Dr Yeung Kam Hing Medical Officer Department of Psychiatry ...
Dr Yeung Kam Hing Medical Officer Department of Psychiatry ...
Dr Yeung Kam Hing Medical Officer Department of Psychiatry ...
You also want an ePaper? Increase the reach of your titles
YUMPU automatically turns print PDFs into web optimized ePapers that Google loves.
<strong>Dr</strong> <strong>Yeung</strong> <strong>Kam</strong> <strong>Hing</strong><br />
<strong>Medical</strong> <strong>Officer</strong><br />
<strong>Department</strong> <strong>of</strong> <strong>Psychiatry</strong><br />
Kowloon Hospital<br />
26 August 2012
Clinical Presentation<br />
� Low Mood
Differential Dx <strong>of</strong> low mood<br />
� Primary mood disorder<br />
� Depressive disorder<br />
� Recurrent depressive disorder<br />
� Dysthymia<br />
� Bipolar affective disorder<br />
� Cyclothymia
Differential Dx <strong>of</strong> Low Mood<br />
� Secondary to medical conditions<br />
� Chronic, severe, painful<br />
� Higher risk<br />
� Neurological disorders: ?shared pathology<br />
� Parkinson’s disease<br />
� MS<br />
� Stroke: left frontal lobe stroke<br />
� Epilepsy<br />
� Post MI<br />
� Diabetic<br />
� cancer
Differential Dx <strong>of</strong> Low Mood<br />
� Secondary to substance abuse including alcohol<br />
� Secondary to other psychiatric disorders<br />
� Psychotic disorders<br />
� Anxiety disorders<br />
� Adjustment disorder<br />
� Eating disorders<br />
� Personality disorders<br />
� Dementia<br />
� Secondary to a general medical condition
General medical condition casusing<br />
low mood (I)<br />
� Neurological<br />
� Multiple sclerosis<br />
� Parkinson’s disease<br />
� Huntington’s disease<br />
� Spinal cord injury<br />
� Stroke: especially left anterior infarcts<br />
� Head injury<br />
� Cerebral tumours
General medical conditions causing<br />
low mood (II)<br />
� Endocrine<br />
� Cushing’s disease<br />
� Addison’s disease<br />
� Thyroid disorders: especially hypothyroidism<br />
� Parathyroid disorders<br />
� Menstrual cycle‐related
Prescribed drugs causing low mood<br />
� Antihypertensives<br />
� Beta‐blockers<br />
� Methyldopa<br />
� Reserpine<br />
� Steroids<br />
� Corticosteroids<br />
� Oral contraceptives
Prescribed drugs causing low mood<br />
� Neurological drugs<br />
� L‐dopa<br />
� Carbamazepine<br />
� Phenytoin<br />
� Benzodiazepines<br />
� Analgesics<br />
� Opiates<br />
� Ipupr<strong>of</strong>en<br />
� Indomethacin
Prescribed drugs causing low mood<br />
� Antipsychotics
Aetiology <strong>of</strong> Depression<br />
� Neurobiological factors<br />
� Functional brain changes<br />
� Neurotransmitter abnormalities<br />
� Endocrine changes<br />
� Changes in sleep pattern<br />
� Genetic factors<br />
� Personality/temperament factors<br />
� Psychological factors<br />
� Gender<br />
� Social factors<br />
Oxford Handbook <strong>of</strong> <strong>Psychiatry</strong>, 2005
Stahl's Essential Psychopharmacology 2008
The biopsychosocial model <strong>of</strong><br />
depression<br />
Genetic<br />
predisposition<br />
Biological<br />
vulnerability<br />
Biological<br />
alterations in brain<br />
functioning<br />
Symptoms <strong>of</strong><br />
depression<br />
Oxford Handbook <strong>of</strong> <strong>Psychiatry</strong>, 2005<br />
Early adverse life<br />
experiences<br />
