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PSYCHIATRY > Affective disorders > Flashcards

Affective disorders Flashcards

1
Q

How is depression categorised?

A

-More Severe - PHQ-9 <16
-Less severe - PHQ-9>16

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2
Q

What is used to classify depression?

A

PHQ-9

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3
Q

1st line treatment for depression?

A

SSRIs (sertraline)

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4
Q

What is the mode of action of SSRI?

A

-Selectively inhibit synaptic 5-HT re-uptake transporters, thereby increasing synaptic 5-HT concentration

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5
Q

What is a good first choice SSRI and why?

A

-Sertraline 50-100mg daily going up to 200mg daily
-it is well tolerated and has fewer interactions compared to other drugs

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6
Q

What SSRI is most useful post myocardial infarction?

A

Sertraline

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7
Q

Give other examples of SSRIs

A

-Citalopram
-Fluoxetine (children and adolescents)
-Paroextine

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8
Q

what is the most common side effects of SSRIs?

A

-GI symptoms are most common side effect

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9
Q

NSAID and SSRI?

A

Prescribe PPI, increase risk of bleeding

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10
Q

Counselling before SSRI?

A

Increased anxiety and agitation after SSRI

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11
Q

What SSRIs have higher propensity for drug interactions?

A

Paroexteine and fluoxetine

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12
Q

What is citalopram associated with?

A

-Dose dependent QT interval prolongation

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13
Q

When should citalopram not be used?

A

-Congential long QT syndrome
-Known pre-existing QT interval prolongation
-Combination with other medicines that cause prolong QT interval

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14
Q

What is the maximum dose of citalopram in adults?

A

40mg

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15
Q

What is the maximum dose of citalopram in patients >65 or with hepatic impairment ?

A

20mg

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16
Q

If warfarin/heparin what other medication should you consider?

A

Mirtazapine

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17
Q

Aspirin with SSRI?

A

Increased risk of bleeding

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18
Q

What drugs SSRIs increase the risk of serotonin syndrome?

A

-Triptans
-MAOIS
-Lithium
-St Johns wort

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19
Q

What are the discontinuation symptoms of SSRIs?

A

-Increased mood change
-Restlesness
-Difficulty sleeping
-Unsteadiness
-Sweating
-GI symptoms
-Paraesthetisa

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20
Q

What SSRI has increase risk of congenital malformations?

A

Paroxentine

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21
Q

What SRRI is more toxic in overdose?

A

Citalopram - avoid in people with suicide ideation

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22
Q

What are the two SNRIs?

A

-Venlafaxine (75-375 mg)
-Duloxetine (60 mg)

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23
Q

What is the mode of action of SNRIs?

A

-Inhibit reuptake serotonin and noradrenaline in synaptic cleft
-Increase concentration of NA and serotonin
-SNRIs do noot block cholinergic receptors

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24
Q

Why are SNRIs useful?

A

-Venlafaxine is thought to be slightly more effective then SSRIs (but not duloxetine)
-Main indication is for a non-SSRI response

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25
Q

Side effects of SNRIs?

A

-Resembles those of SSRI but may be worse
-At high doses hypertension can occur and should be monitored

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26
Q

What drug is a noradrenaline and serotonin specific antidepressant (NASSA)?

A

-Mirtzapine (15-45mg)

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27
Q

What is the mode of action of mirtazapine?

A

Increase the activity of NA and 5-HT systems
-It blocks the negative feedback on NA presynaptic alpha-2 receptors
-Alpha 2 blockade also enhances 5-HT release

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28
Q

When is the NASSA mirtazapine practically useful?

A

-2nd line treatment
-In combination with SRRI for third line treatment

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29
Q

What are the side effects of NASSA mirtazapine?

A

-Relatively sedating so can be useful in those with sleep issues

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30
Q

Side effects of NASSA mirtazapine?

A

-Can be associated with weight gain

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31
Q

What is the mode of action of TCAs?

A

-Inhibit PRESYNAPTIC NA and 5-HT transporters
-Some TCAs are more selective for one monoamine than another e.g. clomipramine mainly acts on 5-HT and desipramine on NA

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32
Q

Why are TCAs less commonly used now?

A

-Side effects as they block various other receptors unlike SSRIs
-Toxic in overdose

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33
Q

Where might TCAs be useful?

