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Affective Disorders Flashcards

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1
Q

What is depression?

A

Mood disorder characterised by a pervasive lowering of mood accompanied by psychosocial and biological symptoms

Most people go through periods of feeling down, but when you have depression, you feel persistently sad for weeks or months and it can cause very distressing symptoms. With the right treatment and support, most people make a full recovery

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2
Q

Describe the DSM-V criteria used to diagnose depression

A

Core symptoms = Low mood, anhedonia, low energy
At least 2 must be present on most days / most of the time for at least 2wks

Adjuncts:
Biological / somatic

  • Fatigue / insomnia / early waking
  • Poor concentration
  • Increased / decreased appetite / weight

Negative cognitions

  • Hopelessness
  • Helplessness
  • Guilt / self-blame
  • Worthlessness
  • Suicidal thoughts or acts

Psychotic

  • Mood congruent delusions (e.g. nihilistic)
  • Hallucinations
  • Catatonia
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3
Q

Describe the Hospital Anxiety and Depression (HAD) scale

A
  • 14 questions > 7 for anxiety and 7 for depression
  • Focuses on the last week
  • Each item scored from 0-3
  • Produces a score out of 21 for both anxiety and depression

Interpretation:
0-7 normal
8-10 borderline
11+ anxiety/depression

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4
Q

Describe the Patient Health Questionnaire (PHQ-9)

A

Multipurpose instrument for screening, diagnosing, monitoring and measuring the severity of depression

  • Asks patients ‘over the last 2 weeks, how often have you been bothered by any of the following problems?’
  • 9 items which can then be scored 0-3
  • Includes items asking about thoughts of self-harm

Interpretation:
0-4 none
5-9 mild
10-14 moderate
15-19 moderately severe
20-27 severe

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5
Q

How is the severity of depression graded?

A

Sub-threshold = Fewer than 5 symptoms

Mild = 2 core and 2 adjuncts

Moderate = 2 core and 3+ adjuncts

Severe = 3 core and 4+ adjuncts

Severe with psychosis = severe plus psychotic symptoms

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6
Q

How is risk assessed?

A

To self:

  • Neglect
  • Suicide
  • Self-harm
  • Physical health e.g. E&D

To others:

  • Arson / weapons
  • Children

From others:

  • “Do you feel safe from others?”
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7
Q

What are the RFs for depression?

A
  • Chronic illness
  • Divorce
  • Unemployment
  • Lack of confiding relationship
  • Low self-esteem
  • Poor social support
  • Low social class
  • Medications - steroids, COCP, beta blockers (propranolol)
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8
Q

What is the aetiology of depression?

A

BIO

  • Genetic
  • Neurochemical changes

PSYCHO

  • Childhood trauma
  • Neurotic personality traits

SOCIAL

  • Traumatic life events
  • Unemployment
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9
Q

What are the signs O/E of depression?

A
  • Signs of neglect e.g. WL, unkempt
  • Poor eye contact, downcast eyes, tearful
  • Slow, non-spontaneous and reduced volume of speech
  • Low mood, suicidal ideation
  • Pessimistic, ideas of guilt
  • Second-person auditory hallucinations, often derogatory
  • Poor concentration

If significant risk to self, refer to specialist MH services urgently

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10
Q

What organic processes need to be ruled out before diagnosing depression?

A
  • Hypothyroidism (TFTs)
  • Anaemia (FBC)
  • Hypercalcaemia (Ca)
  • Delirium (FBC, CRP, urine dip)
  • Dementia
  • Chronic pain
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11
Q

What are the investigations for depression?

A
  • Full history, collateral history, physical exam, and MSE
  • Tests to rule out organic causes - bloods (FBC, CRP, TFT, glucose), urine dip
  • Diagnosis via DSM-V or ICD-10 criteria
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12
Q

What is the management of mild or sub threshold depression?

