Affective Disorders

Question 1

What is the prevalence of depression?

Answer 1

Very common.
2-5% about 1 in 5 people.
Female:Male 2:1

Question 2

What are the 3 core symptoms of depression?

Answer 2

Anhedonia - inability to derive pleasure
Anergia - reduced energy
Low mood - may be diurnal, worse in morning

Question 3

How long do you have to have depression to make a diagnosis?

Answer 3

At least 2 weeks.

NOT secondary to the effects of: drug/alcohol misuse, organic illness and bereavement.

Question 4

Depression in ICD-10

Answer 4

• Low mood
• Loss of interest
• Reduced energy levels
• Sleep disturbance
• Change in appetite
• Reduced concentration
• Reduced sex drive
• Loss of confidence
• Guilt feelings
• Suicidal thoughts

Question 5

How do you judge the severity of depression according to the ICD-10? Mild, moderate and severe.

Answer 5

Mild: 2 core and 2 other.
Moderate: 2 core and 3 other.
Severe: 3 core and 4 other.

Question 6

What is the prevalence of bipolar affective disorder?

What is the mean age of onset?

What is the aetiology of BAD?

Answer 6

1%
Female:Male 1:1

Mean age of onset - 21

Genetic - MZ:DZ 79% : 19%
Life events

Question 7

Manic episode in ICD-10

Answer 7

• Elated mood, Irritable mood, lability
• Increased energy levels, over activity
• Distractibility, reduced concentration, constant change of plans
• Reduced need for sleep
• Inflated self-esteem, grandiosity
• Overfamiliarity, disinhibition
• Reckless behaviour, overspending
• Increase in sex drive
• Racing thoughts or flight of ideas
• Psychotic symptoms

Question 8

What are the two types of bipolar affective disorder?

Answer 8

One Mania with or without Depression

Hypomania with Depression

Question 9

What is the mechanism of action in depression?

Answer 9

Monoamine (MA) Theory of Depression
• Depression associated with decrease in brain NAd (Noradrenaline)
and/or 5HT (serotonin)
Evidence:
• reserpine depletes brain MA and can cause depression
• antidepressants inhibit uptake or breakdown of MA

Question 10

What are the three types of antidepressants?

Answer 10

Monoamine reuptake inhibitors
Receptor antagonists
Monoamine oxidase inhibitors

Question 11

What are the 5 main types of monoamine reuptake inhibitors and an example of each?

Answer 11

Tricyclics (older):
Amitryptyline (toxic in overdose), Lofepramine

Selective serotonin reuptake inhibitors:
Fluoexetine, Citalopram (1st line as safe in overdose)

Noradrenaline reuptake inhibitors:
Reboxetine

Serotonin noradrenaline reuptake inhibitors:
Venlaxafine (causes CVS problems)

Noradrenaline and specific serotonin antidepressant:
Mirtazapine (sedative and weight gain)

Question 12

What are the common side effects of SSRIs?

Answer 12

• Agitation
• Nausea/loss of appetite
• Indigestion/diarrhoea/constipation
• Loss of libido/erectile dysfunction
• Dizziness/dry mouth/blurred vision/sweatiness/headaches

Question 13

Why are monoamine oxidase inhibitors rarely used?

Answer 13

•MAOIs are rarely used due to poorer
tolerability and interactions and diet
restrictions
•Monoamine oxidase breaks down tyramine
in your gut.
•If you eat tyramine containing food- cheese
redwine bovril and many more
•Potential for hypertensive crisis

Question 14

How long should you typically give patients antidepressants for?

Answer 14

6-9 months.

If multiple episodes consider for at least 2 years.

Question 15

What are the indications for Lithium?

Answer 15

• Mania: treatment and prophylaxis
• Bipolar Affective Disorder
• Recurrent depression
• Aggressive or self mutilating behaviour

Question 16

What are the baseline investigations before administering Lithium?

Answer 16

• Physical and weight
• U/E’s, renal function, TFT’s, Ca2+
• ECG
• Pregnancy test?

Question 17

What should you monitor in patients taking Lithium?

Answer 17

• Lithium has a therapeutic window
• Li levels (3/12 when stable)
• Renal, Thyroid, Ca2+, wt. and ECG
• Avoid drugs which reduce Li excretion
e.g. ACE, NSAID’s, diuretics esp.
thiazide

Question 18

What are the early and late side effects of Lithium?

Answer 18

Early:
Dry mouth, metallic taste, nausea, fine tremor, fatigue,
polyuria, polydipsia
Late:
Diabetes insipidus, hypothyroidism, arrhythmias, ataxia,
dysarthria, weight gain

Question 19

What are the causes, levels, symptoms and management of Lithium toxicity.

Answer 19

Causes: drugs (NSAID, diuretics), renal failure, UTI,
dehydration
Levels : may occur if Li >1.5 but treat symptoms not just
levels
Symptoms:
Early: blurred vision, anorexia, nausea, vomiting, diarrhoea,
coarse tremor, ataxia, dysarthria
Late: confusion, renal failure, delirium, fits, coma, death
Management: medical emergency
Stop lithium, give fluids and start diuresis / dialysis; treat cause

Question 20

What is the rate of success of ECT in regards to depression?

Answer 20

70-80%

Question 21

What does NICE recommend for mild to moderate depression?

Answer 21

Low intensity psychological intervention NOT medication:
Advice
Self help CBT
Group CBT
Structured Group Physical Activity Programme

Question 22

What does NICE recommend for moderate to severe depression?

Answer 22

Combination of antidepressant and high intensity psychological intervention.
Usually CBT or IPT.

Question 23

What are the short and mid-long term biological interventions for depression?

Answer 23

Short - Exercise, ECT

Long - Antidepressants, antipsychotics, mood stabilisers

Question 24

What are the short and mid-long term psychological interventions for depression?

Answer 24

Short - Exercise, behavioural activation, problem solving, self help/computer base CBT, psycho-education, CBT/IPT
Long - CBT/IPT, psychoanalysis (if CBT and IPT refused), other psychological therapies

Question 25

What are the short and mid-long term social interventions for depression?

Answer 25

Short - Housing, financial support, exercise, socialisation

Long - Improve social networks, increase daily activities, employment, housing, finances