Affective Disorders Flashcards
How common in depression? BPAD?
Depression: 10-15% lifetime risk
BPAD: 1-2% lifetime risk
What are some risk factors for depression?
Female
Bereavement
Past history of depression, comorbid psych
Physical illness
Family history
Substance abuse
Social stressors eg. unemployment, isolation
What is the monoamine theory of depression?
Depression is due to lack of noradrenaline, serotonin and dopamine in the brain
What are some differential diagnoses for depression?
BPAD Grief reaction Schizoaffective disorder Substance misuse Endocrine abnormalities eg hypothyroidism Dementia, Parkinson's Drugs (steroids)
What are the symptoms of depression? Group them
Core: low mood, anergia, anhedonia
Biological: changes in appetite + sleep
Cognitive: guilt, low self-esteem, hopelessness, poor concentration
What is the ICD-10 criteria for diagnosing depression?
2 core symptoms + 2 other symptoms lasting for at least 2 weeks, not secondary to any other causes
Describe how severity of depression is assessed
Mild: 2 core + 2 other (4-5)
Moderate: 2 core + 3 other (5-6)
Severe: 3 core + 4 other (7-9)
Psychotic: severe depression + psychotic symptoms
When should you make an urgent psych referral for patients with depression?
If suicidal intent, self-harm, neglect, or psychosis
What types of psychotic features would you see in someone with severe depression + psychosis?
Mood congruent symptoms eg
- Auditory hallucinations saying derogatory things
- Nihilistic or persecutory delusions
What are some subtypes of depression? Briefly describe
Atypical depression: young females. Presents with low mood, increased sleep and increased appetite with prominent fatigue
Seasonal affective disorder: symptoms during winter months
Dysthymia: chronic low grade depression
What are some signs that grief may actually be depression?
- Lasting >6 months
- Very severe
- Cognitive symptoms of depression (eg appetite, sleep disruption, low mood are common to both, but guilt and low self-esteem are not)
- Self-harm or suicide
How would you investigate depression?
Collateral history if severe
Blood tests if indicated (such as severe fatigue) eg. FBC, TFTs, U+Es, CRP, glucose
If a person has symptoms of anxiety and depression, which would you treat first?
Depression
Describe the management of mild to moderate depression
1st: low intensity psychological intervention for 9-12 weeks eg. self-guided CBT, computerised CBT, or group-based CBT
* *If they have a physical health problem: group is better
2nd: consider higher intensity psychological therapy eg. CBT or IPT, or medication. Psychodynamic psychotherapy can be used alternatively but ?effectiveness
Describe the management of moderate to severe depression
1st: high intensity psychological therapy 3-4 months eg. CBT or IPT +/or medication
2nd: combined
Describe the principles of CBT
Based on Beck’s theory of negative automatic thoughts:
- Negative thoughts of self, world, future
- Thoughts influence behaviours influence emotions
- By challenging the negative thoughts and changing behaviours, can reduce the negative emotions
Describe CBT as if to a patient
A type of therapy that aims to help you identify the negative ways of thinking that feed into low mood, and provide strategies for breaking that cycle.
Lots of evidence to show it is very effective, can be as effective as medication.
I’ll give you some more information to read about it
What is psychodynamic psychotherapy?
A type of talking therapy that is based on the theory that previous life experiences, eg. relationships, influence the way we feel and behave in the present. A process of talking through and exploring patients past experiences to recognise reasons for current feelings
What is interpersonal therapy?
A type of talking therapy that helps people to identify and address problems in their relationships with others eg. partners, family
What are the different classes of antidepressants? Give examples of each
SSRIs: Sertraline, fluoxetine, paroxetine SNRIs: Venlafaxine, duloxetine NaSSAs: mirtazepine TCAs: Amitriptyline, imipramine MAOis: moclobemide
Which is the first line medication in depression? What are the common side effects and what are things to make patients aware of?
