Affective Disorders Flashcards

Question

Management of all depression uses the biopsychosocial approach; however, management depends on severity. Discuss the management of mild to moderate depression (split your answer into biological, psychological and social)

Answer 1

_Biological_ * Not recommended first line unless certain criteria are filled _Psychological_ * **Watchful waiting & education surrounding depression**: reassess pt in two weeks (if mild depression & don't want intervention or subthreshold depression) * **Low intensity psychosocial interventions** * **Self-help programmes** * **CBT**(computerised or group if refuse other) * **Physical activity programme** e.g. group exercise class _Social_ * Depression support groups * Helping them to find support for finances, accomodation, employment etc... * Advice regarding general coping strategies e.g. regula routines * Safeguarding

Answer 2

* Depression has lasted a long time/subthreshold depression lasted \>2 years * Past history of moderate or severe depression * Symptoms persist after other interventions * Depression complicates care of other physical health problem

Answer 3

_Biological_ * Antidepressants * First line= SSRIs *(if it is reccurrent depressive disorder consider an antidepressant they previously had good respone to)* * Others e.g. TCA's, SNRIs, MAOIs * Adjuvants e.g. antipsychotics, lithium * ECT _Psychological_ * **High intensity psychosocial interventions:** * Individual CBT * Interpersonal therapy * Behavioural activation * Counselling * Psychodynamic therapy _Social_ * Depression support groups * Helping them to find support for finances, accomodation, employment etc... * Advice regarding general coping strategies e.g. regula routines * Safeguarding

Answer 4

* Suicide risk is high * Depression is severe * Recurrent depression * Unresponsive to initial treatment

Answer 5

* First depressive episode: 6 months after resolution of symptoms * Second depressive episode: 2 years after resolution of symptoms * Third or more episode: long term

Answer 6

* Acute treatment of severe depression which is life-threatening * Severe psychomotor retardation or stupor * Failure of other treatments * Depression with psychotic symptoms *\*NOTE: there are more indications for ECT, these are just ones related to depressive disorder*

Answer 7

Sertraline Lower risk of drug interactions

Answer 8

* **With treatment most episodes of depression last about 3-6 months** * \>50% with major depressive episode recover in 6 months * **Likelihood of recurrence is high and increases with each episode** *(first= 50%, second= 80%)* * **About 10% develop persistent depression** * The prognosis is worse for people with psychotic features, personality disorders, prominent anxiety, severe symptoms *\*Taken from NICE guidance, accessed in 08/21.*

Answer 9

* Personal or family history of depression * Previous PND * Older age * Single mother * Unwanted pregnancy * Poor social support

Answer 10

Characterised by a mixture or a rapid alternation (usually hours) of symptoms of hypomnia or mania and depression

Answer 11

Chronic episodic mood disorder, characterised by at least 1 episode of mania or hypomania and a further episode of mania or hypomania or depression. * Any of depression or mania can occur first. People may be diagnosed with bipolar when only had manic or hypomanic episodes however all cases eventually develop depression (rare just to have manic episodes)* * Requires at least 2 episodes in which person's mood is disturbed; one of which must be mania or hypomania*

Answer 12

* ~1.3 million people in UK (1 in 50 people) * Females = males * 19yrs * Black and other ethnic minorities

Answer 13

_Biological_ * **Monoamine hypothesis** * Mania: central monamines increased * Depression: central monamines decreased * **Dysfunction of HPA and HPT axis** *(hypothyroid present with depression, hyperthyroid present with mania)* * Genetic * In **monozygotic twins** if one has bipolar affective disorder other has 40-70% chance * **1st degree relatives** of BPAD pt is 5-10% _Environmental_ * Adverse life events * Bereavement * Post partum

Answer 14

_Predisposing_ * Biological: FH, age, HPA & HPT axis abnormalities * Psychological: other psychiatric conditions e.g. anxiety disorders * Social: _Precipitating_ * Biological: poor compliance with meds * Psychological: stressful life event * Social: working shifts, employment issues, housing issues etc... _Perpetuating_ * Biological: poor compliance meds * Psychological: lack of insight * Social: disrupted sleep pattern, social isolation, substance misuse

Answer 15

* Hypomania * Mania without pyschosis * Mania with psychosis

Answer 16

Need 3/9 symptoms to be present: * Grandiosity/increased self esteem * Decreased sleep * Pressure of speech * Flight of ideas * Distractability * Psychomotor agitation (restelessness) * Reckless behaviour e.g. spending, driving * Loss of social inhibitions * Marked sexual energy/increased libido

Answer 17

**Bipolar 1** * 1 or more manic or mixed episodes * +/- 1 or more depressive episodes *\*remember if don't have a depressive episode must have had two mania or mixed episodes* **Bipolar 2** * 1 or more hypomanic episodes * + 1 or more dpressive episodes *\*\*KEY DIFFERENCES: bipolar 1 must have mania or mixed affective episode- don't need to have depression. Bipolar 2 must haveat least 1 hypomanic episode and at least 1 depressive episode.*

Answer 18

More than 4 mood swings in a 12 month period with no intervening asymptomatic periods.

