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4. Mood Disorders Flashcards

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1
Q

Etiology of Depression

A
  1. Genetics
    - 40-70% chance of developing depressive episode if 1st degree relative suffer from depressive episode
  2. Organic
    - Cushing syndrome, Addison disease, Parkinson disease, stroke, epilepsy, coronary artery disease, thyroid
    - Medications
  3. Psychosocial Factors
    - Adversity in childhood
    — Maternal loss, disruption of bonding
    — Poor parental care
    — Physical / sexual abuse
    - Adversity in adulthood
    — Women: absence of a confiding relationship
    — Men: unemployment, divorce
    - Recent life events
    — Loss of a child
    — Death of a spouse
    — Divorce
    — Marital separation
    — Imprisonment
    — Recent death of a close family member
    — Unemployment
  4. Presence of cognitive errors
    - Magnification: tendency to magnify the magnitude of a failure and dismiss all previous successes
    - Overgeneralisation: generalisation of failure in one area of life to other areas of life
    - Personalisation: feeling that one is entirely responsible for failure and discounting the role of other individuals in responsibility for failure
    - Selective abstraction: choose to focus on negative aspects, forget positive aspects
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2
Q

DSM-5 Diagnostic Criteria for Depressive Disorder

At least __ of the following symptoms for a minimum duration of __ weeks

A

At least 5 of the following symptoms for a minimum duration of 2 weeks:

MSIGECAPS
1. Low mood for most of the days (core feature)
2. Anhedonia: Diminished interest (no derived pleasure) in almost all activities (core feature)
3. Weight loss, loss of appetite
4. Sleep difficulties
5. Psychomotor changes (agitation or retardation)
6. Low energy
7. Feeling worthless, or excessive guilt
8. Attention and concentration difficulties
9. Recurrent passive or active ideations of self-harm and suicide

+ Symptoms must cause marked impairments in terms of premorbid functioning

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3
Q

More serious depressive subtypes

A

With psychotic features (mood congruent/incongruent)
With catatonia

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4
Q

Recurrent Depressive Disorder

A

At least 2 MDD episodes with intervals of at least 2 consecutive months (in which criteria are not met for a major depressive episode)

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5
Q

Cyclothymia

A

Numerous episodes with hypomanic symptoms and depressive symptoms over a duration of at least 2 years

*episodes do not meet the full diagnostic criteria for hypomania or depression
*must not be free from symptoms for more than 2 months in duration each time

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6
Q

Dysthymia (persistent depressive disorder)

A

Pervasive depressed mood for most part of the days for a total duration of at least 2 years

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7
Q

For dysthymia, apart from depressed mood, patient should have at least 2 of the following symptoms:

A

HE’S 2 SAD

Hopelessness
Energy loss or fatigue
Self-esteem is low
2 years minimum of depressed mood most of the day, for more days than not
Sleep is increased or decreased
Appetite is increased or decreased
Decision-making or concentration is impaired

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8
Q

Premenstrual Dysphoric Disorder

A

Onset of symptoms should be at least in the week prior to the onset of menstruation, and symptoms should improve a few days after the onset of menstruation

Intensity of symptoms should be minimal or resolved post-menstruation

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9
Q

Features of Atypical Depression

A

Reactive Mood
Appetite increase
Increase sleep
Leaden paralysis (heavy sensations in limbs)
Sensitivity to interpersonal rejection

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10
Q

Differential diagnosis for depressive disorder

A

Adjustment disorder
Bipolar disorder
Schizoaffective disorder
Schizophrenia with predominant negative symptoms
Dementia
Parkinson’s disease
Post-stroke depression
Organic causes
Substance misuse
Medication-induced

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11
Q

Questionnaires used in depression

A
  • Beck Depression Inventory
  • Hamilton Depression Scale
  • Montgomery-Asberg Depression Rating Scale
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12
Q

“Psychosocial” management of patients with depression

A

Cognitive Behavioural Therapy
Interpersonal Therapy
Psychoeducation
Supportive therapy
Counselling
Sleep hygiene advice

