Abnormal mood Flashcards
what is adjustment disorder
getting over a significant life event (may present similar to depression but not depression)
how long does adjustment disorder last
<1 month from event
50% of mental health disorders start before the age of
14
50% of mood disorders start before the age of
30
risk factors for depression
significant life events - loss of primary caregiver <11yo
chronic illness - eg cancer, diabetes, stroke
typical age of onset of depression
10-20yo
what age does late onset depression occur in
what is it associated with
> 60yo
loneliness
are men or women more likely to get depression
women
which pathways are decreased in depression (2)
serotonin pathway
noradrenaline pathway
what is the neurotransmitter in the serotonin pathway that is decreased in depression
5-hydroxytrytamine (5-HT)
what part of the brain does the serotonin pathway innervate (and hence is less stimulated in depression)
amygdala
what chemical normally recycles serotonin and noradrenaline (and is hence a target for treatment of depression)
monoamine oxidase (MAO)
how do monoamine oxidase inhibitors (MAOi) work
decrease how much serotonin ad noradrenaline are recycled = increase conc of them = decrease depressive symptoms
what 2 (main) endocrine changes happen in depression
increased cortisol
large adrenal glands
what happens to hippocampal volume in depression
decreases
presentation of depression (things you must ask!)
sleep disturbance = tiredness suicidal ideation loss of appetite = weight loss amotivation - housebound? anhedonia - loss of enjoyment in things previously enjoyable lack of concentration irritable psychomotor retardation - slowing of thoughts/movements
ask about delusions for ?psychosis
ask about manic symptoms for ?bipolar
what is initial insomnia
when you cant get to sleep for hours
what is middle/interrupting insomnia
when you wake in the middle of the night and cant get back to sleep
what is late insomnia
when you wake up several hours earlier than normal and cant get back to sleep
when is depression typically worse (what time of day)
worse in morning, better as day goes on
diurnal variation
what is loss of pleasure/joy in things previously enjoyable called
associated with depression
anhedonia
what is psychomotor retardation
associated with depression
slowing of thoughts/movements
what is it called when someone has depressive delusions (of worhlessness etc), 2nd person hallucinations (people telling them theyre useless), nilhistic delusions (walking corpse)
psychotic depression
what is a nilhilistic delusion
what syndrome is this characteristic of
the idea that their body is dying
that they are a walking corpse
coharts syndrome - in the elderly, rare
social history questions to ask in ?depression
finances people at home (esp if suicidal) sexual function upbringing recent traumatic event/change
describe the mental state examination (MSE) findings likely in someone with depression
appearance - disheveled, furrowed brow, reduced facial expression
behavior - difficult rapport, reduced eye contact
speech - slow, low, quiet, monotonous, unresponsive to Qs
emotion - low, depressed, flat, tearful, ‘empty’
perception - probs none
thoughts - normal form, slow/absent, negative content, pessimism, guilt, suicide
insight - usually yes, sometimes blame other things
cognition - slow, poor memory
walking corpse
elderly person
coharts syndrome
how long does depressive symptoms need to be present for diagnosis
what are the other 2 core symptoms included in diagnosis
> 2 weeks
loss of interest/pleasure
decreased energy
what must you rule out before you give antidepressants in ?depression
bipolar
mild depression criteria
2/3 core symptoms
2/7 additional symptoms
moderate depression criteria
2/3 core symptoms
4/7 additional symptoms
severe depression criteria
3/3 core symptoms
5/7 additional symptoms (suicidal ideation = severe)
treatment of mild depression
NOT anti depressants exercise!! hobbies, socializing improve sleep time off work online CBT
treatment of moderate depression
SSRI (antidepressant) and CBT
after how long could you consider anti depressants for mild depression
> 8 weeks
treatment of severe depression
psych referral
ECT
?detention
how long should you continue an antidepressant for once its started working (if first episode)
6-12 months after started working
how long should you continue an antidepressant for once its started working (if second episode)
