3 - Affective/Mood Disorders Flashcards
What is a mood disorder and some examples of these disorders?
Mental health problem that primarily affects someones emotional state
It is a disorder in which a person experiences long periods of extreme happiness, extreme sadness, or both
Examples: Depression, Bipolar, SAD, Dysthymia
What is the epidemiology of depression?
Fourth cause of disability worldwide with 5.8% of men and 9.5% women experiencing an episode in a 12 month period
300 million people at any given time
Accounts for a third of GP consultations
What are some risk factors for depression?
- Chronic conditions
- History of depression or other mental health illness
- Female sex
- Medication (e.g. corticosteroids)
- Older age
- Recent childbirth
- Psychosocial issues (e.g. unemployment, homelessness)
- Genetic factors
- History of childhood abuse
- History of head trauma
What are some of the symptoms of depression?
- Low mood
- Loss of interest or pleasure in daily life
- Fatigue
- Loss of concentration
- Psychomotor retardation/agitation
- Poor appetite
- Disrupted sleep
- Decreased libido
- Suicidal ideation
How is a diagnosis of depression made?
- Must be 2 core symptoms for at least 2 weeks: Low mood and Little enjoyment/interest in things
- Must then have 2 typical/biological symptoms: Poor appetite, fatigue, disrupted sleep, psychomotor agitation or retardation, decreased libido, low concentration, feelings of worthlessness, suicidal ideation
How do you classify the severity of depression?
- Mild: few or no extra symptoms beyond the five to meet the diagnostic criteria
- Moderate: symptoms and impairment between mild and severe
- Severe: most or all the symptoms (see above) causing marked functional impairment with or without psychotic features
What is sub threshold depression?
- Subthreshold depressive symptoms: patients with a number of depressive symptoms not meeting the criteria described above
- Persistent subthreshold depressive symptoms: subthreshold depressive symptoms that persist for two years or more.
What are some depression questionnaires validated for use in primary care?
- PHQ9
- HADS
- BDI-II
What investigations should you do for someone you suspect is suffering from depression?
Need to do Ix to rule out secondary causes
- FBC
- LFTs
- Bone profile
- HbA1c
- Thyroid function tests
- Serum cortisol
- B12 / folate
- Syphilis serology
What are some differentials for depressive symptoms?
(Medical and Psychiatric differentials)
- Bipolar
- Anxiety
- Substance misuse
- Sleep disorders
- MS
- Dementia
- Adjustment disorder
- Hypothyroidism
- Cushing’s
- Pancreatic cancer
- Drug SE’s e.g steroids, isotretinoin
What is adjustment disorder and how can you differentiate it from a major depressive episode?
“Subjective distress and emotional disturbance that interferes with social functioning and would not have arisen without a stressor”
Similar symptoms but lasts <6 months and has a cause e.g death of loved one, terminal illness, divorce, loss of job
Usually needs no treatment with antidepressants
How is depression managed in general terms?
- Assess suicide risk
- Biopsychosocial model: Antidepressants, Rule out secondary causes, CBT, Sleep hygiene, Follow up
How do you assess suicide risk?
Ask the person:
- Do you have thoughts about death or suicide?
- Do you feel that life is not worth living?
- Have you made a previous suicide attempt?
- Is there a family history of suicide?
If the answer to any of these questions is yes, ask about their plans for suicide:
- Have you considered a method?
- Do you have access to the materials?
- Have you made any preparations (for example, written a note)?
Also ask about any protective factors, for example:
- What keeps you from harming yourself?
- Is there anything that would make life worth living?
Identify risk factors that increase the risk of suicide:
- Previous suicide attempts or self-harm.
- Active mental illness.
- Family history of mental disorder, suicide or self-harm.
- Male gender.
- Being unemployed.
- Physical health problems.
- Living alone.
- Being unmarried.
- Drug/alcohol dependence.
- Feelings of hopelessness.
- Exposure to suicidal behaviour
- Occupation
After assessing suicide risk, what do you do if someone is high or low risk?
High risk: Refer urgently to specialist secondary care mental health services
Low risk: Create safety plan in case it deteriorates
How do we treat depression based on the severity?
