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
Monitoring of sodium valproate
LFTs
Side effects of lithium
Weight gain
Tremor
Muscle weakness
GI
Metallic taste
Nephrogenic DI (renal impairment)
T wave inversion
Leucocytosis which is benign
Hypothyrodism and hyperparathyroidism
Therapeutic range for lithium, what gives increased risk for side effects and toxicity levels
Range-0.6-1
SEs- 1.2
Toxic- 1.5
What can precipitate lithium toxicity
Antidepressants
Anticonvulsants
Diuretics
Ca blockers
Dehydration
Management of lithium toxicity
Stop drug
Measure levels
Fluids
Osmotic or forced alkaline diuresis may be required
Haemodialysis may be used if severe
When is lithium contraindicated
Cardiac rythm disorders
Renal impairment
Addisons
Low sodium diet
Untreated hypothyroidism
Which conditions can lithium exacerbate
Psoriasis
Acne
How is lithium monitored
Every week when increasing the dose
Every 3 months should have levels measured if dose stable
Every 6 momnths BMI, U&Es, calcium, TFTs and eGFR measured
Signs of lithium toxicity
Muscle weakness
D&V
Coarse tremor
Tremor of extremities and jaw
Hyper-irritibality
Polyuria and polydispisa
Giddiness
In severe cases psychosis, coma, seizures
Side effects of lamotrigine
Most common is maculopapular rash where must withdraw drug immediately
GI
Headache
Diplopia
SSRIs options in depression
Sertraline
Fluoxetine
Citalopram
Paroxetine
Which SSRI gives the worst discontinuation symptoms
Paroxetine as such short half life
Which antidepressants has high chance of death from overdose so avoid in case of suicide risk
Venlafaxine
TCAS except lofepramine
Examples of when switching antidepressants is dangerous
Fluoxetine to any other antidepressant as it has a long half life
Fluoxetine or paroxetine to a TCA as inhibit TCA metabolism and may need higher dose
To a serotonergic or MAOi as risk of serotonin syndrome
From any MAOi you should have 2 week washout
What is done in very severe depression
Use crisis resolution team and home treatment teams to manage
Admit if high risk of neglect, suicide or self harm
May use ECT if depression life threatening and other treatments have completely failed
What is contrainfication to ECT
Raised ICP
Recent MI
Short term SEs of ECT
Headahce
Nausea
Arrythmias
Short term memory loss- antegrade and retrograde
Muscle ache
Longer term can have impaired memory loss
What do you do to dose of SSRI before ECT
Reduce the dose
What factors in mild depression would prompt to treat pharmacologically
Previous depressive episode
Symptoms have been going on for years
Electrolyte abnormality associated with SSRI
Hyponatraemia
Which factors indicate likely to commit suicide again
Avoiding discovery
Violent method
Final acts like sorting out a will
Planning
Leaving a note
How do TCAs cause incontinence
Anti-cholinergic effects which cause urinary retention leading to frequent overflow urination
Contraindications to SSRIs
Hyponatraemia
GI bleeding
Chronic side effects of lithium
CKD
Hypothyroidism
Weight gain
Psychotic presentation of catatonia
Mood congruent delusions
Hallucinations
Catatonia
Categorising depression DSM5
Mild- 2 core symptoms + 2 other symptoms
Moderate- 2 core symptoms + 3+ other symptoms
Severe- 3 core symptoms + over 4 symptoms
Types of depression
Atypical depression
Dysthymia
Seasonal affective disorder
Presentation of atypical depression
Increased appetite, increased sleep, fatigue, leaden paralysis
What is dysthymia
Chronic low grade depressive symptoms for over 2 years
Rating scale questionnaire for depression
PHQ-9
What are secondary causes of mania
Organic brain damage in the right hemisphere of elderly
Levo-dopa and corticosteroids
Illicit stimulants
Hyperthyroidism
How long once well should patients be treated with SSRIs in depression
6 months
2 years if at great risk of relapse
Treatment of serotonin syndrome
Stop meds
Supportive- cooling and fluids
Benzos for muscle rigidity
Can use cyproheptadine which is a serotonin antagonist
Complications of serotonin syndrome
DIC
Rhabdomyolysis
Renal failure
Seizures
Which condition can sodium valproate cause in women
PCOS
What is danger of sodium valproate in women of childbearing age
Neural tube defects
Which antidepressant is associated with SJS
Lamotrigine
If has Bipolar diagnosis and then presents with mania what is treatment
As already on mood stabiliser optimise this dose and then add antipsychotic
Can add benzo too
Which antidepressant most likely to cause insomnia
Citalopram
When checking lithium when levels when should levels be taken with regards to taking last dose
12 hours after
Once a lithium dose is changed when should it be monitored next
1 week then from then on every 3 months
Which antidepressant associated with torsades des pointes
Citalopram
Which SSRI is used when patient particulalry concerned about sleep and appetite
Mirtazapine
Which drugs most associated with discontinuation syndrome
Paroxetine
Venlafaxine
What is when a few hours after drinking you start hallucinating but are aware
Alcoholic hallucinosis- typically verbal hallucinations
Best antipsychotic if want to not put on weight
Quetiapine
Difference in congenital defects between the mood stabilisers
Lithium- ebsteins anomaly
Sodium valproate and carbamezepine- spina bifida
Indications for ECT in severe depression
Catatonia
Risk of not eating/drinking
High suicide risk
Psychotic features
When withdrawn following death of family what is called
Reactive depression- bereavement reaction
What non-pharm methods can be used for reactive depression
CBT
Grievance counselling
What would differ depression from normal bereavement
Normal bereavement would not present with psychotic symptoms, active suicidal thoughts, persistent thoughts of hopelessness, worthlessness and guilt
Becks cognitive triad
Negative views about self- worthless
Negative views about world- helpless
Negative views about future- hopeless
Physical causes of depression