SSRIs eg Sertraline
- GI disturbance: nausea, diarrhoea/constipation
- Sleep disruption: insomnia, vivid dreams
- Low libido
- Usually will have effect within 2 weeks. May make things worse before better, increase in suicide risk
- Take in the morning. Avoid alcohol
- Discontinuation syndrome: abruptly stopping causes shooting pains and flu-like symptoms
- Will continue for several months to prevent relapse
What are the more serious complications of SSRIs?
GI bleeding
Hyponatraemia
Suicidality
Serotonin syndrome
When should SSRIs not be given?
If patient taking warfarin, triptans. Caution with aspirin and NSAID use (eg start PPI)
What is serotonin syndrome?
Complication of serotonin overload:
- Neurological signs: myoclonus, increased tone and reflexes, seizures
- Autonomic signs: increased HR + RR + temp, sweating
You have just prescribed a patient an SSRI for moderate depression. When do you want to review? What would you do if there is no improvement?
Review in 2 weeks unless risk of suicide (1 week)
Review every 2-4 weeks for several months
If no improvement by 4 weeks: check compliance, increase dose, change medication
How long should antidepressants be continued for?
6 months after the resolution of symptoms or 2 years if risk of relapse
When would you consider inpatient treatment for depression?
High risk of suicide, self-harm or neglect
When would you refer to secondary care if someone has depression?
Mod-severe not responsive to treatments
Risk of suicide, self-harm or neglect
What are the indications for ECT?
Psychotic depression
Catatonia
Refractory depression
Life-threatening depression
What are the side effects of SNRIs?
Same as SSRIs plus hypertension, high cholesterol
What are the side effects of NaSSAs?
Increased appetite, weight gain, drowsiness, dizziness
What are the side effects of TCAs?
Cholinergic: dry mouth, blurred vision, constipation, urinary retention, postural hypotension
Weight gain
Cardiotoxicity (increased QTc, AV block)
Lethal in OD
What are the side effects of MAOis?
Drowsiness, nausea, constipation
Cheese reaction: severe hypertension, stroke, death
What is important to advise in patients taking MAOis?
Low-tyramine diet: no cheese, wine, soybeans
What is the definition of refractory depression?
Failure to respond to 2 trials of different classes of antidepressants, each trialled at adequate dose for 6-8 weeks
What can cause serotonin syndrome? What are the complications? Management?
High dose/combination medications, opiate use, drugs
Rhabdomyolysis, renal failure, seizures
Management: consider admission, stop medications, cyproheptadine antidote
What are the risk factors for suicide?
Severe depression Previous attempts Male Extremes of age Substance misuse Personality disorder Schizophrenia Life events and stressors eg. loss Social isolation
What are some reasons for self-harm? Who most commonly self-harms?
Self-punishment
Substituting psychological distress
Overcoming numbness
Common in young people, PD, substance misuse
What are some features from history of more serious suicide attempt/self-harm?
Premeditation/planning
Attempts to not be found eg. locking doors
Writing a note
Violent method, certainty method would work
Intent to cause death
Ongoing wish to die/regret that the method did not work
What are some questions to help differentiate self-harm from suicide attempt?
What were you thinking about beforehand? What made you want to do it?
What were you hoping would happen? Did you want to die?
How did you feel afterwards?
Describe the management of attempted suicide
Risk assessment!!!! +assess capacity
-> consider admission, crisis team
If sending home, create a plan for if future feelings eg who they will tell + how they will get help
Follow up to treat underlying condition eg. SSRIs, CBT
What is the management of self-harm?
Risk assessment!
Treat the immediate condition eg. antidote to overdose, dressings for wound
Treat underlying condition
Alternatives to self-harm: sharp rubber band, lemon, distraction eg. call friend/hotline
How is ECT done? How effective is it?
Under general anaesthetic
Pass an electrical current through the brain to induce a generalised seizure lasting 15-25s. 6-12 sessions
Very effective. 80% will have a response
What are the side effects of ECT?
Confusion, headache, amnesia, muscle pain
Define BPAD
2+ episodes of mood disorder with at least 1 episode of mania/hypomania.
