MOOD DISORDERS ASSESSMENT & MANAGEMENT

Dr Aparna Laddipeerla MBBS DPM Senior Psychiatry Registrar

Country Health SA

You should be familiar with:

• The clinical features of Mood Disorders: • Major Depressive Disorder

• Dysthymic Disorder

• Bipolar Disorders

• Cyclothymic Disorder

• Other disorders with affective features: • Schizoaffective Disorder

• Adjustment Disorders

• Mood Disorder due to General Medical Condition

• Mood Disorder due to Substances

• How to assess an affective presentation

• Treatment of Mood Disorders • Pharmacology of anti-depressants and mood stabilising agents

• ECT

• Psychotherapies

• Other supportive measures

Learning objectives

Framework

THEORY

• Epidemiology

• Etiology

• Clinical features

• Diagnosis DD

• Management

PRACTICE

• HPC

• PH

• FH

• PH

• MSE

• Unipolar vs. bipolar

• DSM-IV-TR

NB. Unipolar MDD may be an unstable diagnosis over time

Classifications

Unipolar Bipolar

DSM-IV-TR Major Depressive

Disorder

Dysthymic

Disorder

Bipolar I Disorder

Bipolar II Disorder

Bipolar Disorder NOS

Cyclothymic Disorder

(“bipolar spectrum”)

• Gender

Major Depressive Disorder F:M=2:1

Bipolar disorders (all) F:M=1:1

(Some subtype has gender preponderance)

• Age of onset

BDs <20 yrs

Dysthymic Disorder Childhood – adolescence

Recurrent MDD 30-35 yrs

Single episode MDD Mid-late adulthood

Epidemiology

Epidemiology

DEPRESSION

• Life time prevalence –20%

• Co-morbidity is the rule

• National Co morbidity survey and Epidemiological Catchment Area survey (ECA) -74% & 75% respectively with other lifetime diagnoses

• Risk –ECA study-Lifetime risk of suicide 7.9% , 19.5% with concurrent alcohol and drug misuse

• Risk of suicide 21times that of normal population

BIPOLAR DISORDER

• 65% co morbidity

• High SMR´s: 15–20 times

more likely to die by

suicide

• High rates of

cardiovascular disease

‘SKETCH ARTIST’ MISTAKE:

TOO LITTLE INFORMATION

CASE EXAMPLE:

XYZ is a 44 yr old Caucasian female, currently in a relationship with a 37 yr old man on Disability support pension, lives with her 9 yr old son, also has a 5 year old daughter who doesn’t live with her. She has been on unemployment benefits for the last 2 years. She is currently a voluntary in-patient on the ward. She gives a 2 year history of depressive symptoms.

Establish broad spectrum

• –neurosis, depression or psychosis

• Once domain breached establish diagnosis according to

DSM criteria.

• Follow up immediately with most important co morbidities

and differentials.

• Depression-bipolarity, anxiety, substance misuse and

personality dysfunction

• Psychosis- depression, mania, substance misuse or

schizophrenia

• Establish criteria for domains!!

• At least 5 of the following occurring nearly every day (except for #9) over at least 2 weeks, which are a change from previous functioning:

1) Depressed mood, most of the day*

2) Loss of interest or pleasure, most of the day*

3) Psychomotor agitation or retardation

4) or appetite, or significant weight loss or gain

5) Insomnia or hypersomnia

6) Loss of energy

7) concentration or indecisiveness

8) Feelings of worthlessness or excessive/inappropriate guilt

9) Recurrent thoughts of death or suicide

*One of the symptoms must be either (1) or (2)

• Symptoms cause clinically significant distress or functional impairment

• Excludes bereavement, substance, general medical condition and mixed episode

DSM-IV-TR criteria for MDD

• With Catatonic Features

• rare

• With Melancholic Features

• older people

• no pre-morbid personality traits

• marked weight loss, early morning wakening, psychomotor retardation/agitation, diurnal mood variation, anhedonia

• can present with delusions (psychotic depression)

• responds well to antidepressants and ECT

• responds less well to psychotherapies

• With Atypical Features

• With Postpartum Onset

MDE Subtypes

• Dysthymic Disorder • DSM-IV-TR criteria:

• Depressed mood plus at least 2 other symptoms Poor appetite or overeating Insomnia or hypersomnia Low energy or fatigue Poor concentration or indecisiveness Feelings of hopelessness Low self-esteem

• For most days over at least 2 years, during which no asymptomatic periods have exceeded 2 months

• Cyclothymic Disorder • DSM-IV-TR criteria:

• Fluctuating mood over at least 2 years, involving numerous periods of hypomanic and depressive symptoms, which do not meet the criteria for Manic Episode or Major Depressive Episode

• No asymptomatic periods have exceeded 2 months

Longitudinal diagnosis: Mood Disorders

- Dysthymic and Cyclothymic Disorders

• Individuals with mood disorders

• Risk of substance use disorders (especially alcohol)

• Risk of anxiety disorders (e.g. OCD, panic disorder, social anxiety disorder)

• Magnitude of risk:

• Bipolar disorders > MDD > general population

• Risk of mood disorders in those with • Substance use disorders

• Anxiety disorders

• Some personality disorders

• Medical co-morbitidy

Comorbidity

Depression

• Anxiety

• Bipolarity

• Substance misuse

• Personality disorder

Depression • How are you feeling in yourself / in your spirits. On a scale of 1-10 if 10 was really down

where would you put yourself. How long does it last for? (mood, clinical depression)

• Have you been tearful lately? (mood)

• When was the last time you smiled/cried? (mood)

• What are the kinds of things you normally enjoy doing. / how do you spend your day? (anhedonia)

• If TV, mowing the lawn etc -have you been enjoying these things as much as you’ve done in the past. (anhedonia)

• When was the last time you played….(anhedonia)

• What have your energy levels been like. / do your energy levels keep up with .e.g. physical work (anergia)

• What about your concentration/ how long can you read a book for/ do you find it difficult taking things in when watching TV or reading a book .Has that affected your work? (anergia)

• What are your plans for the future? /How do you see your future? (hopelessness)

• Is there anything hurting your conscience? Have you been blaming yourself lately? (guilt)

• Do you feel there is something wrong with functioning of your body? (hypochondriacal ideation)

• What about your confidence levels? (self esteem, self confidence)

• Do you think other people would be better off without you? (worthlessness)

ANY SUGGESTIONS/ INSIGHTS INTO ASKING

THESE QUESTIONS OR STARTING THIS

CONVERSATION?

-Listen to patients’ cues: use experience-near terms (down not ‘depressed’)

• CLUB 2 OR 3 CRITERIA:

NEGATIVE THOUGHTS (GUILT, HOPELESS, HELPLESS,

WORTHLESS) OR

PHYSICAL EFFECTS (PANIC ATTACKS, ENERGY, MEMORY,

CONCENTRATION, SLEEP, APPETITE CHANGES ETC.) OR

EMOTIONS (SAD, DIURNAL VARIATION, ANHEDONIA, CRYING)

OR

BEHAVIOURS (AVOIDANCE, SOCIAL ISOLATION, POOR

FUNCTIONING, DRINKING)

-Cognitive model (depression & mania)

-Psychosis: positive, negative, cognitive domains & mood

Anxiety: …

STRESSORS & PRECIPITANT(S)

What does the ‘precipitant’ tell us?

“Could you please tell me how you came about to being in hospital?”

Chronic histories- “I wonder what made you seek help now!” “Why now?”

Risk factors Sociodemographic factors

Life stressors

Sociodemographic factors

• Largely weak correlation • Marital status

• Separation/divorce: Bipolar > MDD > Dysthymia

• Socioeconomic status • Lower SES: MDD and BD

• Geography • Distance from the Equator

• Distal from the Equator: Depression

• Proximity to the Equator: Mania

• Western > Far Eastern countries

• Urbanicity • Urban residence > Rural

residence

• Season • Spring & Autumn: Depression

• Summer: Mania

• Diet • Folate

• Omega-3-fatty-acids

• Western diet > Traditional diet

• Physical activity • with MDD

• Adiposity • with MDD

Life stressors

• Life stressors

• Stressors are not all the same in pertinence

• Less consistent association with bipolar disorder and melancholic/psychotic MDD cf non-melancholic/non-psychotic MDD

