Mood disorder - Differential Diagnosis & Management
Differential Diagnosis
Step 1 - exclude a disorder with known organic cause. e.g. mood disorder, dementia etc.
Step 2 - rule out possibility of acute & transient psychotic disorders, schizophrenia, schizo-affective disorder
Step 3 - exclude possibility of other non-organic psychoses like delusional disorder
Step 4 - exclude the possibility of adjustment disorder with depressed mood, generalised anxiety disorder, normal grief reaction, ocd.
look for co-morbid medical and/or psychiatric disorders
Management
Somatic Treatment
Psychosocial treatment
Antidepressants
treatment of choice for vast majority of depressive episodes
e.g. Agomelatin, Amitriptyline, Amoxapine, Bupropion,Citalopram, Clomipramine etc.
can take 3 weeks before any appreciable response can be noticed. Before stopping/changing the drug it should be given in a therapeutically adequate dose for atleast 6 weeks
TCAs ( Tricyclic antidepressants) - Imipramine, amitriptyline & other related drugs come under this
SSRI (Selective serotonin reuptake inhibitors)- fluoetine, sertraline, citalopram, mirtazapine
SNRI ( serotonin norepinephrine reuptake inhibitors) - venlafaxine, duloxetine have little anticholinergic side effects and are safer to user in elderly patients
Electroconvulsive therapy (ECT)
3 main phases of treatment
Acute - till remission occurs
Continuation treatment - from remission till end of treatment
Maintenance - to prevent further recurrences
may be indicated in following patients
Partial response to acute treatment
poor symptom control during continuation treatment
more than 3 episodes
more than 2 episodes with early age of onset/recurrence within 2 yrs of stopping antidepressants
chronic depression (>2 yrs)/double depression
indications
severe depression with suicidal risk
severe depression with stupor, sever psychomotor retardation/somatic syndrome
severe treatment refractory depression
delusional depression
presence of significant antidepressant side effects/intolerance to drugs
can be used for acute manic excitement
antidepressants are also required alongwith ECT
Lithium
traditional drug of choice for treatment of manic episode (acute phase)/prevent bipolar mood disorder
common chronic side effects are nephorlogical and endocrinal
Antipsychotics
commonly used drugs - ROTOR
Risperidone
Olanzapine
queTiapine
halOperidol
aRipiprazole
customary to use atypical antipsychotics
indications
Acute manic episode
delusional depression
alongwith mood stabilisers, before the effect of mood stabilisers become apparent
where mood stabilisers are not effective or have significant side-effects
given parenterally for emergency treatment of mania
atypical antipsychotics might have some mood stabilising properties
customary to user atypical antipsychotics - LESS (oLanzapine quEtiapine riSperidone zipraSidone)
Other mood stabilisers
sodium valproate
carbamazepine & oxcarbazepine
Benzodiazepines
Lamotrigine
T3 and T4
GABRIEL (Group psychoAnalytic cognitiveBehaviouR Interpersonal bEhaviour famiLy) Therapy
Interpersonal Therapy
Psychoanalytic Psychotherapy
Behaviour Therapy
Group Therapy
Family and Marital Therapy
Cognitive Behaviour Therapy
aims at correcting depressive negative cognitions like hopelessness, worthlessness etc. useful in mild to moderate, non-nipolar depression. can be used with/without somatic treatment
attempts to recognise & explore interpersonal stressors, role disputes & transitions. useful in treatment of mild to moderate unipolar depression with/without antidepressants
this is short-term and aim at changing the personality itself. usefulness is uncertain
includes the various short term modalities such as social skills training, problem solving training and so on. useful in mild cases of depressions
useful in mild cases of depression.
main use is for family to be educated. However they are of little use in treatment of mood disorders