Affective Disorders Flashcards
What are risk factors for affective disorders?
Childhood adversity/abuse Adulthood vulnerability: - unemployment - lack of relationships - low socioeconomic status
What can precipitate depression?
A stressful life event
- loss event (e.g. loss of role, of autonomy)
What is beck’s model of depression (negative cognitive triad)?
World - Future - Self
Negative thoughts in this lead to:
Helpless. - hopeless - worthless/guilt
What are the core symptoms of depression?
- Low mood >2 weeks
- Anhedonia
- Anergia
What are cognitive sx of depression?
worthlessnesss
guilt
helplessness
hopelessness
What are biological sx of depression?
- Poor sleep (insomnia, waking up early)
- Low appetite, weight loss
- Reduced libido
What are psychotic symptoms of depression?
hallucinations, delusions
What are the categories of symptoms we must ask about in depression?
Can Claudio Be Pussy-whipped
Core
Cognitive
Behavioural
Psychotic
What are organic differentials for depression?
HAEM - ENDO - NEURO Deficiencies: anaemia, B12, Vit D - Hypothyroidism - Hyperparacalcaemia - Addison's disease Cushing's - Dementia, parkinsons, hypoactive delirium - Substance misuse
What are psych differentials. for depression?
- Bereavement
- Adjustment disorder (after a significant life event)
- dysthymia
- BPAD
- schizoaffective disorder
- recurrent depressive disorder
What are the 5 key categories of anti-depressants?
SSRI
SNRI (Serotonin and Noradrenaline Reuptake Inhibitors)
TCA
MAOI (Monoamine Oxidase Inhibitors)
NaSSA (Noradrenergic and Specific Serotonin Antidepressant)
What is the first line antidepressant category?
SSRI
Give examples of SSRIs
Citalopram
Fluoxetine
Sertraline
Escitalopram
What are SE of SSRIs
Nausea, vomiting, diarrhoea, dyspepsia
Anxiety, agitation, insomnia, tremor, headache
Sweating, sexual dysfunction
Hyponatraemia (common in ELDERLY - due to SIADH, where SSRIs stimulate vasopressin release or potentiate its action on renal tubules)
What are examples of SNRIs
Venlafaxine
Duloxetine
What are SE of SNRI
Same a SSRI \+ constipation HTN, raised cholesterol Dry mouth Dizziness, drowsinesss
What are examples of TCAs?
Amiltryptiline
Clomipramine
Why are TCAs hardly ever given?
Cardiotoxicity, so even small ODs can be fatal
Give an example of a MAOI
Phenelzine
What is a dangerous MAOI side effect?
Hypertensive crisis - CHEESE REACTION
Eating tyramine rich food e.g. cheese, pickles, wine
causes NA to build up (as tyramine is converted to NA), leading to hypertensive crisis
What is an example of an NaSSA
Mirtazapine
What is a benefit of Mirtazapine
Sexual dysfunction uncommon
What are concerns with prescribing antidepressants?
Discontinuation syndrome
Serotonin syndrome
What occurs with discontinuation syndrome?
Flu-like symptoms, vivid dreams, dizziness, headache
What causes serotonin syndrome ?
Caused by too much serotonin e.g. giving 2 antidepressants at once / 1 antidepressant + tramadol
What occurs with serotonin syndrome?
Restlessness Sweating Myoclonus Confusion Fits
What can you do for treatment - resistant depression?
Litium
Anti-psychotics
Tri-Iodothyronine (t3)
Combining two antidepressants
What is a manic episode?
Extreme elated mood and manic symptoms significantly impairing social functioning for >1 week OR requiring hospital admission
What is a hypomanic episode?
Persistent mood state that lasts 4 or more days but does not interfere with social functioning
What is a mixed episode?
Mixture/rapid alteration of manic and depressive symptoms over min 2 weeks
What is Type 1 BPAD?
At least one manic/mixed episode and one depressive episode
What is Type 2 BPAD?
At least one hypomanic episode and one depressive episode
What is rapid cycling BPAD?
If a person experiences >= 4 episodes of BPAD within a year
Who is rapid cycling more common in?