Cushings
Hypothyroidism
Addisons
Dementia
Head injury
MS
Stroke
Features of abnormal grief reaction
Delayed- start over 2 weeks after
Prolonged (over 6 months)
Extremely disabling and intense
What support helplines can you offer to people
Samaritans
CALM- campaigning against living miserably MEN ONLY
Management of depression with psychotic symptoms
Start anti-psychotic alongside SSRI
Risk factors for depression
Female
FHx and personal Hx
Chronic illness
Dementia
Asylum seekers/refugees
Which drugs can cause depression
Beta blockers, methylopda, CCB
H2 anti-histamine
Chemo
Oestrogen
Psychiatric conditions
What other invesigations may be indicated for depression other than standard bloods
Magnesium
HIV and syphyllis
Drug screening
CT if suspicion of ICP
Stepped care model approach to depression
Step 1- with any case of depression consider active monitoring and psycho-education
Step 2- step 1 resistant or subclinical/mild depression consider low-intensity psychological therapies
Step 3- severe depression or resistant to the steps consider medication/high intensity psychological intervention
Step 4- whererisk of self harm consider ECT, high intensity psych intervention, medication
Low intensity psych interventions for depression
Self-help
Group physical activity
Computerised CBT
Group CBT
High intensity psych interventions for depression
CBT
Interpersonal therapy
Behavioural activation
What recommend if person (particulalry older) presents with depression and social isolation plays a major role
Recommend group based activities or exercise
What is behavioural activation
Encourage individual to do activities they have been avoiding, doing them may enforce psoitive feelings
3 indications for ECT according to NICE
Uncontrolled mania
Severe depression
Catatonia
Is ECT done under anaesthesia
Yes-general with muscle relaxants
What is done before ECT
Examination
Bloods- FBC, U&Es, LFTs
ECG- over 50 or medical indication
CXR- over 55 or medical indication
NBM for 8 hours
How are patients assessed after ECT
Assess congnition and rating scale
Cognition- MMSE
Rating scale- montgomery asberg depression rating scale (MADRS)
Unilateral versus bilateral ECT
Bilateral has electrodes on both side of head
- more effective
- quicker
Unilateral has 2 electrodes on non-dominant sphere
- slower and less effective
-BUT a lot less side effects
Advantage of unilateral ECT
Much less cognitive side effectd
How often is ECT given
Normally 2 sessions a week
12 sessions in total
What is operant versus classical conditioning
Operant- behaviour determined by either a punishment or reward
Classical- behaviour determined by preceeding stimulus
ECG effects of TCAs
QT prolongation
ST elevation
What is modern and reversible MAOi
Moclobemide
Refractory to SSRI management flow chat
Check adherance->optimise dose->trial other SSRI-> switch class of antidepressant
What can be done in refractory depression
Combine 2 SSRIs
ECT
Add a mood stabiliser
Indications for lithium
Severe depression
Mania
Schizoaffective
How long to taper valproate dose pre conception
At least 4 weeks
What is important diagnostic criteria for depression or mania with psychosis
That psychosis not present when euthymic
How can mania present other than elated mood
Irritability
What is hypoactive delirium
Mimics depression- cause is same as delirium normally aware of
Most important side effect of carbamezapine
BM suppression
Plan if decide on watchful waiting for depression
Review in 2 weeks
If persisted then offer self-help or group-CBT
How switch SSRIs
Taper off for 4 weeks then start next one
When switching what is most common way of doing it (guess if unsure in exam)
Cross taper cautiously
This involves slowly reducing dose of current one while increasing dose of other
How do you switch between SSRI and SNRIs (not from fluoxetine)
Direct switch
How do you switch from fluoxetine to a TCA, SSRI or SNRI
Reduce dose of fluoxetine then start next drug 1 week later
How do you switch from TCA to fluoxetine
Halve the TCA then add fluoxetine
Slowly withdraw TCA
How to switch from TCA to SNRI or non-fluoxetine SSRI
Slowly reduce dose by 25mg then start new one
Remove TCA over next week
What are trazodone and dosulepin
TCA
Which TCAs are the most toxic
Amitriptylline and dosulepin
What is depressive stupor
When present with mutism and akinesis
What is cyclothymia
When present with instability of mood- get days of elated mood then other days of really bad depression
Which antidepressant associated with death from OD
Venlafaxine
Who need to use venlafaxine with caution in
HTN patients
What is effect of carbamazepine on liver
Induces liver enzymes
What is main factor in allowing someone with self harm presentation to be discharged
Whether will be supported by family
Plan if discharge someone after self harm/suicide
Create crisis plan on how to deal with thoughts
- who they will tell
- how they will get help
Arrange follow-up
Management of seasonal affective disorder
CBT
- encourage getting outside and maximising natural light in house
What use as second line to lithium if sodium valproate CI for BPAD
Olanzapine
What makes up a persistent complex grief reaction
When want to die to be with the lost person
What is PHQ-9 cut off for more severe depression
16
Preferred option for more severe depression
Combination of SSRI and CBT
What do for really severe lithium toxicity
Haemodialysis to lower levels
Indications for haemodialysis in severe lithium toxicity
Renal failure and levels over 2.5
Severe signs- nystagum etc
Lithium over 4
Examination findings of TCA overdose
Prolonged QRS
Hypotension
Mydriasis
Tachycardia
Side effects of carbamezapine and how to remember
CABRA MEAN
Confusion
Ataxia
Rashes
Blurred vision
Aplastic anaemia
Marrow suppression
Eosinophilia
ADH release
Neutropenia
How long should someone be on a SSRI for depression before changing dose/drug
4 weeks
6 weeks if elderly