A
  • Active monitoring and follow up within 2 weeks
  • Provide information about depression
  • Safety net - provide 24 hour crisis line and give advice of where to seek help in emergency
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13
Q

What is the management of mild-moderate depression?

A

IMMEDIATE:

1. Education/information
2. Arrange further assessment within 2 weeks
3. Safety net - provide 24 hour crisis line and give advice of where to seek help in emergency

LONG-TERM:
Bio
Do not routinely consider medication unless:

  • Past history of moderate or severe depression
  • Symptoms present for a long time (> 2 years)
  • Symptoms persist after other interventions

Psycho

1. Low-Intensity Psychosocial Intervention
2. Group CBT (if low-intensity psychological intervention declined)

Social

  • Social contact e.g. activities / hobbies / groups
  • Social support e.g. support for family / friends
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14
Q

What are examples of low-intensity psychological interventions?

A

Individual-guided self-help based on CBT

  • Provision of written materials
  • Supported by trained practitioner who reviews progress / outcome
  • 6-8 sessions (F2F or phone) usually taking place over 9-12w including follow-up

Computerised CBT

  • Encourage tasks between sessions, use thought-challenging and active monitoring of behaviour and thought patterns
  • Supported by trained practitioner who reviews progress and outcomes
  • Typically takes place over 9-12w including follow up

Structured group physical activity programme

  • Delivered in groups with support from a trained practitioner
  • Usually 3 sessions /w (45-60m) over 10-14w
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15
Q

What is the management of moderate-severe depression?

A

IMMEDIATE:

1. Education/information
2. Arrange further assessment within 1-2 weeks
3. Safety net - provide 24 hour crisis line and give advice of where to seek help in emergency

LONG TERM:

Bio

  • Antidepressant medication
  • RV after 2w (if low suicide risk), then every 2-4 weeks thereafter for 3 months
  • Patients <30yrs or at increased risk of suicide should be followed-up after 1w
  • RV response to treatment after 3-4 weeks

Psycho

  • High-intensity psychological intervention

Social

  • Social contact e.g. activities / hobbies / groups
  • Social support e.g. support for family / friends
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16
Q

What are examples of high-intensity psychological interventions?

A

Individual CBT or Interpersonal Therapy (IPT)

  • 16-20 sessions over 3-4 months
  • Consider 2 sessions /w in the first 2-3w
  • Consider follow-up sessions over the following 3-6 months

IPT = a talking treatment that helps people with depression identify and address problems in their relationships with family, partners and friends. The idea is that poor relationships with people in your life can leave you feeling depressed.

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17
Q

What medications are used to manage depression?

A

1st line = SSRI

  • E.g. sertraline, citalopram, fluoxetine, paroxetine
  • 2 trials of SSRIs before moving to 2nd line

2nd line = taper down SSRI, switch to SNRI

  • E.g. venlafaxine, duloxetine

3rd line (treatment resistance) = augment treatment with…

  • Antipsychotic (i.e. quetiapine)
  • Lithium
  • Other antidepressant (e.g. mirtazapine or mianserin)

4th line = ECT

> Check compliance at every review

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18
Q

When should a depressive patient be referred to secondary care / psychiatrist?

A
  • Not responding to treatment
  • Risk to others
  • Severely unwell
  • Uncertain diagnosis
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19
Q

You have to be especially cautious when switching which antidepressants?

A
  • Fluoxetine to any other antidepressants (long half-life)
  • Fluoxetine or paroxetine to a TCA (both inhibit TCA metabolism so may need lower starting dose)
  • To a new serotoninergic antidepressant or MAOI (risk of serotonin syndrome)
  • From non-reversible MAOI - 2-week washout period required
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20
Q

What is the drug choice for a recurrent episode of depression?

A
  • Consider an antidepressant that the patient has previously had a good response to
  • Avoid antidepressants that have previously failed
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21
Q

How are antidepressants stopped?

A

Dose should be tapered down over a period of 4 weeks

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22
Q

Which antidepressant is preferred when there is a co-existent chronic physical health problem?

