In the last post we saw that mental health in Nigeria and employment may not be directly related. Stigma in relationships salo lead to single population but this may be attributed to the age of the population of the study we are looking at. We also noted some other neurotransmitters other than serotnin, norepinephrine and dopamin that might be responsible for mood disorders
Welcome to Medic Vibes, where we discuss mental health disorders and make sense of them. Dr. Ebingo Kigigha is a medical doctor (aspiring psychiatrist) and creative person (illustration and music). This has been our routine for two consecutive months. This month will be dedicated to BAD, or Bipolar Affective Disorder. The first month, we discussed Depression, and the subsequent month, anxiety. We'll begin with a discussion of a study, as we did two months ago.
In previous posts, we have introduced the study and discussed previous research describing the characteristics of Bipolar Affective Disorder. In this post, we will continue to discuss the study. This research was conducted in Enugu, Nigeria. About 820 thousand people live in the state of Enugu. Today, we will be continuing with the study's discussions.
Patients who are bipolar have these major depressive episodes and manic episodes. Mood disorders are also called affective disorders 2 months ago, we talked about depression, among the types of depression is Major Depressive Disorder which is otherwise known as unipolar depression.
King Saul's features in the bible, were typical of mood disorders when he would have David play for him in his palace. Hippocrates believed depression was a result of black bile and he called it Melancholic (meaning Black Bile). The first person to describe depression in English text was done by Robert Burton. His book Anatomy of Melancholy dates back as far back as 1621. Emil Kraepelin developed the criteria that is still used for manic-depressive psychosis. It was called folie circularie.
Among all the mood disorders BAD I has the earliest onset. The prevalence of BAD I is equal in men and women. Episodes of mania are seen more in men while depressive episodes occur more in women. Depression appears to have a higher occurrence in rural areas, there is a tendency for schizophrenia to be misdiagnosed by practitioners from a different culture from the patient.
Other Associated Conditions
People who deal with mood disorders are significantly at risk of dealing with alcohol abuse or dependence, anxiety disorders particularly panic, obsessive-compulsive and phobias, particularly for people and socialising. Women particularly have eating disorders when they go through unipolar and bipolar disorders. Biogenic amines affect the concentration and effect of the neurotransmitters at the synaptic cleft. Cholinergic agonists modulate the activities of the pathway between the hypothalamus, Pituitary gland and adrenal gland. GABA inhibits the action of monoamine pathways that ascend especially the mesocortical and mesolimbic.
NMDA receptors bind to a receptor called N- methyl-D-aspartate (NMDA) when there is excess stimulation it leads to toxic effects on the nervous system. This may be because of the effect of glutamate's function in working against neurocognitive decline seen in recurrent severe depression as well as hypercortisolemia. Some drugs that act to synergise with GABA have a noticeable but insignificant antidepressant effect. Patients whose mood disorder is remitting and those that have close relatives have a trait that resembles the sensitivity to cholinergic agonists.
Alterations in Hormone Regulation
There are known documentation about the changes in hormone interplay in the brain and reactions that can be a result of early life stressors. For example, take maternal deprivation, in animal studies, it is known that even one that is for a short period can give rise to an abnormal stress response.
When stress is sustained over a long period, it can give rise to Brain-Derived Neurotrophic Growth factor (BDNF) reduction. What this means is that brain function is altered due to long periods of stress. This can then lead to subsequent cell (Neuronal) death.
Studies done in 2018 have shown that early trauma can lead to increased hypothalamic–pituitary–adrenal(HPA) activity which is followed by cerebral cortex volume depletion and cellular reduction.
Elevated HPA activity is being referred to as a clear feature of mammalian stress and it is a link between depression and the biology of chronic stress. The fact that there is increased cortisol in the bloodstream of those affected by depression suggests that either serotonin tone has become inhibitory, there is a rising drive of norepinephrine or ACh or corticotropin-releasing hormone or the feedback mechanism for hippocampus inhibition is reduced.
