Affective Disorders (Mood Disorders)
They are also known as temperament disorders.
1. Depression
2. Dysthymia (mild depression with symptoms persisting for at least 2 years)
3. Bipolar disorder (mania + depression)
4. Cyclothymia (mild mania + mild depression)
Schizoaffective disorder, in which schizophrenia and mood disorder coexist, is not classified here, but among psychotic disorders.
Complete criteria for Major Depression according to DSM 5
A. At least 5 of the following 9 symptoms must be present during the two-week period
• At least one symptom must be depressed mood or loss of interest.
1. Depressed mood throughout the day
2. Decreased interest and desire throughout the day
3. Weight gain or loss
4. Sleep less or too much each day
5. Psychomotor retardation or agitation every day
6. Fatigue, exhaustion, loss of energy every day
7. Every day thoughts of worthlessness or inappropriate guilt
8. Decreased concentration of thought and attention on one subject each day
9. Recurrent thoughts with death, suicidal.
B. Complaints must cause social and occupational impairment
C. Findings should not be related to substance use
• Cancers (pancreas, breast, lung, head and neck cancers)
• Parkinson's disease
• Thyroid diseases
Psychotic Depression
• Psychotic findings may be seen in severe depressions.
• There may be feelings of worthlessness- guilt, persecutory delusions, nihilistic delusions, and hallucinations compatible with the mood.
• Rarely, there may be psychotic findings incompatible with mood.
• If there are psychotic symptoms, antipsychotic drugs are used together with antidepressant drugs.
• When the depression improves, the psychotic symptoms also disappear.
Differential diagnosis
• Bipolar disorder
• Grief (Self-esteem is not impaired in mourning, thoughts of worthlessness-suicidal thoughts are not expected, there is a lost object)
• Anxiety disorders
• Substance abuse and schizophrenia
• Dementia: Depression patients may complain of forgetfulness due to a decrease in interest and attention to the environment. This picture is called pseudodementia . In such a situation, depression should be treated before dementia can be diagnosed.
Suicide Risk
• 60% of patients have suicidal thoughts.
• 15% of patients die by suicide.
• Some patients with suicidal ideation do not have the energy to attempt suicide.
• Antidepressant medications can lead to increased energy before mood symptoms are fully resolved. For this reason, it is necessary to be more careful in terms of suicide risk in the first weeks of starting antidepressant drugs.
Prognosis
• 75% of patients respond to drug therapy.
Treatment
• Pharmacological treatment - antidepressants
• Psychotherapy and electroconvulsive therapy in severe cases are other treatment options.
• ECT (electroconvulsive therapy) is the most effective treatment. It acts faster than pharmacological treatment.
Antidepressant Drugs
Antidepressants generally increase the effectiveness of monoamines such as serotonin, noradrenaline and dopamine.
Selective serotonin reuptake inhibitors are the first choice in the drug treatment of depression due to their low side-effect profile. (SSRI)
Selective Serotonin Reuptake Inhibitors (SSRI)
Fluoxetine, Fluvoxamine, Sertraline, Paroxetine, Citalopram, Escitalopram are drugs in this group.
Diseases for which SSRIs are the first choice in treatment
• 0 Major depression
• 0 Dysthymia
• 0 Anxiety disorders
• 0 Obsessive compulsive disorder and related disorders
• 0 Trauma and stressor-related disorders
• 0 Premenstrual dysphoric disorder
SSRIs are the most commonly used drugs in psychiatry practice.
The effectiveness of all SSRIs in the treatment of depression is equal.
Receptor interactions and thus side effects are less than tricyclic antidepressants.
They can cause serotonin syndrome when used in very high doses or in combination with MAO inhibitors. There should be a minimum of 15 days between the use of the two drugs.
Findings in serotonin syndrome:
o Diarrhea
o Hyperthermia and excessive sweating
o Severe restlessness and agitation
o Hyperreflexia
o Autonomic dysregulation (fluctuation in vital signs)
o Myoclonias, epileptic seizures
o Delirium, coma
Side effects of SSRIs
Sexual dysfunction
Nausea, diarrhea (sertraline), dyspepsia
Constipation (paroxetine)
QT prolongation
Impairment of platelet functions
Hyponatremia
Serotonin syndrome
Sweating
Tricyclic antidepressants
They are used in depressions that do not respond to SSRI treatment.
Tricyclic antidepressants with preparations in Turkey are amitriptyline, imipramine and clomipramine.
Non-depressive indications of tricyclic antidepressants:
o Enuresis nocturna: Imipramine
o Obsessive compulsive disorder: Clomipramine (the most effective drug in OCD)
o Migraine and chronic pain: Amitriptyline
Due to their anticholinergic side effects, they can cause mydriasis, tachycardia, constipation, and urinary retention.
They cause orthostatic hypotension due to alpha adrenergic receptor blockade.
o They may cause sedation and weight gain due to histamine antagonism.
o They should not be used with MAO inhibitors. (serotonin syndrome)
Other antidepressant
Serotonin-Noradrenaline Reuptake Inhibitors: Venlafaxine, Duloxetine, Milnacipran
Noradrenaline and Dopamine Reuptake Inhibitor: Bupropion (also used in smoking addiction)
Serotonin Receptor Antagonists: Mirtazapine, Mianserin (they cause sedation due to antihistaminic effect), Trazodone (may cause priapism, hypotension due to alpha blockade)
MAO-A inhibitors: Maclobemide
Electroconvulsive Treatment and Usage Areas
Electroconvulsive therapy is performed only under general anesthesia in Turkey.
The most common side effect of electroconvulsive therapy is retrograde amnesia.
It can be applied to pregnant women.
It has no definite contraindications.
1. Depression
The primary indication for ECT is major depression. The most effective treatment method for major depression is ECT.
ECT is usually considered in patients who do not respond to or cannot take medication.
However, the first approach should be ECT in patients who are at high risk of killing themselves or others, are in agitation or stupor, or have nutritional problems.
2. Mania
ECT is as effective as, or even more than, lithium in the treatment of manic episodes:
3. Schizophrenia
ECT is ineffective in chronic schizophrenia.
However, schizophrenic patients with long intervals between attacks may benefit from bilateral ECT during the attack period.
While ECT is effective on symptoms such as delusions of a depressive nature, delusions of control and reference, and catatonia, it is ineffective on first-rank symptoms.
4. Catatonia
5. Malignant Neuroleptic Syndrome (MNS)
6. Other Neuro-Psychiatric Disorders
Although some authors have reported that ECT is used in severe obsessive-compulsive disorder, anorexia nervosa, and chronic pain disorders, these disorders are not usually among the indications for ECT.
ECT is not effective in dysthymic disorder, dissociative disorders, hypochondriasis, conversion disorders, substance use disorders and personality disorders.
7. Delirium
8. Parkinson's Disease
ECT may be useful in Parkinson's disease due to its dopaminergic activity and increase of antiparkinsonian drugs crossing the blood-brain barrier. However, its use is limited due to its temporary effect.
9. Epilepsy
An average increase in epilepsy threshold of 80% in patients treated with ECT indicates that ECT is a potent anticonvulsant. Its use is limited due to its temporary effect.