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13
Q

“Bio” management of depression

A
  1. Selective serotonin reuptake inhibitors (1st line)
  2. Serotonin noradrenaline reuptake inhibitors (2nd line)
  3. Noradrenaline Specific Serotonin Antidepressant (NaSSAs)
  4. Noradrenaline Dopamine Reuptake Inhibitor (NDRI)
  5. Tricyclic Antidepressants (NEVER 1st line)
  6. Monoamine Oxidase Inhibitors (MAOi)
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14
Q

Indications of SSRIs

A
  • Depressive disorder
  • Anxiety disorder
  • Obsessive compulsive disorder
  • Bulimia nervosa (fluoxetine)
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15
Q

Absolute contraindication to SSRIs

A

Mania

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16
Q

MOA of SSRIs

A
  • Selectively block reuptake of serotonin at presynaptic nerve terminals
  • Increase serotonin concentration at synapses
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17
Q

Examples of SSRIs

A

Fluoxetine, fluvoxamine, sertraline, paroxetine, escitalopram

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18
Q

General S/E of SSRIs

A
  • GI (most common): nausea, abdo pain, diarrhoea, constipation
  • Autonomic: agitation, tremor, insomnia
  • Sexual dysfunction (loss of libido, delayed ejaculation)
  • Discontinuation symptoms (flu-like sx upon stopping anti-Ds abruptly)
    — depends on half life
  • [Black box warning] Increased suicidal ideation (in <24yo in first 1-2 weeks of initiation)
  • Serotonin syndrome
  • Maniac episode if underlying bipolar
  • Cardio-toxicity in overdose (very low risk)
  • Hyponatremia 2’ SIADH
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19
Q

Discontinuation symptoms

A

FINISH

  • Flu-like symptoms
  • Insomnia
  • Nausea
  • Imbalance
  • Sensory disturbances
  • Hyperarousal
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20
Q

How does discontinuation symptoms occur?

A

Increased serotonin due to SSRIs -> upregulation of receptors

When SSRI is withdrawn
-> receptors don’t down-regulate immediately

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21
Q

How long does it take for the anti-Ds to take effect?

A

2-4 weeks for initial effects
4-6 weeks for good effects

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22
Q

Pros of Fluoxetine

A

Longest half life
-> lowers risk of discontinuation sx
-> therapeutic effects last longer than 5 days as fluoxetine breaks down into active metabolite which lasts ~1 week
=> requires 5 weeks washout if starting MAOi

Safe in overdose

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23
Q

Duration of washout for fluoxetine if starting MAOi

A

5 weeks

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24
Q

Cons of Fluoxetine

A
  • Significant P450 interactions -> reduce use in patient with multiple medical co-morbids
  • Initial activation -> increase anxiety and insomnia
  • Do not give patients with bipolar depression due to long half life -> can lead to mania
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25
Q

Pros of Fluvoxamine

A
  • Possess analgesic properties
  • Sedating (give @ night)
  • Less initial activation compared to other SSRIs
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26
Q

Cons of Fluvoxamine

A
  • Short half life -> higher risk of discontinuation sx
  • Causes weakness
  • Significant P450 interactions -> reduce use in patient with multiple medical co-morbids
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27
Q

Pros of Sertraline

A
  • Good in prolonged QTc -> safe for cardiac patient
  • Less sedating than paroxetine
  • Very weak P450 interactions
  • Sleep wake neutral
  • Safe for those with recent AMI
  • Safest antiD in pregnancy
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28
Q

Cons of Sertraline

A
  • Full absorption requires a full stomach
  • Increased number of GI effects especially diarrhoea -> colitis
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29
Q

Pros of Paroxetine

A

Short half life with no active metabolite -> no build up

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30
Q

Cons of Paroxetine

A
  • Short half life -> discontinuation sx
  • Significant CYP206 inhibition
  • Sedating
  • Weight gain
  • Anticholinergic sx
  • Avoid in pregnancy (teratogenic)
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31
Q

