease, Wilson disease,
head injures, epilepsia, brain tumors,
strokes, migrain
50
Schizoaffective disorder
These are episodic disorders in which both affective and
schizophrenic symptoms are prominent within the same
episode of illness, preferably simultaneously, but at least
within a few days of each other.
Their relationship to typical mood (affective) disorders and to
schizophrenic disorders is uncertain.
They are given a separate category because they are too
common to be ignored.
Mood-incongruent delusions or hallucinations in affective
disorders do not by themselves justify a diagnosis of
schizoaffective disorder. Patients who suffer from recurrent
schizoaffective episodes, particularly those whose symptoms
are of the manic rather than the depressive type, usually
make a full recovery and only rarely develop 51
a defect state.
Schizoaffective disorder
A diagnosis should be made only when both definite schizophrenic and definite affective
symptoms are prominent simultaneously (or within a few days of each other)
The term should not be applied to patients who exhibit psychotic or mood symptoms in different
episodes of illness (for example post-schizophrenic depression).
MANIC TYPE:
MOOD - elation, increased self-esteem, grandiose ideas, sometimes excitement or irritability,
even aggressive behaviour and persecutory ideas; increased energy, overactivity, impaired
concentration, and a loss of normal social inhibition.
PSYCHOTIC SYMPTOMS: Delusions of reference, grandeur, or persecution (typically
schizophrenic symptoms are required). Careful questioning required! (could this be joking or
metaphors?)
DEPRESSIVE TYPE:
MOOD – depressive, accompanied by retardation, insomnia, loss of energy, appetite or weight,
reduction of normal interests, impairment of concentration, guilt, feelings of hopelessness,
and suicidal thoughts.
PSYCHOTIC SYMPTOMS: for example delusions of thought broadcasting, control,
hallucinations (voices talking of killing the patient or discuss this behavior between
themselves)
52 type, but they tend
- Usually less florid and alarming than schizoaffective episodes of the manic
to last longer, the prognosis is less favorable (danger of developing schizophrenic defect)
F25 Schizoaffective disorder
Note: This diagnosis depends upon an approximate "balance" between the number, severity and duration of
the schizophrenic and affective symptoms.
G1. The disorder meets the criteria of one of the affective disorders of moderate or severe degree, as
specified for each sub-type.
G2. Symptoms from at least one of the symptom groups listed below, clearly present for most of the time
during a period of at least two weeks (these groups are almost the same as for schizophrenia (F20.0 F20.3)):
(1) Thought echo, thought insertion or withdrawal, thought broadcasting (F20 G1.1a)
(2) Delusions of control, influence or passivity, clearly referred to body or limb movements or specific
thoughts, actions or sensations (F20 G1.1b)
(3) Hallucinatory voices giving a running commentary on the patient's behaviour, or discussing him between
themselves; or other types of hallucinatory voices coming from some part of the body (F20 G1.1c)
(4) Persistent delusions of other kinds that are culturally inappropriate and completely impossible, but not
merely grandiose or persecutory (F20 G1.1d), e.g. has visited other worlds; can control the clouds by
breathing in and out; can communicate with plants or animals without speaking, etc.
(5) Grossly irrelevant or incoherent speech, or frequent use of neologisms (a marked form of F20 G1.2f)
(6) The intermittent but frequent appearance of some forms of catatonic behaviour, such as posturing, waxy
flexibility and negativism (F20 G1.2g)
G3. Criteria G1 and G2 must be met within the same episode of the disorder, and concurrently for at least
some time of the episode. Symptoms from both criteria G1 and G2 must be prominent in the clinical
picture.
53
G4. Most commonly used exclusion criteria: the disorder is not attributable to organic brain disease (in the
sense of F0), or to psychoactive substance-related intoxication, dependence or withdrawal (F1).
F25 Schizoaffective disorder
F25.0 Schizoaffective disorder, manic type
A. The general criteria for schizoaffective disorder (F25) must be met.
B. Criteria of a manic disorder must be met (F30.1 or F31.1).
F25.1 Schizoaffective disorder, depressive type
A. The general criteria schizoaffective disorder (F25) must be met.
B. The criteria for depressive disorder, at least moderate severity must be met (F32.1, F32.2,
F31.3 or F31.4).
F25.2 Schizoaffective disorder, mixed type
A. The general criteria for schizoaffective disorder (F25) must be met.
B. The criteria for mixed bipolar affective disorder must be met (F31.6).
F25.8 Other schizoaffective disorders
F25.9 Schizoaffective disorder, unspecified
Comments: If desired, further subtypes of schizo-affective disorder may be specified, according to the
longitudinal development of the disorder, as follows:
F25.x0 Concurrent affective and schizophrenic symptoms (as defined in G2 above) only.
