Psychopharmacology: Affective Disorders

D. Depressive stupor

Depressive stupor (D) is a rare presentation of depressive disorder. It can be characterized by mutism and akinesis (lack of movement). Depression with severe psychomotor retardation can lead to dehydration and pressure sores and should be treated urgently. Seasonal affective disorder (A) is characterized by the same psychiatric and biological symptoms that depressive patients face but is associated with the change of season. Depression will be worse in autumn and winter but will usually resolve in the warmer months. Patients may experience a lack of energy, difficulty waking in the mornings and overeating. Dysthymia (B) consists of chronic low grade mood symptoms not amounting to a depressive illness. Symptoms of atypical depression (C) are the opposite of what is experienced in conventional depression. Patients may have symptoms such as weight gain, increased appetite and hypersomnia. Post-partum depression (E) indicates a depressive disorder that appears after giving birth.

C. Dysthymia

Dysthymia (C) is defined as a chronic low grade mood disorder. Symptoms are not severe enough for a diagnosis of depressive episode although discrete episodes of depression may occur in addition. For a diagnosis of a depressive episode (A), at least one core symptom (low mood, anhedonia and anergia) must be demonstrated for a minimum period of 2 weeks. The grade of depression can be classified as mild, moderate or severe, depending on the number and severity of symptoms. Recurrent depressive disorder (B) is associated with repeated episodes of depression but between episodes the patient is euthymic. Cyclothymia (D) is diagnosed where there is persistent instability of mood with a cycle of low grade elevated and depressed mood. This can be differentiated from bipolar affective disorder (E) which is characterized by discrete episodes of mania or hypomania which may or may not be accompanied by episodes of depression.

D. Stroke

Stroke (D) is a major risk factor for the development of depression and occurs in approximately 30 per cent of patients. The patient has significant risk factors for cerebrovascular disease in terms of his longterm history of smoking and hypertension. Multiple sclerosis (A) is sometimes associated with depression or elevation of mood. Depression is common in Parkinson’s disease (B) but may be missed due to the overlap of symptoms. Depression may be the presenting complaint in patients with Huntington’s disease (C), preceding all other symptoms of this neurodegenerative condition. Disability due to spinal cord injury (E) is associated with depression, which may stem from physical factors such as chronic pain, or psychological factors such as loss of independence.

B. Addison’s disease

The most likely cause is Addison’s disease (B), caused by adrenocortical insufficiency. Symptoms include fatigue, joint/muscle pain in the legs, skin tanning and hyponatraemia and hyperkalaemia. As well as the biological symptoms of Addison’s disease, the condition may present as depression with other manifestations of the disease appearing later. Cushing’s disease (A) results in high circulating cortisol levels and is associated with irritability, aggression and depression. Signs and symptoms of Cushing’s include centripetal obesity, cervical fat pads, plethoric facies and bruising. Signs and symptoms of hypothyroidism (C) include cold intolerance, bradycardia, weight gain and depression. Hypothyroidism can also mimic depression with symptoms such as forgetfulness, low energy and an inability to concentrate. Primary hyperparathyroidism (D) results in an increased production of parathyroid hormone as well as an elevated blood calcium level, leading to the symptoms of moans (depression), groans (abdominal symptoms), stones (kidney stones) and bones (osteoporosis). Premenstrual tension syndrome (E) (menstrual cycle disorders), is characterized by low mood, irritability and stress, associated with alterations in the balance of sex hormones.

D. Brucellosis

Brucellosis (D) is a contagious zoonosis transmitted via unpasteurized goat’s milk or contact with infected animals. The infection induces fevers, headaches, fatigue, pain and depression. Hepatitis C (A) is a viral infection transmitted by intravenous drug use, sexual contact and exposure to infected blood products. As well as the generalized symptoms of fever, appetite loss and nausea, depression can ensue. It is hypothesized that the association with depression may be a due to a direct effect of the virus on neuronal pathways. Infectious mononucleosis (B), a viral disease caused by the Epstein–Barr virus, is characterized by symptoms such as fever, sore throat, fatigue and depression. Herpes simplex (C) infection may sometimes cause depressive symptoms. Syphilis (E) is a sexually transmitted disease that may lead to neurological involvement. Neurosyphilis is associated with several psychiatric conditions including psychosis, dementia, mania and depression.

B. Systemic lupus erythematosus (SLE)

SLE (B) is a multiorgan autoimmune disease associated with anti-nuclear antibodies. The classic manifestation is joint pain and a butterfly shaped malar rash on the face. Neurological involvement can cause headaches, seizures and/or depression. Depression is commonly associated with pancreatic cancer (A) and low mood is sometimes the first symptom of this condition. Rheumatoid arthritis (C) is a chronic inflammatory condition with primarily small joint involvement sometimes associated with depression. Patients do not usually develop a rash. In porphyria (D) there is a deficiency of enzymes in haemoglobin metabolism. Neurological involvement can cause anxiety, hallucinations and/or depression. Patients usually present with abdominal rather than joint pain. Pellagra (E) is caused by deficiency of vitamin B3 (niacin). Sensitivity to sunlight predominates the symptom cluster, which includes dementia and diarrhoea.