• Association with number of episodes (“kindling”)

• For non-melancholic/non-psychotic MDD:

• Cumulative stress (series, chronic) more important than acute stressors

• Early life adversities: E.g. Poor parental relationship, prolonged separation from parent, intrafamilial sexual abuse

• Early parental death (before adolescence)

• For bipolar disorder:

• Disruption in biorhythm

• Negative and positive “stress”

• Social support

• Social isolation: MDD

RISK ISSUES CASE EXAMPLE:

XYZ is a 44 yr old Caucasian female, currently in a relationship with a 37 yr old man on Disability support pension, lives with her 9 yr old son, also has a 5 year old daughter who doesn’t live with her. She has been on unemployment benefits for the last 2 years. She is currently a voluntary in-patient on the ward. She gives a 2 year history of depressive symptoms.

Suicidal ideation

• Sometimes when people get depressed they may find life not

worth living? Have you felt like this ….?

• What thoughts have crossed your mind? (ideation)

• How long have you been thinking about this? (intent/ideation)

• What have you planned? (plans)

• Have you made arrangements for after your death e.g. made a

will or written a note? (intent)

• How close have you come to actually carrying out your plan?(

take patient through) (intent)

• What stopped you/stops you? (protective factors)

• Is there anything to live for at all? Mention friends , family

(protective factors)

Suicidal Attempt

• Go through detail of attempt

• Alcohol

• Seriousness

• Impulsivity-How long had you been planning this?

• Did you make any arrangements for your death e.g. note,

will , finances

• How do you feel now that you have survived?

• Do you really want to die/ have you actually imagined

yourself dead?

• Do you currently have any thoughts of suicide?

BIPOLAR DISORDER

DSM-IV-TR criteria for mania: Distinct period of abnormally & persistently elevated,

expansive or irritable mood, lasting at least 1 week (or if

hospitalised)

Plus 3 of (4 if mood is only irritable): 1) Inflated self-esteem or grandiosity

2) Decreased need for sleep

3) More talkative or pressure to keep talking

4) Flight of ideas or racing thoughts

5) Distractibility

6) Increase in goal-directed activity or psychomotor agitation

7) Excessive involvement in activities that have a high potential for

painful consequences

Severity: cause marked functional impairment, necessitate

hospitalisation, or if psychotic

Exclusion: direct physiological effects of a substance or general

medical condition

• A less severe form of mania

• DSM-IV-TR criteria is the same as Manic Episode, except:

• Duration: at least 4 days (rather than 1 week)

• No psychotic symptoms

• No hospitalisation

• Not severe enough to cause marked impairment in functioning

• Criticism

• Duration is too long

• Recognised brief hypomanic episodes (1-2 days) are common among those

with bipolar disorders

• Subthreshold symptoms still clinically and functionally significant

Hypomanic Episode

• Concurrent presence of both depressive & manic symptoms

• DSM-IV-TR criteria:

• Concurrent fulfilment of criteria for Major Depressive Episode and Manic Episode for at least 1 week

• In broader terms, subthreshold “mixed states” refer to “non-pure” depressive or manic states

• Intrusion of manic features in depression

or

• Intrusion of depressive features in mania

• Mixed Episode and subthreshold mixed states signal bipolarity

Mixed Episode

• History of a single MDE or recurrent MDEs

= Major Depressive Disorder

• History of a single or recurrent Manic or Mixed Episode(s)

+/- MDE(s)

= Bipolar I Disorder

• History of both MDE(s) + Hypomanic Episode(s)

= Bipolar II Disorder

• Schizophrenia + any mood episode

= Schizoaffective Disorder (MDD or Bipolar types)

Longitudinal diagnosis: Mood Disorders

AKISKAL

Bipolar Illness (Mania) • Have you ever had the opposite of depression when you have been extremely

happy, over the top , doing things out of character for 2 weeks or more.? (mood)

• If yes clarify again how long does it last for (DD borderline construct)