Pros of Escitalopram

A

Lesser drug-drug interaction
Sleep wake neutral

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32
Q

Cons of Escitalopram

A

Not safe to combine with other drugs, causing QTc prolongation
Nausea, headache
Expensive

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33
Q

Examples of Serotonin Noradrenaline Reuptake Inhibitors

A

Venlafaxine
Duloxetine

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34
Q

MOA of SNRIs

A

Blocks serotonin and noradrenaline reuptake

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35
Q

Indications for SNRIs

A

MDD
Anxiety disorders
Good for low energy symptoms
Neuropathic pain (has analgesic properties)

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36
Q

C/I for SNRIs

A

Hypertension

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37
Q

S/E of SNRIs

A

Hypertension
Sexual dysfunction
Headache, nausea
Palpitations

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38
Q

Pros of Venlafaxine

A

Minimal DDI, no P450 activity
Short half life and fast renal clearance

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39
Q

Cons of Venlafaxine

A

Increase 10-15mmHg diastolic bp
Sexual S/E
QTc prolongation

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40
Q

Examples of Noradrenaline Specific Serotonin Antidepressant (NaSSAs)

A

Mirtazepine

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41
Q

MOA of NaSSA

A

5HT2 and 5HT3 antagonist

*effect on 5HT3 receptor is less likely to cause nausea side effect

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42
Q

Indications of NaSSA

A

MDD
Good for insomnia sx -> very sedating at lower doses
Good for low appetite (increases appetite and weight gain)

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43
Q

S/E of NaSSA

A

Weight gain (increase serum cholesterol and triglycerides) due to increased appetite
Sedation
Agranulocytosis

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44
Q

Example of Noradrenaline Dopamine Reuptake Inhibitor (NDRI)

A

Bupropion

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45
Q

Pros of NDRI

A

Good as augmenting agent
Weight loss effect
Nil sexual dysfunction
Nil sedation
Nil cardiac s/e
Second line ADHD agent

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46
Q

S/E of NDRI

A

Insomnia
AVOID if risk of seizure (lowers seizure threshold)
Abuse potential
Agitation, anxiety

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47
Q

Examples of Tricyclic Antidepressants

A

Amitriptyline
Nortriptyline
Desipramine
Imipramine

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48
Q

MOA of TCAs

A

Inhibit uptake of serotonin (mainly) and noradrenaline

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49
Q

S/E of TCAs

A
  • Lethal in overdose (avoid in suicidal patients)
  • Cardiotoxic -> QT prolongation even at therapeutic serum level
  • Lower seizure threshold
  • Hyponatremia
  • Anticholinergic (dry eyes, dry mouth, constipation, urinary retention, blurred vision)
  • Anti-histaminic (sedation and weight gain)
  • Anti-adrenergic (orthostatic hypotension, sedation, sexual dysfunction)
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50
Q

Examples of Monoamine Oxidase Inhibitors (MAOi)

A

Moclobemide

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51
Q

MOA of MAOi

A

Binds irreversibly (but moclobemide binds irreversibly) to monoamine oxidase -> increases noradrenaline, serotonin, dopamine

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52
Q

S/E of MAOi

A

Serotonin syndrome (if combined with other antiDs)
Tyramine HTN crisis
- > avoid wines, cheese, fermented beancurd, cheese, cured meats, sympathomimetics

(Tyramine will increase release of noradrenaline hence if patient is on MAOi and eats tyramine, it will increase noradrenaline)

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53
Q

What is the washout period before starting MAOi for other drugs?

A

2 weeks washout period except fluoxetine - 5 weeks

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54
Q

Treatment mx for 1st episode of depression

A

Continue tx for 6-9 months after resolution of sx

If stopped immediately upon recovery, 50% can have relapse

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55
Q

Treatment mx for repeated episodes of depression

A

Continue tx for longer eg 2 years after resolution of sx

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56
Q

What is tx resistant depression?

