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Affective Flashcards

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1
Q

What are 3 core depression symptoms

A

Low mood
Low energy
Loss of interest

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2
Q

Depression symptoms according to ICD-10

A

Low mood
Low energy
Decrease in activity (loss of focus/interest)
Sleep disturbed
Appetite loss
Agitation
Loss of libido
Psychomotor retardation

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3
Q

When would you urgently refer someone to specialist mental health symptoms with depression

A

Evidence of psychosis
Severe depression where risk of self harm, harm to others or neglect

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4
Q

What is seasonal affective disorder

A

Episodes of depression which recur annually at the same time

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5
Q

What are chronic depressive symptoms

A

Symptoms which meet criteria for at least 2 years

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6
Q

What to do if new episode of less severe depression

A

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

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7
Q

What to do if new episode of more severe depression

A

Talk through options
- can start SSRIs if wants
- talk through options such as CBT etc
- discuss with DVLA if needed

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8
Q

When need to talk to DVLA in depression

A

Agitation
Suicidal thoughts
Lack of concentration/focus

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9
Q

First line medications for depression in less severe depression versus more severe depression

A

Less severe
- SSRI
More severe
- SSRI or SNRI

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10
Q

What does less severe versus more severe depression encompass

A

Less severe- subclinial or mild. PHQ under 16
More severe- moderate or severe PHQ over 16

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11
Q

What are examples of SSRIs

A

Citalopram
Fluoxetine
Sertraline
Paroxetine

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12
Q

Side effects of SSRis

A

GI- nausea, weight loss, diarrhoea
Sexual- loss of libido, delayed orgasm
Headache
Sleep disturbance- vivid dreams
Hyponatraemia

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13
Q

How long do antidepressants take to work

A

2-6 weeks

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14
Q

What are the classes of antidepressants and what do they target

A

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

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15
Q

Examples of TCA

A

Amitryptiline
Clomipramine
Lofepramine

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16
Q

Side effects of TCA

A

Anti-muscarinic- dry mouth, blurred vision, constipation and urinary retention
Anti-histaminergic- postural hypotension, sedation, weight gain

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17
Q

When should TCAs be avoided

A

Suicide risk

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18
Q

How does overdose of TCA present

A

Cardiotoxic
- hypotension
- tachycardia
- prolonged QRS
Resp failure
Seizures

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19
Q

What must be done when prescribing MOAi

A

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

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20
Q

Examples of MOAi

A

Phenelzine
Moclobemide- reversible and modern

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21
Q

SEs of MOAis

A

Postural hypotension
Increased appetite
Hepatotoxicity
SNS crisis from interaction with tyramine which can lead to intracerebral bleed
Serotonin syndrome

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22
Q

What happens in serotonin syndrome- triad

A

Physiologically too much serotonin in synapses in brain
Autonomic dysfunction- tachycardia, HTN, diaphoresis, mydriasis
Altered mental state- agitation, confusion
NMJ hyperactivity- tremor, hyperreflexia, myoclonus

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23
Q

Example of SNRI

A

Venlafaxine

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24
Q

SEs of SNRI

A

Constipation
Nausea
Headache
Dizziness
Sleep disturbance
Hypertension

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25
Q

What needs monitoring with SNRIs

A

BP

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26
Q

Examples of NaSSA

A

Mirtazapine

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27
Q

SEs of NaSSA

A

increased appetite and weight gain
Oedema
Sedation

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28
Q

How long should first episode depression be treated for

A

6 months

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29
Q

What is hypomania

A

Includes constellation of mania symptoms but without disrupting work or have social rejection and lasts less than 7 days

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30
Q

Mania symptoms

A

Persistent elevation in mood
Increased mental and physical efficiency
Increased sociability
Increased sexual enegry
Reduced need for food and sleep

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31
Q

What defines mania without psychotic symptoms

A

Symptoms become so severe cant sustain attention
Loss of social inhibitions which result in reckless behaviour

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32
Q

What defines mania with psychotic symptoms

A

Delusions (grandiose)
Hallucinations
Or where flight of ideas are so extreme that subject is incomprehenisble

