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Pyschiatry > Affective Disorders > Flashcards

Affective Disorders Flashcards

1
Q

What is a depressive episode (ICD-11)

A

Almost daily low mood or loss of interest in usual activities for at least 2 weeks

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2
Q

What are the core symptoms of depression

A
  • Low mood
  • Anhedonia
  • Anergia
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3
Q

What is Beck’s cognitive triad

A

Negative views about oneself, the world and the future lead to feeling worthless, helpless and hopeless respectively.

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4
Q

Depression is more common in

A

Females.

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5
Q

Mild depression is defined by

A

Few symptoms, minor functional impairment

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6
Q

Moderate depression is defined by

A

Symptoms or functional impairment between mild and severe

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7
Q

Severe depression is defined by

A

More symptoms with significant functional impairment

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8
Q

Symptoms of depression (DSM-V: need 5/9 for at least 2 weeks for Dx)

A
  • Cognitive changes: indecisiveness/inattention
  • Anhedonia
  • Weight change (5%)
  • Sleep changes: more or less
  • Fatigue (anergia)
  • Low mood/irritability
  • Activity: psychomotor retardation/agitation
  • Guilt/worthlessness
  • Suicidality
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9
Q

Additional symptoms of depression seen in severe cases

A
  • Psychotic features
  • Stupor: mutism, immobility, refusal to eat or drink
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10
Q

What is pseudodementia

A

Common in elderly - memory loss/cognitive impairment from depression instead of dementia

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11
Q

What psychotic symptoms may be seen in severe depression

A
  • Nihilistic/guilty delusions
  • Cotard’s syndrome
  • Hallucinations (e.g. seeing destruction, hearing negative feedback)
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12
Q

Depression bedside investigation

A
  • Collateral history
  • Physical examination
  • HADS or PHQ-9
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13
Q

Depression bloods

A
  • FBC
  • TFT
  • U&E
  • BM/HbA1c
  • Vitamin D and B12
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14
Q

Depression imaging

A

CT/MRI head possibly to exclude dementia - not routine

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15
Q

Depression is usually managed in primary care. GPs can refer to secondary care (Psychiatry) if there is…

A

A high-suicide risk, symptoms of bipolar disorder, symptoms of psychosis, or if there is evidence of severe depression unresponsive to initial treatment.

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16
Q

To manage depression what model is used

A

Stepped care model - always choose least intrusive and most effective intervention

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17
Q

MANAGEMENT:
Persistent subthreshold depressive symptoms or mild-to-moderate depression:

A
  • 1st line: Low level psychological intervention: individual guided self help or computerised CBT
  • 2nd line: high intensity psychological interventions (individual CBT or interpersonal therapy)
  • 3rd line: consider antidepressants
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18
Q

MANAGEMENT:
Mild depression unresponsive to treatment and moderate-to-severe depression:

A
  • 1st line: high intensity psychological interventions + antidepressants
  • 2nd line (treatment resistant depression): switch antidepressants, use adjuncts
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19
Q

MANAGEMENT:
Complex and severe depression

A
  • If crisis: use crisis resolution and home treatment teams
  • Inpatient admission if significant risk to self/others
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20
Q

MANAGEMENT:
Severe depression and poor oral intake/psychosis/stupor:

A

ECT

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21
Q

What to do if a patient presents significant risk to self/others

A

Urgent referral to specialist MH services for possible inpatient admission

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22
Q

How to manage first presentation of mild depressive symptoms or sub threshold symptoms

A
  • Psychoeducation + active monitoring
  • Follow up in 2 weeks.
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23
Q

What is a manic episode

A

Extreme elevated mood lasting for at least 1 week

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24
Q

What is a hypomanic episode

A

Persistent mood state lasting less than a week, less severe symptoms e.g. psychosis, no marked functional impairment

25
Q

What is a mixed episode (BPAD)

A

Rapid alteration between manic and depressive symptoms for at least 2 weeks

26
Q

What is rapid cycling BPAD

A

When 4 episodes/relapses occur within 1year - typically affects women

27
Q

What is cyclothymic disorder

A

Persistent mood instability over at least 2 years - subthreshold hypomania/depressive symptoms to diagnose BPAD

28
Q

What are the core symptoms of mania

A

Elated mood
High energy
Interest in new activities/people

(Opposite of depression ncore symptoms)

29
Q

What are the cognitive symptoms of mania

A

Grandiosity
Hopeful/optimistic
Distractible
High self esteem

30
Q

What are the biological symptoms of mania

A

Reduced need for sleep
Reduced or increased appetite
Increased libido

31
Q

What are the psychotic symptoms of mania

A
  • Delusions of grandeur or persecution
  • Hallucinations of religious callings/fame
  • Mood congruent
32
Q