• Had you/ have you taken on any new activities? (increased goal directed activity)

• What's your sleep been like. Do you feel like you can work all day without needing rest/ do you feel like you don’t need much sleep ? (decreased need for sleep)

• How do you see yourself in comparison to others./ do you consider yourself special in any way? (grandiosity)

• Do you think god has a special purpose for you here? (grandiosity/ delusions)

• Do you find your thoughts racing? (increased psycho(motor) activity)

• Have your friends commented on the way you talk/ too fast? (pressure of speech)

• Have you done any things that may be out of character for you like spending excessive amounts of money, promiscuity ? (reckless behaviour)

• Also ask for depressive symptoms to establish a mixed episode

RISKS Harm to self/ others/ dependents

Past History

• Previous admissions –diagnosis

• Trigger

• Medications/ Psychotherapy

• Leading Q’s- Carbamazepine, Lithium, Valproate

ECT , injections (Depots)

• Self harm

Medical

• Have you had any significant medical illnesses such

as…………diabetes, high blood pressure, seizures/ a

significant head injury

• Diabetes, HT-vascular hypothesis

• Head injury and epilepsy ( composite neuropsychiatric

hypothesis)

• Investigations & treatment

ANY OTHER MEDICAL HISTORY

FOR MOOD DISORDERS

If there is: eg. my patient in the exam had an anaphylactic reaction/ allergy (CL

rotation)

ANY OTHER MEDICAL HISTORY

FOR MOOD DISORDERS

• Temporal correlation

• Medications

• Current state & prognosis

• Stress

Family History

• Is there anyone in your family that has a significant mental

health problem/issue / nervous breakdown such as

parents, uncles, cousins, grandparents….depression,

bipolar /manic depression, schizophrenia

• Has anyone in your family tried to take their own life

(suicide)?

• What about problems with drugs, or alcohol or violence?

• USE OF GENOGRAM

Family history

• Stronger family history in bipolar disorders and early onset MDD

• For 1st degree relatives:

• Risk of BD with BD proband: 7x general population

• Risk of MDD with MDD proband: 2-3x general population

• Cross-over risk:

• BP probands: risk of MDD (MDD>BD)

• UP probands: Minimally risk of BD

• Twin concordance:

• BD: MZ 40% DZ 10%

• MDD: MZ 30% DZ 20%

• Overlap between bipolar disorder and schizophrenia

Genetic

Counselling

Patients frequently ask

clinicians two questions:

1) Are mood disorders

genetic?

2) What is the risk to

my children or

grandchildren?

Genetic Counselling

• Yes, mood disorders are genetic.

• The risk to children and grandchildren is the more difficult question -The family data

indicate that if one parent has a mood disorder, then a child will have a risk for mood

disorder of b/w 10- 25%. If both parents are affected, then this risk roughly doubles

(50%).

• Greater risk :

1. more members affected

2. affected family members are first-degree relatives

3. family history of bipolar disorder (+specifically, a much greater risk for bipolar

disorder)

4. presence of more severe illness

Future Directions

• Though much is understood about the familiality and heritability of mood

disorders, the identification of specific genes has been challenging.

• Studies to date have reproducibly identified a number of genes, although

these genes together explain only a small portion of the genetic variance.

• It remains unclear how many genes are involved and how the illness is

transmitted.

PERSONAL HISTORY

CASE EXAMPLE: XYZ is a 44 yr old Caucasian female, currently in a relationship with a 37 yr old man on Disability support pension, lives with her 9 yr old son, also has a 5 year old daughter who doesn’t live with her. She has been on unemployment benefits for the last 2 years. She is currently a voluntary in-patient on the ward. She gives a 2 year history of depressive symptoms.

Background of 3 previous significant depressive episodes, post natal depression, significant self-harm episode and treatment with ECT, several antidepressants, lithium and psychological treatment and strong family history

Domains

• Birth & development- “Did mom have PND?”

• Childhood- Nurturing, discipline, home atmosphere, Temperament

• Trauma- major developmental disruption, identification, scapegoating.

• Adolescence-

• Education- “How did you get along with?” “Were you bullied? Did you bully

others?”