54
F25.x1 Concurrent affective and schizophrenic symptoms, plus persistence of the schizophrenic symptoms
beyond the duration of the affective symptoms.
Literature and resources
●
●
●
●
●
●
●
●
●
●
●
●
●
Kaplan & Sadock's Comprehensive Textbook of Psychiatry (2 Volume Set) by Benjamin J. Sadock, Virginia A.
Sadock,Lippincott Williams & Wilkins Publishers ©; 7th edition (January 15, 2000)
Robert M. McCarron, Glen L. Xiong, James A. Bourgeois, Lippincott's Primary Care Psychiatry, Lippincott Williams & Wilkins
©, 2009 – 352
Stephen M. Stahl: Stahl's essential psychopharmacology: neuroscientific basis and practical application, Cambridge
University Press ©, 2008, p37-488
Susan D.M. Kelley, Psychopathology handbook (3rd Edition), 2007, Utah State University: National Clearing House of
Rehabilitation Training Materials ©
Madhukar H. Trivedi, MD, Use of Decision Support Tools for Treatment Algorithms, Primary Psychiatry 2007 ©, CNS Spectr
12:8(Suppl 13):9-16
Risk Management Foundation of the Harvard Medical Institutions ©, Incorporated; Guidelines for Suicidality, 1996
S. M. Stahl, Depression and Bipolar Disorder: Stahl’s Essential Psychopharmacology, 3 rd edition, Cambridge University Press
2008 ©
J. Rosack: Imaging Shows Brain Enzyme's Role in Depression, Psychiatric News December 15, 2006 Volume 41 Number 24
Page 21 American Psychiatric Association ©
Christopher H. Warner et al. Antidepressant Discontinuation Syndrome, Am Fam Physician ©. 2006 Aug 1;74(3):449-456.
Wahlbeck K. & Mäkinen M. (Eds). (2008). Prevention of depression and suicide. Consensus paper. Luxembourg: European
Communities 2008 ©
www.nimh.nih.gov
www.mentalhealth.com
ICD-10 copyright © 1992 by World Health Organization. Internet Mental Health (www.mentalhealth.com) copyright © 19952011 by Phillip W. Long, M.D.
55
MOOD DISORDERS
part 2
56
BIPOLAR DISORDER
57
Statistics
Bipolar Disorder's worldwide prevalence is approximately 35%.
It can even present in preschoolers.
There are no significant differences among racial groups in
the prevalence of this disorder.
The lifetime prevalence of Bipolar I Disorder in community
samples has varied from 0.4% to 1.6%.
Current estimates of the lifetime prevalence of Bipolar II
Disorder are 0,5% of the population.
Completed suicide occurs in 10% - 15% of individuals with
Bipolar I Disorder.
There are no reports of differential incidence of 58
Bipolar I
Disorder based on race or ethnicity.
Bipolar disorder – diagnostic
features
Bipolar I Disorder
One or more Manic Episodes or Mixed
Episodes
Often individuals have also had one or more
Major Depressive Episodes.
Bipolar II Disorder
One or more Major Depressive Episodes
accompanied by at least one Hypomanic
59
Episode.
Bipolar I disorder
Untreated patients with Bipolar I Disorder typically
have 8 to 10 episodes of mania and depression in
their lifetime.
Often 5 years or more may elapse between the first
and second episode, but thereafter the episodes
become more frequent and more severe.
The frequency of episodes and the pattern of
remissions and relapses are both very variable,
though remissions tend to get shorter as time goes
on and depressions to become commoner and
longer lasting after middle age.
60
Bipolar I disorder
Bipolar I Disorder may
develop psychotic
symptoms.
The psychotic symptoms
in Bipolar I Disorder
only occur during
severe manic, mixed
or depressive
episodes.
Poor recovery is more
common after
psychosis.
Manic episodes usually
begin abruptly and last
for between 2 weeks
and 4-5 months
(median duration about
4 months)
Depressive episodes
tend to last longer
(median length about 6
months) though rarely
for more than a year,
except in the elderly.