A

MDD that fails to respond to 2 different antiDs (given as monotherapy at optimum doses)

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57
Q

Mx for tx resistant depression

A
  • Change antiD
  • Combine antiD (beware serotonin syndrome esp MAOi)
  • Augmentation (combine antiD with mood stabilisers/anti-psychotics or neurostimulation)
  • ECT (actively suicidal, refusing food, catatonic, refractory to meds)
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58
Q

6 major conditions for ECT

A
  1. Major depressive disorder
  2. Bipolar disorder (mania/depression)
  3. Schizophrenia
  4. Schizoaffective disorder
  5. Catatonia
  6. Neuroleptic malignant syndrome

*ECT also helps improve motor deficits in parkinson’s

59
Q

Types of patient that would benefit from ECT

A
  1. Suicidal
  2. Not eating
  3. Pregnant
  4. Severe, not responding to previous treatments, or previously responded well with ECT

*Must be used along with maintenance phase antiD tx

60
Q

Contraindications of ECT

A

NO absolute C/I
Relative C/I:
1. Raised ICP
2. Recent cerebrovascular event
3. Brain aneurysm or vascular malformations that are susceptible to rupture in the event of increased blood pressure or raised ICP
4. Unstable cardiovascular illness such as recent myocardial infarctions, unstable angina, or poorly compensated heart failure
5. Poor anaesthetic risks
6. Retinal detachment
7. Phaeochromocytoma

61
Q

S/E of ECT

A

Early (Usually transient or temporary):
- Short-term memory loss, usually resolves completely within a few hours
- Headache
- Muscle aches
- Nausea/vomiting
- Giddiness
- Confusion
- Treatment-emergent mania: ECT may cause depressed patients to become manic

Late:
- Memory impairment

+ GA risks
*Cognitive risks are dependent on strength of current, electrode placement and number of applications

62
Q

Electrode Placement - Bitemporal

A

Strongest, fastest response rate, highest chance of cognitive side effects

Conditions: Catatonia / NMS / Urgent response needed

63
Q

Electrode Placement - Bifrontal

A

Strong, fast response rate, lower chance of cognitive side effects, better for psychosis

Conditions: Schizophrenia / Psychosis

64
Q

Electrode Placement - Right unilateral

A

Milder, avoid directly stimulating L brain-memory and cognition, may require 1 or 2 more sessions

Conditions: Depression / Mania

65
Q

Which, out of the 6 conditions, has the highest remission rate from using ECT?

A

Catatonia

66
Q

Advantages of repetitive Transcranial Magnetic Stimulation (rTMS)

A
  • Enables focal stimulation of smaller areas of the brain than is possible
  • Non-invasive
  • No need for anaesthesia
  • No cognitive side effects
67
Q

S/E of rTMS

A
  • Headaches
  • Light-headedness
  • Scalp, facial, eye, jaw twitches/discomfort
  • Dizziness
  • Nausea
  • Tinnitus
  • Hypomanic switch (<1%)
  • Most serious known risk: unintended seizure
68
Q

Contraindications

A

-History of epileptic seizures
- Foreign metal body in eye or cranium (excluding braces or dental fillings)

69
Q

Risk factors for seizures in rTMS

A
  • Personal or family history of epilepsy
  • Post-stroke or head injury with neurologic sequelae
  • Use of seizure-lowering threshold medications
  • Recent dose reduction of medication with anticonvulsant properties (eg. Benzodiazepines)
  • Neurologic disorders or medical conditions that may be associated with lowered seizure threshold
    eg. Sleep deprivation, raised ICP, substance withdrawal
70
Q

rTMS vs ECT

A

Both are neurostimulation methods that are effective for treatment of MDD

  • Patient profile recommended for ECT differ from those recommended for rTMS
  • rTMS response rates are poor in patients whom ECT has failed
  • TMS uses a magnetic coil to stimulate specific regions of the brain that are thought to play a role in depressions symptoms vs ECT uses electrical currents to induce a seizure in a sedated patient’s brain
71
Q

Current indications for rTMS

A

Depression
Post stroke rehabilitation for motor function

72
Q

Factors increasing seizure threshold

A

Male
Old age
Baldness
Paget disease
Dehydration
Previous ECT and BZD tx

73
Q

Factors lowering seizure threshold

A

Caffeine
Low CO2 saturation of blood
Hyperventilation
Sleep deprivation
Raised ICP
Substance withdrawal

74
Q

What is Cognitive Behavioural Therapy?