Women
What are core symptoms for mania?
Elevated mood, energy, enjoyment
Rapidly changing mood
Very energetic, restless, talkative
Take up new activities, make new acquaintances
What are cognitive symptoms for mania?
Elevated confidence and self esteem
Very optimistic about future
Thoughts and concentration feel clearer
BUT distractible, with poor concentration, rapid thoughts (FLIGHT OF IDEAS)
What are biological symptoms for mania?
Reduced need for sleep
Elevated appetite
Elevated libido
What are psychotic symptoms for mania?
Grandiose (or persecutory) elusions
Hallucinations
What is someone in a manic episode like in terms of risky behaviour?
Impulsive/disinhibited Overspending Gambling Driving recklessly Drug/alcohol misuse Sexually disinhibited
What are differentials for BPAD?
- ORGANIC CAUSES
Delirium dementia, frontal lobe damage, cerebral infarct
Intoxication (amphetamine, cocaine)
Myxoedema madness (thyrotoxicosis) - SCHIZOAFFECTIVE DISORDER
- EMOTIONALLY UNSTABLE PD
- ADHD
What categories of drug are used to treat BPAD?
First line are antipsychotics (try one > if not working, change to another)
Then Mood stabilisers (try lithium)
Finally valproate
What are the 4 key mood stabilisers?
LAURA LAZZARI VIOLA CENACCHI Lithium Lamotrigine Valproate Carbamazemine \+ antipsychotic e.g. olanzapine
What are SE of lithium?
Mild tremor GI upset, nausea, vomiting Hypothyroidism, hyperparathyroidism Weight gain Swollen ankes Metallic taste Teratogenicity
What is important to keep in mind when prescribing lithium?
High TERATOGENICITY (Ebsteins anomaly) Narrow therapeutic index, may be toxic
What is important to keep in mind when prescribing Valproate and carbamazepine?
They can cause Spina Bifida
What are interventions for BPAD other than medications?
CBT
Family therapy
IPSRT (interpersonal and social rhythm therapy)
ICD 10 Diagnostic criteria for Mild Depression
2 core symptoms + 2 others
ICD 10 Diagnostic criteria for Moderate Depression
2 core symptoms + 3 others
ICD 10 Diagnostic criteria for Severe Depression
2 core symptoms + min 4 othersb
What its NICE guideline tx for mild to moderate depression?
Watchful waiting (assess again 2 weeks) CBT (self help book, computerised) Brief psych intervention (CBT, counselling, problem solving therapy)
What its NICE guideline tx for moderate to severe depression?
RISK ASSESS
Antidepressant
CBT/IPT
What investigations would you carry out for depression to exclude organic cause?
Bloods
- FBC (anaemia, infection e.g. UTI)
- U&E (dehydration, monitor kidney function)
- LFT (liver metabolism for medication)
- TFT (hypothyroidism)
- Ferritin, B12 (deficiency)
- CRP (infection)
What is the appropriate first line antidepressant in a patient with strong biological symptoms of depression? (e.g. can’t sleep, can’t eat)
NaSSA e.g. Mirtazepine
as they induce sleepiness and hungwr
How long is an adequate trial of antidepressant?
6 weeks
How long do SSRIs take to start working?
3-4 weeks
How long should patients be kept at maintenance dose of their antidepressant once they feel better?
6-12 months
Then weane off gradually
How long after prescribing a first time SSRI should you review the patient, and why?
2 weeks
Because SSRI may increase anxiety/suicidal thoughts before it starts working
What are clinical features of atypical depression?
low mood extreme fatigue reverse diurnal variation in mood (better in am, worse in pm) Hypersomnia Hyperphagia Leaden paralysis Interpersonal rejection sensitivity
What is dysthymia?
Chronic low grade depressive symptoms (>2 years)
What tests must we get before initiating patient on lithium?
ECG (can cause arrhythmia)
Bloods (exclude organic cause, get baseline)
- FBC, TFT, U&E, LFT, GFR, preg test
What are side effects of lithium?
metallic taste in mouth polyuria, polydipsia Tremor Sedation Gi disturbance (nausea, diarrhoea, weight gain)
How often should lithium level be checked?
