Affective Disorders

Question 1

Epidemiology of depression?

Answer 1

Lifetime risk = 15%, prevalence = 5%. F>M 2:1. Old age in males, middle age in females. Geographical variations in presentation (e.g. somatic presentation common in Asian and African cultures).

Question 2

Genetic aetiology of depression?

Answer 2

First degree relatives of depressed patient at 15% increased risk. 46% MZ concordance, 20% DZ.

Question 3

Neurochemical aetiology of depression?

Answer 3

Monoamine hypothesis – depletion/change in function of receptors of noradrenaline, serotonin and dopamine.

Endocrine – plasma cortisol levels increased 50% in depression sufferers.

Question 4

Organic aetiology of depression?

Answer 4

Neuro - Stroke, AD/dementia, PD, Huntington’s, MS, epilepsy, intracranial tumours

Endocrine - Cushing’s, Addison’s, hypothyroidism, hyperparathyroidism,

Metabolic - iron deficiency, B12/folate deficiency, hypercalcaemia, hypomagnesaemia,

Infectious - influenza, infectious mononucleosis, hepatitis, HIV/AIDS

Cancer - non-metastatis effects of carcinoma

Drugs - L-Dopa, steroids, beta-blockers, digoxin, cocaine, amphetamines, opioids, alcohol.

Question 5

Social/psychological aetiology of depression?

Answer 5

Social
Adverse life events – loss of parent (before age 11), neglect, sexual abuse. ‘Excess of life events’, lack of supportive relationship, three or more children under 14 at home, not working outside home.

Psychological
Bowlby’s attachment theory, Freud’s psychoanalytical theory, Beck’s cognitive theory, learned helplessness.

Question 6

Symptoms of depression? (Core, psychological and somatic)

Answer 6

Core = Low mood, loss of interest/enjoyment (anhedonia), reduced energy levels

Psychological = Poor concentration, Poor self-esteem, Guilt, Pessimism, Suicidal thoughts

Somatic = Sleep disturbance, Early morning waking, Morning depression, Loss of appetite and weight loss, Loss of libido, Agitation

Question 7

Assessment/diagnosis of depression?

Answer 7

Mild = 2 core + 2 other
Moderate = 2 core + 3 other
Severe = 3 core and 4 other
FOR AT LEAST 2 WEEKS

Question 8

1st line biological treatment for depression?

Answer 8

SSRI – Fluoxetine, Citalopram, Sertraline. Good because safe in overdose.

Question 9

Side effects of SSRIs?

Answer 9

mild GI, loss of libido, dizziness, dry mouth, blurred vision, sweating, headaches.

Question 10

What is 2nd/3rd line biological treatment for depression?

Answer 10

NARI (Reboxetine) or SNRI (Venlafaxine) or NaSSa (Mirtazapine)

Question 11

When are SNRIs contradindicated?

Answer 11

CV disease - QT interval increased

Question 12

Possible extra benefit of mirtazapine?

Answer 12

Sedation

Question 13

Length of drug treatment for depression?

Answer 13

6-9 months following recovery. If multiple episodes consider at least 2 years. At least 4-6 initially if tolerated.

Question 14

Switching/augmentation of biological treatments for depression?

Answer 14

Common. Never stop any suddenly. Some antipsychotics have an antidepressant effect. Adding antidepressants of different classes – some never used together (TCA + SSRI) and no point in two of same group.

Question 15

When is lithium indicated for depression?

Answer 15

Severe

Question 16

Investigations prior to administering lithium?

Answer 16

physical/weight, U&Es, renal function, TFTs, Ca2+, ECG, pregnancy test.

Question 17

Side effects of lithium?

Answer 17

dry mouth, metallic taste, nausea, fine tremor, fatigue, polyuria, polydipsia. Late = diabetes insipidus, hypothyroidism, arrhythmias, ataxia, dysarthria, weight gain.

Question 18

What should be avoided when taking lithium?

Answer 18

drugs which reduce Li excretion (renal) – ACEi, NSAIDs, diuretics.

Question 19

ECT response rate? What is process?

Answer 19

70-80% response in depression. 2x weekly treatment, 12 in total. Unilateral vs bilateral made on case by case basis. Short general anaesthetic and muscle relaxant.

Question 20

Side effects of ECT?

