Affective Flashcards
What are 3 core depression symptoms
Low mood
Low energy
Loss of interest
Depression symptoms according to ICD-10
Low mood
Low energy
Decrease in activity (loss of focus/interest)
Sleep disturbed
Appetite loss
Agitation
Loss of libido
Psychomotor retardation
When would you urgently refer someone to specialist mental health symptoms with depression
Evidence of psychosis
Severe depression where risk of self harm, harm to others or neglect
What is seasonal affective disorder
Episodes of depression which recur annually at the same time
What are chronic depressive symptoms
Symptoms which meet criteria for at least 2 years
What to do if new episode of less severe depression
Determine if wants treatment or if symptoms impriving
If does not want treatment or symptoms improving
- offer active monitoring with option to consider treatment
- ensure adequate social support
If wants treatment
- do not routinely offer antidepressant but if patient wants you can
- consider first line options such as CBT, group mindfulness etc
What to do if new episode of more severe depression
Talk through options
- can start SSRIs if wants
- talk through options such as CBT etc
- discuss with DVLA if needed
When need to talk to DVLA in depression
Agitation
Suicidal thoughts
Lack of concentration/focus
First line medications for depression in less severe depression versus more severe depression
Less severe
- SSRI
More severe
- SSRI or SNRI
What does less severe versus more severe depression encompass
Less severe- subclinial or mild. PHQ under 16
More severe- moderate or severe PHQ over 16
What are examples of SSRIs
Citalopram
Fluoxetine
Sertraline
Paroxetine
Side effects of SSRis
GI- nausea, weight loss, diarrhoea
Sexual- loss of libido, delayed orgasm
Headache
Sleep disturbance- vivid dreams
Hyponatraemia
How long do antidepressants take to work
2-6 weeks
What are the classes of antidepressants and what do they target
SSRI- presynaptic serotonin uptake channel
TCA- blockade of noradrenaline, serotonin and to lesser extent dopamine reuptake channels- also blocks muscarinic and histaminergic
MOA- non selective and irreversible inhibition of MOA A and B
SNRI- presynaptic blockade of both noradrenaline and serotonin (high doses dopamine)
NaSSA- blocks alpha 2 which increases noradrenaline and seorotonin
Examples of TCA
Amitryptiline
Clomipramine
Lofepramine
Side effects of TCA
Anti-muscarinic- dry mouth, blurred vision, constipation and urinary retention
Anti-histaminergic- postural hypotension, sedation, weight gain
When should TCAs be avoided
Suicide risk
How does overdose of TCA present
Cardiotoxic
- hypotension
- tachycardia
- prolonged QRS
Resp failure
Seizures
What must be done when prescribing MOAi
Wait 1 week to finish other antidepressants
Can not prescribe other antidepressants for another 2 weeks
Must carry card saying they are taking one
Education about foods to avoid
Examples of MOAi
Phenelzine
Moclobemide- reversible and modern
SEs of MOAis
Postural hypotension
Increased appetite
Hepatotoxicity
SNS crisis from interaction with tyramine which can lead to intracerebral bleed
Serotonin syndrome
What happens in serotonin syndrome- triad
Physiologically too much serotonin in synapses in brain
Autonomic dysfunction- tachycardia, HTN, diaphoresis, mydriasis
Altered mental state- agitation, confusion
NMJ hyperactivity- tremor, hyperreflexia, myoclonus
Example of SNRI
Venlafaxine
SEs of SNRI
Constipation
Nausea
Headache
Dizziness
Sleep disturbance
Hypertension
What needs monitoring with SNRIs
BP
Examples of NaSSA
Mirtazapine
SEs of NaSSA
increased appetite and weight gain
Oedema
Sedation
How long should first episode depression be treated for
6 months
What is hypomania
Includes constellation of mania symptoms but without disrupting work or have social rejection and lasts less than 7 days
Mania symptoms
Persistent elevation in mood
Increased mental and physical efficiency
Increased sociability
Increased sexual enegry
Reduced need for food and sleep
What defines mania without psychotic symptoms
Symptoms become so severe cant sustain attention
Loss of social inhibitions which result in reckless behaviour
What defines mania with psychotic symptoms
Delusions (grandiose)
Hallucinations
Or where flight of ideas are so extreme that subject is incomprehenisble
What is criteria for bipolar affective disorder
At least 2 episodes of extremes of mood including a hypomania episode
When can first rank symptoms of schizophrenia be seen in mania