A

Widely used in treatment of neuropathic pain - however smaller doses are required

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34
Q

how do other receptors impact TCAs side effect profile?

A
  1. Antagonism of histamine - drowsiness
    -Weight gain
  2. Antagonism muscarinic receptors
    -Dry moth
    -Blurred vision
    -Consitpation
    -Urinary retention
    -Tachycardia
  3. Antagonism of adrenergic receptors
    -Postural hypotension
    -Sexual dysfunction
  4. Lengthening of QT interval
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35
Q

Examples of more sedative TCAs

A

-Amitriptyline
-Clompramine
-Dosulepin

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36
Q

Examples of less sedating TCAs

A

-Impramine
-Lofepramine
-Notriptyline

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37
Q

What TCA is used commonly used in the management of neuropathic pain and prophylaxis of headache?

A

-Tension headache and migraine
-Also can be used for insomnia

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38
Q

What TCAs are considered the most toxic?

A

-Amitriptyline
-Dosulepin

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39
Q

Why is mirtazapine (NASSA) good for older people?

A

-Fewer side effects and interaction than many other antidepressants so can be useful in older people that are taking multiple medications
-Two side effects - increased appetite and sedation so useful insomnia and poor appetite

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40
Q

Mode of action of MAOIs (monoamine oxidase inhibitors)?

A

-Serotonin and NA are metabolised by monoamine oxidase in presynaptic cell
-MAOIS prevent the breakdown of monoamines in the presynaptic terminals
-Increase transmitter availability

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41
Q

Examples of MAOI?

A

-Tranylcypromine (10-30mg a day)
-Phenelzine (15-90mg)

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42
Q

MOI compared to SSRI and TCA?

A

Due to side effects and efficacy are seen inferior

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43
Q

When can MOI be useful in depression?

A

-The main induction is atypical depression
-Can be used in treatment resistant depression

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44
Q

What is atypical depression?

A

-Increased sleep
-Increased appetite
-Phobic anxiety

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45
Q

What are the side effects of MAOIS?

A

-Hypertensive reactions with tyramine containing foods e.g. cheese, pickled herring, Bovril, oxo, marmite , broad beans
-Anticholinergic effcets (dry mouth, blurry vision, drowsiness, sedation)

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46
Q

When to avoid MAOIs?

A

Cardiac failure, hepatic failure

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47
Q

Overdose MAOIs?

A

-Hypertension, delirium, coma and death

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48
Q

Risk associated with each antidepressant?

A

Risks
1.Drug interaction - fluoxetine, fluvoxamine, paroxetine
2.Discontinuation Symptoms: paroxetine
3.Death from Overdose: venlafaxine
4.Overdose: TCAs (except lofepramine)
5.Stopping due to side effects: venlafaxine, duloxetine, TCAs
6. Blood Pressure Monitoring Needed: venlafaxine
7. Worsening Hypertension: venlafaxine, duloxetine
8. Postural Hypotension and Arrhythmia: TCA

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49
Q

Switching from fluoxetine to other antidepressants?

A

NICE recommends a washout period of 4-7 days with NO antidepressant before starting a low dose of another SSRI

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50
Q

Switching form fluoxetine or paroxetine to a TCA?

A

Both drugs inhibit TCA metabolism so a lower starting dose may be needed to reduce risk of serotonin syndrome

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51
Q

From non-reversible MAOI?

A

A 2-week washout period is required (other antidepressants should not be prescribed during this period)

52
Q

How common is it for a depressive episode to not respond to first-line treatment?

A

2/3 cases do not respond to 1st line antidepressant

53
Q

What to do when patient has not improved when given antidepressant?

A

-Check compliance
-Increase to maximum dose tolerated
-Review the case - is the diagnosis right?

54
Q

If patient has not improved after compliance checked, the diagnosis is correct and is on the maximum dose?

A

-Switch SSRI to different SSRI or SNRI 9limited evidence with either strategy )
-If depression is severe add lithium (risks and drawback limit popularity)
-Add mirtazapine if insomnia or agitation is the issue
-Add CBT
-Add second generation antipsychotic (quetiapine or olanzapine) especially if psychotic symptoms or agitation or insomnia
-Psychiatric referral if not already occurred

55
Q

When to refer psychiatry for depression?

A

-Not responding to treatment
-Substansital risk to self or other
-Second option of diagnosis
-Combination or rare agent being considered
-Patient severely unwell and hospital admission is required such as ECT

56
Q

Hyponatrameia and SSRI?