A

Sertraline (lower risk of drug interactions)

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23
Q

What is the management for severe/complex depression?

A

IMMEDIATE:
>Consider inpatient treatment if significant risk of suicide, self-harm or neglect

  • 1. Refer to HTT to manage crises
  • 2. Safety net - provide 24 hour crisis line and give advice of where to seek help in emergency
  • 3. Refer to CMHT

LONG-TERM:

Bio

  • Increase dose / change antidepressant
  • Consider ECT for acute treatment of severe depression (life-threatening / rapid response required / other treatments have failed)

Psycho

  • Psychoeducation
  • CBT

Social

  • Social contact e.g. activities / hobbies / groups
  • Social support e.g. support for family / friends
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24
Q

What is bipolar affective disorder (BPAD)?

A

A chronic mental health disorder characterised by recurrent periods of both mania/hypomania and depression

The recovery between episodes is usually complete and the frequency and pattern of episodes is variable

> > AKA manic depression

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25
Q

What is the ICD-10 criteria for BPAD?

A
  • At least 2 episodes > 1 must be manic-associated (the other can be depressive), AND
  • Complete recovery between 2 episodes

(Mania lasts ~4m, Depression lasts ~6m)

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26
Q

What are the types of BPAD?

A

Type I Disorder = Mania and depression (most common)

Type II Disorder = Hypomania and depression

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27
Q

What is the aetiology of BPAD?

A
  • Strong genetic contribution > heritability ~85%
  • First episode usually occurs in early 20s / late teens
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28
Q

What are the S/S of BPAD?

A

Distinct period of abnormally and persistently elevated, expansive or irritable mood

  • Increased energy / activity
  • Pressure of speech
  • Feelings of high creativity and mental efficiency can lead to grandiose ideas
  • Expenditure can be excessive and lead to debts
  • Sexual disinhibition / increased libido
  • Reduced sleep may lead to physical exhaustion
  • Talkative, overfamiliarity

Mania

  • Lasting ≥7 days (ICD-10)
  • Severe symptoms
  • Impaired occupational/social functioning
  • ± psychosis

Hypomania

  • Lasting ≥4 days
  • Mild-moderate symptoms
  • Does not impair occupational / social functioning
  • NO psychosis or delusions

Mixed

  • Mixture, or rapid alternation (within a few hours) of manic / hypomanic and depressive symptoms
29
Q

What are the investigations for BPAD?

A

To exclude other causes for a manic episode: substance misuse, SOL, hyperthyroidism, corticosteroids, anabolic androgenic steroids

  • Full history, collateral history, physical examination (establish baseline state)
  • Bloods: FBC, TSH, U&E, LFT
  • ECG
  • Urine drug screen
  • Rating scale: Young Mania Rating Scale
30
Q

What is the referral process for BPAD?

A

To specialist care for diagnosis (urgent OR non-urgent) as cannot be diagnosed in primary care

Symptoms of hypomania = routine referral to CMHT

Symptoms of mania or severe depression = urgent referral to CMHT / admission to psychiatric ward

31
Q

What is the management of acute mania / hypomania?

A

1 = Taper off and stop inducing medications

  • I.e. anti-depressants, recreational drugs, steroids and dopamine agonists

If NOT on tx: Aim is to stabilise before starting lithium

  • 1st line = antipsychotic (e.g. olanzapine, haloperidol, quetiapine, risperidone)
  • 2nd line = different antipsychotic
  • 3rd line = add lithium or sodium valproate

If ON tx

  • Check compliance
  • Optimise medication / stop antidepressant
  • Short term sedatives (benzodiazepines)
  • Check lithium levels > add atypical

ECT only if mania is not responsive to treatments above

32
Q

What is the long-term management of BPAD?

