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Stage 3 Case 2 > Affective disorders care > Flashcards

Affective disorders care Flashcards

1
Q

Depression is characterised by:

A
  • persistent low mood and/or
  • loss of pleasure in most activities and
  • a range of associated emotional, cognitive, physical, and behavioural symptoms.
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2
Q

Consider asking the person about the two ‘core’ symptoms of depression. Ask:

A
  • During the last month have you often been bothered by feeling down, depressed, or hopeless?
  • Do you have little interest or pleasure in doing things?
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3
Q

Why use Depression questionnaires?

A

Can be helpful in detecting depression and in assessing severity, but should not be used alone to determine the presence of depression which needs treatment.

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4
Q

The three recommended questionnaires, which are validated for use in primary care,

A
  • PHQ-9 (Patient Health Questionnaire 9),
  • HADS (Hospital Anxiety and Depression Scale), and
  • BDI-II (Back Depression Inventory-II).
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5
Q

How is depression diagnosed?

A

Depression is diagnosed according to the DSM-5 classification by the presence of at least five out of a possible nine defining symptoms, present for at least 2 weeks, of sufficient severity to cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.

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6
Q

Subthreshold depression

A

At least 2 but less than 5 symptoms of depression

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7
Q

Mild depression

A

In excess of 5 symptoms and minor functional impairment

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8
Q

Moderate depression

A

Symptoms or functional impairment are between mild and severe

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9
Q

Severe depression

A

Most symptoms and marked impact on functioning

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10
Q

Persistent subthreshold depressive symptoms

A

Subthreshold symptoms for more days than not for at least 2 years, which is not the consequence of a partially resolved ‘major’ depression

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11
Q

Seasonal affective disorder (SAD)

A

Episodes of depression that recur annually at the same time each year with remission in between

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12
Q

Depression: Complications (3)

A
  • Exacerbation of the pain, disability, and distress associated with a range of physical diseases.
  • Reduced quality of life for the person and their families.
  • Increased morbidity and mortality.
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13
Q

Depression: Risks

People with depression should be assessed and managed for (4)

A
  • The risk of suicide.
  • Any factors which may affect the development, course and severity of depression.
  • Any safeguarding concerns for children or vulnerable adults in their care.
  • Comorbid conditions associated with depression.
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14
Q

9 questions from DSM-V for depression diagnosis

A
  1. Depressed mood most of the day
  2. Diminesh interest or pleasure in all or most activities
  3. Significant unintentional weight loss or gain
  4. Insominai or too much sleeping
  5. Agitation or psychomotor retardation noticed by others
  6. Fatigue or loss of energy
  7. Fellings of worthlessness or excessive guilt
  8. Diminshed ability to think or concentrate, or indecisiveness
  9. Recurrent thought of death.
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15
Q

Comorbidities that may be the underlying cause of depression (5)

A 
alcohol/substance misuse
 anxiety
 psychotic symptoms
 eating disorder
 dementia
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16
Q

Mild-to-moderate depression management

A
  1. Offer low-intensity psychosocial interventions (such as individual guided self-help, computerized cognitive behavioural therapy (CCBT) or a structured group-based physical activity programme).
  2. Antidepressants should not be used routinely, but may be used for people with a history of depression, persistent subthreshold symptoms, or a concomitant chronic physical health problem.
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17
Q

Moderate or severe depression

A
  1. Offer a combination of an antidepressant and a high-intensity psychological intervention (such as individual CBT, interpersonal therapy, behavioural activation, or couples therapy).
  2. For a first episode of depression, a generic selective serotonin reuptake inhibitor such as citalopram, fluoxetine, paroxetine, or sertraline should be offered.
  3. For a recurrent episode, an antidepressant that has previously elicited a good response should be offered
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18
Q

Considerations for those starting an antidepressant

A
  • Consider suicide risk and toxicity in overdose.
  • Explain that symptoms of anxiety may initially worsen.
  • Explain that antidepressants take time to work.
  • Explain that antidepressants should be continued for at least 6 months following remission of symptoms, as this greatly reduces the risk of relapse
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19
Q

Arrange follow up to discuss 4 things

A
  • response to treatment
  • need for further management
  • adverse effects
  • compliance issues
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20
Q

What should be done if the person needs to go into hospital?

