Affective Disorders Flashcards
Depression Ix
Collateral hx Physical exam Bloods: FBC, TFT, U+E Rating scales: PHQ9, HAD, CDI (children) Risk assessment Assess severity (no, Sx + severity, duration) Explore possibility of previous episodes of depression and mood elevation (BPAD) ALWAYS assess suicide risk
Stepped care model depression
Step 1: All known and suspected depression
- Assessment, support, psychoeducation, active monitoring
Step 2: Persistent subthreshold, mild-mod depression
- Low intensity psychological intervention, medication
Step 3: Persistent subthreshold, mild-mod not responding or severe
- medication, high intensity pyschcological intervention
Step 4: severe and complex
- medication and high intensity psychological intervention (ECT, crisis service)
Explain Sx may get worse after starting treatment and give advise about seeking help
Mild-mod depression Mx
Sleep hygiene
FU in 2w
Low intensity psych intervention
Group CBT (if decline low intensity) 12-16wks
NOT routinely meds unless long term Sx, or Hx of mod/severe
Low intensity psychcological intervention
Individual guided self help based on principles of CBT
Computerised CBT (both over 9-12wks)
Structured group physical activity programme
Moderate-Severe Depression Mx
Combination of antidepressant and High intensity psychological intervention (CBT/IPT)
Antidepressant meds
First line: SSRI (sertraline)
Caution bleeding: give NSAIDs w/PPI
R/v at 2wks (if low risk suicide) and then monthly
Patients <30y or an increased risk of suicide FU at 1w
Antidepressant w/drug interactions
fluoxetine, fluvoxamine, paroxetine
Discontinuation syndrome antidepressant
paroxetine
Death from overdose antidepressant
venlflaxine
Overdose antidepressants
TCAs except lofepramine
Stopping treatment due to side effects antidepressants
venlaflaxine, duloxetine, TCAs
Blood pressure monitoring required antidepressant
Venlaflaxine
Worsening hypertension antidepressant
venlaflaxine, duloxetine
Postural hypotension and arrhythmia antidepressant
TCA
High intensity psychological interventions
Individual CBT:
16-20 sessions over 3-4m
Consider 2 sessions/wk in the first 2 weeks
Consider FU sessions over the following 3-6m
Interpersonal Therapy:
16-20 sessions over 3-4m
consider 2 sessions/wk in first 2 weeks
helps identify how interactions are affecting mood and finding ways to improve this
Caution when swtiching antidepressants
fluoxetine to others (has long half life)
From fluoxetine or paroxetine to a TCA (both inhibit TCA metabolism)
To new serotoninergic antiderpressant of MAOI (risk serotonin syndrome)
From non-reversible MAOI: 2 week wash out period required, w/ no other antidepressants
Complex and severe depression
Crisis resolution and home treatment teams for crises
Develop crisis plan to avoid triggers
Consider inpatient treatment if risk of harm or self neglect
Consider ECT as acute treatment if rapid response required
Summary of depression Mx
Mild or subthreshold: active monitoring, 2w FU
Persistent subthreshold, or mid-mod: consider low intensity pysch intervention, avoid routine antidepressant use
Mod-sev: antidepressant and high intensity
First episode: SSRI (citalopram, sertaline)
Recurrent: consider antidepressant that had good response in the past
If co-existing physical health condition - sertraline (low drug interaction)
Depression Dr Nayrouz Mx
Mod-sev needs Mx
if develop psychosis at any point add antidepressant
Stopping antidepressants should be done over 4weeks
Dr Nayrouz Depression first line
SSRI (sertraline best)
Increase from 50mg-200mg in steps of 50 every 2wks
sertraline is nonsedative
Other SSRI: citalopram (CI in any QTc prolongation)
Dr NayrouzDepression second line
taper down SSRI switch to SNRI eg venlaflaxine, duloxetine V: 37.5mg BD to 75mg BD, to 75mg in morning and 150mg in evening SNRI pharmacology does not switch from its SSRI effect to SNRI until you reach max dose At this point check: adherence Dx - ?BPAD drug interactions perpetuating factors
Dr Nayrouz Depression third line
treatment resistence
add augmentation (atypical e.g. quetiapine 150-300mg or Li (aim for blood level 0.4-0.8
or another antidepressant eg mirtazipine or mianserin
Dr Nayrouz Depression fouth line
ECT
Catch up phenomena
if pt recovers from depression due to Rx when it is stopped the depression will be worse
Serotonin syndrome
Clin fx.: fever, agitation, confusion, hypertension, hyperreflexia, clonus, tremor, diarrhoea, dilated pupils Withdraw offending drug supportive care 1-3d duration benzos for agitation ?cyproheptadine (antihistamine)
Mania and biplar affective disorder Ix
Collateral hx physical exam Blood: FBC TFT U+E LFT ECG urine drug screen rating scale: Young Risk assessment
Mood stabilisers Mania and biplar affective disorder
Even extreme highs and lows More effective against mania 3 main drugs: Lithium Na valproate Carbamezapine MOA ?Na/GABA channel intearction
Lithium Mania and biplar affective disorder
Therapeutic range: 0.6-1mmol/L Toxicity >1.2mmol/L Check levels weeks until steady level achieved Then monitor 3monthly U+E + TFTs every 6m (hypothyroid)
