Affective Disorders Flashcards
What are the main types of affective disorder?
Depression
Mania
Women are __?__ as likely as men to develop depression.
twice
F:M 2:1
What is the prevalence of depression?
5%
remember, prevalence is the proportion of the population with a disease at any given time
What is the lifetime rate of depression?
20%
That is, 20% of people will experience depression at some point in their lifetime.
What are the core symptoms of depression?
- Low mood (may be diurnal)
- Anhedonia (inability to derive pleasure)
- Anergia (↓ energy)
True or false: a person must be experiencing symptoms for at least three months for a diagnosis of depression to be made,
False.
For a diagnosis of depression to be made, a patient must experience symptoms every day for two weeks.
AND the symptoms can’t be secondary to the affects of drug/alcohol use, organic disease, or bereavement.
In addition to the core symptoms, what other symptoms are characteristic of depression?
Poor concentration
Worthlessness/guilt
Suicidal thoughts
Poor sleep
Reduced libido
Change in appetite
Psychomotor retardation
How is severity assessed in depression?
Mild: 2 core + 2 other
Moderate: 2 core + 3 other
Severe: 3 core + 4 other
Although it is based on symptom count, suicidal intentions or the presence of psychosis indicate a severe depression.
True or false: Patients with untreated bipolar affective disorder will go on to have an average of at least 10 depression/mania episodes in their lifetime.
True
What is the cure for bipolar affective disorder?
There isn’t one!
The aim of treatment is to reduce number and severity of relapses.
True or false: There is no link between genetics and bipolar affective disorder.
False
Genes are a major aetiological factor.
The prevalence of bipolar is roughly __?__%
1%
True or false, bipolar affects as many men as it does women.
True.
The M:F ratio is similar.
When a patient is experiencing a manic episode, what symptoms might they commonly display?
Elevated mood
Increased energy
↓ concentration
↓ need for sleep
Grandiosity
Reckless, disinhibited behaviour (overspending, promiscuity)
Increased libido
Racing thoughts, pressured speech
Irritability, aggression
Psychomotor agitation
How is a diagnosis of mania made?
Distinct period lasting at least 1 week of abnormally elevated mood + at least three other symptoms. Impacting negatively on occupational and social functioning.
Your patient is displaying elevated mood, irritability and boorish behaviour. They are not displaying signs of psychosis and their symptoms do not seem to majorly interfere with work or social functioning.
What term describes this patient’s mood?
Hypomania
How is a diagnosis of bipolar affective disorder made?
At 2 least episodes of disturbed mood, one of which is manic or hypomanic.
What are the three broad classifications of antidepressants, based on their action?
1) Monoamine reuptake inhibitors - block reuptake of synaptic neurotransmitters, increasing their availability.
2) Receptor antagonists
- ?
3) Monoamine Oxidase inhibitors
- Inhibit the enzyme that degrades synaptic neurotransmitters, increasing their availability.
What are the most commonly used antidepressants?
SSRI’s
- safer in overdose
Citalopram Escitalopram Fluoxetine Sertraline Paroxetine
What are the common side effects of SSRI’s?
Agitation
Nausea/loss of appetite
GI problems: indigestion, diarrhoea, constipation
Loss of libido, erectile dysfunction
Dizziness/dry mouth/blurred vision/sweating/headaches
Why are monoamine oxidase inhibitors rarely used?
Poorer tolerability, interactions and dietary restrictions.
Dangerous interactions with amphetamines and certain anaesthetic agents.
As well as monoamine neurotransmitters, Monoamine Oxidase also breaks down tyramine in the gut. Accumulation can lead to fatal hypertensive crisis, therefore sources must be avoided (cheese, red wine, bovril and many more).
True or false: Initially when starting antidepressants, there may be an increased risk of suicide.
True.
Motivation improves quicker than mood, giving a period of increased risk if a patient has suicidal ideas.
SSRI’s may be implicated more than others, but they have less risk of OD.
How might antidepressants cause serotonin syndrome?
