Anne Washington Derry (1927) Oil on canvas by Laura Wheeler Waring(1887 - 1948)

1. 1st CME Mood Disorders Anne Washington Derry (1927) Oil on canvas by Laura Wheeler Waring(1887 - 1948)

2. Assumption No dichotomy between mind and body/ mind and brain All mental processes, even the most complex psychological processes, derive from operations of the brain. The central tenet of this view is that what we commonly call mind is a range of functions carried out by the brain. (Kandel, 1998) René Descartes: Res Cogitans VS Res Extensa (1596 - 1650)

3. Biopsychosocial model Engel (1977) Biological factors Psychological factors Social factors

4. Mental Status Examination • Appearance(hygiene, dressing) • Behavior(psychomotor acitivity) • Cooperation/ Attitude • Speech(to much, dysartric, disorganized, prosody) • Thought Process/Form (Circumstantiality, Tangentiality, flight of ideas, Idiosyncracies, loose of association) • Thought Content (delusions, obsessions) • Perceptions(illusion, hallucinations) • Mood and Affect • Insight and Judgment • Cognitive Functioning and Sensorium

5. Disorders Major Depression Dysthymia Bipolar I Biploar II MDD (Postpartum) Prevalence 4.9% 3.2% 0.8% 0.5 13% Mood Disorders: Prevalence

6. Kenian Data

7. Our data Depression longer: 18,6 months = 1,5 years Association with gastric pain and headache

8. Mood Disorders (DSM-IV) • Depressive Disorders -Major Depressive Disorder -Dysthymic Disorder -Depressive Disorder, Not otherwise specified • Bipolar Disorders -Bipolar I Disorder -Bipolar II Disorder -cyclothymic Disorder

9. 1) Major Depressive Disorder

10. Diagnostic Criteria for Major Depressive Episode: • 5 of following symptoms, must include one of first two, occurred almost every day for two weeks • Depressed mood • Pleasure or interest/ Loss • Appetite • Sleep disturbance, too much or too little • Agitation or retardation • Fatigue • Feelings of worthlessness or guilt • Difficulty concentrating or deciding • Recurrent thoughts of death, suicide

11. C) Significant distress or impairment in social, occupational or other important areas of functioning D) Exclusion effect of: • Substance: drugs, medications (benzo- diazepines, beta-blockers, narcotics and steroids • general medical condition (es. Hypothyroidism, diabetes, cancer) E) Not better account by a bereavement (only after 2 months or with marked impairement)

12. Other sintoms of depression • Mood irritable • Less libido • Somatic complains: persistent pain, strange sensation in the head like warms, insects • Diziness, fainting, loose of memory • Paranoid ideas (persecution) gastrits, headache, backpain DSM modified criteria for Sub-saharian Africa (Berstchy et al., 1992)

13. MDD, Single episode 1 major depressive episode Absence of mania or hypomania MDD, Recurrent 2 major depressive episodes, separated by at least a 2 month period with more or less normal functioning/mood Major Depressive Disorder

14. Major Depressive Disorder: Etiological Theories • Biological (genetic, brain structures, neurotransmitters) • Behavior and cognition • Emotion • Social and cultural factors • Developmental factors • Life events 30 % Genetic power

15. Depression is a sistemic disorder

16. BIOLOGICAL BASIS 5HT - NE- DA neurotrasmettitorial HPA - HPT hormonal NK - IL immunological neurotrophic BDNF - NGF Mood depression

17. Major Depression - Treatment • Farmacotherapy: Antidepressants • Psychotherapy (Behavioural,Cognitive, interpersonal, dinamic) • Electroconvulsive therapy (ECT) • Vagal Nerve Stimulation Combined!

18. Preliminary assessment Identified patients at risk: • family or personal history of depression • multiple medical problems • unexplained physical symptoms • chronic pain • use of medical services that is more frequent than expected • Trauma or hard life events Sex: + F + Middle Age

19. Have you been consistently depressed or down, most of the day, nearly every day, for the past 2 weeks? NO YES • In the past 2 weeks, have you been much less interested in most things or much less able to enjoy the things you used to enjoy most of the time? NO YES • Screen for Depression if at least one of this 2 item is code yes

20. Preliminary assessment • Exclude organic illness (Hypothyroidism, diabetes, cancer, neurological disease) • Exclude Substance abuse disorder • Medical and psychiatric history • Physical and neurologic examination • Mental status assessment

21. Ask for suicidality!!! • C1 Think you would be better off dead or wish you were dead? NO YES1 • C2 Want to harm yourself? NO YES2 • C3 Think about suicide? NO YES6 • C4 Have a suicide plan? NO YES10 • C5 Attempt suicide? NO YES10

22. 1° steps • Information • Empathetic listening • Reassurance • psychological support (e.g. problem solving counselling) • referral to relevant social services and resources in the community.