A

Can occur in elderly possibly due to inappropriate secretion of ADH

57
Q

How long should patent continue antidepressant treatment?

A

For at least 9 months

58
Q

Peventing relapse in patient?

A
59
Q

How much does continuation of antidepressant after recovery prevent relapse?

A

by at least 50% in patient with recurrent depressive episode

60
Q

What is bipolar disorder?

A

Replacing and remitting condition characterised by presence of periods of elated mood and depressed mood - however presence of elated mood alone is sufficient for diagnosis to be made

61
Q

Features of hypomania ?

A

-Present for at least 4 days
-Core features mild or moderate
-mild or moderate dysfunction
-Patiral insight persevered
-No psychotic features

62
Q

Features of mania?

A

Present for at least 7 days needing hospital admission
-Core features marked
-Substantial dysfunction
-Minimal or absent insight
-Psychotic symptoms may occur

63
Q

Heritability of bipolar disorder?

A

Strongly heritable - 80%

64
Q

When are benzodiazepines used in bipolar?

A

Useful when sedation is required

65
Q

Treatment of mania and mixed episodes of bipolar?

A

-Antipsychotics such as risperiodone, olanzapine
-Valporate and lithium are antimanics

66
Q

Antipsychotics and lithium effectiveness?

A

Antipsychotics probably more effective but cause more sedation and weight gain

67
Q

Mania not responding to drug treatment?

A

ECT highly effective

68
Q

Antidepressant in manic episode?

A

Stop antidepressant

69
Q

Promodal symptoms of mania?

A

Sodium valproate can be useful

70
Q

Treatment of depressive episode in bipolar?

A

-Quetiapine - an atypical antipsychotic is the first line treatment
-Rapid onset of action
NOTE: antidepressants may be less effective as they can precipitate mood destabilisation and mania

71
Q

What limits quetiapine long term use?

A

Sedation and weight gain

72
Q

Preventing relapse in bipolar disorder?

A

-Patient needs to understand own illness
-Long term mood monitoring
-Relapses in bipolar disorder due to non-specific symptoms - helpful if patient recognisises these warning signs

73
Q

When is going term drug treatment recommended in bipolar disorder?

A

-At least two manic episodes
- one manic and one depressive episode
NOTE: effective early treatment may improve long term outcome so usually long term treatment is after one serious episode especially if family history

74
Q

What is the standard prophylaxis of bipolar disorder?

A

-Lithium treatment is the gold standard for bipolar disorder
-Reduces the risk of manic and depressive relapse by 40-50%

75
Q

What are organic mood disorders?

A

mood disorders with a physical cause

76
Q

Three main drugs used in mania?

A

-Lithium
-Sodium valproate
-Carbamazepine

77
Q

What is the therapeutic range of lithium?

A

0.6-1.0mmol/L

78
Q

Dose for lithium naive patients?

A

0.6-0.8

79
Q

Dose for patients with previous lithium use or relapse in symptoms?

A

0.8-1.0

80
Q

What range does lithium toxicity occur?

A

-1.5mmol/L
-Severe 2mmol/L

81
Q

Blood before starting lithium?

A

-BMI
-FBC
-Uand E
-TFTs

82
Q

When should plasma lithium be checked?

A

-1 week after starting and changing dose
-monitored weekly until steady therapeutic level achived
NOTe: blood sample 12 hours after taking lithium dose

83
Q

how often should lithium levels be measured when stable levels reached?

A

-Every 3 months

84
Q

Why should U&Es and TFTs be monitored every 6 months?

A

-Lithium can cause renal impairment and hypothyroidism

85
Q

What are the signs and symptoms of lithium overdose?

A
  • GI disturbance
  • Polyuria/polydipsia
  • Sluggishness or giddiness
  • Ataxia
  • Gross tremor
  • Seizures
  • Renal failure
86
Q

What can trigger lithium toxicity?

A

-Salt balance and electrolyte changes
-Drugs interfering with lithium excretion (diuretics and NSAIDs)
-Overdose

87
Q

How to manage lithium overdose?

A

-Stop lithium (note that can precipitate mania/depression)
-Medical care (rehydration and osmotic diuresis)
-Overdose severe - gastric levage

88
Q

When is sodium valproate used?