Personality / temperament<br />
Traumatic or adverse life events<br />
Social circumstances<br />
Alcohol / substance misuse<br />
Physical illness
Epidemiology <strong>of</strong> depression<br />
� Lifetime risk:<br />
� 10‐20%<br />
� Sex ratio:<br />
� Male:Female : 1:2<br />
� Risk factors<br />
� Genetic heritability<br />
� Childhood adverse experience<br />
� Personality traits: neurotism/anxiety<br />
� Social status: “loss” life events<br />
� Alcohol abuse
Diagnostic criteria (I)<br />
� Symptoms should be present for at least 2 weeks<br />
� At least 2 <strong>of</strong> the following CORE symptoms<br />
� Depressed mood<br />
� Loss <strong>of</strong> interest and enjoyment<br />
� Reduced energy or increased fatiguebility<br />
� AND<br />
� At least 2 <strong>of</strong> the following:<br />
� Reduced concentration and attention<br />
� Reduced self‐esteem and self‐confidence<br />
� Ideas <strong>of</strong> guilt and unworthiness<br />
� Bleak and pessimistic views <strong>of</strong> the future<br />
� Ideas or acts <strong>of</strong> self‐harm or suicide<br />
� Disturbed sleep<br />
� Diminished appetite
Diagnostic criteria (II)<br />
� Severity<br />
� Mild: total <strong>of</strong> 4 or more symptoms<br />
� Moderate: total <strong>of</strong> 5 (preferably 6) or more symptoms<br />
� Severe: total <strong>of</strong> 7 or more symptoms including all 3 core<br />
symptoms<br />
� Severe with psychotic symptoms: in cases with<br />
delusions, hallucinations or stupor<br />
� With somatic syndrome: if 4 or more <strong>of</strong> 8 biological<br />
symptoms present
Stahl's Essential Psychopharmacology 2008
Stahl's Essential Psychopharmacology 2008
Cognitive symptoms <strong>of</strong> depression<br />
� Reduced concentration & attention<br />
� Poor self esteem<br />
� Guilt<br />
� Hopelessness<br />
� Suicidal idea
Biological symptoms <strong>of</strong> depression<br />
� Loss <strong>of</strong> interest or pleasure<br />
� Reduced emotional reactivity<br />
� Early morning awakening<br />
� Depression worse in the morning<br />
� Psychomotor retardation or agitation<br />
� Marked loss <strong>of</strong> appetite<br />
� Weight loss<br />
� Loss <strong>of</strong> libido
Psychotic & severe motor<br />
symptoms <strong>of</strong> depression<br />
� Delusion<br />
� Hallucinations<br />
� Depressive stupor
Investigations <strong>of</strong> depression<br />
� No specific tests for depression<br />
� Investigations focus on the exclusion <strong>of</strong> treatable<br />
causes<br />
� Standard tests<br />
� FBC, ESR, B12/folate, U&Es, LFTs, TFTs, glucose,<br />
Calcium
Antidepressants<br />
� Mode <strong>of</strong> actions<br />
� Increasing availability <strong>of</strong> the 3 monoamines<br />
� 5HT<br />
� NE<br />
� DA
Stahl's Essential Psychopharmacology 2008
Stahl's Essential Psychopharmacology 2008
Stahl's Essential Psychopharmacology 2008
Stahl's Essential Psychopharmacology 2008
Serotonin Selective Reuptake Inhibitors<br />
• Fluoxetine (Prozac)<br />
• Sertraline (Zol<strong>of</strong>t)<br />
• Parosetine (Paxil, Aropax, Seroxat)<br />
• Fluvoxamine (Luvox, Faverin)<br />
• Citalopram (Celexa, Cipramil)<br />
• Escitalopram (Lexapro, Cipralex)<br />
Stahl's Essential Psychopharmacology 2008
Minimum effective doses <strong>of</strong> antidepressants<br />