A

Cognitive: identify and challenge negative automatic thoughts
- dysfunctional thought diary
- consists of: defining high risk situation
Behaviour: activity scheduling (for depressed) / relaxation techniques (mixed anxiety and depression)

75
Q

What is interpersonal therapy?

A
  • depression precipitated by interpersonal problems
  • improve interpersonal relationships
76
Q

Duration of depressive disorder (mild/severe/chronic)

A

Mild/moderate depressive disorder: 4-30 weeks
Severe depressive disorder: 6 months
Chronic disorder: 2 years

77
Q

Favourable prognostic factors of depression remittance

A

Acute onset, reactive depression, earlier age of onset

78
Q

Favourable prognostic factors of depression remittance

A

Acute onset, reactive depression, earlier age of onset

79
Q

Poor prognostic factors for depression remittance

A

Insidious onset, old age of onset, neurotic depression, low self esteem, residual symptoms

80
Q

What is bipolar disorder?

A

Bipolar disorder is a mood disorder with 2 different phases (manic phase and depressive phase)

81
Q

Aetiology of bipolar disorder

A

Genetics: children of parents suffering from bipolar disorder have a -fold increase risk

Monoamine theory:
- increased levels of dopamine, noradrenaline and serotonin
- excitatory neurotransmitter glutamate

82
Q

Onset of 1st manic episode

A

mid-20s

83
Q

Precipitants of 1st manic episode

A
  • Often precipitated by life events eg. bereavement, personal separation, work-related problems, loss of role
  • In patients predisposed to bipolar disorder, antidepressant monotherapy can precipitate 1st manic episode
84
Q

Important precipitating factors of manic episodes

A

High expressed emotion
Sleep deprivation
Flying overnight from west to east

85
Q

Antidepressant monotherapy is a recognised precipitant of first manic episode in patients predisposed to bipolar disorder

A

-

86
Q

Organic causes of mania

A
  1. Cerebrovascular event
  2. Head injury
  3. Endocrine causes
  4. Illicit substances (cannabis, amphetamine, cocaine)
  5. Medications
  6. Other CNS disorders
87
Q

Lesions in the ____ are associated with mania

A

right cerebral hemisphere

88
Q

DSM-5 Criteria for Manic Episode

A

Individual having persistent elevated or irritable mood for most of the days within a time period of at least 1 week

+ at least 3 of the following sx (4 if mood is only irritable):

RADSSSS
1. Increased self- confidence
2. Reduced need for sleep
3. Increased talkativeness, with increased pressure to talk (hard to interrupt)
4. Racing thoughts
5. Easily distractible
6. Increase in number of activities engaged
7. Engage in activities with potential risks for serious consequences

+ Marked functional impairment

89
Q

RADSSSS

A
  • Racing thoughts
  • increase in number of - - Activities engaged
  • easily Distractible
  • Self-confidence increase
  • Speech - increased talkativeness
  • Sleep - reduced
  • Serious consequences
90
Q

What is Bipolar 1 Disorder?

A

Individual must have at least 1 manic episode

91
Q

What is Bipolar 2 Disorder?

A

Individual must have a past or current hypomania episode + past or current major depressive episode

+ sx affects functioning but must not be severe enough to cause marked impairment

92
Q

What is a hypomania?

A

Individual having persistent elevated or irritable mood for most of the days within a time period of at least 4 days

+ at least 3 of the following sx (4 if mood is only irritable):

RADSSSS
1. Increased self- confidence
2. Reduced need for sleep
3. Increased talkativeness, with increased pressure to talk (hard to interrupt)
4. Racing thoughts
5. Easily distractible
6. Increase in number of activities engaged
7. Engage in activities with potential risks for serious consequences

+ level of function will NOT be markedly impaired

93
Q

Difference between mania and hypomania

A

Duration: 1 week (M) vs 4 days (HM)
Functional impairment: Marked impairment (M) vs not markedly impaired (HM)

94
Q

What is Rapid Cycling Disorder?