61
Unipolar vs. Bipolar Depression
●
Unipolar
●
Impacts women more than men
●
Later onset (around 40)
●
●
●
●
●
●
Personality traits: higher neuroticism,
introvertion; anancastic, melancholic
Phases: 3-4, only depressive
Mean length of a phase: 6 -9 months, long
phases
depression with anxiety, insomnia,
psychomotor agitation,
hyperchondriasis
Bipolar
Impacts men and women equally
Genetic load: first-degree relatives of a bipolar
patient have an approximate 10% lifetime risk
of bipolar affective disorder, and also have
increased risks of unipolar depression and
schizoaffective disorder.
●
Early onset (20-30)
●
Personality traits: extravertic, cyclothymic
●
Phases: 6-10, depressive, manic, hypomanic
●
Mean length of a phase: 3 months, short
phases
typical depression with
hypersomnia, psychomotor
retardation, more likely psychotic
symptoms during DE
Bipolar I disorder – treatment
features
* The usual - lifelong therapy with a mood-stabilizer (either
lithium, carbamazepine, or divalproex / valproic acid) often in
combination with an antipsychotic medication.
- treatment results in a dramatic decrease in
suffering, and causes an 8 – fold lower rate reduction in
suicide risk.
* In mania: an antipsychotic medication and/or a
benzodiazepine medication is often added to the moodstabilizer.
* In depression: quetiapine, olanzapine, or lamotrigine is often
added to the mood-stabilizer. Alternatively, in depression, the
mood-stabilizer can be switched to another mood-stabilizer,
or two mood-stabilizers can be used together. Sometimes, in
depression, antidepressant medication is used.
63
Bipolar I disorder – treatment
features
* Since antidepressant medication can trigger mania,
antidepressant medication should always be combined with a
mood-stablizer or antipsychotic medication to prevent mania.
* According to research the most effective treatment is a
combination of:
supportive psychotherapy,
psychoeducation,
and the use of a mood-stabilizer (often combined with an
antipsychotic medication).
* There is no research showing that any form of psychotherapy
is an effective substitute for medication.
64
The best recoveries are achieved when
individuals with Bipolar I Disorder:
(according to www.mentalhealth.com)
1. Get the correct diagnosis (since many are misdiagnosed as having
schizophrenia or "just borderline personality")
2. Get effective treatment and faithfully stay on it for a lifetime (most
individuals require the combination of a mood-stabilizer plus an
antipsychotic medication)
3. Adopt a healthy lifestyle (regular sleep and exercise; no alcohol or drug
abuse; low stress)
4. Regularly see a supportive physician who is knowledgeable about the
psychiatric management of this disorder
5. Learn which symptoms predict the return of this illness, and what
additional "rescue" medication should be taken
6. Learn to trust the warnings given by family and friends when they see early
signs of relapse
7. Learn as much as possible about this illness from therapists, the Internet,
books, or self-help groups
65
Patient and his family education
EFFECTIVE TREATMENT = COOPERATION
BETWEEN PATIENT AND PRACTICIONER
The patient should be informed of:
- the diagnosis
- prognosis
- treatment options (costs, duration, potential side effects)
Patient's family should also be educated.
The family should be informed that: depression is a medical illness (not a
character defect or weakness); treatments are effective (there is
variety of options); the aim of treatment is complete - total symptom
remission and keeping it up; there is significant risk of recurrence
(50 percent after one episode, 70 percent after two episodes, 90
percent after three episodes); they should be sensitive to early
66 as possible.
symptoms of recurrence and provide care as quickly
SUICIDE
67
The detection of suicidality
The clinician evaluates:
1. Suicidal intent and lethality
2. Dynamic meanings and motivation for suicide
3. Presence of a suicidal plan
4. Presence of overt suicidal/self-destructive behavior
5. The patient’s physiological, cognitive, and affective
states
6. The patient’s coping potential
7. The patient’s epidemiologic risk factors
68
Risk of suicide in mood disorders
(by Risk Management Foundation of the Harvard Medical Institutions, Incorporated)
1. The absence of psychosis does not imply safety.
2. A misleading reduction of anxious or depressed affect can occur in some patients who have resolved
their ambivalence by deciding to commit suicide. A patient who has made the decision to die may
appear at peace and not show signs of an inner struggle. Concern is warranted especially when the
patient appears emotionally removed, shows constricted affect, or is known to have given away
belongings.