In acute episode
What does mute patient suggest
Schizophrenia
Extremely severe mania
What does prolonged 1st rank symptoms in mania suggest
Schizoaffective disorder
Which factors influence whether admitted to hospital or managed at home
Risk to self and risk to others
Lack of insight into care
Lack of support at home
What are the 2 types of bipolar disorder
type I disorder: mania and depression (most common)
type II disorder: hypomania and depression
Factors which lead to mania over hypomania
- over 7 days
- psychotic symptoms
- daily life interrupted
If patient presents with mania for first time what do
If hypomania- refer routinely to community mental health team
If mania- refer urgently to community mental health team
Do not start antipsychotics unless under advice of consultant
Management of acute phase mania
Trial oral antipsychotic choosing from
- haloperidol
- olanzapine
- quetiapine
- risperidone
If not tolerated then add another from list
If second line not effective lithium may be added, if thats not successful then valproate added unless pre-menopausal woman
If suffering from a manic episode then what do with antidepressants
Taper off them typically as can aggravate psychosis
How are mixed mania/depression episodes managed in bipolar
Same as mania
Longer term management after acute episode of mania resolved
Bio
Offer choice to either continue mania treatment or start long term lithium after 4 weeks
If lithium not effective then add valproate or olanzapine
If lithium not tolerated then either valproate/olanzapine
Psych
Specific CBT and bipolar interventions
Social
Establish LPA
How is bipolar depression managed
Bio either
- Quetiapine alone
- Fluoxetine and olanzapine
- Olanzapine
- Lamotrigine
Psychological intervention
- CBT or specifically designed bipolar depression intervention
What must be given alongside SSRI if taking a NSAID
PPI- like omeprazole as increases risk of an ulcer
What is choice of SSRI post MI
Sertraline
What is choice of antidepressant in children
Fluoxetine but should always be used with caution
Adverse effects of SSRIs
GI symptoms most common
Also very common to have increased anxiety and agitation after starting them
Which antidepressant is associated with longer QT interval
Citalopram
Shouldnt be used in those who have long QT and medications which cause long QT
What antidepressant should be used if taking warfarin/heparin/aspirin
Avoid SSRIs
Use mirtazapine
What antidepressant should be used if on triptans
Mirtazapine- avoid SSRIs as increased risk of serotonin syndrome due to triptans being serotonin agonists
What antidepressant should be used if on MAOi
Mirtazapine
As increased risk of serotonin syndrome
Which drugs when coupled with SSRI can cause serotonin syndrome
Triptans
MAOi
Amphetamines
Examples of MAOi
Selegiline
Rasagiline
When should patients be reviewed after starting antidepressants
2 weeks
If under 30 or at increased risk of suicide- 1 week
How should SSRIs be stopped
Gradually reduced over 4 week period as risk of discontinuation symptoms
With fluoxetine do over 2 weeks with week washout
Common discontinuation symptoms of SSRI
Increased mood change
Flu like symptoms
Restlessness
Poor sleep
Sweating
GI symptoms
Parasthesia- electric shocks
Why cant use paroxetine in first trimester of pregnancy
Risk of congenital malformations
What is risk of using SSRIs in third trimester of pregnancy
PPHN
Why is mirtazapine good in the elderly
Is taken in the evening to help them sleep and increases appetite
Risk factors for suicide
Divorced
Living alone
Unemployed
Substance abuse
Chronic illness
Protective factors for suicide
Religious belief
Social support
No substance abuse
In the in patinet population when are people most likely to commit suicide
Bank holidays
As soon as possible into admission
Most common method of suicide in menkind
Hanging
What are 3 main mood stabilisers
Lithium
Sodium valproate
Carbamazepine
MOA of lithium, sodium valproate and carbamezapine
Inhibits recycling of neuronal membrane phosphoinositides
Contraindications of carbamezapine
AV condution abnormalities
History of bone marrow suppression
Acute porphyria
Monitoring of carbamezepine treatment
Pretreatment- FBC, LFT, U&E, ECG
Monitoring- FBC
Side effects of sodium valproate
GI
Weight gain
Hair loss or hair becomes curly
Pancreatitis
Pancytopenia
Rare- hepatic failure
Contraindications to sodium valproate
Hepatic dysfunction (including family history of severe drug induced hepatic dysfunction)
Porphyria