Encourage all people to do physical activity e.g yoga and address co-morbid issues e.g alcohol and smoking
Mild or Persistent Subthreshold:
- Low intensity psychological interventions
- Antidepressants: Only in those who fail above or previous history of depression
- Sleep Hygiene
- Follow up: 2 weeks
Moderate-Severe
- High Intensity Psychological Intervention PLUS
- Antidepressants
- Sleep hygeine
- Follow up: Within 1 week of starting SSRI then weekly for a month
What are some examples of high and low intensity psychological interventions?
Low Intensity
- Guided self help e.g Headspace, books, websites
- Group CBT
- Computerised CBT
High Intensity
- Individual CBT — usually given over 16–20 sessions over 3–4 months.
- Interpersonal therapy
- Behavioural activation
- Couples therapy — usually consists of 15–20 sessions over 5–6 months.
What are some sleep hygiene tips?
Sleep environment.
- Not too hot, cold, noisy, or bright.
- The bedroom should only be used for sleep and intimacy.
- Checking or watching the clock throughout the night should be avoided.
- Avoid phones 2 hours before bed because of blue light
Regular sleep schedules
- Waking up and getting out of bed at the same time every morning including weekends and after a poor night’s sleep
- Increase exposure to bright light in the morning.
- Avoiding napping during the day.
- Relaxation before going to bed (for example reading a book or having a bath).
Limiting/avoidance of caffeine, nicotine and alcohol
- Caffeine should be avoided after midday and nicotine, alcohol, and large meals within 2 hours of bedtime
- Avoid exercise 4 hours before bed
What is important to ask someone before they are given antidepressants?
Are you taking St John’s Wort?
Effective and less side effects than SSRIs but enzyme inducer so reduces efficacy of other drugs e.g COCP
When is ECT used for depression and what are the side effects?
Used when severe symptoms and adequate trial of other treatments has failed. When life-threatening or rapid response needed e.g prolonged manic episode, catatonia
Given 2 sessions weekly for 6 weeks and carry on antidepressants to prevent recurrence
SEs: Memory less, retrograde amnesia, confusion, headaches, anaesthetic side effects, damage to teeth
How does ECT work?
Inducing seizure interrupts hyperconnectivity between areas of the brain that maintain depression
How do you choose which antidepressant to prescribe?
Collaborative decision with patient
- Toxicity: avoid certain antidepressants in patients with suicide risk or a history of overdose (e.g. tricyclics, venlafaxine)
- Side effects: antidepressants may cause weight gain, sexual dysfunction.
- Interactions: review any current medication and potential interactions
What advice do you need to give somebody when they start antidepressants?
- May worsen anxiety at first
- Suicide risk
- Can take up to 6 weeks to see effect
- Need to continue for at least 6 months after recovery to reduce recurrence
- Titrate dose up slowly
- If no response after 4 weeks switch antidepressant
- Do not stop without medical advice
What are the first to fourth line antidepressants?
First Line: SSRI such as Sertraline (good in IHD), Fluoxetine (good <18) or Citalopram
Second Line: Alternate SSRI
Third Line: Mirtazapine (NaSSA) or Venlafaxine (SNRI)
Fourth Line: Lithium as an adjunct to other antidepressants, be aware of toxicity
What monitoring needs to be done with SSRIs?
They are the safest class of antidepressants
- FBC (look for anaemia due to GI bleeding, avoid NSAIDs)
- U+Es (hyponatraemia)
- ECG (long QT dose dependent in Citalopram use that can turn to Torsades De Pointes)
What monitoring needs to be done on Venlaxafine?
BP and ECG as can cause hypertension and cardiac arrhythmias
If one type of antidepressant isn’t working how do you switch to another?
Cross Taper
Some combinations have a risk of serotonin syndrome so be careful
What is important for people with epilepsy to know about antidepressants?
All antidepressants lower seizure threshold
How often should you follow up a patient with depression?
-
For people not considered to be at an increased risk of suicide:
- Within 2 weeks.
- Every 2–4 weeks for the first 3 months and if the response to treatment is good, longer review intervals can be considered
-
For people at an increased risk of suicide, or people aged under 30 years:
- Within 1 week.
- Review frequently until the risk is no longer
How are antidepressants stopped?
Should be continued for a minimum of 6 months to lower relapse rates
If do not want to stop review at 2 years
Slowly titrate down over 4 weeks
What are the three classes of symptoms in depression?
- Core
- Somatic
- Cognitive
What is bipolar affective disorder?
Cyclical mood disorder that fluctuates between episodes of mania and depression
What is the epidemiology of bipolar disorder?