A

Every attempt to make then go voluntarily

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21
Q

Necessary admission but the person declines.

A

Compulsory admission may be arranged under sections of the Mental Health Act.

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22
Q

6 things to consider when deciding an antidepressant

A
  • The person’s preference.
  • Toxicity in overdose
  • The adverse effect profile — for example, sedation, sexual adverse effects, weight gain.
  • Any associated psychiatric disorder or concurrent medical illness or condition.
  • Potential for drug interactions
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23
Q

In the 1st episode of depression, consider:

A

generic selective serotonin reuptake inhibitor (SSRI), such as citalopram, fluoxetine, paroxetine, or sertraline.

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24
Q

In recurrent episode of depression, consider:

A
  • antidepressant that the person has had a good response to previously.
  • avoiding antidepressants that the person has previously failed to respond to or could not tolerate.
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25
Q

If the person has a chronic physical health problem:

A
  • Sertraline may be preferred, because it has a lower risk of drug interactions.
  • If an SSRI is prescribed, consider gastroprotection in older people who are taking nonsteroidal anti-inflammatory drugs (NSAIDs) or aspirin.
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26
Q

Give advice about guided self-help groups, support groups and other local and national resources. Guided self-help may include:

A
  • Self-help leaflets or books, using cognitive behavioural therapy principles.
  • Self-help computer programmes or the internet.
  • Exercise sessions (three each week for up to 1 hour), for 10–12 weeks.
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27
Q

How long does it usually take for symptoms to improve?

A

2-4 weeks

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28
Q

How long should the antidepressant be continued to prevent relapse?

A

6 months, may require longer if higher risk.

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29
Q

Are antidepressants addictive?

A

No, but discontinuation symptoms experienced in one third of people.

30
Q

What can happen is if they stop taking antidepressants abruptly, miss doses, or do not take the full dose?

A

Discontinuation symptoms

31
Q

Discontinuation symptoms

A

restlessness, problems sleeping, unsteadiness, sweating, abdominal symptoms, altered sensations (for example electric shock sensations in the head), or altered feelings (irritability, anxiety, confusion).

32
Q

How can come antidepressants affect driving?

A

Potentially have sedating effects, and may affect the person’s ability to drive. Most affect during 1st month

33
Q

What can you not use during antidepressants?

A

St John’s wort

34
Q

Frequent, regular review should be arranged for all people with depression to assess:

A

-Suicide risk.
-Safeguarding concerns.
-Response to treatment.
Adherence to treatment and adverse effects.

35
Q

For people not considered to be at an increased risk of suicide (depression review)

A
  • Arrange an initial review within 2 weeks.
  • Review regularly thereafter — for example, every 2–4 weeks for the first 3 months and if the response to treatment is good, longer review intervals can be considered.
36
Q

For people at an increased risk of suicide, or people aged under 30 years (depression review)

A
  • Arrange an initial review within 1 week.

- Review frequently thereafter until the risk is no longer considered clinically important.

37
Q

Bipolar disorder

A

A serious long-term mental illness, which is usually characterized by episodic depressed and elated moods, and increased activity (hypomania or mania).

38
Q

The most important complications of bipolar disorder

A

Suicide and deliberate self-harm

39
Q

Consequences of acute episodes of bipolar

A
  • Financial difficulties from overspending.
  • Traumatic injuries and accidents.
  • Sexually transmitted infections and unplanned pregnancy from disinhibition and increased libido.
  • Damage to reputation, income and occupation, and relationships.
  • Self-neglect, exhaustion, and dehydration.
  • Exploitation by others.
  • Alcohol and substance misuse.
  • Harm to others.
40
Q

If a person has suspected bipolar disorder

A

Should be referred for specialist mental health assessment, management, and follow-up. A risk assessment should be done to determine the urgency of referral.