Increase available serotonin, especially if take with other drugs that increase serotonin levels (e.g. other antidepressants, MaOI’s, St John’s Wort, ecstasy).
What are the symptoms of serotonin syndrome?
Restlessness, fever, tremor, myoclonus, confusion, seizures, arrhythmias
How do you manage serotonin syndrome?
Stop the drug(s)
Supportive therapy and monitoring
True or false: Antidepressants cause hypernatraemia
False
Hyponatraemia is a problem sometimes seen with patients taking antidepressants.
Esp. older thin females in summer with poor renal function. Therefore, monitor at-risk group
SSRI’s are worst culprits
How long should an antidepressant be trialled for?
At least 4-6 weeks, if tolerated.
It can take this long to see the benefits.
When should an antidepressant be stopped?
6 to 9 months AFTER RECOVERY.
Stopping earlier can cause a relapse that is more severe than the initial episode.
If relapse is seen, consider taking treatment for at least two years.
And never stop suddenly!
What other drugs can be used to augment the effects of antidepressants?
Mood stabiliser - lithium
Antipsychotic
What are the indications for treatment with lithium?
Mania: treatment and prophylaxis
Bipolar affective disorder
Recurrent depression
Aggressive or self-mutilating behaviour
True or false: Lithium is absorbed rapidly
True
True or false: Lithium is excreted by the liver
False.
Lithium is excreted via the kidneys, therefore baseline renal function must be checked prior to commencing
True or false: Patients on lithium require monitoring.
True
Lithium has a narrow therapeutic window and must be monitored:
Weekly after initiation/dose change
Once stable, every three months (for one year)
Every 6 months after first year
True or false: When monitoring lithium levels, sample should be taken 6 hours after the last dose
False
Sample should be taken 12 hours after last dose.
What are the guidelines for lithium use in pregnancy
Avoid if possible, particularly in the first trimester (risk of teratogenicity, including cardiac abnormalities).
If lithium is used during pregnancy, the physiological changes may affect excretion and therefore dose requirements increase during the second and third trimesters (but on delivery return abruptly to normal).
What is the recommended serum lithium concentration?
05-1.0 mmol/L
Side effects of lithium?
Early:
Dry mouth, metallic taste, nausea, fine tremor, fatigue, polyuria, polydipsia
Late:
Diabetes insipidus, hypothyroidism, arrhythmias, ataxia, dysarthria, weight gain
What drugs should be avoided when taking lithium as they may lead to lithium toxicity?
The drugs that decrease Li excretion:
- ACEi’s. NSAIDs, diuretics (esp. thiazide)
What are the symptoms of lithium toxicity?
Early:
Blurred vision, anorexia, nausea, vomiting, diarrhoea, coarse tremor, ataxia, dysarthria
Late:
Confusion, renal failure, delirium, fits, coma, death
What management is required for lithium toxicity?
Medical emergency
STOP lithium
Fluids
Dialysis/diuresis
Treat the cause
What are the more common causes of lithium toxicity?
Drugs (ACEi, NSAID, diuretics)
Renal failure
UTI
Dehydration
When does NICE recommend using ECT?
“Severe life threatening or treatment-resistant depression, catatonia or severe mania”
How much ECT is usually required?
Twice-weekly for approximately 12 sessions in total
True or false: Light sedation is given prior to ECT
False
ECT is carried out under general anaesthetic + muscle relaxant
What are the common side effects of ECT?
Headache, nausea, muscle pan, amnesia
What treatment is recommended for mild to moderate depression?
Low intensity psychological interventions, not medication.
Sleep hygiene
Regular exercise
Self-help CBT or group CBT
What treatment is recommended for moderate to severe depression?
Antidepressant medication and high intensity psychological intervention. 16-20 session over 3-4 months.
CBT
IPT
Behavioural activation
What are the stepped tiers for mental health referrals to secondary care?
Tier 1: GP
Tier 2: Primary care mental health worker
Tier 3: Community mental health team
Tier 4: Home treatment or in-patient
When should patients be referred for emergency secondary mental health care?
Significant risk of harm to self or others
Psychotic symptoms
Severe agitation
