Affective disorders Flashcards
What are the ‘A’ symptoms of depression?
Depressed mood
Loss of interest and enjoyment
Reduced energy and decreased activity
What are the ‘B’ symptoms of depression?
Reduced concentration Reduced self-esteem and confidence Ideas of worthlessness and guilt Pessimistic thoughts Ideas of self harm Disturbed sleep Diminished appetite
What is Cotard’s Syndrome?
Patient feels that they are dead (either figuratively or literally), dying, are putrefying or have lost their blood or internal organs
What is the criteria for ‘mild’ depression?
Depressed mood must be sustained for at least 2 weeks and At least 2 symptoms from category A and At least 2 symptoms from category B
What is the criteria for ‘moderate’ depression?
Depressed mood must be sustained for at least 2 weeks and At least 2 symptoms from category A and At least 3 symptoms from category B
What is the criteria for ‘severe’ depression?
Depressed mood must be sustained for at least 2 weeks and All symptoms from category A and At least 4 symptoms from category B
What type of delusions are usually seen in a person with a depressive episode associated with psychosis?
Mood congruent delusions e.g. guilt, worthlessness, ill-health, poverty, persecution
What type of hallucinations are usually seen in a person with a depressive episode associated with psychosis?
Classically second person auditory hallucinations (or olfactory sometimes)
Is there a difference in prevalence for depression between men and women?
Yes - Until the age of 55, women are more at risk than men (ratio 1:2), but after age 55 the risk evens out
What treatment is recommended for mild depression?
Psychological therapies only e.g. CBT
No medication recommended
What is the first-line antidepressant choice for people with moderate to severe depression?
SSRI
What is the treatment regime for starting antidepressants?
- Commence SSRI, reassess after 4-8 weeks
- If successful, continue until 6 months after recovery
- If unsuccessful, change to alternative and do another 4-8 week trial
- If successful, continue until 6 months after recovery
- If unsuccessful, this is ‘refractory depression’
Why are SSRIs given first line?
They are safest in overdose so carry the lowest risk in patients with underlying, undisclosed suicidal thoughts
Give 4 examples of SSRIs
Fluoxetine
Paroxetine
Citalopram
Sertraline
Do SSRIs cause QT prolongation?
No - They are useful in patients with cardiac problems
What is a common 2nd line choice for antidepressant?
Mirtazepine
List some side effects of SSRIs
Nausea and vomiting, headache, drowsiness, increased suicidal thoughts, change in sexual feelings, bleeding risk (they are enzyme inhibitors), hyponatraemia, serotonin syndrome
What is Serotonin Syndrome?
Caused by too much serotonin, usually presents with restlessness, confusion, tremor (triad of autonomic hyperactivity, altered metal state, neuromuscular excitation). Symptoms improve on stopping the medication.
Give 3 side effects of mirtazepine
Drowiness
Weight gain
Neutropenia
Give 2 examples of Serotonin-Noradrenaline reuptake inhibitors
Venlafaxine
Duloxetine
Does venlafaxine cause QT prolongation?
Yes - It should be avoided in patients with cardiac problems
Give 4 examples of tricyclic antidepressants
Amitriptyline
Clomipramine
Dothiepin
Lofepramine
Are tricyclic antidepressants dangerous in overdose?
Yes - They cause QT prolongation
Why is it important not to stop antidepressant therapy suddenly?
There is a risk of ‘discontinuation’ symptoms if they are stopped suddenly e.g. sweating, GI symptoms, mood changes, restlessness, difficulty sleeping
What are the available options for treatment of ‘treatment resistant depression’?
Consider a different diagnosis - Has an underlying psychosis been missed? Venlafaxine ECT Lithium augmentation Antipsychotic augmentation SSRI + Mirtazepine
What is ‘Bipolar I’ as defined by the DSM-IV?
One or more manic or mixed episode with or without episode(s) of severe depression
What is ‘Bipolar II’ as defined by the DSM-IV?
One or more depressive episode accompanied by at least one hypomanic episode
What are the symptoms of hypomania?
