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Y5 Psychiatry > Affective Disorders > Flashcards

Affective Disorders Flashcards

1
Q

What are the ICD-10 core features of depression?

A
  • Low mood
  • Anhedonia (inability to enjoy oneself)
  • Anergia (lack of energy)
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2
Q

What are the adjunct symptoms of depression?

A
  • Insomnia/early waking
  • Poor concentration
  • Increased OR descreased appetite/weight
  • Suicidal thoughts/acts
  • Agitation OR Slowing of movements
  • Guilt/Self blame
  • Low libido
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3
Q

Name medication known to cause depression.

A
  • Steroids
  • COCP
  • Beta-blockers (propranolol)
  • Statins
  • Ranitidine
  • Retinoids (isotretinoin)
  • Chemo
  • HIV medications
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4
Q

What is seasonal affective disorder?

A

Episodes of depression, recurring annually at the same time in the year with remission in between

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5
Q

What is atypical depression?

A

Somatic symptoms (weight gain, hypersomnia)

  • Symptoms are opposite of expected/classical depression
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6
Q

What is anxiety-induced insomnia?

A
  • Lack of sleep/ability to fall to sleep due to anxiety
    • An increase in sleep + eating = increased mood
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7
Q

What is agitated depression?

A

Psychomotor agitation instead of retardation

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8
Q

What is depressive stupor?

A

Psychomotor retardation so bad that they grind to halt

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9
Q

What are some causes of depression, split into biological or psychosocial factors?

A
  • Biological
    • Endocrine - chronic stress (increased cortisol causes decreased neurotrophin expression and damaged hippocampal neurones)
    • Illness - direct (Cushing’s) or indirect (cancer)
    • Medication - steroids, anti-HTN, COCP
  • Psychosocial
    • Childhood - adverse events/abuse/criticism etc
    • Vulnerability - reduced resilience due to unemployment, isolation
    • Life events - death, divorce, jail
    • Substance abuse
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10
Q

What investigations should be done for suspected depression?

A
  • Full history/collateral history
  • Physical exam
  • Bloods
    • FBC (anaemia), TFT (hypothyroid), glucose/HbA1c (diabetes), U&Es, calcium
    • HIV, Syhillis, drug screening
  • Imaging – rule out intracranial physical pathology
  • Screening Scale
    • PHQ9, HADS, BDI-II (adults) or CDI (children) – EPDS (pregnancy)
  • MSE
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11
Q

What might be expected in a depressed patients MSE?

A
  • Apearance and Behaviour - signs of neglect, dehydration, miserable, disinterested, anxious movements, poor eye contact, tearful, posture
  • Speech - slow, quiet, mute
  • Emotion - restricted range of affect, Nihilism (exsistence is meaningless and useless)
  • Perception - if severe: hallucinations, nilihistic or persectutory delusions, evil images, guilt
  • Thought - Beck’s triad
  • Insight - Nil
  • Cognition - psychomotor retardation can mimic cognitive impairment
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12
Q

What differential diagnoses should be considered in depression?

A
  • Physical – hypothyroid, head injury, ‘quiet’ delirium, low Vit D, drug-induced, Parkinson’s, Chronic diseases/pain, anaemia
  • Adjustment disorder – mild affective symptoms following life events à do not reach the severity of depression
  • Bereavement – normal grief for <6m
  • BPAD, schizoaffective disorder, schizophrenia – previous mania or psychotic features
  • Substance withdrawal/misuse
  • Postnatal – depression/puerperal illness
  • Dementia
    • ​Pseudodementia is global memory loss in severe depression
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13
Q

What is Pseudodementia?

A

Global memory loss in severe depression

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14
Q

What is the management of mild depression in children/young people?

A
  • 1st line: Watchful waiting (for 2 weeks, and follow-up)
    • Self-help (mind.org, youngminds.org)
    • Lifestyle advice (i.e. sleep hygiene, diet, exercise)
  • 2nd line: CBT (digital, group)
  • Not successful/sufficient improvement in 2-3m = referral to CAMHS
  • Treated in primary care
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15
Q

What is the management of moderate to severe depression in children/young people?