• Occupation- “How long have you been?” “How do you get along?”

• Relationships-

• “What did you like about her/ him?” “What led to the break-up?”

• “How many children do you have?”

• Sexual history

Personality

• Life/ PMP- “How would you describe yourself? How

would others describe you? How do you cope with stress?

What are your ambitions/ goals?”

• You get major clues from how people cope or appraise

illness, forensic history, relationship and work history.

Forensic history

• Have you ever been in trouble with the police? yes-

• Have you ever been charged or convicted? Ask for

charges

• Have you ever been in jail?-period

• If no-have you ever been violent towards others?

MENTAL STATE EXAMINATION

MSE (http://aitlvideo.uc.edu/aitl/MSE/MSEkm.swf)

• A) Paint a picture of the person in front

of you= Personal description(novelist

like) +general – apparent age, physical

stigmata, attire, hygiene, eye contact,

attitude

• B) Psychomotor activity (examiner’s

description of amount of motor and

cognitive activity by the pt- excessive &

non productive or visible slowing of

thoughts, speech & movements)

• C) Speech is examiner’s description of

pt’s ability to articulate thoughts. (RATE;

AMOUNT; PRAGMATICS-inflection,

reciprocal flow, articulation); Thought

form/ process/ content (delusions/

overvalued ideas/ obsessions/

ruminations/ suicidal or homicidal

ideation)

• A) CHARACTER, INTENSITY, RANGE;

REACTIVITY; APPROPRIATENESS;

MOBILITY; difficulty initiating, sustaining

or terminating emotional response. Give

examples.

• P) Mental process by which sensory

stimuli are brought to awareness.

Hallucinations/ illusions/

depersonalisation/ derealisation/

agnosia/ synaesthesia.

• C) Cognition- AOCM

• I) Recognition of having a mental illness

and the degree of personal awareness

and understanding of the illness.

• J) How does all the mental state you

have presented impact on decision

making regarding action. Clearly key

ones = suicide, risk to others and ability

to self care. Again don’t make global

statements without discussion – not

adequate to say “ judgement is

impaired” without saying why and how;

Social j. (subtle manifestations of

behaviour that are harmful to the patient

and are contrary to acceptable

behaviour in the culture, whether the

patient understands the likely outcome

of personal behaviour and is influenced

by that understanding.) Test j.

• R) Attitude towards the examiner and

the countertransference.

Marjorie

Insight

• What in your opinion is the issue/causing this distress?

• What do you think would help you?

• Do you think medication/talking therapy would help you?

DIAGNOSIS AXIS I- V

Consider 2 components:

• Cross-sectional clinical picture Does the picture fit with a mood syndrome (that is pathological)?

A mood episode i.e. major depressive, manic, hypomanic, mixed

Others e.g. Adjustment Disorders, Mood Disorder due to a GMC, Substance-Induced Mood Disorder

• Longitudinal clinical picture History of only MDE(s) = MDD

History of both MDE(s) and Hypomanic Episode(s) = Bipolar II Disorder

History of at least one Manic or Mixed episode = Bipolar I Disorder

Schizophrenia + any mood episode = Schizoaffective Disorder (MDD or Bipolar types)

Chronic low-grade depression = Dysthymic Disorder

Chronic low-grade bipolarity = Cyclothymic Disorder

*The combination of dysthymia and MDD is often called “double depression”

Diagnosis: Summary

Ms XYZ is a … who presents with a h/o…. (Crises or Axis I) associated with …

(risks). This is in the context of …stressor (grief/ re-traumatisation/ rejection).

Predisposing factors (PH,FH, PH) to XYZ’s mental illness include

Perpetuating factors (axis II/ III) include

Precipitating factors (axis II/ III/ IV) for the current exacerbation include

Protective factors

Formulation 4 Ps

Cultural

Bio Psycho Social

PREDISPOSING

PERPETUATING

PRECIPITATING

Biological

• Genetic predisposition

• Neurodevelopmental hypothesis (schizophrenia)

• Drugs and alcohol (schizophrenia)

• Head injury

• Epilepsy

• Other medical conditions

• Drugs causing psychiatric conditions

Psychological- Psychodynamic

• Response to Loss/Anger Turned Inward: LOSS

• Narcissistic vulnerability (from early loss or experiences with parents perceived as traumatically unempathic, frustrating, or rejecting): FAILURE

• Insecure attachments : RELATIONSHIP BREAKUPS

• Freud described mania as a fusion of the ego with its superego; defense mechanism of denial

• Mania could be considered a defensive reaction to depression.