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33
Q

What is criteria for bipolar affective disorder

A

At least 2 episodes of extremes of mood including a hypomania episode

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34
Q

When can first rank symptoms of schizophrenia be seen in mania

A

In acute episode

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35
Q

What does mute patient suggest

A

Schizophrenia
Extremely severe mania

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36
Q

What does prolonged 1st rank symptoms in mania suggest

A

Schizoaffective disorder

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37
Q

Which factors influence whether admitted to hospital or managed at home

A

Risk to self and risk to others
Lack of insight into care
Lack of support at home

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38
Q

What are the 2 types of bipolar disorder

A

type I disorder: mania and depression (most common)
type II disorder: hypomania and depression

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39
Q

Factors which lead to mania over hypomania

A
  • over 7 days
  • psychotic symptoms
  • daily life interrupted
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40
Q

If patient presents with mania for first time what do

A

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

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41
Q

Management of acute phase mania

A

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

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42
Q

If suffering from a manic episode then what do with antidepressants

A

Taper off them typically as can aggravate psychosis

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43
Q

How are mixed mania/depression episodes managed in bipolar

A

Same as mania

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44
Q

Longer term management after acute episode of mania resolved

A

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

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45
Q

How is bipolar depression managed

A

Bio either
- Quetiapine alone
- Fluoxetine and olanzapine
- Olanzapine
- Lamotrigine
Psychological intervention
- CBT or specifically designed bipolar depression intervention

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46
Q

What must be given alongside SSRI if taking a NSAID

A

PPI- like omeprazole as increases risk of an ulcer

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47
Q

What is choice of SSRI post MI

A

Sertraline

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48
Q

What is choice of antidepressant in children

A

Fluoxetine but should always be used with caution

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49
Q

Adverse effects of SSRIs

A

GI symptoms most common
Also very common to have increased anxiety and agitation after starting them

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50
Q

Which antidepressant is associated with longer QT interval

A

Citalopram
Shouldnt be used in those who have long QT and medications which cause long QT

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51
Q

What antidepressant should be used if taking warfarin/heparin/aspirin

A

Avoid SSRIs
Use mirtazapine

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52
Q

What antidepressant should be used if on triptans

A

Mirtazapine- avoid SSRIs as increased risk of serotonin syndrome due to triptans being serotonin agonists

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53
Q

What antidepressant should be used if on MAOi

A

Mirtazapine
As increased risk of serotonin syndrome

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54
Q

Which drugs when coupled with SSRI can cause serotonin syndrome

A

Triptans
MAOi
Amphetamines

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55
Q

Examples of MAOi

A

Selegiline
Rasagiline

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56
Q

When should patients be reviewed after starting antidepressants

A

2 weeks
If under 30 or at increased risk of suicide- 1 week

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57
Q

How should SSRIs be stopped

A

Gradually reduced over 4 week period as risk of discontinuation symptoms
With fluoxetine do over 2 weeks with week washout

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58
Q

Common discontinuation symptoms of SSRI

A

Increased mood change
Flu like symptoms
Restlessness
Poor sleep
Sweating
GI symptoms
Parasthesia- electric shocks

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59
Q

Why cant use paroxetine in first trimester of pregnancy

A

Risk of congenital malformations

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60
Q

What is risk of using SSRIs in third trimester of pregnancy

A

PPHN

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61
Q

Why is mirtazapine good in the elderly

A

Is taken in the evening to help them sleep and increases appetite

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62
Q

Risk factors for suicide

A

Divorced
Living alone
Unemployed
Substance abuse
Chronic illness

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63
Q

Protective factors for suicide

A

Religious belief
Social support
No substance abuse

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64
Q

In the in patinet population when are people most likely to commit suicide

A

Bank holidays
As soon as possible into admission

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65
Q

Most common method of suicide in menkind

A

Hanging

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66
Q

What are 3 main mood stabilisers

A

Lithium
Sodium valproate
Carbamazepine

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67
Q

MOA of lithium, sodium valproate and carbamezapine

A

Inhibits recycling of neuronal membrane phosphoinositides

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68
Q

Contraindications of carbamezapine

A

AV condution abnormalities
History of bone marrow suppression
Acute porphyria

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69
Q

Monitoring of carbamezepine treatment

A

Pretreatment- FBC, LFT, U&E, ECG
Monitoring- FBC

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70
Q

Side effects of sodium valproate

A

GI
Weight gain
Hair loss or hair becomes curly
Pancreatitis
Pancytopenia
Rare- hepatic failure