3. The likelihood of suicide within one year is increased when the patient exhibits:
a. Panic attacks
b. Psychic anxiety
c. Anhedonia
d. Alcohol abuse
4. The likelihood of suicide during the ensuing 1-5 years is increased when the patient exhibits:
a. Increased hopelessness
b. Suicidal ideation
c. History of suicide attempts
69
Other risk factors
●
By American Foundation for Suicide Prevention:
–
–
Genetic Predisposition (family history of
suicide, suicide attempts, depression
or other psychiatric illness)
Conncomitant
factors:
●
Neurotransmitters (relationship between
low concentrations of the serotonin
metabolite 5-hydroxyindoleactic acid
(5-HIAA) in cerebrospinal fluid and an
increased incidence of attempted and
completed suicide in psychiatric
patients)
–
Impulsivity
–
Demographics (males are three to five
times more likely to die by suicide than
females; elderly Caucasian males
have the highest suicide rates)
- unemployment
- living in a villages
- weapon
- poverty
- social isolation
- lonelyness
[Mann et al 1999, 2002]
70
Facts about depression and suicide
●
●
●
●
About 10 to 15 percent of patients formerly hospitalized with
depression commit suicide (Angst et al., 1999).
Major depressive disorders account for about 20 to 35 percent
of all deaths by suicide (Angst et al., 1999).
Completed suicide is more common among those with more
severe and/or psychotic symptoms, with late onset, with coexisting mental and addictive disorders (Angst et al., 1999),
as well as among those who have experienced stressful life
events, who have medical illnesses, and who have a family
history of suicidal behavior (Blumenthal, 1988).
In the United States, men complete suicide four times as often
as women; women attempt suicide four times as frequently
as do men (Blumenthal, 1988).
71
MOOD DISORDERS IN GRAPHS
72
MANIA
hypomania
EUTHYMIA
dysthymia
DEPRESSION
73
Major Depression – single episode or recurrent
MANIA
hypomania
EUTHYMIA
dysthymia
DEPRESSION
74
Dysthymia
MANIA
hypomania
EUTHYMIA
dysthymia
DEPRESSION
75
Double Depression
MANIA
hypomania
EUTHYMIA
dysthymia
2 years
DEPRESSION
6-24
months
76
Manic or mixed episode (bipolar I)
MANIA
hypomania
EUTHYMIA
dysthymia
DEPRESSION
77
DSMIV Rapid cycling!
Rapid cyclic mania
MANIA
hypomania
EUTHYMIA
….....................12 months.....................
dysthymia
DEPRESSION
78
Depressive and Hypomanic Episodes
(bipolar II)
MANIA
hypomania
EUTHYMIA
dysthymia
DEPRESSION
79
Cyclothymic disorder
MANIA
hypomania
EUTHYMIA
dysthymia
DEPRESSION
80
All graphs adapted from S. M. Stahl, Depression and Bipolar Disorder: Stahl’s Essential Psychopharmacology, 3rd edition, Cambridge University Press 2008 ©
TREATMENT OF MOOD
DISORDERS
81
Initial treatment objectives:
(1) symptom remission (acute phase) and
restoration of psychosocial functioning
(acute and continuation phases),
(2) prevention of a relapse (continuation
phase)
(3) prevention of recurrences, or new
episodes in patients with recurrent
depressions (maintenance phase).
82
Factors deciding of treatment
location
(1) the imminent risk of suicide,
(2) the capacity of the patient to recognize and
follow instructions or recommendations
(adherence, psychosis),
(3) the level of psychosocial resources,
(4) the level of psychosocial stressors,
(5) the level of functional impairment.
83
Choice among acute-phase
treatments
MEDICATION
PSYCHOTHERAPY
COMBINATION OF M+P
ECT – ELECTROCONVULSIVE
THERAPY
84
Selecting initial treatment
●
The selection of initial treatment depends on:
- the chronicity of the condition,
- the history of recurrences (which predicts the likelihood of future
recurrences),
- family history of illness,
- symptom severity,
- associated comorbid general medical or other psychiatric
conditions,
- prior treatment responses to other acute-phase treatments,
- patient preference.
85
Selecting second treatment options
●
●
If the first treatment fails (e.g., due to intolerance or lack of efficacy), a strategic
decision on the second treatment after the differential diagnosis has to be
reconsidered.
Common options:
- extending the trial period
- switching to an alternative treatment
- adding a second treatment to the initial one
●
●
●
The choice to switch from the initial single treatment to a new single treatment
depends on the philosophy guiding the clinician, the patient's prior treatment
history, and other clinical issues.
If the initial trial is the patient's first treatment and there are clinical/economical
reasons for monotherapy, switching rather than augmenting is preferred.
The use of two different medications, seem effective in patients who have failed one
or more well-conducted single medication trials.
86
●
If the initial medication is ineffective or cannot be tolerated, it is reasonable to switch
medication classes.