1 week after starting
monitor weekly as you uptitrate prescription level
Until therapeutic level is achieved, then every 3 months
Above what level is lithium toxic?
1.2mmol/L
What are symptoms of lithium toxicity?
GI disturbance Sluggishness Giddiness Ataxia Gross tremor, fits LONG TERM;: Renal failure, hypothyroidism
What are triggers to lithium toxicity?
Salt balance changes e.g. dehydration, D&V
Drugs interfering with lithium excretion - thiazides, NSAIDS
OD
What questionnaires can you use for depression
PHQ 9 (Patient Health QUestionnaire)
HADS (Hospital Anxiety and Depression Scale)
BDI2 (Beck Depression Inventory 2)
What is treatment resistant depression??
Depression that does not respond to min TWO different classes of antidepressants at adequate doses for period 6-8 weeks
How to you manage mild-moderate depression? BSO approach
SOCIAL:
- sleep hygiene
- information on mind.co.uk / samaritans
- Self help app on samaritans
PSYCHOLOGICAL: low intensity - individual guided self help based on CBT (written materials, supported by trained professional, 6-8 sessions) - Computerised CBT - structured group physical activity Group CBT
What is seasonal affective disorder
low mood occurring with change in season (depression in winter, remission in spring)
Presents with symptoms similar to atypical depression (hhyperphaagia, hypersomnia)
how can you manage seasonal affective disorder
Conservative:
- natural sunlight (walk outside, exercise)
- light box phototherapy, for 30 mins each day
- dawn simulating alarm clock
Medical
- antidepressant
What are delusions that occur in mania
mood congruent
- grandiose delusions
- persecutory delusions
what is thought disorder. occurring in mania
- pressure of speech
- flight of ideaas
what is the approach to managing a patient presenting with first episode mania / BPAD?
- Stop any medication that could be interfeering / worsening symptoms e.g. antidepreessants
- Start second gen antipsychotic
- If antipsychotic ineffective > alternative antipsychotic > max dose
- Change to lithium
- Change to valproate
What medication can you give in adjunct to BPAD tx if patient is agitated
short term benzo
what else can you consider for resistant mania / BPAD
ECT
What medication must you change BPAD patients to for the long term
LITHIUM
When should you start lithium in BPAD
about 4 weeks after acute manic episode
When must you measure bloods in patient on lithium
Before starting
5 days after starting OR five days after change in dose
Weekly until dose settled
Then once every three monthly
what time of the day must you measure lithium blood
12h after dose, so usually in the morning
How can you treat severe depression in bipolar
Fluoxetine + Olanzapine
How does CBT work in depression
It identifies negative beliefs (worthlessness, hopelessness, helplessness)
Challenges these negative beliefs
Therapist helps the person identify more realistic beliefs about themselves
Also increases exposure of the patient to positive stimulating activities
How do you manage moderate-severe depression
BioPsychoSocil
- Social: same as mild
- Psych: HIGH INTENSITY PRYCH INTERVENTIONS (individual CBT or interpersonal therapy)
- Bio: Antidepressants
How does interpersonal therapy work for depression
helps identify how interactions with others affect the patient’s mood, and ways of improving those interactions
How do you manage complex and severe depression
Crisis resolution team Home treatment team Develop a crisis plan COnsider inpatient treatment if severe risk Consider ECT for acute treatment
What is the SSRI of choice for adolescents?
fluoxetine
what is the risk of SSRI effect on the stomach
gastric bleed esp with NSAID
if taken with NSAID; prescribe gastroprotectant
How do you manage social aspect for BPAD
Famaily support and therapy
Aid returning to work
How do you manage psych. tx for BPAD
CBT: helps patients to test out thei excessively positive thoughts to gain perspective
- identify replapse indicators
- develop relapse prevention strategies
Psychodynamic psychotherapy (once mood is stabilised)
When do you need to refer BPAD/manic patient in primary care?
Hypomania > routine referral to CMHT
Mania/severe depression> URGENT referral to the community mental health team