A

Consists of at least 4 episodes of mood disturbance in one year
- Mania
- Hypomania
- Major depressive episode

*more common in women

95
Q

Questionnaire used in Bipolar Disorder

A

Young mania rating scale

96
Q

Mania: Acute Management

A
  1. Antipsychotics: Haloperidol, olanzapine, quetiapine
  2. Mood stabiliser: sodium valproate or carbamazepine monotherapy
  3. For agitation: Haloperidol, olanzapine or lorazepam
97
Q

Bipolar Depression: Acute management

A

For MILD depressive sx: review patients in 1 to 2 weeks without giving an antiD

For MODERATE to SEVERE sx: add antiD to mood stabiliser

  • Mood stabiliser: Lithium
  • Antipsychotics: Quetiapine or olanzapine monotherapy or olanzapine-fluoxetine combi
  • Anti-depressants (use with CAUTION): combine fluoxetine with mood stabilisers
  • Psychotherapy: CBT
98
Q

Maintenance treatment for bipolar disorder

A

Lithium, valproate or olanzapine may be used to prevent relapse

99
Q

Examples of mood stabilisers

A
  1. Lithium
  2. Sodium valproate
  3. Carbamazepine
  4. Lamotrigine
100
Q

Indications of Lithium

A
  • 1st line tx in bipolar disorder
  • Benefit of reduced suicide rate
  • Effective prophylaxis of both mania and depressive episodes
101
Q

Baseline investigations before starting lithium

A

FBC, RP, TFT
+ UPT in woman

102
Q

Monitoring for lithium

A
  • Steady state achieved after 5 days
  • Check lithium levels 12h after last dose
  • Once stable -> check lithium levels every 3 months and TFT & RP every 6 months
  • Goal
    Depression: 0.4-0.6
    Bipolar: 0.6-1.2
103
Q

S/E of lithium

A
  • Metallic taste
  • Nausea
  • Polydipsia
  • Polyuria
  • Edema
  • Weight gain
  • Fine tremor
104
Q

Long term complications of lithium

A

Hypothyroidism
Renal failure

105
Q

Lithium toxicity - causes of a raised lithium level

A

Drugs
- Thiazides
- ACE-i
- NSAIDs
- Antibiotics
Dehydration
Chronic Kidney Disease (reduced excretion)

106
Q

Signs of mild lithium toxicity (1.5-2mmol/L)

A

Drowsiness
GE-like symptoms (Diarrhoea)
Fine tremor
Nystagmus

107
Q

Signs of moderate lithium toxicity (2-3mmol/L)

A

Arrythmia
Coarse tremor
Ataxia

108
Q

Signs of severe lithium toxicity (>3mmol/L)

A

Confusion, convulsion, coma
Severe oliguria

109
Q

Management of lithium toxicity

A

Cessation of lithium and haemodialysis

110
Q

Use of lithium in pregnant woman can cause

A

Ebstein abnormality in foetal hearts -> pathology of tricuspid valve

111
Q

Sodium valproate as prophylaxis

A

As effective as lithium in mania prophylaxis but less so for depression prophylaxis

112
Q

Indications to use sodium valproate

A
  • Rapid cycling bipolar patients (F>M)
  • Comorbid substance abuse (eg. alcohol)
  • Mixed (mania and depressive sx for at least 1 week)
  • Comorbid anxiety disorder
  • Irritable mania
113
Q

C/I of sodium valproate

A

Patients with liver failure

114
Q

S/E of sodium valproate

A

GI effects
Weight gain
Hair loss

115
Q

Serious S/E of sodium valproate

A

Hepatotoxic
Pancreatitis
Thrombocytopenia
Polycystic ovary syndrome

116
Q

Use of sodium valproate in pregnant woman can cause

A

Increase risk of neural tube defect
-> folic acid supplementation to be given

117
Q

Baseline investigations before starting sodium valproate

A

FBC, LFT, pregnancy test

118
Q

Benefit of using carbamazepine over lithium/valproate

A

Does not cause weight gain

119
Q

S/E of carbamazepine

A

Severe adverse cutaneous reaction (SCAR) - test for HLA-B*1502)
Agranulocytosis
Leucopenia
Reduce efficacy of oral contrapceptives if taken together

120
Q

What must be tested for before starting carbamazepine?