A. Methyldopa

Corticosteroids (D) such as prednisolone, hydrocortisone and dexamethasone are associated with mania but may also cause depression. The side effects of methyldopa include depression, suicidal ideation and nightmares. Some beta-blockers which cross the blood–brain barrier, such as propranolol, may cause depression but atenolol (B) does not. Ibuprofen (C) is a non-steroidal anti-inflammatory drug and is rarely associated with depression. Amlodipine (E) is a calcium-channel blocker, indicated for the treatment of hypertension. Depression is an occasional side effect of calcium channel blockers.

D. Hypothyroidism

Hypothyroidism is associated with fatigue, weight gain and cold intolerance. On examination the patient may be bradycardic and have slow-relaxing reflexes. Low circulating thyroxine is associated with depression and should be further investigated with thyroid function tests (D). Cushing’s disease (A) may be associated with depression (and other psychiatric disorders) and is characterized by centripetal obesity, cervical fat pads, plethoric complexion and bruising, but not cold intolerance or bradycardia. Hypocalcaemia (B) is rarely associated with depression. Addison’s disease (C) can be associated with depression but not cold intolerance or bradycardia. Diabetes mellitus (E) can be associated with depression but would usually be associated with weight loss in a woman of this age.

A. Hypomania

Hypomania (A) is associated with elevated mood (elation) and/or irritability which interferes with activities of daily living but is not severely disruptive or associated with psychotic symptoms. Mania (B) occurs over a time-course of at least a week and is defined by a significantly elevated mood which has a noticeable effect on work and social activities and is often associated with psychotic features (mood-congruent delusions and/or hallucinations). Cyclothymia (C) is persistent instability of mood, not a discrete episode. Agitated depression (D) may present with an irritable mood and anxiety, but not elation. A diagnosis of bipolar affective disorder (E) can be made if there has been a history of two more affective episodes at least one of which must include elevated mood.

D. Pressure of speech

Pressure of speech (D) in mania is the result of pressure of thought. The speech of a patient become increasingly difficult to interrupt as the patient wants to portray all of his/her thoughts. Speech is rapid and is worse with increased severity of mania. Manic patients may have an elevated mood (A) which may manifest as being over-cheerful or irritable. Manic patients find it difficult to maintain focus on one thing which leads to poor concentration (B). Flight of ideas (C) occurs when patients thoughts move from topic to topic, although there is usually a connection between the ideas. Mania often leads to impaired judgement (E).

B. Lyme disease

Lyme disease (B) is an infectious disease caused by bacteria belonging to the genus Borrelia, transmitted to humans via tick bites. Early symptoms will include fever, headache, fatigue and mood changes. An expanding rash known as erythema chronicum migrans (bulls eye rash) appears at the site of the tick bite and is strongly suggestive of the diagnosis. People with HIV (A) infection may develop manic symptoms. Symptoms of encephalitis (C) may include headache, fever and confusion, hallucinations, cognitive decline and mania. Neurosyphilis (D) is a sexually transmitted disease, associated with several psychiatric conditions including psychosis, mania and depression. People with meningococcal septicaemia (E) are acutely unwell and have a generalized erythematous rash.

A. Anergia

The three core features of depression are anergia (loss of energy) (A) anhedonia (loss of enjoyment) and low mood. At least one feature must be present for at least 2 weeks. Biological features include change in appetite (C) and weight, change in sleep pattern (classically waking early (E)), loss of libido and diurnal variation of mood (B), where the mood is worse in the morning. Psychological features of depression include feelings of guilt, hopelessness, and suicidal ideation (D).

C. Mirtazapine

Mirtazapine (c) is a noradrenergic and specific serotinergic antidepressant with a tetracyclic structure. Mirtazapine is often used second line. It differs from SSRIs (A, B, D, E) in that it does not usually cause nausea or weight loss and induces sleep.

E. Social isolation

Risk factors for depression include having a family history, female gender (B), childhood abuse, poverty and social isolation (E). Being older (D) does not increase risk of depression and higher education may be protective (A). Obesity (C) is a risk factor for dementia but not depression as such.

A. The bank has said I’m bankrupt and are going to sell all my clothes

Psychosis is an infrequent complication of depression although may be seen quite commonly in psychiatric settings. Delusions in depression are usually ‘mood congruent’, i.e. are understandable in the context of being depressed. Examples include delusions of poverty or low self-worth (A). Delusions in mania are frequently grandiose (B). Bizarre delusions, especially with passivity (C) or thought alienation, are suggestive of schizophrenia. Option (E) is suggestive of de Clérembault’s syndrome which usually occurs in mania or schizophrenia, rarely depression. It is important to distinguish delusions from non-delusional ideation (D) which is not held with subjective certainty.

C. Previous suicide attempt

Approximately 1 per cent of people who attempt suicide will kill
themselves in the following year making this (C) the most significant risk factor. Suicide is always more common in men (A). Although rates used to rise in older age (B), more recent data suggest this is no longer a risk factor. Unemployment (E) is associated with increased risk but obsessive– compulsive disorder (D) may be protective

B. Nihilism

Nihilism (B) is a psychological feature of depression characterized by an overwhelming feeling of hopelessness and negativity which may amount to delusional intensity. Other psychological features include persistent low mood, loss of enjoyment (anhedonia), hopelessness, guilt, poor concentration, irritability, low self-esteem, and suicidal thoughts. Diurnal variation of mood (A) where the patient usually feels worse in the morning is regarded as a biological feature as are loss of libido (C), and changes in appetite (D) and sleep (E).