Type I: episode of mania (7+ days) with/without history of depressive episode
Type II: episode of hypomania (4+ days) with history of depressive episode/s
Both have recovery period between affective episodes
Define a manic episode. What is hypomania?
Mood disorder characterised by elation/irritability and significant impairment in functioning, lasting at least 1 week, with the presence of other symptoms such as:
Biological: decreased appetite, poor sleep
-Increased energy and feelings of productivity
-Increased self-esteem
-Talkativeness
-Disinhibition eg. sex, drugs, spending money
Hypomania is high mood/irritability with features of mania but not causing impairment in functioning
What are the risk factors for BPAD?
Family Hx, high socioeconomic status
Describe the psychotic symptoms of BPAD
Usually mood congruent eg
- Grandiose delusions: feeling gifted, special, famous
- Auditory hallucinations
What are the risks of BPAD?
- During mania: risky sexual behaviours, drug taking, gambling, neglect of needs eg food, sleep. At risk from others taking advantage
- During depression: self-harm, suicide
What are some differential diagnoses for BPAD?
- Schizophrenia or schizoaffective disorder
- Drug misuse
- Dementia eg. fronto-temporal
- Brain damage/SOL
- Steroid induced psychosis
What is cyclothymia?
Persistent mood instability with episodes of mild low mood and mild elation
Not severe enough or long-lasting enough to meet diagnosis of BPAD
How would you investigate BPAD?
Collateral history important
Urine drug screen
Bloods if indicated eg. TFTs
CT/MRI if indicated (eg if neuro signs)
What is the general management of BPAD?
Biopsychosocial approach Bio: -Mood stabilisers eg Lithium -Antipsychotics eg. olanzapine -Antiepileptics eg. valproate Psycho: CBT, IPT Social: employment help, educational help
When should you refer a patient with BPAD to secondary care?
Suspected diagnosis- for assessment
Presenting with worsening symptoms while managed in primary care
Describe the management of an acute manic episode
Risk assessment!!
Consider need for admission, crisis team, etc
Secondary care must be involved
1st episode: start antipsychotic eg. olanzapine
-> switch antipsychotic -> start lithium/valproate
On lithium: check levels, add antipsychotic
On antipsychotic: increase dose
What are the important things to do before starting mood stabilisers? What should the patient be aware of?
Measure BMI, FBC, U+Es, TFTs, ECG -> 6 monthly
Measure lithium levels after 1 week and weekly until levels are stable -> every 3 months for 1 year -> 6 months after that
TCI if D+V, pregnancy, or experiencing symptoms
Important to hydrate well, not use NSAIDs
Common side effects include: tremor, GI upset, metallic taste in the mouth, weight gain
What is the normal therapeutic window for lithium?
NICE says 0.6-0.8 mmol/L, up to 1.0 in some cases
What are the side effects and complications of lithium?
SEs: fine tremor, mild GI upset, metallic taste, weight gain
Complications:
-Renal disease (DI, CKD)
-Thyroid dysfunction
-Leucocytosis
Lithium toxicity: GI upset, ataxia, dysarthria, coarse tremor, reduced consciousness, seizures, nystagmus
At what levels does lithium toxicity occur?
> 1.5 mmol/L
When is lithium used in BPAD?
Usually as a longer-term treatment or if antipsychotics don’t work in acute episodes
If someone wants to stop their medication for BPAD, what would you discuss?
- The reason for stopping eg. intolerable side effects, feeling like they are OK now?
- Current state of symptoms, !!risk assessment!!
- Explain that BPAD is often long-term, relapsing and remitting
- The reason they feel better is because of the medication, but when it is stopped, the symptoms will likely come back
- Explain the risks of BPAD: gambling/spending, sex, relationships, low mood
- Create a plan/address concerns eg. consider switching medication, trial of reducing medication
- Safety net: if symptoms start again- what to look out for, who to contact
What are the side effects of valproate?
Weight gain, hair loss, GI upset, abnormal LFTs, BM suppression
What are some ways of assessing depression severity?
PHQ-9, HADS (in hospital), Beck depression inventory