� SSRIs<br />
� Fluoxetine 20mg/day<br />
� Citalopram 20mg/day<br />
� Escitalopram 10mg/day<br />
� Paroxetine 20mg/day<br />
� Sertraline 50mg/day<br />
� TCAs<br />
� At least 75‐100 mg/day<br />
� Others<br />
� Duloxetine 60mg/day<br />
� Mirtazapine 30mg/day<br />
� Reboxetine 8mg/day<br />
� Venlafaxine 75mg/day
Side effects <strong>of</strong> antidepressants<br />
� SSRIs<br />
� Nausea, vomiting, abdominal pain, diarrhoea<br />
� Anxiety, headache, insomnia<br />
� Sexual dysfunction<br />
� TCAs<br />
� Sedation, postural hypotension, arrhythmia<br />
� <strong>Dr</strong>y mouth, blurred vision, constipation, urinary<br />
retention
Recognised problems <strong>of</strong> antidepressants<br />
� Serotonin syndrome<br />
� Withdrawal syndrome<br />
� Sexual dysfunction<br />
� Hyponatraemia<br />
� Bleeding
Serotonin syndrome<br />
� Risk factor<br />
� Taking 2 antidepressants at the same time<br />
� Symptoms:<br />
� Restlessness<br />
� Diaphoresis<br />
� Tremor<br />
� Shivering<br />
� Myoclonus<br />
� Confusion<br />
� Convulsions<br />
� Death
Antidepressant discontinuation symptoms<br />
Flu‐like symptoms<br />
‘Shock‐like’ sensations<br />
Dizziness<br />
Insomnia<br />
Irritability,<br />
Crying spells
Antidepressant discontinuation symptoms<br />
� High risk factors<br />
� Pts with short half‐life drugs: paroxetine, venlafaxine<br />
� Pts not taking antidepressant regularly<br />
� Pts having anxiety symptoms at the start <strong>of</strong> treatment<br />
� Pts receiving other centrally acting medications such as<br />
antihypertensives, antihistamines, antipsychotics<br />
� Children & adolescents<br />
� Pts having discontinuation symptoms before
To avoid discontinuation<br />
syndromes<br />
� Avoid abrupt stopping <strong>of</strong> antidepressants<br />
� Antidepressants should be stopped for at least 4 weeks<br />
period
Stahl's Essential Psychopharmacology 2008
Stahl's Essential Psychopharmacology 2008
Stahl's Essential Psychopharmacology 2008
Nonpharmacological treatments <strong>of</strong> depression<br />
� Cognitive behavioural therapy<br />
� Interpersonal psychotherapy<br />
� Mildfulness‐based cognitive therapy<br />
� Electroconvulsive therapy
Putative antidepressant<br />
mechanism (I)<br />
� SSRI: Serotonin selective reuptake inhibitor<br />
� SNRI: Serotonin norepinephrine reuptake inhibitor<br />
� NDRI: Norepinephrnien dopamine reuptake inhibitor<br />
� Selective NRI: selective norepinephrine reuptake<br />
inhibitor<br />
� A2A: Alpha 2 antagonist<br />
� SARI: Serotonin antgonist/reuptake inhibitor<br />
Stahl's Essential Psychopharmacology 2008
Putative antidepressant<br />
mechanism (II)<br />
� MAOI: Monoamine oxidase inhibitor<br />
� TCA: Tricyclic antidepressant<br />
� 5‐HT2C antagonist: Serotonin 2C antagonist<br />
� SNDI: Serotonin norepinephrine disinhibitor<br />
� NDDI: Norepinephrine dopamine disinhibitor<br />
� TMM: Trimonoamine modulator<br />
Stahl's Essential Psychopharmacology 2008
Antidepressants<br />
� Selectivity vs specificity<br />
� New antidepressants<br />
� More selective<br />
� Not more specific for any particular type <strong>of</strong> depressive<br />
symptoms<br />
� SSRIs<br />
� Nausea & GI symptoms may not tolerable to some pts<br />
� TCAs<br />
� Side effect <strong>of</strong> sedation useful for pts with insomnia