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Affective Disorders Flashcards

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1
Q

What are risk factors for affective disorders?

A 
Childhood adversity/abuse
Adulthood vulnerability: 
- unemployment 
- lack of relationships
- low socioeconomic status
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2
Q

What can precipitate depression?

A

A stressful life event

- loss event (e.g. loss of role, of autonomy)

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3
Q

What is beck’s model of depression (negative cognitive triad)?

A

World - Future - Self

Negative thoughts in this lead to:
Helpless. - hopeless - worthless/guilt

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4
Q

What are the core symptoms of depression?

A
  1. Low mood >2 weeks
  2. Anhedonia
  3. Anergia
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5
Q

What are cognitive sx of depression?

A

worthlessnesss
guilt
helplessness
hopelessness

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6
Q

What are biological sx of depression?

A
  • Poor sleep (insomnia, waking up early)
  • Low appetite, weight loss
  • Reduced libido
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7
Q

What are psychotic symptoms of depression?

A

hallucinations, delusions

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8
Q

What are the categories of symptoms we must ask about in depression?

A

Can Claudio Be Pussy-whipped

Core

Cognitive

Behavioural

Psychotic

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9
Q

What are organic differentials for depression?

A 
HAEM - ENDO - NEURO
Deficiencies: anaemia, B12, Vit D 
- Hypothyroidism 
-  Hyperparacalcaemia
- Addison's disease Cushing's 
- Dementia, parkinsons, hypoactive delirium 
- Substance misuse
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10
Q

What are psych differentials. for depression?

A
  • Bereavement
  • Adjustment disorder (after a significant life event)
  • dysthymia
  • BPAD
  • schizoaffective disorder
  • recurrent depressive disorder
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11
Q

What are the 5 key categories of anti-depressants?

A

SSRI
SNRI (Serotonin and Noradrenaline Reuptake Inhibitors)
TCA
MAOI (Monoamine Oxidase Inhibitors)
NaSSA (Noradrenergic and Specific Serotonin Antidepressant)

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12
Q

What is the first line antidepressant category?

A

SSRI

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13
Q

Give examples of SSRIs

A

Citalopram
Fluoxetine
Sertraline
Escitalopram

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14
Q

What are SE of SSRIs

A

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)

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15
Q

What are examples of SNRIs

A

Venlafaxine

Duloxetine

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16
Q

What are SE of SNRI

A 
Same a SSRI 
\+ constipation
HTN, raised cholesterol 
Dry mouth 
Dizziness, drowsinesss
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17
Q

What are examples of TCAs?

A

Amiltryptiline

Clomipramine

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18
Q

Why are TCAs hardly ever given?

A

Cardiotoxicity, so even small ODs can be fatal

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19
Q

Give an example of a MAOI

A

Phenelzine

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20
Q

What is a dangerous MAOI side effect?

A

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

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21
Q

What is an example of an NaSSA

A

Mirtazapine

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22
Q

What is a benefit of Mirtazapine

A

Sexual dysfunction uncommon

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23
Q

What are concerns with prescribing antidepressants?

A

Discontinuation syndrome

Serotonin syndrome

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24
Q

What occurs with discontinuation syndrome?

A

Flu-like symptoms, vivid dreams, dizziness, headache

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25
Q

What causes serotonin syndrome ?

A

Caused by too much serotonin e.g. giving 2 antidepressants at once / 1 antidepressant + tramadol

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26
Q

What occurs with serotonin syndrome?

A 
Restlessness 
Sweating 
Myoclonus 
Confusion 
Fits
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27
Q

What can you do for treatment - resistant depression?

A

Litium
Anti-psychotics
Tri-Iodothyronine (t3)
Combining two antidepressants

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28
Q

What is a manic episode?

A

Extreme elated mood and manic symptoms significantly impairing social functioning for >1 week OR requiring hospital admission

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29
Q

What is a hypomanic episode?

A

Persistent mood state that lasts 4 or more days but does not interfere with social functioning

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30
Q

What is a mixed episode?

A

Mixture/rapid alteration of manic and depressive symptoms over min 2 weeks

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31
Q

What is Type 1 BPAD?

A

At least one manic/mixed episode and one depressive episode

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32
Q

What is Type 2 BPAD?

A

At least one hypomanic episode and one depressive episode

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33
Q

What is rapid cycling BPAD?