Li toxicity
>1.2mmol/: Life threatening Presentation: GI disturbance polyuria/polydipsia sluggishness giddiness ataxia tremor fits renal failure Trigger: Salt balance change, diuretics, overdose
Li toxicity Mx
check level
stop dose (risk precipitating mania/depression)
Transfer for medical care
?gastric lavage/dialysis
Valproate Mania and biplar affective disorder
Treats acute mania Prophylaxis in BPAD No plasma monitoring No accepted therapeutic range Dose related toxicity not an issue
Carbamazepine Mania and biplar affective disorder
Toxicity at high dose
induces liver enzymes
close monitoring essential
check interactions before prescribing
Pregnancy Mania and biplar affective disorder
Mood stabilisers teratogenic
Harm vs risk of manic episode
Li - Ebsteins anomaly
Valproate and carbamazepine - spina bifida
Give contraceptive advise and folate supplement if valproate
non mood stabilisers in Mania and biplar affective disorder
antipsychotics (olanzapine)
anticonvulsants (lamotrigine) is second line prophylaxis for BPAD type II
Acute treatment of mania or hypomania
Stop all meds that may induce Sx (antidep, drugs of abuse, steroids, dopamine agonists)
Monitor food and fluids to prevent dehydration
If treatment free: antipyschotic or mood stabiliser, short course benzos
If on Rx:
optimise, check compliance, consider adding agent (antipsychotic), ?short term benzos
ECT if unresponsive to medication
Long term treatment of Mania and biplar affective disorder
Mood stabilisers mainstay
other drugs symptomatically
Depression in BPAD: hard bc antideps can cause mania, so need to be given w/mood stabiliser/antipsych.
1st line: fluoxetine + olanzapine/quetiapine
2nd: lamotrigine
Monitor for sx of mania
Cautiously withdraw meds if sx free for a while
Psychological treatment Mania and biplar affective disorder
CBT: identify relapse indicators and strategies
Psychodynamic psychotherapy: useful if mood stabilised
Social intervention Mania and biplar affective disorder
family support and therapy
aiding return to work
Prognosis of Mania and biplar affective disorder
manic episodes begin abruptly and are usually shorter than depressive (2wks-5m)
Recovery usually complete between episodes
Remissions shorter w/age and depression more common
15% will commit suicide
Li reduces this level to same as population
Mania Dr Nayrouz Mx
2 antimanic classes:
Mood stabilisers (eg Li)
- not as effective in manic phase, if you start it during mania add atypical antipsych
Atypical antipsychotics
- more freq. used, work quickly, if fails add a mood stabiliser
atypical antipychotics
aripiprazole
quetiapine
olanzapine
risperidone
Dr Nayrouz stabilising bipolar
use mood stabiliser or atypical antipsychotic
either will work equally well
Bipolar depression Dr Nayrouz
SSRI (fluoxetine first line) w/atypical antipsychotic (olanzapine, quetiapine)
always check Li levels if it appears ineffective
Self harm and suicide Physical treatment
OD: activated charcoal for some substances ingested (antidepressants) must be <1hr after ingestion, antidotes eg NAC for paracetamol
Laceration: suture/steristrip, plastic surg for deep cuts, analgesia
Self harm and suicide risk assessment
Thoughts of hurting themselves again Thoughts of hurting others Thoughts of being hurt by others Specific features: careful planning acts preparing for death precaution to prevent discovery suicide note definite intent belief of legality Violent method ASSESS CAPACITY BIG MAN
Immediate intervention Self harm and suicide
at risk of suicide and lacking capacity: admit to psych ward
pts at lower risk Mx at home
Crisis plan (who they will tell, how they’ll get help)
Followup intervention Self harm and suicide
FU within 1wk of self-harm d/c
Treat underlying dx
Psychological therapy (CBT/DBT, mentilisation based Mx)
Coping strategies Self harm and suicide
Distraction mood raising technique Supportive environment Avoiding substances bite into strong flavoured thing eg lemon
Schizophrenia Ix for first line psych
Collateral history physical exam bloods: FBC, U+E, lipids, LFT Urine drug screen rating scale: brief psychiatric rating scale ADL assessment and housing/finance
Early intervention in psychosis service
Psychosis is toxic, the longer it happens the more it will affect cognitive abilities, insight, social situation
Sooner treatment means better prognosis
This service engages w/very early sx pts
offered antipsych and psychosocial intervention to keep DUP under 3mo
Can be used by children >14
Schizophrenia psychological Mx
Antipsychotics: block D2R
Extrapyramidal side effects can occur at high conc. of ALL antipsych. but less common w/atypicals
Avoid using more than 1 antipsych
typical antipsychs
older drugs Chlorpromazine Haloperidol Flupentixol decanoate Cause EPSE at normal dose Effective, cheap, depot options
atypical antipsychs
in addition to dopamine R also block Serotonin 5-HT2 R Eg. Olanzapine risperidone (depot available) Quetiapine Apiprazole Clozapine Amisulpride
Consider starting atypical antipsych
1st line newly dx schiz.