A

Mood stabilisers are the mainstay
Other medications may be added when new symptoms arise or when facing stress that could precipitate relapse (e.g. antipsychotics or benzodiazepines)

4 weeks after acute episode

1st line = lithium alone

  • Monitor for lithium toxicity
  • May take up to 5wks to titre properly

2nd line = lithium and valproate

  • No monitoring for valproate

3rd line (if lithium poorly tolerated)

  • Valproate alone OR olanzapine alone
33
Q

What are the SEs of valproate?

A

Hair loss, weight gain, nausea

34
Q

What is the management for co-existent depression with BPAD?

A

You can’t use antidepressants by themselves as they may cause a switch to mania. To reduce the risk, only give antidepressants with a mood stabiliser or an antipsychotic:

  • 1st line = fluoxetine and olanzapine
  • 2nd line = quetiapine alone
  • 3rd line = olanzapine alone OR lamotrigine alone
35
Q

What are the psychological interventions for BPAD?

A

CBT

  • Identify relapse indicators
  • Create relapse prevention strategies - developing routine, promoting healthy lifestyle, addressing substance misuse, ensuring good quality sleep, avoiding excessive stress/stimulation, ensuring drug compliance

Psychodynamic psychotherapy

  • Useful if mood stabilised

> May improve compliance with medications long term
Offered after acute manic episode has resolved

36
Q

What are the social interventions for BPAD?

A
  • Can aid return to education and/or work
  • Family support and therapy
37
Q

What co-morbidities are associated with BPAD?

A

Increased risk of diabetes, CVD, COPD

38
Q

What is lithium toxicity?

A

Level >1.2 mmol/L
Life-threatening

Therapeutic range = 0.4-1.0

39
Q

What are the S/S of lithium toxicity?

A
  • Acute confusion
  • Coarse tremor (fine tremor seen in therapeutic levels)
  • Hyperreflexia
  • Polyuria/polydipsia
  • Seizures
  • Coma
  • GI disturbance
40
Q

What may precipitate lithium toxicity?

A
  • Salt balance changes (e.g. dehydration, D&V)
  • Drugs interfering with lithium excretion (e.g. diuretics)
  • Accidental or deliberate overdose
41
Q

What is the management of lithium toxicity?

A
  1. Stop lithium dose
  2. Transfer for supportive medical care (rehydration, correction of electrolyte imbalances)
  3. Monitor lithium levels closely (every 6-12 hours)
  4. If overdose is severe, the patient may need gastric lavage or dialysis

WARNING: stopping lithium abruptly could precipitate symptoms of mania/depression

42
Q

What are some consequences of lithium therapy?

A

Thyroid, cardiac, renal and neurological sequelae

  • Benign leucocytosis
  • Acquired nephrogenic diabetes insipidus
  • Hyperparathyroidism and resultant hypercalcaemia (bones, groans, stones)
43
Q

Can mood stabilisers be used in pregnancy?

A

Mood stabilisers are teratogenic:
Lithium > Ebstein’s anomaly
Valproate and carbamazepine > spina bifida

  • Risk of harm to fetus should be weighed against harm of manic relapse
  • Women of childbearing age should be given contraceptive advice and prescribed a folate supplement if using valproate
  • Closely monitor the fetus if mood stabilisers are used in pregnancy
44
Q

What is a characteristic SE of Mirtazapine?

A

It commonly causes increased appetite and sedation

45
Q

What is the SSRI of choice post myocardial infarction?

A

Sertraline

46
Q

What medications should be avoided in patients taking a SSRI?

A
  • Triptans
  • MAOIs e.g. Rasagiline
  • Warfarin / heparin
47
Q

What are some adverse effects of non-selective monoamine oxidase inhibitors?

A
  • Hypertensive reactions with tyramine containing foods e.g. cheese, pickled herring, Bovril, Oxo, Marmite, broad beans
  • Anticholinergic effects (dry mouth, blurred vision, constipation, confusion)
48
Q

Describe the monitoring required for patients on lithium therapy

A
  • When checking levels - sample must be taken 12hrs post-dose
  • After starting / changing dose - levels should be performed weekly until concentration stable
  • Once established - checked every 3m
  • Thyroid and renal function - every 6m
49
Q

What are the discontinuation symptoms of SSRIs?