Lifetime prevalence : 1.5% (0.1-2.4%)
Incidence: 0.7 per 100,000 person-years
Usually presents before 30 years, younger in females. Significant delay (average of eight years) between first onset of symptoms and presentation to services
What is the aetiology of bipolar disorder?
Unknown but strong genetic link
5-10x more likely to develop if first degree relative has bipolar
Triggers: stressful life events, physical illness, illicit drug use, antidepressants
What is mania and some of the signs of this?
Abnormal and persistently elevated, expansive or irritable mood, which leads to impairment in social function
- Euphoria
- Extreme irritability and/or aggression
- Increased energy
- Grandiose
- Restlessness
- Decreased need for sleep
- Flight of ideas
- Racing thought
- Pressure of speech
- Increase libido and disinhibition
- Distractibility, poor concentration
- Psychotic features: mood congruent delusions or hallucinations
What is hypomania?
Features of mania but no psychotic symptoms and no impairment in social/occupational function
- Elevated mood
- Irritability
- Increased energy
- Feeling of physical and/or mental efficiency
- Increased sociability
- Talkativeness
- Over-familiarity
What is cyclothymia?
Rare mood disorder
Cyclical mood swings with subclinical features of depression and mania
What are some causes of mania that are not due to bipolar affective disorder?
Psychiatric: schizophrenia, personality disorder
Substance misuse: cocaine, ecstasy or amphetamines
Organic: hyperthyroidism disorder, MS, epilepsy, systemic lupus, encephalitis
Iatrogenic causes: antidepressants, corticosteroids, levodopa or dopamine agonists
If someone presents with mania, what investigations should you do?
History: Ask about drug use, ask about personal and family history of psychiatric disorders
Ix: CT head, EEG, screen for drugs/toxins, TFTs
How do you diagnose the following:
- Manic Episode
- Hypomanic Episode
- Depressive Episode
- Mixed Episode
- Manic episode: abnormal and persistently elevated, expansive, or irritable mood. Symptoms last ≥ 1 week. Three additional symptoms are supportive of mania. Presence of impairment in social and/or occupational function, necessitates hospitalisation or psychotic features present
- Hypomanic episode: abnormal and persistently elevated, expansive, or irritable mood. Symptoms last ≥ 4 days. Three additional symptoms are supportive of mania. No impairment in social and/or occupational functioning, requirement for hospitalisation or psychotic features
- Depressive episode: depressed mood or loss of interest/pleasure in nearly all activities. Symptoms last ≥2 weeks. Four additional symptoms are supportive of depression. Causes distress and impairs function.
- Mixed episode: rapid alternating between manic and depressive symptoms, or criteria for mania/hypomania and at least three symptoms of depression for ≥1 week, or criteria for a depressive episode and at least three mania/hypomania symptoms for ≥ 2 weeks
What is the ICD-10 and DSMV criteria for Bipolar Affective Disorder to be diagnosed?
ICD-10
At least two mood episodes, one of which must be mania or hypomania
DSM-V
- Bipolar I disorder: at least one manic episode. Depression episode not required for diagnosis
- Bipolar II disorder: at least one major depressive episode and one major hypomanic episode
- Cyclothymia: chronic mood disturbance with depression and hypomania symptoms that do not meet the criteria for a full episode.
What is the acute drug management of bipolar disorder (mania/depression)?
Encourage voluntary admission to mental health unit, if cannot then detain under section 2. Mix of drugs and psychosocial interventions
Assess suicide risk
Manic/Mixed Episode
- Antipsychotic e.g Haloperidol, Olanzapine or Quetiapine
- Taper off any antidepressants they are on
- Add Lithium if 2 different antipsychotics haven’t worked
Depressive Episode
- Mood stabilizer and/or atypical antipsychotic and/or antidepressant
What psychological interventions are offered to people with bipolar disorder?
(All should be high intensity)
Aim: provide information about the condition, enable identification of warning signs and symptoms, and develop skills to be able to cope with the challenges of living with bipolar
- Individual psychoeducation: identify and cope with early warning signs of mania and/or depression.
- CBT
- Interpersonal and social rhythm therapy: focuses on the role of interpersonal factors (i.e. interpersonal relationships, role conflicts) and circadian rhythm stability (i.e. sleep-wake cycle, work-life balance) in the context of bipolar
- Group psychoeducation: Aims to improve mood stability, medication adherence and self-management.
