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Dr Yeung Kam Hing Medical Officer Department of Psychiatry ...

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<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

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