A
  • 5-11yo – psychological intervention:
    • Family-based IPT (Interpersonal Therapy); OR
    • Family therapy; OR
    • Individual CBT
  • 12-18yo – psychological intervention:
    • Individual CBT
    • If needs arent met then family therapy, IPT-A (“Adolescents”), psychodynamic psychotherapy
    • SSRI (fluoxetine) can be added but is rare and avoided in must cases
  • Treated in CAMHS
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16
Q

Which anti-depressant is specifically licenced for it use in children?

A

Fluoxetine

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17
Q

What is the management of depression which is unresponsive to treatement in children/young people?

A
  • Intensive psychological therapy
  • Treated by CAMHS
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18
Q

What is the management of depression in adults?

A
  • CHECK SUICIDE RISK: suicidal acts or intent? Have they made plans? P**rotective factors/risk factors?
  • Step 1 – Indications: initial suspected depression or subthreshold symptoms
    • Watchful waiting with follow-up in 2 weeks
    • Education – sleep hygiene, exercise, self-help, information, support
  • Step 2 – Indications: mild depression or persistent subthreshold symptoms
    • Low-intensity psychosocial interventions:
      • Group/Computerised CBT
      • Guided self-help (based on the principles of CBT)
      • Structured group physical activity programme
    • Medications if:
      • History of moderate-to-severe depression
      • Subthreshold depressive symptoms lasting >2 years
      • Mild depression complicating care of chronic physical health problems
  • Step 3 – Indications: moderate depression or refractory persistent subthreshold symptoms
    • High-intensity psychosocial interventions
      • Individual CBT
      • Interpersonal Therapy (IPT)
        • IPT > CBT if due to death
    • Medications - regular review: every 2 weeks for 3 months; every week if suicidal
  • Step 4 – Indications: severe depression or risk to life or neglect
    • If suicidal = urgent referral to crisis team
    • High-intensity psychosocial interventions
    • Medications
    • ECT if necessary
    • Section via 2, 3 or 4 if necessary
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19
Q

What are the risk factors for suicide?

A

Risk factors = young male, occupation (doctor, vet), live alone, mental illness, unmarried

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20
Q

In what order are anti-depressants prescribed in adults?

A
  • 1st line = SSRI (sertraline, citalopram, fluoxetine, paroxetine):
    • Sertraline: stepped increase from 50mg to 200mg (50mg increase every 2 weeks; over 6 weeks)
    • 2 trials of SSRIs before moving to 2nd line
  • 2nd line = Taper down SSRI and switch to SNRI (venlafaxine, duloxetine):
    • Venlafaxine: stepped increase from 37.5mg BD to 75mg BD to 75mg morning + 150mg evening
  • 3rd line/Treatment resistant = Augment treatment with:
    • Antipsychotic (i.e. quetiapine 150-300mg)
    • Lithium (blood level of 0.4-0.8)
    • Other antidepressant (e.g. mirtazapine or mianserin)
  • 4th line = ECT
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21
Q

What should be checked at every review of a depressed individual?

A
  • Any new suicidal indeation
  • Compliance to medication
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22
Q

What is “Catch-up” phenomena?

A
  • Recovery from depression with treatment, which is subsequently stopped, and that person falls back into depression leads to a worse depression state than before
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23
Q

How should anti-depressants be used in pregnancy?

A
  • No antidepressant is specifically licenced for use in pregnancy
  • No antidepressant has been found to cause significant negative effects to the foetus or mother during pregnancy
    • However, the lowest-effective dose should be used if possible
  • Paroxetine may have mild risks:
    • 1st trimester = congenital heart defects
    • 3rd trimester = persistent pulmonary hypertension
  • Mild or moderate depression = encourage to taper down and switch (if possible)
    • Mild - facilitated self-help
    • Moderate - CBT (or switch to a drug with lower risk of adverse effects)
  • Severe depression = continue antidepressant or switch to a drug with lower risk of adverse effects
24
Q

Define psychotic depression.