Answer 20

headache, nausea, muscle pain, temporary anterograde memory impairment.

Question 21

NICE recommendations for psychological management of depression?

Answer 21

Mild to moderate depression - Low intensity psychological interventions. Moderate to severe – combination of antidepressant and high intensity psychological intervention (CBT/IPT).

Question 22

Low intensity and high intensity psychological interventions for depression?

Answer 22

Low Intensity = advice, CBT based self-help, structured physical activity programme.

High Intensity = CBT, interpersonal therapy (IPT), behavioural activation.

Question 23

CBT?

Answer 23

Talking therapy based on cognitive behavioural model – not the event that causes problems but how we appraise it. Define problem and goals – map out problem in terms of thoughts, behaviours, physiology, emotions. Use diaries to monitor and identify problematic thoughts – help patient learn to think in more helpful ways.

Question 24

What is IPT?

Answer 24

Time-limited and structured psychotherapy. Focuses on interpersonal difficulties, roles, conflicts, life changes and grief.

Question 25

What is behavioural activation?

Answer 25

Involves getting people to act according to a plan rather than how they feel – involves doing things. Breaking cycle of doing nothing and avoidance.

Question 26

Social interventions in depression?

Answer 26

Important to address social problems as they often act as precipitating and/or perpetuating factors. ADLs, housing, isolation, support at home, work, carers, finances. Improve social networks.
Address holes in ADL (care home etc), debts (citizens’ advice), various options like food banks, voluntary organisations etc.
Carer support, education and respite.

Question 27

Prognosis in depression?

Answer 27

Average length of depressive episode = 6 months. 80% of patients have further depressive episodes. 10% develop chronic unremitting disorder, 10% ‘convert’ to bipolar affective disorder.

Question 28

Neurochemical aetiology of mania?

Answer 28

Monoamine hypothesis suggests mania results from increased levels of NA, serotonin and dopamine. Stimulant drugs like cocaine and amphetamines can exacerbate mania.

Question 29

Life events/environmental factors in aetiology of mania?

Answer 29

Life events, severe stresses and disruptions in daily routine and circadian rhythm may provoke the onset of a first manic or hypomanic episode. More manic episodes in late spring/summer and in postpartum period.

Question 30

Presenting features of mania?

Answer 30

A+B – flamboyant clothing, unusual combinations of clothing, heavy makeup and jewellery. Hyperactive, entertaining, flirtatious, hypervigilant, assertive, aggressive, reduced need for sleep, increased sex drive.
S – pressured speech, neologisms, clang associations.
M – euphoric/elated, irritable, labile.
Tf – pressure of thought, flight of ideas, loosening of associations, circumstantiality, tangentiality.
Tc – Optimistic, self-confident, grandiose, mood congruent delusions (grandiose - in keeping with elated mood).
P – hallucinations
IQ – poor concentration but intact memory and abstract thinking
In – very poor insight

Typically full of grandiose and unrealistic plans that they begin to act upon but soon abandon. Often engage in impulsive, pleasure-seeking and disinhibited behaviour.

Question 31

ICD-10 criteria for diagnosis of mania?

Answer 31

ICD-10 – episode should last for at least one week and be severe enough to disrupt ordinary work and social activities more or less completely.

Question 32

What is hypomania?

Answer 32

A lesser degree of mania. Mood is elevated, expansive or irritable but there are no psychotic features and no marked impairment of social functioning.

Question 33

Investigations in mania?

Answer 33

Serum and/or urine drug screen, liver, renal and thyroid function tests, FBC, ESR, urine test (including pregnancy test) – rules out drug abuse, establish baseline for administration of mood-stabilising medication, uncover possible medical causes for symptoms.
Pretreatment ECG important prior to starting lithium/other drugs. If already on lithium, lithium level should be taken.

Question 34

Management of mania?

Answer 34

Start an antipsychotic and wait for recovery before starting a long-term mood stabiliser. Antipsychotics = fast-acting and effective in mania. But relatively high doses required and do not protect against further depressive episodes (unlike mood stabilisers).

Can give fast acting sedative (lorazepam) if patient agitated, and sleeping tablet (temazepam, zopiclone) if patient is sleep deprived.

Any antidepressant medications should be rapidly tapered off and stopped.