- Elevated mood or irritability sustained for at least 4 days
- At least 3 of the following, leading to some interference with personal function: Increased activity or restlessness, increased talkativeness, distractibility, decreased need for sleep, increased sexual energy, mild reckless or irresponsible behaviour, increased sociability
What are the symptoms of mania?
- Predominantly elevated mood or irritability sustained for at least 1 week
- At least 3 of the following, leading to severe interference with personal function: Increased activity or restlessness, increased talkativeness, flight of ideas, loss of normal social inhibitions, distractibility or constant changes in activity, decreased need for sleep, inflated self-esteem or grandiosity, behaviour that is foolhardy or reckless
What is ‘Bipolar III’ as defined by the DSM-IV?
Cyclothymia i.e. fluctuations in mood but that don’t quite meet thresholds for bipolar. These fluctuations will have occurred over at least 2 years.
What is ‘Bipolar IV’ as defined by the DSM-IV?
Iatrogenic hypomania / mania i.e. caused by giving drugs for depression but which ‘overshoot’ the normal range for mood and tip someone into being hypomanic / manic
What is the first line treatment for acute mania? Why?
Stop anti-depressant if they are on one as it may have contributed to episode.
Atypical antipsychotic e.g. olanzapine, risperidone, quetiapine. These are useful as they have mood stabilising properties and are sedative.
Is lamotrigine used in the treatment of acute mania?
No - This is a mood stabiliser and anti-epileptic and reserved for manic depressive episodes and not mania
What type of drug is lithium?
Mood stabiliser
How long does lithium take to work?
7-14 days
What investigations should be done before lithium is started?
Baseline ECG
TFTs, U+E
What monitoring is required for patients on lithium, and how frequently?
3 monthly lithium levels - At the same time interval each time (ideally 12-18 hours)
6 monthly: U+E, TFTs, eGFR, weight, BP, HR, ECG
What is the lifetime risk of bipolar for men and women?
Lifetime risk is about 1%, there is equal risk between sexes.
What is rapid cycling bipolar disorder?
4 or more episodes in 1 year
What levels of lithium are likely to cause toxicity?
More than 1.5mmol/L (Less in elderly)
What are the signs of lithium toxicity?
Drowsiness Dysarthria Coarse tremor Hypokalaemia Muscle twitching Ataxia Nystagmus Coma Death
List some side effects of lithium
Dry mouth Weight gain Nausea and vomiting Hypothyroidism Fine tremor Polyuria, polydipsia - diabetes insipidus Muscle weakness Renal impairment
When should lithium levels be checked?
12 hours after the dose
Describe the monitoring required for lithium therapy
Initially: Check lithium levels every week until therapeutic dose has been stable for 3 weeks
Monitoring: Lithium levels every 3 months, U+E, TFTs every 6 months, ECG every year
What is generally considered to be the therapeutic range for lithium?
0.4 - 1.0mmol/L
What are the Brown and Harris criteria for identifying those vulnerable to depression?
Lack of confiding partner
Maternal separation before age of 11
Lack of employment
3 or more children under the age of 14
Give 2 tools which can be used to assess a patient’s degree of depression
Hospital Anxiety and Depression Scale (HADS)
Patient Health Questionnaire (PHQ-9)
Give some side effects of tricyclic antidepressants
Dry mouth Drowsiness Constipation Urinary retention Blurred vision QT prolongation - dangerous in overdose
Diabetes insipidus is most associated with which drug in psychiatry?
Lithium
What effect do SSRIs have on cytochrome p450 enzymes?
Enzyme inhibition
True / False: Clozapine should not be taken alongside fluoxetine
True - Fluoxetine (an SSRI) is an enzyme inhibitor, and it increases levels of clozapine thus causing toxicity
What type of drug is mirtazepine?
Noradrenergic and Specific Serotoninergic Antidepressant (NaSSA)
What type of drugs are venafaxine and duloxetine?
Serotonin - Noradrenaline reuptake inhibitors (SNRIs)
Give 2 side effects of SNRIs
Increased BP
QT prolongation
Which drug might be useful in toxicity produced by tricyclic antidepressants?
IV bicarbonate - Might reduce seizure risk and arrhythmias