- Family-focused therapy: psychoeducation for families, looks at risks, communication and problem-solving within the family to prevent relapses.
Once the acute episode in Bipolar has been resolved for at least 4 weeks, what medication are patients put on to try and reduce relapse?
Mood Stabiliser
Lithium: Gold standard 1st line
Sodium Valproate/Carbamazepine/Lamotrigine: 2nd line
- Switch any antipsychotics out for mood stabiliser. If resistant can keep antipsychotic in.
- Continue psychological therapies and make a care plan
What are some points included in a care plan for a patient with bipolar?
- Clear, individualised social and emotional recovery goals
- Crisis plan: indicating early warning symptoms and triggers of both mania and depression relapse and preferred response during relapse, including liaison and referral pathways
- Medication plan: with a date for review by primary care, frequency and nature of monitoring for effectiveness
- An advance statement
- A statement of wishes and feelings as to how they would prefer to be treated
- Key clinical contacts in case of emergency or impending crisis
What tests need to be done before commencing on Lithium?
- U+Es
- ECG
- T4 levels
Also need to check likely compliance of patient as need plasma levels of 0.6-1 by day 7
What monitoring needs to be done on Lithium?
When starting check levels weekly 12 hours post dose until constant for 4 weeks. Narrow therapeutic index so risk of toxicity
Then monthly for 6 months, then 3 monthly if stable
Every 6 months check U+Es and TSH
What are the side effects of Lithium and what are some signs of Lithium toxicity?
If levels rise >1.4 this is dangerous and suspect progressive nephrotoxicity
SE: Hypothyroidism, Nephrogenic Diabetes Insipidus, Teratogenic
Toxicity: Decreased vision, D+V, HypoK, Ataxia, Tremor, Dysarthria, Coma
What are some emotional consequences of having bipolar disorder?
- Stigma
- Fear of recurrence (I’m happy but am I too happy?)
- Consequences of mania e.g overspending, hyper sexuality
Why are antidepressants avoided in bipolar and if they are used which one is used?
Can induce mania or cause rapid cycling SO ALWAYS USE IN CONJUNCTION WITH A MOOD STABILISER
Fluoxetine (SSRI) and Venlaxafine commonly used if there is a depressive episode but taper after 2-6 months once resolved
What are some complications with bipolar?
- Very high lifetime risk of suicide and self harm: 60% will attempt
- Consequences: STIs, unplanned pregnancies, financial difficulties
- CKD
- CVD
- Alcohol misuse
- Chronic Lung Disease
- Linked to ADHD and anxiety
What are some signs that a bipolar patient is at high risk of suicide?
- Previous attempt
- Family history of suicide
- Early onset Bipolar
- Bad affective signs
- Rapid cycling
- Abuse of alcohol or drugs
Lithium does reduce risk of suicide, if contraindicated Olanzapine and Fluoxetine better than Lamotrigine for suicide risk
What is the prognosis with bipolar disorder?
50% risk of a recurrence at one year following an acute episode in bipolar disorder
Episodes may become more frequent and with shorter intervals. As episodes develop may be incomplete recovery
Higher risk of death by suicide and CVD compared to general public
What is the prognosis with depression?
First Episode: AD for min 6 months
Recurrent Episodes: AD for >6months
80% will have recurrence, 10% will have severe unremitting depression
What is the issues that can arise if taking Lithium during pregnancy?
- Ebstein’s anomaly: ASD, tricuspid valve lower than should be
- Floppy Baby syndrome
- Thyroid issues for baby
What are some indications for ECT?
Given twice a week, maximum of 12 weeks
80% recover from severe depression with this
What bipolar medications cannot be used in women of childbearing age?
- Lithium
- Carbamazepine
- Sodium Valproate
What social interventions can be put into place to help people with bipolar/depression and complete the biopsychosocial care plan?
What is the probability that someone with mania and bipolar affective disorder will go on to experience an episode of depression?
90%
What drugs are useful in acute mania?
- Antipsychotics like Olanzapine and Aripriprazole (START LOW)
- Benzodiazepines like Clonazepam and Lorazepam
Are psychological interventions given in the acute phase of mania?
NO!!!!
Can be used in acute phase of depression
Is Clozapine used in schizophrenia?
Reserved for treatment-resistant schizophrenia
How long do mania symptoms have to be around for a diagnosis?
Mania >7 days
Hypomania >4 days
