Affective Disorders Flashcards
What is a depressive episode (ICD-11)
Almost daily low mood or loss of interest in usual activities for at least 2 weeks
What are the core symptoms of depression
- Low mood
- Anhedonia
- Anergia
What is Beck’s cognitive triad
Negative views about oneself, the world and the future lead to feeling worthless, helpless and hopeless respectively.
Depression is more common in
Females.
Mild depression is defined by
Few symptoms, minor functional impairment
Moderate depression is defined by
Symptoms or functional impairment between mild and severe
Severe depression is defined by
More symptoms with significant functional impairment
Symptoms of depression (DSM-V: need 5/9 for at least 2 weeks for Dx)
- 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
Additional symptoms of depression seen in severe cases
- Psychotic features
- Stupor: mutism, immobility, refusal to eat or drink
What is pseudodementia
Common in elderly - memory loss/cognitive impairment from depression instead of dementia
What psychotic symptoms may be seen in severe depression
- Nihilistic/guilty delusions
- Cotard’s syndrome
- Hallucinations (e.g. seeing destruction, hearing negative feedback)
Depression bedside investigation
- Collateral history
- Physical examination
- HADS or PHQ-9
Depression bloods
- FBC
- TFT
- U&E
- BM/HbA1c
- Vitamin D and B12
Depression imaging
CT/MRI head possibly to exclude dementia - not routine
Depression is usually managed in primary care. GPs can refer to secondary care (Psychiatry) if there is…
A high-suicide risk, symptoms of bipolar disorder, symptoms of psychosis, or if there is evidence of severe depression unresponsive to initial treatment.
To manage depression what model is used
Stepped care model - always choose least intrusive and most effective intervention
MANAGEMENT:
Persistent subthreshold depressive symptoms or mild-to-moderate depression:
- 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
MANAGEMENT:
Mild depression unresponsive to treatment and moderate-to-severe depression:
- 1st line: high intensity psychological interventions + antidepressants
- 2nd line (treatment resistant depression): switch antidepressants, use adjuncts
MANAGEMENT:
Complex and severe depression
- If crisis: use crisis resolution and home treatment teams
- Inpatient admission if significant risk to self/others
MANAGEMENT:
Severe depression and poor oral intake/psychosis/stupor:
ECT
What to do if a patient presents significant risk to self/others
Urgent referral to specialist MH services for possible inpatient admission
How to manage first presentation of mild depressive symptoms or sub threshold symptoms
- Psychoeducation + active monitoring
- Follow up in 2 weeks.
What is a manic episode
Extreme elevated mood lasting for at least 1 week
What is a hypomanic episode
Persistent mood state lasting less than a week, less severe symptoms e.g. psychosis, no marked functional impairment
What is a mixed episode (BPAD)
Rapid alteration between manic and depressive symptoms for at least 2 weeks
What is rapid cycling BPAD
When 4 episodes/relapses occur within 1year - typically affects women
What is cyclothymic disorder
Persistent mood instability over at least 2 years - subthreshold hypomania/depressive symptoms to diagnose BPAD
What are the core symptoms of mania
Elated mood
High energy
Interest in new activities/people
(Opposite of depression ncore symptoms)
What are the cognitive symptoms of mania
Grandiosity
Hopeful/optimistic
Distractible
High self esteem
What are the biological symptoms of mania
Reduced need for sleep
Reduced or increased appetite
Increased libido
What are the psychotic symptoms of mania
- Delusions of grandeur or persecution
- Hallucinations of religious callings/fame
- Mood congruent
How does mania present as a risk
- 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
Mania bedside investigations
- Collateral history
- Physical examination
- Urinary drug screen - exclude drug use
Mania bloods
- FBC w/CRP and ESR- rule out delirium secondary to infection
- TFT - myxoedema madness
- B12 and folate
Mania imaging/other
Neuroimaging to exclude neoplasm or encephalitis, which can also be ruled out with LP
Hypomania referral
Routine referral to CMHT (community mental health team)
Mania/severe depression referral
Urgent referral to CMHT
Acute management of mania without agitation
- Stop antidepressants
- Oral antipsychotics (haloperidol, olanzapine, risperidone, quetiapine)
- If 2 are tried but unsuccessful: mood stabiliser
- ECT = last resort
Acute management of mania with agitation
IM neuroleptic or benzodiazepine, possible section under MHA
When should chronic management of BPAD be initiated
4 weeks after resolution of the acute episode (mania or depression)
Chronic management of BPAD
- 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
How long do manic episodes last
2 weeks - 5 months
BPAD prognosis
Recovery usually complete between episodes but remission becomes shorter with age and depressive episodes begin to predominate
Acute depression management (BPAD)
Antidepressant with mood stabiliser or atypical antipsychotic:
1st line = fluoxetine + olanzapine/quetiapine
2nd line = lamotrigine
Fluoxetine = antidepressant of choice in BPAD depression
Lithium therapeutic range
0.6-1.0mmol/l
Mood stabilisers used in BPAD
Lithium
2nd line = sodium valproate
3rd line = carbamazepine
When does lithium become toxic
Usually occurs above 1.5mmol/L but can appear at normal levels
Lithium levels should be checked X after starting or changing the dose, and then monitored every X until a steady therapeutic level is achieved
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
Once lithium levels are stable they should be monitored every X months
3 months
What else should be monitored in patients on lithium and how often?
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.
Lithium side effects at therapeutic dose
Leucocytosis
Insipidus
Tremor (fine)
Hypothyroid
Increased weight
Upset stomach
Metallic taste
Signs of lithium toxicity
- Coarse tremor
- CNS disturbance (seizures, impaired coordination, and dysarthria)
- Cardiac arrhythmias (T wave inversion/flattening)
- Can’t see (Visual disturbance)
Causes of lithium toxicity
- Salt balance changes (dehydration, D&V)
- Drugs interfering with lithium excretion (thiazide diurectics, ACEis, NSAIDs)
- Overdose/renal failure
Management of lithium toxicity
- Check lithium levels
- Stop lithium dose (warning, as this may precipitate sudden mood change)
- Mild - IV fluids
- Severe - haemodialysis
What teratogenic effect does lithium have
Ebstein anomaly
What teratogenic effect does valproate and carbamazepine have
Spina bifida
If women of childbearing age are given valproate what should be given
Contraceptive advice and 5mg folate supplement. Foetus should then be closely monitored throughout pregnancy (prenatal US + genetic testing)