How does mania present as a risk

A
  • Risk to self - 15% of BPAD patients commit suicide, self neglect from not sleeping or eating
  • Financial risk of over spending or exploitation from others
  • Irritable therefore maybe risk to others
  • Sexual disinhibition
33
Q

Mania bedside investigations

A
  • Collateral history
  • Physical examination
  • Urinary drug screen - exclude drug use
34
Q

Mania bloods

A
  • FBC w/CRP and ESR- rule out delirium secondary to infection
  • TFT - myxoedema madness
  • B12 and folate
35
Q

Mania imaging/other

A

Neuroimaging to exclude neoplasm or encephalitis, which can also be ruled out with LP

36
Q

Hypomania referral

A

Routine referral to CMHT (community mental health team)

37
Q

Mania/severe depression referral

A

Urgent referral to CMHT

38
Q

Acute management of mania without agitation

A
  • Stop antidepressants
  • Oral antipsychotics (haloperidol, olanzapine, risperidone, quetiapine)
  • If 2 are tried but unsuccessful: mood stabiliser
  • ECT = last resort
39
Q

Acute management of mania with agitation

A

IM neuroleptic or benzodiazepine, possible section under MHA

40
Q

When should chronic management of BPAD be initiated

A

4 weeks after resolution of the acute episode (mania or depression)

41
Q

Chronic management of BPAD

A
  • Lithium (1st line)/valproate (2nd line) + psychotherapy e.g. CBT.
  • Psychoeducation should be provided to all patients to help them identify relapse indicators, this could be done in the context of family therapy.
  • Support groups e.g. Bipolar UK can provide facilitated self help e.g. self monitoring
42
Q

How long do manic episodes last

A

2 weeks - 5 months

43
Q

BPAD prognosis

A

Recovery usually complete between episodes but remission becomes shorter with age and depressive episodes begin to predominate

44
Q

Acute depression management (BPAD)

A

Antidepressant with mood stabiliser or atypical antipsychotic:

1st line = fluoxetine + olanzapine/quetiapine
2nd line = lamotrigine

Fluoxetine = antidepressant of choice in BPAD depression

45
Q

Lithium therapeutic range

A

0.6-1.0mmol/l

46
Q

Mood stabilisers used in BPAD

A

Lithium
2nd line = sodium valproate
3rd line = carbamazepine

47
Q

When does lithium become toxic

A

Usually occurs above 1.5mmol/L but can appear at normal levels

48
Q

Lithium levels should be checked X after starting or changing the dose, and then monitored every X until a steady therapeutic level is achieved

A

Lithium levels should be checked 1 week after starting or changing the dose, and then monitored every week until a steady therapeutic level is achieved.

Nb - measure levels 12 hours post dose

49
Q

Once lithium levels are stable they should be monitored every X months

A

3 months

50
Q

What else should be monitored in patients on lithium and how often?

A

Before starting do:
- ECG - lithium causes T wave inversion/flattening
- TFT: lithium causes hypothyroidism
- eGFR: lithium causes renal impairment
- U&E: as above
- BMI: lithium causes weight gain

Ideally, these should all then be monitored every 6 months - TFTs and U&Es at a minimum.

51
Q

Lithium side effects at therapeutic dose

A

Leucocytosis
Insipidus
Tremor (fine)
Hypothyroid
Increased weight
Upset stomach
Metallic taste

52
Q

Signs of lithium toxicity

A
  • Coarse tremor
  • CNS disturbance (seizures, impaired coordination, and dysarthria)
  • Cardiac arrhythmias (T wave inversion/flattening)
  • Can’t see (Visual disturbance)
53
Q

Causes of lithium toxicity

A
  • Salt balance changes (dehydration, D&V)
  • Drugs interfering with lithium excretion (thiazide diurectics, ACEis, NSAIDs)
  • Overdose/renal failure
54
Q

Management of lithium toxicity

A
  • Check lithium levels
  • Stop lithium dose (warning, as this may precipitate sudden mood change)
  • Mild - IV fluids
  • Severe - haemodialysis
55
Q

What teratogenic effect does lithium have

A

Ebstein anomaly

56
Q

What teratogenic effect does valproate and carbamazepine have

A

Spina bifida

57
Q

If women of childbearing age are given valproate what should be given

A

Contraceptive advice and 5mg folate supplement. Foetus should then be closely monitored throughout pregnancy (prenatal US + genetic testing)

58
Q
A

Pyschiatry (6 decks)

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