Psychological theories: Cognitive

• Cognitive

• The cognitive model is based on the recognition that an individual's

idiosyncratic perception of events affects his or her emotions and

behaviors.

• Triad of Affect, Behaviour, Cognition

• Negative cognitive schemata negative automatic thoughts

(cognitive distortions) depressed mood and behaviours

• Cognitive triad of negativity toward self, environment & future

• Foundation of CBT

Aaron Beck

Cognitive Model: Bipolar Illness

• Based on Diathesis stress model

• Patients with bipolar disorder also have an inherent

underlying biological vulnerability for instability of

circadian rhythms and motivational system controlling

reward and approach

Interpersonal therapy

• In simplest terms, interpersonal theory as applied to IPT can be understood as a link between mood and events

• For all people, upsetting external events evoke a sad or demoralized mood: In lay terms, they are “depressing.” For biologically or environmentally predisposed individuals, however, a sufficiently disturbing life event can trigger an episode of major depression

• 4 domains: grief, role transition, role disputes, interpersonal deficits

SOCIO-CULTURAL

Causes of poor mental health in

Aboriginal people • Intergenerational transmission of trauma through

psychodynamic, sociocultural and genetic mechanisms (Kellerman ,2001)

• Grief, loss and trauma resulting from high mortality rates, loss of land and culture and continuing impact of political policies that result in sociocultural dislocation

• Unresolved identity issues has been identified as source of stressor when people had not dealt with or felt they had lost or were uncertain about their aboriginal identity. (Swan P and Raphael B, 1995)

• Poor access to mental health services underpinned by cultural disparities

DIFFERENTIAL DIAGNOSIS

• Adjustment Disorders • An Adjustment Disorder is a psychological response to an identifiable

stressor that results in clinically significant symptoms. • DSM-IV-TR criteria:

• Clinically significant emotional or behavioural symptoms in response to an identifiable stressor(s), occurring within 3 months of its (their) onset & not persisting beyond 6 months upon its (their) termination.

• Clinical significance is defined as either marked distress in excess of what one would generally expect relative to the stressor(s), or significant impairment in social or occupational functioning.

• Symptoms do not represent bereavement or meet the criteria for another Axis I disorder.

• Mood Disorders due to Substances

• Mood Disorders due to a General Medical Condition

Other disorders with mood features

Depression vs. Grief

• Grief • Response to loss, threatened or actual

• Kübler-Ross’ stages of anticipatory grief (1969) • Denial, Anger, Bargaining, Depression, Acceptance

Not chronological or “stage-wise” progression

Not necessarily experience these

• Wide variations from person to person • Influenced by many factors:

• Personality, coping style, resilience

• Past experience of losses & traumas

• Nature & quality of relationship with lost object

• Available supports

• Culture

• Spiritual beliefs

• Duration varies, can be ongoing

Depression vs. Grief

Grief Depression

Symptoms occur in waves Low mood is persistent

Reactivity preserved Symptoms are pervasive

Yearning/longing a prominent

part of the affect

Apathy among range of

affects

Preserved hedonic capacity Anhedonic

Preserved self-esteem Worthlessness

Able to look forward to the

future

Hopelessness

MANAGEMENT OF MOOD DISORDERS

SHORT TERM

LONG TERM

RISK ASSESSMENT Static v/s dynamic

Acute v/s chronic

Intent Plan Means

• HIGH

• CHRONIC

• LOW

• CHRONIC

• HIGH

• ACUTE

• LOW

• ACUTE

CHRONIC

ACUTE

LOW HIGH

RANZCP GUIDELINES

Initial Clinical Assessment

CLARIFICATION & CONFIRMATION OF DIAGNOSIS

• Anti-depressants

• SSRI (Selective Serotonin Reuptake Inhibitor)