A

A severe depression with delusions and hallucinations

25
Q

How can a schizophrenic delusion be distinguished from a depressed delusion?

A
  • Ask why is that?
    • “He wants to kill me with an axe”
      • Psychotic depression = ‘the world is better off without me’
      • Schizophrenia = ‘I have no idea, but I got the message’
26
Q

Why does suicidal ideation increase in the first few weeks of SSRI use?

A
  • Medication takes some time to make a patient feel better
  • However, they do improve motivation
    • Makes any ideas of suicide more likely to follow through on them
27
Q

What are the risk factors for serotonin syndrome?

A
  • Antidepressants – especially combination or overdose
  • Lithium
  • ECT
  • Opiates
28
Q

What are the complications of serotonin syndrome?

A
  • DIC
  • Rhabdomyolysis
  • Renal failure
  • Seizures
29
Q

What is the ICD-10 defintion of BPAD?

A
  • ≥2 episodes
    • ​1 must be manic associated (hypomania/mania/mixed; the other can be depressive); AND
    • Mania lasts ~ 4m
    • Depression lasts ~ 6m
  • Complete recovery between 2 episodes
30
Q

What percentage of BPAD patients will experience depression after mania?

A

>90%

31
Q

What might be expected in a BPAD patient with mania MSE?

A
  • Apearance and Behaviour - excitable, irritable, distracted, inapprpriate/flashy clothing
  • Speech - pressured, mutism (severe cases)
  • Emotion - increased self-esteem, grandiose, labile mood, irritable, insomnia, loss of inhibition, increased appetite
  • Perception - Grandiose delusions, paranoia, catatonia (stupor)
  • Thought - flights of ideas, racing thought, over-optimism, suicidal ideas, Schneider’s 1st rank symptoms (not present outside of manic episode)
  • Insight - Minimal - reckless/risky behaviour - particularly sexual
  • Cognition - Nil
32
Q

Define mania.

A

A distinct period of abnormally and persistently elevated, expansive or irritable mood with ≥3 characteristics of mania, lasting at least 7 days (ICD-10)

  • Impairs occupational/social functioning
  • ± Psychosis
33
Q

Define hypomania.

A

>3 characteristic symptoms of mania lasting ≥4 days

  • Does not impair occupational/social functioning / no psychosis or delusions
  • Slightly less exaggerated mania symptoms
    • Mildly elevated mood; feeling of well-being, mental, or physical efficiency
34
Q

What is mixed bipolar?

A

Mixture, or rapid alternation (within a few hours) of manic/hypomanic and depressive symptoms

35
Q

Define Type 1 BPAD.

A

Manic episodes interspersed with depressive episodes

36
Q

Define Type 2 BPAD.

A

Recurrent depressive episodes, with less prominent hypomanic episodes

37
Q

Define Rapid cycling BPAD.

A

≥4 episodes/year

38
Q

What does Rapid cycling BPAD respond well to?

A

Sodium valporate

39
Q

What are the risk factors for BPAD?

A
  • Genetics - 1st degree relative = 7x increase
  • Stressful life events are triggers - e.g. pregnancy
  • More common in upper social classes
40
Q

What biological changes occur in people with BPAD?

A
  • Anatomical – decreased grey matter mass in emotional regulation areas; increased ventral limbic area activity
  • Transmitters - increased NA, DA and serotonin trigger mania
41
Q

What investigations should be done for suspected BPAD?

A
  • Full psychiatric history/Collateral history
  • Physical examination (establish baseline state)
  • Bloods: FBC, TSH, U&E, LFT, ECG
  • Urine drug screen
  • Rating scale: Young Mania Rating Scale
  • Risk assessment
42
Q

How do most BPAD present?

A
  • Most present in their depressive episodes
    • ​Empathises the importance of always asking about manic symptoms
43
Q

What differential diagnoses should be considered in BPAD?