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71
Q

Contraindications to sodium valproate

A

Hepatic dysfunction (including family history of severe drug induced hepatic dysfunction)
Porphyria

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72
Q

Monitoring of sodium valproate

A

LFTs

73
Q

Side effects of lithium

A

Weight gain
Tremor
Muscle weakness
GI
Metallic taste
Nephrogenic DI (renal impairment)
T wave inversion
Leucocytosis which is benign
Hypothyrodism and hyperparathyroidism

74
Q

Therapeutic range for lithium, what gives increased risk for side effects and toxicity levels

A

Range-0.6-1
SEs- 1.2
Toxic- 1.5

75
Q

What can precipitate lithium toxicity

A

Antidepressants
Anticonvulsants
Diuretics
Ca blockers
Dehydration

76
Q

Management of lithium toxicity

A

Stop drug
Measure levels
Fluids
Osmotic or forced alkaline diuresis may be required
Haemodialysis may be used if severe

77
Q

When is lithium contraindicated

A

Cardiac rythm disorders
Renal impairment
Addisons
Low sodium diet
Untreated hypothyroidism

78
Q

Which conditions can lithium exacerbate

A

Psoriasis
Acne

79
Q

How is lithium monitored

A

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

80
Q

Signs of lithium toxicity

A

Muscle weakness
D&V
Coarse tremor
Tremor of extremities and jaw
Hyper-irritibality
Polyuria and polydispisa
Giddiness
In severe cases psychosis, coma, seizures

81
Q

Side effects of lamotrigine

A

Most common is maculopapular rash where must withdraw drug immediately
GI
Headache
Diplopia

82
Q

SSRIs options in depression

A

Sertraline
Fluoxetine
Citalopram
Paroxetine

83
Q

Which SSRI gives the worst discontinuation symptoms

A

Paroxetine as such short half life

84
Q

Which antidepressants has high chance of death from overdose so avoid in case of suicide risk

A

Venlafaxine
TCAS except lofepramine

85
Q

Examples of when switching antidepressants is dangerous

A

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

86
Q

What is done in very severe depression

A

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

87
Q

What is contrainfication to ECT

A

Raised ICP
Recent MI

88
Q

Short term SEs of ECT

A

Headahce
Nausea
Arrythmias
Short term memory loss- antegrade and retrograde
Muscle ache

Longer term can have impaired memory loss

89
Q

What do you do to dose of SSRI before ECT

A

Reduce the dose

90
Q

What factors in mild depression would prompt to treat pharmacologically

A

Previous depressive episode
Symptoms have been going on for years

91
Q

Electrolyte abnormality associated with SSRI

A

Hyponatraemia

92
Q

Which factors indicate likely to commit suicide again

A

Avoiding discovery
Violent method
Final acts like sorting out a will
Planning
Leaving a note

93
Q

How do TCAs cause incontinence

A

Anti-cholinergic effects which cause urinary retention leading to frequent overflow urination

94
Q

Contraindications to SSRIs

A

Hyponatraemia
GI bleeding

95
Q

Chronic side effects of lithium

A

CKD
Hypothyroidism
Weight gain

96
Q

Psychotic presentation of catatonia

A

Mood congruent delusions
Hallucinations
Catatonia

97
Q

Categorising depression DSM5

A

Mild- 2 core symptoms + 2 other symptoms
Moderate- 2 core symptoms + 3+ other symptoms
Severe- 3 core symptoms + over 4 symptoms

98
Q

Types of depression

A

Atypical depression
Dysthymia
Seasonal affective disorder

99
Q

Presentation of atypical depression

A

Increased appetite, increased sleep, fatigue, leaden paralysis

100
Q

What is dysthymia

A

Chronic low grade depressive symptoms for over 2 years

101
Q

Rating scale questionnaire for depression

A

PHQ-9

102
Q

What are secondary causes of mania

A

Organic brain damage in the right hemisphere of elderly
Levo-dopa and corticosteroids
Illicit stimulants
Hyperthyroidism