A

If a person experiences >= 4 episodes of BPAD within a year

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34
Q

Who is rapid cycling more common in?

A

Women

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35
Q

What are core symptoms for mania?

A

Elevated mood, energy, enjoyment
Rapidly changing mood
Very energetic, restless, talkative
Take up new activities, make new acquaintances

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36
Q

What are cognitive symptoms for mania?

A

Elevated confidence and self esteem
Very optimistic about future
Thoughts and concentration feel clearer
BUT distractible, with poor concentration, rapid thoughts (FLIGHT OF IDEAS)

37
Q

What are biological symptoms for mania?

A

Reduced need for sleep
Elevated appetite
Elevated libido

38
Q

What are psychotic symptoms for mania?

A

Grandiose (or persecutory) elusions

Hallucinations

39
Q

What is someone in a manic episode like in terms of risky behaviour?

A 
Impulsive/disinhibited
Overspending 
Gambling 
Driving recklessly 
Drug/alcohol misuse 
Sexually disinhibited
40
Q

What are differentials for BPAD?

A
  • ORGANIC CAUSES
    Delirium dementia, frontal lobe damage, cerebral infarct
    Intoxication (amphetamine, cocaine)
    Myxoedema madness (thyrotoxicosis)
  • SCHIZOAFFECTIVE DISORDER
  • EMOTIONALLY UNSTABLE PD
  • ADHD
41
Q

What categories of drug are used to treat BPAD?

A

First line are antipsychotics (try one > if not working, change to another)

Then Mood stabilisers (try lithium)

Finally valproate

42
Q

What are the 4 key mood stabilisers?

A 
LAURA LAZZARI VIOLA CENACCHI
Lithium 
Lamotrigine 
Valproate 
Carbamazemine
\+ antipsychotic e.g. olanzapine
43
Q

What are SE of lithium?

A 
Mild tremor 
GI upset, nausea, vomiting 
Hypothyroidism, hyperparathyroidism 
Weight gain 
Swollen ankes 
Metallic taste 
Teratogenicity
44
Q

What is important to keep in mind when prescribing lithium?

A 
High TERATOGENICITY (Ebsteins anomaly)
Narrow therapeutic index, may be toxic
45
Q

What is important to keep in mind when prescribing Valproate and carbamazepine?

A

They can cause Spina Bifida

46
Q

What are interventions for BPAD other than medications?

A

CBT
Family therapy
IPSRT (interpersonal and social rhythm therapy)

47
Q

ICD 10 Diagnostic criteria for Mild Depression

A

2 core symptoms + 2 others

48
Q

ICD 10 Diagnostic criteria for Moderate Depression

A

2 core symptoms + 3 others

49
Q

ICD 10 Diagnostic criteria for Severe Depression

A

2 core symptoms + min 4 othersb

50
Q

What its NICE guideline tx for mild to moderate depression?

A 
Watchful waiting (assess again 2 weeks) 
CBT (self help book, computerised)
Brief psych intervention (CBT,  counselling, problem solving therapy)
51
Q

What its NICE guideline tx for moderate to severe depression?

A

RISK ASSESS
Antidepressant
CBT/IPT

52
Q

What investigations would you carry out for depression to exclude organic cause?

A

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)
53
Q

What is the appropriate first line antidepressant in a patient with strong biological symptoms of depression? (e.g. can’t sleep, can’t eat)

A

NaSSA e.g. Mirtazepine

as they induce sleepiness and hungwr

54
Q

How long is an adequate trial of antidepressant?

A

6 weeks

55
Q

How long do SSRIs take to start working?

A

3-4 weeks

56
Q

How long should patients be kept at maintenance dose of their antidepressant once they feel better?

A

6-12 months

Then weane off gradually

57
Q

How long after prescribing a first time SSRI should you review the patient, and why?

A

2 weeks

Because SSRI may increase anxiety/suicidal thoughts before it starts working

58
Q

What are clinical features of atypical depression?

A 
low mood 
extreme fatigue 
reverse diurnal variation in mood (better in am, worse in pm) 
Hypersomnia 
Hyperphagia 
Leaden paralysis
Interpersonal rejection sensitivity
59
Q

What is dysthymia?

A

Chronic low grade depressive symptoms (>2 years)

60
Q

What tests must we get before initiating patient on lithium?