A
  • Organic
    • Drugs, dementia, frontal lobe disease, delirium, cerebral HIV, ‘Myxoedema Madness”
  • Schizophrenia/schizoaffective disorder
  • Cyclothymia
  • Puerperal disorders
44
Q

What is cyclothymia?

A

Persistent mild mood instability

  • Never sufficiently severe to be BPAD/depression
45
Q

What is the management of acute mania or hypomania?

A
  • Gradually taper off and stop inducing medications (i.e. SSRIs)
  • If NOT on treatment = aim is to stabilise before starting lithium
    • 1st line = antipsychotic (olanzapine > haloperidol, quetiapine, risperidone)
    • 2nd line = different antipsychotic (switch to different antipsychotic)
    • 3rd line = Add lithium or sodium valproate
      • Lithium is not as effective acutely (needs higher doses so risks toxicity)
  • If ONn treatment
    • Optimise medication/stop antidepressants
      • Check compliance
    • Check lithium levels and possibly add atypical
    • Short-term sedatives (benzodiazepines)
  • Monitor fluid/food intake
  • Sedation may be required (clonazepam, lorazepam)
  • ECT only if mania is not responsive to treatments below
46
Q

What is the long-term management of BPAD?

(4 weeks after an acute episode)

A
  • 1st line = Lithium
    • Monitor for lithium toxicity
    • Monitoring required – may take up to 5 weeks to titre correctly
  • 2nd line = Lithium and Valproate
  • If Lithium poorly tolerated = Valproate alone or Olanzapine alone
47
Q

What are some side effects of long-term sodium valporate use?

A
  • Hair loss
  • Weight gain
  • Nausea
48
Q

How is depression managed in BPAD?

A
  • Can’t use antidepressants by themselves as they may cause a switch to mania
    • Only give antidepressants with a mood stabiliser or an antipsychotic
  • 1st line = Fluoxetine and olanzapine
  • 2nd line = Quetiapine
  • 3rd line = Olanzapine or Lamotrigine
49
Q

What is the use of psychological therapy in BPAD?

A
  • Indications and purpose
    • May improve compliance with medications long-term
    • Offered after the acute manic event has resolved
  • CBT – Test excessively positive thoughts and gain a sense of perspective
    • Identify relapse indicators
    • Create relapse prevention strategies:
      • Developing routine
      • Ensuring good-quality sleep
      • Promoting a healthy lifestyle
      • Avoiding excessive stimulation/stress
      • Addressing substance misuse
      • Ensuring drug compliance
  • Psychodynamic Psychotherapy (useful if mood stabilised)
50
Q

What is the prognosis of BPAD?

A
  • Remissions becomes shorter with age and depressions become more frequent
  • 15% with BPAD will commit suicide - 15x higher than general population
    • Lithium reduces this to same levels as general population
51
Q

What social interventions can be used in the management of BPAD?

A
  • Supported employment programmes
  • Adaption in education systems
  • Family support and therapy
52
Q

What is the mean age of onset of BPAD?

A
  • 30
    • Before 25 is Early onset
    • Very rare after 40
53
Q

What are the risk factors for depression?

A
  • Female (1 in 4 over 1 in 10 in men)
  • Past history of depression
  • Significant physical illness
  • Other mental illness
  • Afro-Caribbean, Asian, Refugee
  • Social factors
  • Abuse
54
Q

What are the ICD-10 and DSM-V classification of depression?

A

Symptoms

ICD-10

DSM-V

1 core symptom and 1-3 other

Minor Depression

2 core symptom and 2+ other

Mild Depression

Mild

1-2 core symptom and 4+ other

Major Depression

2 core symptom and 4+ other

Moderate Depression

3 core symptom and 5+ other

Severe Depression

3 core symptom, 5+ other + Psychosis

Severe with Psychosis

55
Q

What is the monoamine theory of depression?

A
57
Q

What are some causes of secondary mania?

A
  • Organic brain damage - especially in the right hemisphere
  • Medication
    • Levo-dopa
    • Corticosteroids
  • Illicit drugs
  • Hyperthyroidism - can present as hypomanic or agitated

Y5 Psychiatry (11 decks)

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