A

HLA-B*1502

121
Q

Use of Lamotrigine is more effective for __ than __

A

Use of Lamotrigine is more effective for bipolar depression than mania (acute and prophylactic)

122
Q

S/E of lamotrigine

A

Severe adverse cutaneous reaction (SCAR)
- a/w SJS & TEN but less so compared to carbamazepine

*stop if rash develops

123
Q

Questionnaire to assess suicide risk

A

SAD PERSONS

Sex: male
Age: <19 or >45
Depression/hopelessness
Previous suicide attempt
Excessive alcohol/drug use
Rational thinking loss -> Psychosis
Separated/widowed/divorced
Organised & serious attempt
No social support
Stated future intent

124
Q

C/I of lithium

A

Renal failure patients

125
Q

Abnormal grief can be…

A
  1. inhibited
  2. delayed
  3. chronic
126
Q

Which gene is associated with increased risk of depression?

A

Presenilin-1 gene on chromosome 14

127
Q

What herb is most commonly used to treat mild to moderate depression?

A

St. john’s wort

128
Q

MOA of lamotrigine

A

Acts at voltage sensitive sodium channels
Inhibits release of excitatory amino acid neurotransmitters

129
Q

5 stages of bereavement (normal grief)

A

1: Denial
2: Anger
3: Bargaining
4: Depression
5: Acceptance

  • guilty about certain action to be taken at the time of death
  • feeling like I should have died instead of the deceased person
  • sensations about seeing & hearing the deceased person
130
Q

Inhibited grief

A

absence of expected grief symptoms at any stage

131
Q

Delayed grief

A

avoidance of painful symptoms within 2 weeks of loss

132
Q

chronic grief

A

continued significant grief-related symptoms > 6 months after loss of

133
Q

Indicators of progression of bereavement into depression

A
  • symptoms still present 2 months after loss
  • guilt, suicide thoughts, hallucinations unrelated to the dead person
  • marked worthlessness
  • marked psychomotor retardation
  • prolonged and marked functional impairment
134
Q

If patient presents with low mood first, and then have psychosis for a short duration of time… what ddx to consider?

A

Psychosis depression

135
Q

Treatment for pseudodementia (cognition impairment presents first, followed by depressive symtoms and rather acute onset)

A

Vortioxetine

136
Q

Common psychiatric co-morbidities of MDD

A
  • Anxiety disorder
  • Other depressive disorders eg dysthymia
  • Personality disorder
  • Substance use disorder
137
Q

Which mood stabiliser has anti-suicide property?

A

Lithium

138
Q

MDD vs Dysthymia

A

MDD is episodic vs Dysthymia is pervasive

139
Q

Risk factors for pathological grief

A

Multiple losses
Psychiatric illness
Traumatic/unnatural death
Lack of closure
Enmeshed relationship with deceased
No avenue to grief
Poor social support

140
Q

Mania vs hypomania

A
  • Presents with psychotic features
  • Hospitalised due to symptoms
  • Functional impairment
  • Duration (7 days vs 4 days)
141
Q

Medications that may cause mania

A

BAAD MACS

Bronchodilators
Antidepressants
Anticholinergics
Dopamine agonist
MDMA
Amphetamines
Cocaine
Steroids

142
Q

For lithium level > ____, emergent haemodialysis is required

A

4mmol

143
Q

Drugs that decreases lithium serum levels

A

Potassium sparing diuretics
Theophylline

m4 psych (18 decks)

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