Implementation of strategies
requires:
(1) Careful attention to adherence
(2) Careful evaluation of outcome
- choice of medication
(3) Proper dosing and duration of the trial
(4) Timely declaration of treatment failure.
* Lack of efficacy is the most common reason for medication
failure, but this cannot be fully gauged until patients have
had several weeks of treatment at adequate dosages (4 to 6
weeks).
87
Maintenance treatment
●
●
●
●
●
●
Aims at preventing recurrences
Appropriate for recurrent but not for single episode of
major depressive disorder.
Those with three or more episodes should receive
maintenance-phase treatment.
If symptom breakthrough:
- modest and time-limited - requires only minor shifts in
the treatment plan (e.g., dosage adjustment,
reassurance)
- profound/prolonged/does not respond to dosage
adjustment and reassurance - must be treated
88
TREATMENT OF DEPRESSION
89
Definitions of outcomes in
depression
Response: Patient no longer fully symptomatic but evidence
of more than minimal symptoms.
Remission: Patient no longer meets syndromal criteria and
has no or minimal symptoms.
Relapse: A return to a fully symptomatic state that occurs
during remission.
Recovery: Extended period of remission indicating end of
current episode.
Recurrence: Appearance of a new episode of major
depression; occurs only during recovery.
Pharmacotherapy
EPISODE
GETTING BETTER VS. FULL REMISSION
6 months = recovery (WHO)
91
Medicals
Psychoeducati
on
Sleeping drugs
Hormonal
replace
therapy
Anxiolitics and
antidepressants
!
phototherapy
ECT
Psychosurgery
Thyroid
hormons
Betablockers
Atypic
neuroleptics
Stimulants
VNS
92
Pharmacotherapy 2
RELAPSES
1 relaps
2 relapses
relatively
absolutely
treatment
relatively
5 years
absolutely
2 years
93
93
Pharmacotherapy 3
PROGNOSIS
DRUG 1
Remission 1/3 … Recovery 1/3 … Lack of recovery 1/3
DRUG 2
1/3 … 1/3 … 1/3
Problems with achieving recovery.
Significant disability, reduced quality of life, increased risk for all-cause 1/9
mortality.
One strategy - augmentation of an initial antidepressant with either a second antidepressant or
94
another
agent (e.g., lithium)
Pharmacotherapy of depression
●
●
●
●
●
The end of 19th century: opium (tincture)
1951: monoamine oxidase inhibitor (MAOI) and monoamine
(re)uptake inhibitor (MAUI)
1957: tricyclic antidepressants (TCA) - imipramine, amitryptyline,
doxepin, clomipramine, dibenzepin, opipramol
1974: tetracyclic antidepressant (TeCA) – maprotiline, mianserin
'80, '90s: Selective serotonin reuptake inhibitors or serotonin-specific
reuptake inhibitor (SSRI) - fluoxetin, fluwoksamine, sertraline,
paroxetine, citalopram, escitalopram
95
'90s and present
Drugs influencing specificaly 1 neurotransmitter:
- sertraline (SSRI): 5-HT blocade
- reboxetine (NRI): Na blocade
Drug influencing several neurotransmittors
(5-HT,
NA, DA):
- moclobemid (RIMA): 5HT, NA, (DA)
- venlafaxine (SNRI): 5HT, NA, (DA)
- mirtazapine (NASSA): 5HT, NA
Drug influencing hipothalamus- pituary Axis HPA:
- tianeptyna
96
Monoamine hypothesis 1
PET imaging data suggest increased activity of monoamine oxidase A (MAO-A) during a
major depressive episode (B), resulting in reduced monoamine activity in the synapse,
compared with healthy subjects (A). This elevation, paired with fewer monoamine
transporters during a mood episode, only modestly reduces available monoamine and
leads to mild-to-moderate symptoms (C). However, if increased MAO-A activity occurs with
increased numbers of transporters, a severe depletion in available monoamines could
occur, possibly leading to more severe symptoms (D).