12-24 months after started working
how long should you continue an antidepressant for once its started working (if third episode)
indefinitely - patient decides but recommend to continue low dose
be aware of side effects
patient probs will want to be on it
if after 6 weeks antidepressant isnt working, what do you do
increase dose
if increased dose of antidepressant isn’t working what do you do
change drug
first line antidepressant for depression
SSRIs
second line antidepressant for depression
diff SSRI
first line SSRI choice for depression
citalopram
indication for fluoxetine for depression (as first line)
<18yo
SSRIs used for depression (4)
citalopram
sertraline
paroxetine
fluoxetine
indication for sertraline for depression (first line)
cardiac problems
what do you do if citalopram is ineffective
try diff SSRI - fluoxetine, paroxetine, sertraline
what do you need to monitor if you give citalopram
ECG for QT prolongation
if someone on antidepressants starts feeling better and just stops medication then starts getting headaches, sweaty, needle like sensation in head and anxiety, what has happened
discontinuation syndrome (bc stopped taking drug)
SNRI example
venlafaxine
when are SNRIs used in depression
fourth line
after
SSRI
diff SSRI
SSRI + mirtazapine
indication for mirtazapine in depression
insomnia
poor appetite
bc SEs are weight gain and sedation
what is bad about SNRIs (venlafaxine)
SEs are worse than SSRIs
alternative antidepressant options after SSRI/diff SSRI/mirtazepine/SNRI
tricyclics (TCAs)
monoamine oxidase inhibitors (MAOi)
lithium carbonate - last line
alternative to antidepressants in severe depression
ECT (electroconvulsive therapy)
indications for ECT (electroconvulsive therapy) in severe depression
suicide risk
not eating
patients choice - past good experience from it
how many treatments are involved in ECT therapy for severe depression
over what time
9 treatments
2 per week
lasts 4.5 weeks
alternative to antidepressants in someone that doesn’t want to take drugs (eg side effects), or childhood abuse
mild/moderate depression
CBT
psychoeducation
which herbal remedy do people take for depression but you should discourage (hence ask if theyre taking it)
st johns wort (hypericum perforatum)
side effects of CBT
headache
tooth damage (given block)
memory/cognitive problems
does bipolar or depression have a higher suicide risk
why
bipolar
bc the change between mania and depression (the highs and lows) is so drastic
psychotic symptoms after birth
puerperal psychosis
note diff from post natal depression
how many people get post natal depression
how many people et postnatal blues
10%
75%
= important to differentiate
how long does post natal depression usually last
1-4 weeks after birth
how long does baby blues usually last `
3-10days after birth
differences in treatment of baby blues and post natal depression
baby blues - reassurance
post natal depression - counselling (mild), antidepressants and CBT (moderate), mother baby unit admission (severe)
what medication can trigger bipolar disorder
SSRIs
what causes bipolar disorder
multifactorial - genetic and environmental
bipolar I
mania and depression
bipolar II
hypomania and depression
cyclothymia
mild bipolar
cycling of mood lots of times per day
mixed affective disorder
major depressive episodes and mania/hypomania at same time/during same day
do people with bipolar usually have insight
nah
hypomania vs mania
which is abnormal for the individual but DOESNT interfere with their normal function
hypomania
MSE findings for mania
appearance - bright colours
behavior - inappropriate, reckless, loss of normal inhibitions
speech - pressured, uninterruptable, puns ,rhyming
emotion - elated, irritable
perception - probs no hallucinations, maybe delusions
thoughts - increased flow, tangential, flight of ideas (NOT knights move), grandiosity
insight - probs nah
cognition - ? depends robs don’t know
differences between mania and hypomania (5)
mania has; (hypomania doesn’t)
psychosis flight of ideas grandiosity interferes with their normal function requires hospitalisation
what must you ALWAYS ask in bipolar
suicidal ideation
what is speech like in MSE of mania
uninterruptable
use of puns (words with same sounds)
use of rhymes
if you ?mania as part of bipolar, what endocrine condition do you need to rule out
hypo/hyperthyroidism
what drugs do you need to stop ASAP if diagnosis of bipolar
why
antidepressants
can cause a manic episode - dangerous!