A

ECG (can cause arrhythmia)
Bloods (exclude organic cause, get baseline)
- FBC, TFT, U&E, LFT, GFR, preg test

61
Q

What are side effects of lithium?

A 
metallic taste in mouth 
polyuria, polydipsia 
Tremor
Sedation 
Gi disturbance (nausea, diarrhoea, weight gain)
62
Q

How often should lithium level be checked?

A

1 week after starting
monitor weekly as you uptitrate prescription level
Until therapeutic level is achieved, then every 3 months

63
Q

Above what level is lithium toxic?

A

1.2mmol/L

64
Q

What are symptoms of lithium toxicity?

A 
GI disturbance 
Sluggishness 
Giddiness 
Ataxia
Gross tremor, fits
LONG TERM;: Renal failure, hypothyroidism
65
Q

What are triggers to lithium toxicity?

A

Salt balance changes e.g. dehydration, D&V
Drugs interfering with lithium excretion - thiazides, NSAIDS
OD

66
Q

What questionnaires can you use for depression

A

PHQ 9 (Patient Health QUestionnaire)
HADS (Hospital Anxiety and Depression Scale)
BDI2 (Beck Depression Inventory 2)

67
Q

What is treatment resistant depression??

A

Depression that does not respond to min TWO different classes of antidepressants at adequate doses for period 6-8 weeks

68
Q

How to you manage mild-moderate depression? BSO approach

A

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
69
Q

What is seasonal affective disorder

A

low mood occurring with change in season (depression in winter, remission in spring)

Presents with symptoms similar to atypical depression (hhyperphaagia, hypersomnia)

70
Q

how can you manage seasonal affective disorder

A

Conservative:

  • natural sunlight (walk outside, exercise)
  • light box phototherapy, for 30 mins each day
  • dawn simulating alarm clock

Medical
- antidepressant

71
Q

What are delusions that occur in mania

A

mood congruent

  • grandiose delusions
  • persecutory delusions
72
Q

what is thought disorder. occurring in mania

A
  • pressure of speech

- flight of ideaas

73
Q

what is the approach to managing a patient presenting with first episode mania / BPAD?

A
  1. Stop any medication that could be interfeering / worsening symptoms e.g. antidepreessants
  2. Start second gen antipsychotic
  3. If antipsychotic ineffective > alternative antipsychotic > max dose
  4. Change to lithium
  5. Change to valproate
74
Q

What medication can you give in adjunct to BPAD tx if patient is agitated

A

short term benzo

75
Q

what else can you consider for resistant mania / BPAD

A

ECT

76
Q

What medication must you change BPAD patients to for the long term

A

LITHIUM

77
Q

When should you start lithium in BPAD

A

about 4 weeks after acute manic episode

78
Q

When must you measure bloods in patient on lithium

A

Before starting
5 days after starting OR five days after change in dose
Weekly until dose settled
Then once every three monthly

79
Q

what time of the day must you measure lithium blood

A

12h after dose, so usually in the morning

80
Q

How can you treat severe depression in bipolar

A

Fluoxetine + Olanzapine

81
Q

How does CBT work in depression

A

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

82
Q

How do you manage moderate-severe depression

A

BioPsychoSocil

  • Social: same as mild
  • Psych: HIGH INTENSITY PRYCH INTERVENTIONS (individual CBT or interpersonal therapy)
  • Bio: Antidepressants
83
Q

How does interpersonal therapy work for depression

A

helps identify how interactions with others affect the patient’s mood, and ways of improving those interactions

84
Q

How do you manage complex and severe depression

A 
Crisis resolution team
Home treatment team
Develop a crisis plan 
COnsider inpatient treatment if severe risk 
Consider ECT for acute treatment
85
Q

What is the SSRI of choice for adolescents?

A

fluoxetine

86
Q

what is the risk of SSRI effect on the stomach

A

gastric bleed esp with NSAID

if taken with NSAID; prescribe gastroprotectant

87
Q

How do you manage social aspect for BPAD

A

Famaily support and therapy

Aid returning to work

88
Q

How do you manage psych. tx for BPAD

A

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)

89
Q

When do you need to refer BPAD/manic patient in primary care?

A

Hypomania > routine referral to CMHT

Mania/severe depression> URGENT referral to the community mental health team

Y5 Psych (17 decks)

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