Question 35

Disadvantage of starting mood stabiliser during manic episode?

Answer 35

patient can’t participate in decision – compromises long-term compliance.

Question 36

Epidemiology of BAD?

Answer 36

Lifetime risk = 0.3-1.5% - prevalence similar as is a chronic disorder. Sexes and races equally affected. Prevalence higher in in higher SE groups – tend to be creative people like artists.
Mean age onset = 21 but variable – first mania after 50 should lead you to think of organic/metabolic/endocrine cause.

Question 37

Genetic aetiology of BAD?

Answer 37

First degree relatives of BAD sufferer – 10% lifetime risk, and increased risks of unipolar depression + schizoaffective disorder. MZ concordance = 79%, DZ = 19%. Children of

BAD sufferers remain at increased risk of affective disorders even after adoption by unaffected parents – indicates stronger genetic component, probably more than any other psychiatric disorder.

Question 38

ICD-10 criteria for diagnosis of BAD?

Answer 38

Requires at least 2 epsidoes, one of which must be hypomanic, manic or mixed, with recovery usually complete between episodes.
Hypomania/mania without depressive episode = manic episode.

Question 39

Therapeutic range of lithium (for BAD)?

Answer 39

0.4-1.0mmol/L

Question 40

Response rate of lithium in BAD?

Answer 40

75% in acute manic episodes but takes several weeks to take effect. In BAD prophylaxis, reduces rate of relapse by 1/3, but more effective against mania than depression. Lithium should only be started if there is a clear intention to continue it for at least three years, as poor compliance and intermittent treatment may lead to rebound mania.

Question 41

Symptoms of Li toxicity?

Answer 41

Early = Blurred vision, anorexia, nausea, vomiting, diarrhoea, coarse tremor, ataxia, dysarthria. Late = confusion, renal failure, delirium, fits, coma, death.

MEDICAL EMERGENCY – stop Li, give fluids, diuresis/dialysis; treat cause.

Question 42

How can patients be advised to avoid Li toxicity?

Answer 42

drink plenty of fluids and to avoid reducing their salt intake

Question 43

Mood stabilisers other than lithium?

Answer 43

Anticonvulsants (valproate, lamotrigine and carbamezapine) - enhance action of GABA

Question 44

Valproate in BAD? Side-effects? Contraindication?

Answer 44

Similar efficacy to Li but quicker onset, so is useful in rapid cycling BAD. Often tolerated better than Li.

Side effects = nausea, tremor, sedation, weight gain, alopecia (with curly regrowth), blood dyscrasias, hepatotoxicity and pancreatitis (important to check blood counts and liver function before starting, and continue to monitor).

Should be avoided in women of child-bearing age – teratogen.

Question 45

Lamotrigine in BAD? Side effects?

Answer 45

More effective against relapses of depression than mania, can be used in relapses of bipolar depression and prophylaxis of BAD. Fewer side effects than lithium/valproate and doesn’t require long-term monitoring.

Side effects = nausea, vomiting, headaches, dizziness, clumsiness, blurred vision, diplopia, flu-like symptoms, sedation, insomnia, skin rash, severe skin reactions.

Question 46

Carbamezapine in BAD? Side effects? Contraindication?

Answer 46

2nd/3rd line in prophylaxis of BAD, but has particular value in treatment-resistant cases and in rapid-cycling.

Side effects = nausea, headache, dizziness, sedation, diplopia, ataxia, skin rashes, rare but potentially fatal blood dyscrasias and leukopenia. Regular bloods.

Contraindicated in pregnancy (spina bifida) but can be used by breastfeeding mothers. Is a CYP450 inducer.

Question 47

ECT in BAD?

Answer 47

ECT rarely used – in depressive episodes so severe or unresponsive to medication, or mania that cannot be treated medically, either because it is unresponsive or because medication is contraindicated.

Question 48

Psychosocial interventions in BAD?

Answer 48

Education – about symptoms, course, treatment, importance of drug compliance, advice about lifestyle (avoidance of triggers).

Question 49

Prognosis of BAD?

Answer 49

Manic episode on average lasts 4 months. Prognosis poor - after first manic episode, 90% of patients experience further manic/depressive episodes. Inter-episode interval tends to become progressively shorter. 10% go on to commit suicide.