This increased HPA activity is seen in 20 to 40% of depressed patients and 40 to 60% of patients who have depression.
The study was done with Urinary Free Cortisol, 24 house intravenous taps for plasma cortisol, cortisol in saliva and a test of feedback inhibition.
The feedback inhibition is done with dexamethasone (0.5 to 2.0 mg) to suppress HPA activity for 24 hours. When cortisol is not suppressed in the morning or it escapes suppression by 4 pm it shows that the inhibition is faulty.
60% of the time cortisol is not suppressed. An improvement of the test is to inject a small dose of the cortisol-releasing hormone after dexamethasone.
This test does not provide a diagnosis for mood disorders because the same results are seen in mania and other psychiatric conditions.
Up to 5 to 10% of those who are depressed usually have a thyroid abnormality, this is seen in the amount of thyroid-stimulating hormone or the fact that there is an abnormally high reaction to 500 mg of hypothalamic neuropeptide thyroid releasing hormone.
Abnormalities of this sort are typically seen when there is antithyroid antibody affectation. If this is not fixed with hormone replacement it might not allow for pharmacotherapy.
There is also a larger group of depressed (20 to 30%) patient that has no response to Thyroid-stimulating Hormone when placed on a Thyrotropin Releasing Hormone test. What is known is that these patients have a higher chance of relapse when placed on antidepressants.
Prolactin is a hormone released in response to serotonin stimulus and inhibited by dopamine stimulus. So far there has not been any major correlation between prolactin and depression. Prolactine stimulation by serotonin can be halted by serotonin agonists.
Discussions (Demographics Part 2)
One of the factors that can affect the financial state of those affected by BAD is the health-seeking behaviour of the patient. Almost all patients sort for help when the condition started. 51.3% looked for psychiatrists, 36% met herbalists or native doctors and hoses of prayer.
Gureje et al 2006 note that Nigerians do not typically behave this way when it comes to health seeking in mental health. However, it is worthy of note that in this study most of the patients who were sorted out were those who presented themselves. Also, most patients in the southeast pay out of pocket for health care as the National Health insurance only covers those who are employed.
The other issues that those who seek treatment may have on psychiatry are stigma, access, poverty and the belief that mental health is more spiritual than physical. Razali and Najib 2000 confirmed this to be the case in developing counties.
These same factors are also the reason why those who have mental health issues are maltreated. An example is a physical abuse when a patient has manic symptoms. Close to 50% of the patients in this study were either beaten or made to wear chains. Some of these patients are locked up in rooms and others were put in prisons.
Cognitive Behavioural Therapy was first developed by Aron beck, but now late (however his family still teaches his doctrines) puts more energy on the distortions that are brought about by cognition in major depression. The features of these distortions are focused on the negative aspects of a problem, the unreal negative results of an action.
The reason a patient is so apathetic and does not try is that they expect that they will fail.
The goal of CBT is to stop the current depression and prevent it from happening again by helping to point out negative thought patterns and put them to the test. The patient is thought to bring out alternatives, let go of negative thought patterns and practice positive thinking and reactions.
Studies have shown that this form of therapy is effective in dealing with major depression. Many studies have also seen that CBT Is equally effective as drugs and the follow-up rate is even better. The most effective treatment method however is the use of both treatment methods but to be frank it was not all studies that saw this effect.
One study by the NIMH Treatment of Depression Collaborative Program saw that pharmacotherapy alone or with CBT was the best for Major depression.
Dysphasia, one of the most difficult language disorders to treat.
In this post @estheffcr talks about the speech disorder that Dysphasia is. In it she talks about CBT as a means of treatment.
Read this post here
- What did you learn about mood disorders?
- What did you learn about Bipolar disorder?
- What's the most interesting aspect of this study?
There may be some hormonal interplay in mood disorders, we looked at cortisol, thyroid hormone, prolactin and growth hormone. We have also seen that CBT is a very effective form of therapy for major depression especially.
I hope that you learned a lot from this post.
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