31. Mood problem Flashcards
History taking low mood
PC:
low mood -
“what does a typical day look like for you?”
screening: “has anything triggered this change in mood?”
anhedonia - “are you able to find enjoyment in things?” “is there anything you enjoy doing that you no longer do/find enjoyment in?”
psychological - “how is your motivation?” “how is your concentration?” “we’ve spoken about your mood and how it is low, have you got any specific negative thoughts that have come with that?” - “about yourself, about others, about the future…”
screening: do you ever experience periods of time where your mood is really good? do you ever see or hear things that other people don’t? any relation to menstrual cycle? any symptoms such as gaining weight, constipation etc? (hypothyroid)
biological - sleep disturbance, fatigue, irritability, lack of concentration, appetite change, slowing movements, self-neglect, tearful
SHx: who do you live with? support? things they do? work? support at work?
Risk: With the negative thoughts you are experiencing, do you ever get thoughts about harming yourself? or others? active plans? impulsive? when you get those thoughts, is there anything that stops you from acting on them?
MHx:
DHx:
FHx: does anyone in your family have any mental health conditions
ICE: what do you think is going on? have you got anything in mind that you might want to help?
History taking elevated mood/manic presentation
Hello, my name is Ailsa I’m… I’ve come to talk to you about how you’re doing.
Please could you tell me your name and DOB.
comms scenario:
I know it must be confusing being brought in by the police but you’re not in any trouble. My job is to see how you are, have a chat about the last few days and to keep you safe. I’m going to ask you some questions and then if you have any questions for me we can talk about them at the end.
What have you been up to for the last few days? How has your mood been? Have you been sleeping much? Please could you tell me about…? Do you work? is there any projects you’re working on? Who have you spent time with in the last few days? Have you taken any drugs? Have you been drinking alcohol? Have you bought anything nice recently? do you drive? what are your hobbies?
do you have any new beliefs? special powers?
screening: do you ever feel low in mood and stop doing things? do you ever see or hear things that other people dont? do you have any beliefs that other people dont share/agree with? do you feel safe?
“Do you think that may be dangerous for you to be doing that?”
Try and do as much of standard history afterwards…
Presentation depression
Symptoms ongoing for >2w
Core symptoms: low mood, anhedonia
Psychological symptoms: feelings of worthlessness and hopelessness, tearfulness, irritability, poor concentration, lack of motivation, psyctotic symptoms may be present in severe depression, inappropriate guilt
Biological: disturbed sleep (esp EMW), fatigue, appetite change (esp reduced), slowing of movements
FUNCTIONAL IMPAIRMENT
Invetsigations low mood
PHQ-9, FBC, TFT, U&E, any specific for ?ddx
Diagnostic criteria major depressive disorder - mild, moderate, severe…
The presence of at least 5 symptoms (at least 1 core symptom) during the same 2w period and represent a change from previous functioning
- mild: req no. w/ minor functional impairment
- moderate: more than req no with greater intensity and functional imapairment
- severe: many more symptoms with intense functional imapirment. may include psychotic symptoms sucha s paranoia, hallucinations or functional incapacitation
differentials for depression
grief reaction
bipolar depression
anxiety state
other causes
- hypothyroid
- parkinsons
- MS
- dementia
classification of depression severity
‘less severe’ depression = a PHQ-9 score of < 16
‘more severe’ depression = a PHQ-9 score of ≥ 16
management of ‘less severe’ depression
discuss options and come up with a shared decision
in order of preference by NICE:
guided self-help
group cognitive behavioural therapy (CBT)
group behavioural activation (BA)
individual CBT
individual BA
group exercise
group mindfulness and meditation
interpersonal psychotherapy (IPT)
selective serotonin reuptake inhibitors (SSRIs)
counselling
short-term psychodynamic psychotherapy (STPP)
should you offer an antidepressant for ‘less severe’ depression
dont routinely offer antidepressant medication as first-line treatment for less severe depression, unless that is the person’s preference
Management of more severe depression
shared decision
in order of preference by NICE:
a combination of individual cognitive behavioural therapy (CBT) and an antidepressant
individual CBT
individual behavioural activation (BA)
antidepressant medication
individual problem-solving
counselling
short-term psychodynamic psychotherapy (STPP)
interpersonal psychotherapy (IPT)
guided self-help
group exercise
antidepressant medication for more severe depression
- SSRI or SNRI
- another antidepressant if indicated based on previous clinical and treatment history
mania vs hypomania
mania = severe functional impairment for 7 days or more
hypomania = functional impairment for 4 days or more
from an exam point of view the key differentiation is psychotic symptoms (e.g.delusions of grandeur or auditory hallucinations) which suggest mania
management of acute mania
- start antipsychotic therapy (e.g olanzapine or haloperidol)
+ consider stopping their antidepressant if they take one
Long term management of bipolar disorder
Mood stabiliser
1. lithium
2. valproate
Depression
+ psychological interventions
+ fluoxetine
management of a pt presenting to primary care with mania / hypomania
Referral from primary care:
Hypomania → routine referral to CMHT
Mania → urgent referral to CMHT