what is the only exception to not giving antidepressants in bipolar
bipolar depression
give fluoxetine (SSRI) with antipsychotic SHORT TERM, alongside antipsychotic (not alone
first line class of antipsychotics for bipolar
atypical second generation antipsychotics
second line class of antipsychotics for bipolar
typical first generation antipsychotics
example of first line antipsychotic for bipolar (atypical second generation antipsychotics )
olanzepine
quetiapine
risperidone
example of second line antipsychotic for bipolar (typical first generation antipsychotics )
haloperidol
side effects of atypical second generation antipsychotics (eg olanzepine) (3)
weight gain
sedation
prolonged QT syndrome
side effects of typical first generation antipsychotics (eg haloperidol)
extra pyramidal side effects (EPSE)
how do you treat extra pyramidal side effects (EPSE) if the occur when taking haloperidol
procyclidine
last line antipsychotic for bipolar (after olanzepine and haloperidol)
clozapine
if antipyschotics (olanzepine, haloperidol then clozapine) are ineffective then what would you add on
who needs to do this
lithium carbonate
psychiatrist, not GP
what must you do if you start someone on lithium
check lithium levels regularly
what is the gold standard long term treatment for bipolar
lithium
side effects of lithium
hypothyroidism (need to check TFTs)
dry mouth, salty taste
diabetes - polydipsia, polyuria
tremor
alternative to lithium if antipsychotics alone are ineffective in bipolar
sodium valproate
non drug treatments of bipolar
ECT - ?hospitalization
CBT
how long do antidepressants take to work
weeks-months - warn patients!
how long should you trial an antidepressant for before changing it
6 months
are antidepressants addictive
no
this is sometimes why people aren’t keen, just reassure them
how do SSRIs work
selective serotonin reuptake inhibitors = increases conc of serotonin at synaptic cleft = decreases depressive symptoms
SSRI examples (4)
fluoxetine
citalopram
sertraline
paroxetine
which SSRI is first line (for anything)
citalopram
side effect of citalopram
long QT syndrome
what do you use in patients with cardiac problems instead of citalopram (as causes long QT)
sertraline
side effects of SSRIs
nausea
headache
worsened anxiety
sexual dysfunction
what happens if you just stop taking a SSRI all of a sudden
discontinuation syndrome = need to warn patient not to!
which age group shouldn’t get SSRIs
why
<25s
increases risk of suicide
how do SNRIs work
selective noradrenaline reuptake inhibitors = increases conc of noradrenaline at synaptic cleft = decreases depressive symptoms
SNRI examples (2)
duloxetine, venlafaxine
why aren’t SNRIs used much
side effects worse than SSRIs eg insomnia (need to take it in the morning)
how do tricyclics (TCAs) work
prevent reuptake of serotonin and noradrenaline = increase conc and presynaptic terminal = decreases depressive symptoms
are TCAs used much
why
no
side effects not great - dry mouth, falls, cognitive impairment, postural hypotension
but good as an antidepressant if willing to tolerate SEs
tricyclic examples (3)
imipramine
amitriptyline
clomipramine
which group of people are contraindicated tricyclics (if you give must be low dose)
why
elderly
increased risk of falls and cognitive impairment
if someone has ?dementia and is on amitriptyline (tricyclic) what should you do
take them off amitriptyline to see if it resolves
which antidepressants are monoamine reuptake inhibitors
SSRIs
SNRIs
tricyclics
which antidepressants aren’t monoamine reuptake inhibitors
monoamine oxidase inhibitors (MAOi)
example of monoamine oxidase inhibitors (MAOi)
phenelzine
moclobemide
how do monoamine oxidase inhibitors work (MAOi)
monoamine oxidase usually breaks down serotonin and noradrenaline
so MAOi = stops break down happening = increases conc of serotonin and noradrenaline = decreases depressive symptoms
side effects of monoamine oxidase inhibitors (MAOi) (3)
hypertensive crisis
postural hypotension
insomnia
what do you need to avoid if you are taking a monoamine oxidase inhibitor
what foods contain this (5)
what can it cause if you don’t avoid these foods
tyrosine
avoid; red wine, cheese, yeast products, gravy, caffiene
= HYPERTENSIVE CRISIS
when are MOAi used in depression
last line, in SSRI/SNRI/tricyclic resistant depression
why isn’t MOAi (monoamine oxidase inhibitors) used earlier on in treatment pathway for depression if they are better than the other antidepressants
hard compliance! need to avoid red wine, cheese, yeast etc
needs to carry a MAOi card
restrictions with medication also
which antidepressant drug isn’t a monoamine oxidase inhibitor, SSRI, SNRI or tricyclic (hence is an atypical antidepressant)
mirtazapine
how does mirtazapine work
blocks alpha2, 5-HT2, 5-HT3
side effects of mirtazapine
weight gain
sedation (may be good)
when would you use mirtazapine in depression
alongside SSRI/SNRI
amitriptyline mechanism
inhibits monoamine reuptake in presynaptic membrane