103
Q

How long once well should patients be treated with SSRIs in depression

A

6 months
2 years if at great risk of relapse

104
Q

Treatment of serotonin syndrome

A

Stop meds
Supportive- cooling and fluids
Benzos for muscle rigidity
Can use cyproheptadine which is a serotonin antagonist

105
Q

Complications of serotonin syndrome

A

DIC
Rhabdomyolysis
Renal failure
Seizures

106
Q

Which condition can sodium valproate cause in women

A

PCOS

107
Q

What is danger of sodium valproate in women of childbearing age

A

Neural tube defects

108
Q

Which antidepressant is associated with SJS

A

Lamotrigine

109
Q

If has Bipolar diagnosis and then presents with mania what is treatment

A

As already on mood stabiliser optimise this dose and then add antipsychotic
Can add benzo too

110
Q

Which antidepressant most likely to cause insomnia

A

Citalopram

111
Q

When checking lithium when levels when should levels be taken with regards to taking last dose

A

12 hours after

112
Q

Once a lithium dose is changed when should it be monitored next

A

1 week then from then on every 3 months

113
Q

Which antidepressant associated with torsades des pointes

A

Citalopram

114
Q

Which SSRI is used when patient particulalry concerned about sleep and appetite

A

Mirtazapine

115
Q

Which drugs most associated with discontinuation syndrome

A

Paroxetine
Venlafaxine

116
Q

What is when a few hours after drinking you start hallucinating but are aware

A

Alcoholic hallucinosis- typically verbal hallucinations

117
Q

Best antipsychotic if want to not put on weight

A

Quetiapine

118
Q

Difference in congenital defects between the mood stabilisers

A

Lithium- ebsteins anomaly
Sodium valproate and carbamezepine- spina bifida

119
Q

Indications for ECT in severe depression

A

Catatonia
Risk of not eating/drinking
High suicide risk
Psychotic features

120
Q

When withdrawn following death of family what is called

A

Reactive depression- bereavement reaction

121
Q

What non-pharm methods can be used for reactive depression

A

CBT
Grievance counselling

122
Q

What would differ depression from normal bereavement

A

Normal bereavement would not present with psychotic symptoms, active suicidal thoughts, persistent thoughts of hopelessness, worthlessness and guilt

123
Q

Becks cognitive triad

A

Negative views about self- worthless
Negative views about world- helpless
Negative views about future- hopeless

124
Q

Physical causes of depression

A

Cushings
Hypothyroidism
Addisons
Dementia
Head injury
MS
Stroke

125
Q

Features of abnormal grief reaction

A

Delayed- start over 2 weeks after
Prolonged (over 6 months)
Extremely disabling and intense

126
Q

What support helplines can you offer to people

A

Samaritans
CALM- campaigning against living miserably MEN ONLY

127
Q

Management of depression with psychotic symptoms

A

Start anti-psychotic alongside SSRI

128
Q

Risk factors for depression

A

Female
FHx and personal Hx
Chronic illness
Dementia
Asylum seekers/refugees

129
Q

Which drugs can cause depression

A

Beta blockers, methylopda, CCB
H2 anti-histamine
Chemo
Oestrogen
Psychiatric conditions

130
Q

What other invesigations may be indicated for depression other than standard bloods

A

Magnesium
HIV and syphyllis
Drug screening
CT if suspicion of ICP

131
Q

Stepped care model approach to depression

A

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

132
Q

Low intensity psych interventions for depression

A

Self-help
Group physical activity
Computerised CBT
Group CBT

133
Q

High intensity psych interventions for depression

A

CBT
Interpersonal therapy
Behavioural activation

134
Q

What recommend if person (particulalry older) presents with depression and social isolation plays a major role

A

Recommend group based activities or exercise

135
Q

What is behavioural activation

A

Encourage individual to do activities they have been avoiding, doing them may enforce psoitive feelings

136
Q

3 indications for ECT according to NICE

A

Uncontrolled mania
Severe depression
Catatonia

137
Q

Is ECT done under anaesthesia

A

Yes-general with muscle relaxants

138
Q

What is done before ECT

A

Examination
Bloods- FBC, U&Es, LFTs
ECG- over 50 or medical indication
CXR- over 55 or medical indication
NBM for 8 hours

139
Q

How are patients assessed after ECT

A

Assess congnition and rating scale
Cognition- MMSE
Rating scale- montgomery asberg depression rating scale (MADRS)