97
J. Rosack: Imaging Shows Brain Enzyme's Role in Depression, Psychiatric News December 15, 2006 Volume 41 Number 24 Page 21 , American
Psychiatric Association ©
Monoamine hypothesis 2
(…) when there is „normal“ amount of,
monoamine neurotransmitter activity, there
is no depression present
(…) if the „normal“ amount of monoamine
neurotransmitter activity becomes reduced,
deleted or dysfunctional for some reason,
depression may ensue
98
Stephen M. Stahl: Stahl's essential psychopharmacology: neuroscientific basis and practical application, Cambridge University Press, 2008©, p487-488
Monoamine hypothesis 3
(…) deficient activity of monoamine neurotransmitter causes upregulation of postsynaptic
monoamine neurotransmitter receptors,(...) this leads to depression
99
Stephen M. Stahl: Stahl's essential psychopharmacology: neuroscientific basis and practical application, Cambridge University Press, 2008©, p487-488
SSRIs
●
●
●
●
●
SSRIs are believed to increase the extracellular level of the
neurotransmitter serotonin by inhibiting its reuptake into the
presynaptic cell, increasing the level of serotonin in the synaptic
cleft available to bind to the postsynaptic receptor.
It often takes 6–8 weeks for the drug to begin reaching its full
potential
Drugs in this class include: citalopram, dapoxetine, escitalopram,
fluoxetine, fluvoxamine, indalpine, paroxetine, sertraline,
vilazodone, zimelidine
They have wide therapeutic index, are relatively safe (no serious
systemic toxity), have minimal cholinergic, histaminic,
dopaminergic and noradrenergic effects, currently are considered
first-line medications for depression.
100
Adverse effects: psychosexual side effects, hyponatremia,
effects
on cyp450 enzymes.
Antidepressant Discontinuation
Syndrome
●
●
●
●
●
●
Occurs in approximately 20 percent of patients after abrupt discontinuation of an
antidepressant medication that was taken for at least six weeks.
Typical symptoms include: flu-like symptoms, insomnia, nausea, imbalance, sensory
disturbances, and hyperarousal.
These symptoms usually are mild, last one to two weeks, and are rapidly
extinguished with reinstitution of antidepressant medication.
ADS more likely with a longer duration of treatment and a shorter half-life of the
treatment drug.
Before prescribing medications, patient education should include warnings about
the potential problems associated with abrupt discontinuation.
Education about this common and likely underrecognized clinical phenomenon will
help prevent future episodes and minimize the risk of misdiagnosis.
101
Christopher H. Warner et al. Antidepressant Discontinuation Syndrome, Am Fam Physician©. 2006 Aug 1;74(3):449-456.
When should general practitioner
send a patient to psychiatric
consultation
●
●
The increase of depressive symptoms although
medication
The presence of psychotic symptoms (delusions,
hallucinations
●
Suicidal thoughts or tendencies
●
Difficulties in choosing the right drug
●
Intolerance of antidepressants
●
Non-cooperative patient
●
Serious overall somatic state
102
Literature and resources
●
●
●
●
●
●
●
●
●
●
●
●
●
Kaplan & Sadock's Comprehensive Textbook of Psychiatry (2 Volume Set) by Benjamin J. Sadock, Virginia A.
Sadock,Lippincott Williams & Wilkins Publishers ©; 7th edition (January 15, 2000)
Robert M. McCarron, Glen L. Xiong, James A. Bourgeois, Lippincott's Primary Care Psychiatry, Lippincott Williams & Wilkins
©, 2009 – 352
Stephen M. Stahl: Stahl's essential psychopharmacology: neuroscientific basis and practical application, Cambridge
University Press ©, 2008, p487-488
Susan D.M. Kelley, Psychopathology handbook (3rd Edition), 2007, Utah State University: National Clearing House of
Rehabilitation Training Materials ©
Madhukar H. Trivedi, MD, Use of Decision Support Tools for Treatment Algorithms, Primary Psychiatry 2007 ©, CNS Spectr
12:8(Suppl 13):9-16
Risk Management Foundation of the Harvard Medical Institutions ©, Incorporated; Guidelines for Suicidality, 1996
S. M. Stahl, Depression and Bipolar Disorder: Stahl’s Essential Psychopharmacology, 3 rd edition, Cambridge University Press
2008 ©
J. Rosack: Imaging Shows Brain Enzyme's Role in Depression, Psychiatric News December 15, 2006 Volume 41 Number 24
Page 21 American Psychiatric Association ©
Christopher H. Warner et al. Antidepressant Discontinuation Syndrome, Am Fam Physician ©. 2006 Aug 1;74(3):449-456.
Wahlbeck K. & Mäkinen M. (Eds). (2008). Prevention of depression and suicide. Consensus paper. Luxembourg: European
Communities 2008 ©
www.nimh.nih.gov
www.mentalhealth.com
ICD-10 copyright © 1992 by World Health Organization. Internet Mental Health (www.mentalhealth.com) copyright © 19952011 by Phillip W. Long, M.D.
103