• sertraline, citalopram, escitalopram, fluoxetine, paroxetine, fluvoxamine

• SNRI (Serotonin Noradrenaline Reuptake Inhibitor)

• venlafaxine, desvenlafaxine, duloxetine

• NaSSA (Noradrenergic and Specific Serotonergic Antidepressant)

• mirtazapine, mianserin

• NARI (Noradrenaline Reuptake Inhibitor)

• reboxetine

• TCA (Tricyclic Antidepressant)

• MAOI (Monoamine Oxidase Inhibitor)

• tranylcypromine

• RIMA (Reversible Inhibitor of Monoamine Oxidase A)

• Moclobemide

• Agomelatine

• Mood stabilising agents

• Lithium

• Mood stabilising anti-convulsants (Na valproate, carbamazepine, lamotrigine)

• Atypical antipsychotics

Pharmacotherapy

DEPRESSION

Summary of STAR*D guidelines

• Number of patients that participated in medication trials

was 4 times that of Psychotherapy

• In primary switch any option is reasonable and no

statistical difference between different classes

• Cognitive therapy did as well as medication switching and

augmentation

• Overall 70% remission after 4 levels

• Not applicable for Psychotic depression

Treatment resistant depression

• Greater than or equal to 2 adequate monotherapy trials with antidepressants of 2 different classes fail to elicit a therapeutic response (APA DSM 2003)

• Prevalence :10-30% (Joffe,1996)

• Misdiagnosis

• Non-Compliance

• Inadequate duration, dose

• Psychosocial factors

• Medical condition –e.g. Hypothyroidism

• Drugs-B-Blockers, Methyldopa

Psychotic Depression

• First line –TCA +antipsychotic

• ECT is effective treatment

• 2 metaanalyses (Spiker,1985 & Parker,1992): 80%

response rate to ECT

• 80% response rate to combination antidepressant and

antipsychotic

• 33% to antipsychotic alone

• 25% to antidepressant alone

ECT

• Unilateral placement associated with less severe cognitive deficits

• Case by case basis

• Standard practice: D’Eliaposition (Non-Dominant unilateral ECT)

• If no response after 4-6 sessions consider Bilateral

• Stimulus dosing –titration method /fixed dose

• RUL-2.5-3 times seizure threshold

• BL-1.5 times seizure threshold

• Other types: Bifrontal , Right frontotemporal and left frontal

• EEG characteristics for response : short recruitment phase , high amplitude slow

waves, morphological regularity, bilateral synchronicity , post seizure suppression

• Inadequate seizures –<20-30sec EEG evidence

• Procedure

• General anaesthetic (pre-anaesthetic work up required)

• Frequency usually 3 times per week at the start, can be reduced as

clinically indicated

• Maintenance ECT can be an option

ECT - 2

ECT - 3

• First session: “Titration” (determine seizure threshold)

• Paralysed (minimal motor activity)

• Adequacy of seizure as determined by EEG tracing

• Minimum duration: 20 seconds

• Response judged on clinical basis

• Total number of treatments depend on response & tolerability

• Contraindication • Raised intracranial pressure

• Relative contraindications:

• Recent CVA

• Cerebral aneurysm or vascular malformations

• Unstable cardiovascular condition

• High anaesthetic risk

• Risks & adverse effects • General anaesthetic

• Post-ictal confusion

• Memory loss (anterograde & retrograde)

• Headache, aches and pains

• Chipped tooth, skin burns

ECT - 4

• Consent

• Informed consent from patient

or

• Guardianship Board consent

*Note: Detention is inadequate to give involuntary ECT

ECT - 5

BIPOLAR DISORDER

RANZCP- Treatment of manic episode

Texas Implementation of Medication Algorithm -Bipolar

I Disorder (Suppes, 2005 )

TIMA guidelines –Maintenance

Treatment: Hypomania/Mania

TIMA Guidelines –Maintenance Treatment +

Most Recent Episode Depression

Long term

THANK YOU Questions?