140
Q

Unilateral versus bilateral ECT

A

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

141
Q

Advantage of unilateral ECT

A

Much less cognitive side effectd

142
Q

How often is ECT given

A

Normally 2 sessions a week
12 sessions in total

143
Q

What is operant versus classical conditioning

A

Operant- behaviour determined by either a punishment or reward
Classical- behaviour determined by preceeding stimulus

144
Q

ECG effects of TCAs

A

QT prolongation
ST elevation

145
Q

What is modern and reversible MAOi

A

Moclobemide

146
Q

Refractory to SSRI management flow chat

A

Check adherance->optimise dose->trial other SSRI-> switch class of antidepressant

147
Q

What can be done in refractory depression

A

Combine 2 SSRIs
ECT
Add a mood stabiliser

148
Q

Indications for lithium

A

Severe depression
Mania
Schizoaffective

149
Q

How long to taper valproate dose pre conception

A

At least 4 weeks

150
Q

What is important diagnostic criteria for depression or mania with psychosis

A

That psychosis not present when euthymic

151
Q

How can mania present other than elated mood

A

Irritability

152
Q

What is hypoactive delirium

A

Mimics depression- cause is same as delirium normally aware of

153
Q

Most important side effect of carbamezapine

A

BM suppression

154
Q

Plan if decide on watchful waiting for depression

A

Review in 2 weeks
If persisted then offer self-help or group-CBT

155
Q

How switch SSRIs

A

Taper off for 4 weeks then start next one

156
Q

When switching what is most common way of doing it (guess if unsure in exam)

A

Cross taper cautiously
This involves slowly reducing dose of current one while increasing dose of other

157
Q

How do you switch between SSRI and SNRIs (not from fluoxetine)

A

Direct switch

158
Q

How do you switch from fluoxetine to a TCA, SSRI or SNRI

A

Reduce dose of fluoxetine then start next drug 1 week later

159
Q

How do you switch from TCA to fluoxetine

A

Halve the TCA then add fluoxetine
Slowly withdraw TCA

160
Q

How to switch from TCA to SNRI or non-fluoxetine SSRI

A

Slowly reduce dose by 25mg then start new one
Remove TCA over next week

161
Q

What are trazodone and dosulepin

A

TCA

162
Q

Which TCAs are the most toxic

A

Amitriptylline and dosulepin

163
Q

What is depressive stupor

A

When present with mutism and akinesis

164
Q

What is cyclothymia

A

When present with instability of mood- get days of elated mood then other days of really bad depression

165
Q

Which antidepressant associated with death from OD

A

Venlafaxine

166
Q

Who need to use venlafaxine with caution in

A

HTN patients

167
Q

What is effect of carbamazepine on liver

A

Induces liver enzymes

168
Q

What is main factor in allowing someone with self harm presentation to be discharged

A

Whether will be supported by family

169
Q

Plan if discharge someone after self harm/suicide

A

Create crisis plan on how to deal with thoughts
- who they will tell
- how they will get help
Arrange follow-up

170
Q

Management of seasonal affective disorder

A

CBT
- encourage getting outside and maximising natural light in house

171
Q

What use as second line to lithium if sodium valproate CI for BPAD

A

Olanzapine

172
Q

What makes up a persistent complex grief reaction

A

When want to die to be with the lost person

173
Q

What is PHQ-9 cut off for more severe depression

A

16

174
Q

Preferred option for more severe depression

A

Combination of SSRI and CBT

175
Q

What do for really severe lithium toxicity

A

Haemodialysis to lower levels

176
Q

Indications for haemodialysis in severe lithium toxicity

A

Renal failure and levels over 2.5
Severe signs- nystagum etc
Lithium over 4

177
Q

Examination findings of TCA overdose

A

Prolonged QRS
Hypotension
Mydriasis
Tachycardia

178
Q

Side effects of carbamezapine and how to remember

A

CABRA MEAN
Confusion
Ataxia
Rashes
Blurred vision
Aplastic anaemia
Marrow suppression
Eosinophilia
ADH release
Neutropenia

179
Q

How long should someone be on a SSRI for depression before changing dose/drug

A

4 weeks
6 weeks if elderly

Psych (9 decks)

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