SE from typicals
relapse on typucal
Extrapyramidal side effects - dystonia
Onset: early
Sx: involuntary painful sustained muscle spasms e.g. torticollis (neck twists to one side) oculogyric crisis
Rx: anticholinergic (procyclidine)
Extrapyramidal side effects - Akathsia
Onset: hours-weeks
Unpleasant subjective feeling of restlessness (pacing, jiggling)
Rx: decrease dose/change antipsychotic, add propranolol/benzo
Extrapyramidal side effects - parkinsonism
Onset: days-weeks Triad: -resting tremor - rigidity - bradykinesia Mask like face Shuffling gait Rx: decrease dose/change antipsych, try anticholinergic (procyclidine) but r/v frequently and do not use as proph.
Extrapyramidal side effects - tardive dyskinesia
Onset: months-yrs
Sx: Rhythmic involuntary movements of mouth, face, trunk which are v distressing
Pts may grimace, make chewing/sucking movements
Rx: stop antipsych. or reduce dose if poss. (may worsen sx initially) Avoid anticholinergics (often worsen problem), swtich to atypical or clozapine
Often irreversible
Other side effects of antipsychotics (not extra pyramidal)
Hyperprolactinaemia (galactorrhoea, amenorrhoea, gyanaecomastia, hypogonadism, sexual dysfunction, osteoporrosis) Wt gain (olan/clozapine) Sedation Risk DM Dyslipidaemia Anticholinergic effects (proSNS) Arrythmia Seizure (reduces threshold)
Schizophrenia: psychological Mx CBT
Offer to ALL
Emphasis on reality testing
Aim to gently challenge beliefs, aid awareness of illogical thinking
Encourage thinking about evidence and consider alternative explanations
Can also help with troublesome hallucinations/delusions
>15 sessions
Schizophrenia: psychological Mx Family therapy
Can reduce relapse rate
Effects of high expressed emotion can be ameliorated through comms skills, education about dx, expanding social network
Offer respite for family
10+ sessions
Schizophrenia: psychological Mx Concordance therapy
collaborative approach where pt encouraged to consider pros and cons of Mx
Schizophrenia: social Mx
?admission for observation, treatment, refuge Help w/practical needs Social skills training Need to address: - education - skills - housing - accessing social activities - developing personal skills
Schizophrenia other Mx Physical health (
Offer combined healthy eating and physical activity programme
Offer interventions for metabolic cx of antipsych (wt gain, cholesterol)
Help w/smoking cessation
Monitor physical parameters regularly
Schizophrenia other Mx: negative sx
arts therapy
Schizophrenia other Mx: carer support
Offer support (education and programmes)
Right to carers assessment (free from social services)
Consider peer support (someone who has recovered from psychosis)
Schizophrenia other Mx: monitoring: baseline
Baseline (pre-antipsych): - wt - waist circ. - pulse and BP - Fasting BM, HbA1c, lipid profile, prolactin - assess for movement disorder - assess nutritional status, diet, exercise - ECG if CV RFs or req for meds Children: height every 6m
Schizophrenia other Mx: monitoring ongoing
Response to rx and SE Emergence of movement disorders Waist circumference Adherence Overall phys. health Weight: - weekly for 6w - at 12w - at 1y - annually after Pulse and BP: -12w - 1yr - annually
Schizophrenia Treatment resistance
1st line: clozapine
Definition: failure to respond to 2+ antipsych. at least 1 of which was atypical each at therapeutic dose for 6w
Warning: small but sig risk agranulocytosis
Weekly blood tests
If poor response to clozapine consider adding another antipsych.
Summary of Schizophrenia
1st line; atypical antipsychotic (eg qeutiapine)
CBT offered to all
Close attenion paid to CV RF modification
Schizoprhrenia Dr nayrouz Mx
- Atypical:
- apiprazole (10mg)/quetiapine (50->750mg)
- olanzapine (10mg)/risperidone (3-6mg) (stronger but SE)
Max quetiapine dose in mania:800 - If this doesn’t work after 2-4wks try new class
- If no response after 2 classes consider clozapine
- Schizoaffective disorder: same meds but add mood stabiliser if you feel affective component, consider antidepressant
Rapid tranq: lorazepam (1mg), haloperidol (5mg)
Neuroleptic maliganant syndrome MoA, Sx
Sympathetic hypersensitivity resulting from dopaminergic antagonism (onset 1-3d)
Muscle rigidity, fever, sweating, confusion, autonomic dysfunction
Neuroleptic maliganant syndrome Ix
High CK
high WCC
Altered LFTs
U+E(can cause AKI) and creatinine
Neuroleptic maliganant syndrome Mx
Stop antipsych urgent medical treatment (ITU) Treat hypothermia ?bromocriptine Dantrolene for rigidity benzo for agitation ?IV fluids/dialysis
