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Personality
Neuroticism
Environmental factors
Recent stressful life events
Lack of social support
Vulnerability factor (Brown & Harris,1978)
Loss of mother before age of 11
Not working outside the home
Having no one to confide in
Having the care of young children ( 3
children aged under 14 years)
DEPRESSION
5 or > of the following symptoms present
for 2 weeks (based on DSM IV)
Depressed mood most of the day, nearly
everyday
Markedly diminished interest or pleasure
in all/almost all activities
Decrease/increase in appetite; significant
weight loss or weight gain
Insomnia/hypersomnia
Psychomotor agitation or retardation
Fatigue or loss of energy
Feelings of worthlessness or
excessive/inappropriate guilt
Diminished ability to think or concentrate,
or indecisiveness
Recurrent thoughts of death, suicide
ideation, suicide attempt
+/- psychotic features
- hallucination
- delusion
=> mood congruent
PNEMONIC
S leep
I nterest
G uilt feeling
E nergy
C oncentration
A ppetite
P sychomotor
S uicide
Mental state examination
General description
Stoopedposture, downcast gaze, frowning
Psychomotor retardation / agitation
Mood and affect
Depressed
Speech
Decreased rate and volume of speech
Delayed responses to questions
Respond to question with single words
perceptual disturbance
Mood-congruent hallucination
Theme: guilt, sinfulness, worthlessness, poverty,
failure etc
Thought
Mood-congruent delusion
Negative view of self, world and future
Cognitive function
Poor memory, impaired attention and concentration
=> pseudodementia
Insight - good
Management
Biological
- pharmacotherapy
- electroconvulsive therapy
Psychological
Pharmacotherapy
Antidepressant
Tricyclic antidepressant
(TCA) Dose (mg)
Prothiaden 25-150
Imipramine 25-150
Amitriptylline 25-100
Clomipramine 25-100
Selective serotonin reuptake inhibitor
(SSRI)
Dose (mg)
Fluoxetine (Prozac) 20-60
Sertraline (Zoloft) 50-200
Fluvoxamine (Luvox) 50-300
Escitalopram (Lexapro) 10-20
others
Dose(mg)
Venlafexine (Efexor XR) 75-150
Mirtazapine (Remeron) 15-45
Moclobomide (Aurorix) 300-600
Duloxetine (Cymbalta) 60-90
Side-effects : TCA
Anti-cholinergic
Dry mouth, blurred vision, tachycardia,
glaucoma, constipation, urinary retention,
sexual dysfunction, cognitive impairment
Anti-adrenergic
Drowsiness, postural hypotension, sexual
dysfunction
Anti-histaminic
Drowsiness, weight gain
Membrane-stabilising properties
Cardiac conduction defects, cardiac
arrythmia, epileptic seizures
Others
Rash, oedema, elevated liver enzymes
Side-effects : SSRI
Gastrointestinal
Nausea, dry mouth, diarrhoea, constipation,
dyspepsia, bloating, flatulence
Uncommon: vomiting, weight loss
Central nervous system
Headache, insomnia, dizziness, anxiety,
fatigue, tremor, somnolence
Others
Sexual dysfunction
Anxiolytic
Lorazepam, alprazolam
Hypnotic
diazepam, midazolam, zolpidem
Electroconvulsive therapy
Indication
High risk of suicide
Depressive stupor
Danger to physical health ( not drinking
enough to maintain adequate renal
function)
Postpartum depression
Unsuccessful medication
Psychological
Supportive psychotherapy
Dynamic psychotherapy
Cognitive therapy
BIPOLAR MOOD DISORDER
Bipolar I
manic episode + depressive episode
Bipolar II
hypomanic episode + depressive episode
Manic episode
Distinct period of abnormally and
persistently elevated, expansive or irritable
mood, lasting at least one week
3 or > of following symptoms have
persisted
Inflatedself-esteem or grandiosity
Decreased need for sleep
More talkative than usual, pressure to keep
talking
Flight of ideas
Distractibility
Increase in goal-directed activity /
psychomotor agitation
Excessive involvement in pleasurable
activities that have a high potential for painful
consequences (eg: engaging in unrestrained
buying sprees, sexual indiscretions, or foolish
business investments)
The mood disturbance is sufficiently
severe to cause marked impairment in
occupational functioning or in usual social
activities or relationship with others, or to
necessitate hospitalization to prevent harm
to self or others, or there are psychotic
features
PNEMONIC
D istractability
I ndiscretion
G randiosity
F light of ideas
A ctivity increased
S leep deficit
T alkativeness
Mental state examination
General description
exited,talkative, overfriendly, sometimes amusing
excessive make-up, bright clothing
Perceptual disturbance
75% has delusion
Grandiose, a/w great wealth, extraordinary abilities or
power
Thought
Flight of ideas
Impaired judgement
Poor insight
Hypomanic episode
A distinct period of persistently elevated,
expansive, or irritable mood, lasting
throughout at least 4 days, that is clearly
different from the usual nondepressed
mood
Not severe enough to cause marked
impairment in social or occupational
functioning, or to necessitate
hospitalization and no psychotic features
Management
Acute manic episode
- antipsychotic + mood stabilizer
Prophylaxis
- mood stabilizer
Mood stabilizer
Lithium
Anticonvulsant
Sodiumvalproate (Epilim)
Carbamazepine (Tegretol)
Atypical antipsychotic
Olanzapine (Zyprexa)
Quetiapine (Seroquel)
Dose
- depends on the plasma level
Lithium
Start with 200mg bd, check level after 5-7
days
Acute phase: 0.8-1.2 mmol/l
prophylaxis : 0.6-0.8 mmol/l
Sodium valproate
Start with 200mg – 400mg bd, check level after
3-5 days
Plasma level: 50-100mg/l
Carbamazepine
Start with 200mg bd until 600-1000 mg/day
Paras plasma: 8-12mg/l
Side-effects
Lithium
Acute: tremor, diarrhoea, nausea and
vomiting.
chronic: hypothyroidism, impaired renal
function
Sodium valproate
Sedation, tremor, weight gain
Carbamazepine
Nausea and vomiting, rashes, sedation,
neutropenia
Steven-Johnson’s syndrome
DYSTHYMIA
Depressed mood for most of the day, for at
least 2 years
Presence while depressed, of 2 or > of
following
1) poor appetite or overeating
2) insomnia or hypersomnia
3) low energy or fatigue
4) low self-esteem
5) poor concentration or difficulty making
decisions
6) feelings of hopelessness