A

-Treat acute mania
-Prophylaxis is BPAD

89
Q

Benefits of using sodium valporate over lithium>

A

-Plasma levels do not need monitoring
-Dose-related toxicity is not usually an issue

90
Q

What should you check before starting sodium valproate?

A

BMI, FBC, LTFs

91
Q

What is carbamazepine?

A

An anticonvulsant

92
Q

what percent of women get hypothyroidism from lithium?

A

20%

93
Q

Contraindication of lithium use?

A

-Avoid in renal failure and pregnancy
-Do not combine with diuretics, ACE inhibiors or high dose antipsychotics
-Be cautious with NSAID use (can rise lithium levels)

94
Q

Practical use of sodium valporate?

A

Has a place where lithium is not tolerated

95
Q

What is the dosing of sodium valporate?

A

-Usually maintenance dose 750-1250mg but starting dose is lower 250-500mg

96
Q

What are the side effects of sodium valporate?

A

-Sedation
-Tiredness
-GI distrubances
-Can cause thrombocytopenia
-Reversible hairloss in 10% patients

97
Q

What does sodium valporate cuase in pregnancy?

A

-Associated with neural tibe defects
-Spina bifida

98
Q

Carbamazepine for bipolar disorder compared with sodium valproate and lithium?

A

-Thought to be less effective than both
-May be used when contraindicated, ineffctive or not tolerated

99
Q

How does sodium valporate work?

A

Blocking sodium channels and increasing GABA turnover

100
Q

If signs of toxicity with carbamazepine uses?

A

-Check plasma levels

101
Q

What levels should you check in carbamazepine uses?

A

-White blood cells - can cause low white blood cells

102
Q

What are the side effects of carbamazepine?

A

-Leucopenia
-Dizziness
-Drowsiness
-Hyponatreamia

103
Q

Why is the fact that carbamazepine induces liver enzymes significant?

A

-other drugs are metabolised faster such as the contraceptive pill

104
Q

When to stop carbamazepine?

A

-Erythematous rash
-Leucoytopenia

105
Q

When is lamotrigine useful in bipolar disorder?

A

-When treating a depressive episode
-is second line for prophylaxis in BPAD typeII

106
Q

What is the mode of action of lamotrigine?

A

-Blocks calcium and sodium channels
-Decreases glutamate release

107
Q

Dose of lamotrigine in bipolar?

A

-100-300mg
-Start 25 mg 2 weeks, then 50 mg two weeks
-Gradual increase reduces side effects

108
Q

side effects of lamotrigine?

A

-rash - discontinue
-Stevens-Johnson syndrome/toxic epidermal necrolysis

109
Q

Valporate and lamotrigine?

A

-Valporate increases lamotrigine levels causing neurotoxcity be cauitious

110
Q

Childbrearing age and valporate

A

-Contraceptive advice
-Folate supplement

111
Q

mood stabilizers in pregnancy?

A

-Teratogenic
-Risk of harm vs risk of manic relapse
-Closely monitor fetus

112
Q

Acute treatment of mania or hypomania?

A

-Stop all medications that induce symptoms
-Give antipsychotic and short course of benzodiazepines

113
Q

What may be used if patients are unresponsive to medication in bipolar disorder?

A

ECT

114
Q

Long term treatment of bipolar disorder?

A

-Mood stabilizers are the mainstay
-Antipsychotica or benzodiazepines can be added when new symptoms arise or stress

115
Q

Depression in BPAD?

A

1st line: FLuoxetine and olanzepine/quetiapine
2nd line: lamotrigine

116
Q

How to refer if symptoms of hypomania?

A

-Routine referal to CMHT

117
Q

How to refer if mania or severe depression?

A

urgent referral

118
Q

Medication for overdose on opiod?

A

Naloxone

119
Q

Overdose of other medication e.g. antidepressants?

A

-Activated charcoal
-Use less one hour ingestion

120
Q

What can be used for paracetmol overdose?

A

-N-acetylcystine

121
Q

Contraindication for ECT therapy?

A

-Mainly related to anesthetic risk
-Avoid if patient has intracranial lesion

122
Q

Prolonged grief?

A

Prominent symptoms more than 6-12 months

123
Q

Excessive grief?

A

> 12 months, may reflect persons closeness, personality or depressive disorder

124
Q
A
125
Q
A

PSYCHIATRY (3 decks)

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