A
  • GI symptoms e.g. pain, cramping, diarrhoea, vomiting
  • Increased mood change
  • Restlessness
  • Difficulty sleeping
  • Unsteadiness
  • Sweating
  • Paraesthesia
  • Dizziness
  • Electric shock sensations
  • Anxiety
50
Q

What are the SEs of TCAs?

A
  • Anticholinergic e.g. dry mouth, blurred vision and urinary retention
  • Weight gain
  • Constipation
  • Mydriasis
  • Drowsiness
  • Lengthening of QT interval
51
Q

What are the SEs of SSRIs?

A
  • GI symptoms are most common
  • Increased risk of GI bleeding (PPI should be prescribed if a patient is also taking a NSAID)
  • Hyponatraemia
  • Increased anxiety and agitation after starting (patients should be counselled to be vigilant for it)
  • Sexual dysfunction
  • Restlessness / insomnia

> fluoxetine and paroxetine have a higher propensity for drug interactions

52
Q

What is Cotard Syndrome?

A

A rare mental disorder where the patient believes that they / a part of their body is either dead or non-existent

This delusion is often difficult to treat and can result in significant problems due to patients stopping eating or drinking as they deem it not necessary.

Cotard syndrome is associated with severe depression and psychotic disorders.

53
Q

What are the symptoms of serotonin syndrome?

A
  • Autonomic instability e.g. dizziness / urinary sx
  • Neuromuscular hyperreactivity e.g. tremor, myoclonus, hyperreflexia, and bilateral Babinski sign
  • Mental status changes
54
Q

Fluoxetine?

A

SSRI

55
Q

Paroxetine?

A

SSRI

56
Q

Duloxetine?

A

SNRI

57
Q

Venlafaxine?

A

SNRI

58
Q

Mirtazapine?

A

Noradrenergic and specific serotonergic antidepressant

Atypical TCA

59
Q

Amitriptyline?

A

TCA

60
Q

What is a SE of amitriptyline?

A

Overflow incontinence (anticholinergic effect)

61
Q

What is Seasonal Affective Disorder?

A

SAD describes depression which occurs predominately around the winter months.

  • Treated same way as depression, therefore as per the NICE guidelines for mild depression, you would begin with psychological therapies and follow up with the patient in 2 weeks to ensure that there has been no deterioration.
  • Following this an SSRI can be given if needed
62
Q

Imipramine?

A

TCA

63
Q

What are the SEs of citalopram?

A

QT prolongation and Torsades de pointes

The BNF advises taking an ECG and measuring the QT interval in patients with a history of cardiac disease prior to starting citalopram.

64
Q

What needs to be monitored with SNRIs?

A

Associated with the development of hypertension

  • NICE recommend that all patients have their blood pressure monitored at initiation and each dose titration of venlafaxine.
  • If the patient is hypertensive a dose reduction should be considered.
65
Q

What needs to be monitored with SSRIs?

A

Signs of hyponatraemia (e.g. new-onset confusion)

For people at high risk, measure the serum sodium level (U&Es) before starting treatment, 2–4 weeks after starting treatment and every 3 months thereafter.

66
Q

Can you continue medication when starting ECT?

A

Antidepressant medication should be reduced but not stopped when a patient is about to commence ECT treatment

67
Q

Can SSRIs be used in pregnancy?

A

BNF says to weigh up benefits and risk when deciding whether to use in pregnancy.

  • Use during the first trimester gives a small increased risk of congenital heart defects
  • Use during the third trimester can result in persistent pulmonary hypertension of the newborn
68
Q

How do you switch fluoxetine?

A

Reduce fluoxetine gradually over 2 weeks, wait 4-7 days, then start e.g. sertraline

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