23. When to use antidepressants? • moderate to severe major depression • functional impairment • Long duration of illness/ Remittent course • Severe somatic complains / concomitant chronic ilness • Alcol or substance abuse • Familiarity for mood disorders • Psychotic sintoms

24. Antidepressants Effective in around 60% of patients 3 weeks: improving/ 6-8 weeks full therapeutic effect. • Amitriptyline 50 mg NOCTE: gold standard 2) Fluoxetine 20 mg OD Explain! Contraindications Not tollerate side effects

25. Amitriptyline *If Severe Depression start with 50 mg: -25 mg 1° week - 50 mg 2° week Start with: 25 mg NOCTE 1/12 * 2 weeks If problem to review soon Monitoring acute treatment Psychological counseling 4-6 weeks Evaluation of response to treatment Remarkable emprouvement Light emprouvement NO emprouvement Long term therapy at least 6-8 months + 25 mg every week (max: 200 mg) Change antidepressant Refer Psychiatrist

26. Amitriptyline Contraindication: : Pregnancy and breast feeding, Glaucome, hyperthyroidism, prostatic hypertrophy, Stenosis pillorica, heart failure, serious rhythm disturbances, Hypotension, treatment with thyroid ormons, liver diseases, Dementia. Inform patients about side effects - Dosage in elders

27. Fluoxetine *Better 10 mg 1° week 20 mg 2° week Administer in morning or after lunch Start with: 20 mg die 1/12 * 2 weeks Monitoring acute treatment Psychological counseling 4-6 weeks Evaluation of response to treatment Remarkable emprouvement Light emprouvement NO emprouvement Long term therapy at least 6-8 months + 10 mg every week (max: 40-60 mg) Change antidepressant Refer Psychiatrist

28. Fluoxetine Contraindication: Pregnancy and breast feeding, Hypersensibility

29. Bipolar Disorders • Bipolar I Disorder • Bipolar II Disorder • Cyclothymic Disorder

30. Hypomanic Episode: Diagnostic Criteria • A distinct period (at least 4 days) of abnormally and persistently elevated, expansive, or irritable mood. Different from usual non depressed mood. • Mood disturbance plus three of the following symptoms (four if the mood is only irritable): • Inflated self esteem or grandiosity • Decreased need for sleep • More talkative than usual or pressure to keep talking • Flight of ideas, or racing thoughts • Distractibility • Increase in goal directed activity • Excessive involvement in pleasurable activities C. Unequivocal change in functioning that is uncharacteristic of the person when is not sintomatic D. Disturbance in mood and the change in functioning are observable by others E. Not organic Disease or substanec

31. Manic episode: Diagnostic Criteria • All the criteria of a Hypomanic episode plus: • Marked impairment(psychotic sintoms, explosive behaviour, high social-occupational disfunction, hospitalisation)

32. Bipolar I Alternation of full manic and depressive episodes Average onset is 18 years Tends to be chronic High risk for suicide Bipolar II Alternation of Major Depression with hypomania Average onset is 22 years Tends to be chronic 10% progess to full biploar I disorder Bipolar Disorder Sex: + M Genetic power: 80% High familiarity

33. Our data

34. Major Depressive Episode in Bipolar 2 Mood Stabilizers + 200 mg every week Controindication: serious liver, kidney, heart disease, history of aplasia, pregnancy Monitoring after 2 and 6 weeks If effetictive: long term therapy: at least 2 years Not effective: + dosage or add an antidepressant hepatic enzyme induction.

35. Carbamazepine *If Severe Depression start with 400 mg: -200 mg 1° week - 400 mg 2° week Start with: 200 mg NOCTE 1/12 * 2 weeks If problem to review soon Monitoring acute treatment Psychological counseling 4-6 weeks Evaluation of response to treatment Remarkable emprouvement Light emprouvement NO emprouvement - Add an antidepressant - Refer Psychiatrist if no emprouvement Long term therapy at least 2 years + 200 mg every week (max: 800 mg)

36. Before and during carbamazepine therapy, monitoring: • full blood count • liver and renal function tests • pregnancy test. If not feasible • Regularly medical examination, • recent medical history that may help rec- ognize symptoms suggesting the development of blood or renal or hepatic abnormalities.

37. Questions to do • Have you ever had a period of time when you were feeling 'up' or 'high' or ‘hyper’ or so full of energy or full of yourself that you got into trouble, or thatother people thought you were not your usual self? Have you ever been persistently irritable, for several days, so that you had arguments or verbal or physical fights, or shouted at people outsideyour family? Have you or others noticed that you have been more irritableor over reacted, compared to other people, even in situations that you feltwere justified? (Do not consider times when you were intoxicated on drugs or alcohol.)

38. Hypomanic Episode (Bipolar 2 ) • ACUTE TREATMENT: Haloperidol 5-10 mg nocte PO + Carbamazepine 200 mg nocte • LONG TERM TREATMENT: Continue only with Carbamazepine (see 2a) (see 2a) Resolution of Hypomanic Episode

39. Manic Episode (Bipolar 1 ) • ACUTE TREATMENT: Haloperidol 10 mg IM or Chlorpromazine: 150-200 mg IM POST-ACUTE TREATMENT: Haloperidol 5-10 mg Nocte PO + Carbamazepine (see 2a) • LONG TERM TREATMENT: Carbamazepine (see 2a); if not enough add Haloperidol 5-10 mg Nocte PO Untill patient can not be managed PO Resolution of Manic Episode

40. Bipolar 1 Manic Episode ACUTE: • Haloperidol 10 mg IM • Clorpromazine: 150-200 mg IM LONG TERM: • Haloperidol 5-10 mg PO nocte

41. Asante sana for your attention Utopia lies at the horizon. When I draw nearer by two steps, it retreats two steps. If I proceed ten steps forward, it swiftly slips ten steps ahead. No matter how far I go, I can never reach it. What, then, is the purpose of utopia? It is to cause us to advance.” Eduardo Hughes Galeano For any suggestion: jean.84@libero.it 0735525429