Answer 19

* Mania/hypomania: 2 weeks to 4/5 months (median= 4 months. Usually abrupt onset) * **Depression: median= 6 months**

Answer 20

TRUE May not disclose if you don't ask and they may have bipolar not depressive disorder or recurrent depressive disorder

Answer 21

_Bedside_ * Urine drug test _Bloods_ * TFTs (hyperthyroidism) * U&Es (baseline renal func for starting lithium) * LFTs (baseline liver function start mood stabilisers) * Calcium (biochemical disturbances can affect mood) _Imaging_ * CT or MRI head

Answer 22

* Risk assessment * Suicidal ideation * Financial * Children? * Risk to others e.g. driving * Do you need to contact DVLA? * Will the pt go to hospital voluntarily, if necessary, or wil they need sectioning under MHA?

Answer 23

* **First line= antipsychotic** (e.g. olanzapine, resperidone, quetiapine, haloperidol) *\*if first is not tolerated or poorly affective offer a second* * **Second line= add mood stabiliser** (e.g. lithium, valporate) * **If pt taking antidepressant taper and discontinue** * **Benzodiazepines** may be required to help sleep & agitation * **Haloperidol and/or lorazepam** may be used for rapid tranquilisation * \*NOTE: antipsychotics are used as they have rapid onset of action compared to mood stabilisers* * \*NOTE: mixed episodes treated in same way as manic episodes*

Answer 24

* Atypical antipsychotics (e.g. olanzapine alone, olanzapine combined with fluoxetine, quetiapine) * Mood stabilisers (e.g. lamotrigine, lithium) *\*NOTE: antidepressants alone are avoided, even if pt is predominantly depressed, as they can induce mania. Only be prescribed in conjuction with an anti-manic medication*

Answer 25

* **First line= lithium** * *Should be offered 4 weeks after acute episode has resolved to prevent relapses if not already added to regime* * Second line= * Other mood stabiliser e.g. **valporate can be added to lithium regime or tried on it's own** if lithium not tolerated * **Antipsychotic e.g. olanzapine**, quetiapine

Answer 26

Lithium & sodium valporate

Answer 27

* For at least two years after one episode of bipolar disorder. * Five years if there have been: * frequent previous relapses * psychotic episodes * alcohol or substance misuse * continuing stress at home or at work.

Answer 28

* For bipolar depression offer high intensity psychosocial intervention e.g. CBT According to NICE there are psychological interventions that have been specially developed for bipolar depression which may include: * Family focused therapy * Psychoeducation * Interpersonal social rhythm therapy *(help regulate sleep, social & daily activities)*

Answer 29

* Support groups * Self-help groups * Encourage calming activities * Encourage routines * Helping to manage e.g. accomodation, finances *(particularly after manic episode if spending)*

Answer 30

Not first line but may be used if antipsychotic drugs ineffective and pt is so disturbed that trying fruther medication or waiting for natural recovery is too risky.

Answer 31

* Initially once a week * Every 2-4 weeks for first few months

Answer 32

* Behaviour means they are a risk to others or themselves * Severe psychotic symptoms * Impaired judgement * Psychomotor agitation

Answer 33

* Catatonia is a severe neuropsychiatric disorder that affects movement, speech and activity levels (a psychomotor sydnrome) * Causes: * Psychiatric: depression, bipolar, psychosis e.g. schizophrenia, withdrawal from medications such as clopazine * Organic: CNS infections, normal pressure hydrocephalus, delerium, vit b12 deficiency, Parkinson's disease, subarachnoid haemorrhage * See image for signs & symptoms * Management: * Benzodiazepines * ECT

Answer 34

Compared with younger adults more likley to presetn with: * Disturbed sleep * Dependency having previously been independent * Motor disturbance e.g. retardation or agitiation * Multiple physical problems for which no cause can be found Less likely to present with low mood and express duicidal ideation. Management is similar but be cautious with medications due to interactions, issues with compliance etc.. Reducing social isolation is key.

Answer 35

Elderly pts with mania often have: * Irritability * Labile mood * Perplexity (inability to deal with or understand something much like that in delerium but they have clear consciousness) * Grandoise ideation Less likely to preset with overt elation. Treatment is with antipsychotics but be careful in pts with dementia or vascular risk factors due to increased risk of stroke. Lithium can be used although a proportion of elderly ptsdevelop neurotoxicity; would have to be certain pt is capable of understanding and implementing lithium taking instructions.

Answer 36

True; may experience pseudohallucinations of deceased (both auditory & visual) and sometimes people focus on physical objects that remind them of that person or even prepare meals for them.