41
Q

During the acute phase, people who have been newly diagnosed with bipolar disorder may be offered the following drug treatments:

A

A therapeutic trial of an oral antipsychotic (haloperidol, olanzapine, quetiapine, or risperidone).

42
Q

If the first antipsychotic is not tolerated or not effective, (bipolar)

A

a second antipsychotic (from one of the four antipsychotics listed above) is usually offered.

43
Q

If a second-line antipsychotic is not effective, (bipolar)

A

lithium may be added, or if this is not suitable, sodium valproate may be added instead (unless the person is a pre-menopausal female).
Antidepressant medication is usually tapered and discontinued if the person develops mania while taking an antidepressant.

44
Q

For the treatment of depression options include:

A

Quetiapine alone, or
Fluoxetine combined with olanzapine, or
Olanzapine alone, or
Lamotrigine alone.

45
Q

Four weeks after the acute episode has resolved, the secondary care team will usually discuss the long-term management plan.
To prevent relapses, the person is usually offered a choice to:

A

Continue their current treatment for mania, or
Start long-term treatment with lithium to prevent relapses, or
If lithium is not effective, valproate may be added to lithium treatment.
If lithium is poorly tolerated, valproate alone or olanzapine alone may be considered.

46
Q

Psychological therapies may also be offered:

A

People with bipolar depression may be offered a psychological intervention that has been specially developed for bipolar depression.
Alternatively, a high-intensity psychological intervention used to treat depression (for example cognitive behavioural therapy) may be offered.

47
Q

Secondary care will usually:

A
  1. Monitor the person’s physical health, mental health, and the effects of antipsychotic drug treatment for at least the first 12 months, or until the person’s condition has stabilized.
  2. Encourage the person to make a lasting power of attorney
  3. Write a care plan with the person and/or their carer (with a copy sent to the primary care team) that defines the roles of primary and secondary care (see below).
48
Q

Why get patient to make a lasting power of attorney (bipolar)

A

So that a trusted person or an advocate can express the person’s point of view as expressed in the advanced statement or statement of wishes and feelings, especially if there are financial consequences resulting from mania or hypomania episodes.

49
Q

People with bipolar disorder whose symptoms have responded effectively and remained stable following secondary care treatment may be offered the option to return to primary care for ongoing management. In this event, a care plan should have been received by the primary care physician that includes: (7)

A
  1. Clear, individualised social and emotional recovery goals.
  2. An assessment of the person’s mental state.
  3. A crisis plan
  4. A medication plan with a date for review by primary care, medication in the event of a relapse.
  5. An advance statement
  6. A statement of wishes and feelings
  7. Key clinical contacts in case of emergency or impending crisis.
50
Q

What does a crisis plan indicate? (bipolar)

A

Indicating early warning symptoms and triggers of both mania and depression relapse and preferred response during relapse, including liaison and referral pathways.

51
Q

What should a medication plan indicate?(bipolar)

A

frequency and nature of monitoring for effectiveness and adverse effects, and what should happen with

52
Q

What is an advance statement? (bipolar)

A

a written statement, drawn up and signed when the person is well, which sets out if there are treatments that the person does not wish to receive if they lose their capacity to make decisions for themselves through illness.

53
Q

A statement of wishes and feelings

A

as to how they would prefer to be treated (or not treated) if they were to become ill in the future, who would be told about the illness or anything else of importance such as financial affairs, care of pets or at-risk relatives (but this is not binding with respect to children).

54
Q

Pharmaceutical considerations:

Lithium

A
  1. Always prescribe lithium by brand name as preparations vary widely in bioavailability.
  2. Initial adverse effects of lithium therapy include nausea, diarrhoea, vertigo, muscle weakness, and a ‘dazed’ feeling. These effects often resolve with continued therapy. Fine hand tremors, polyuria, and polydipsia may persist.
55
Q

Longer-term adverse effects include: Lithium

A 
Hypothyroidism 
 Hyperthyroidism 
 Hyperparathyroidism 
 Nephrotoxicity 
 Renal tumours 
 Rhabdomyolysis
56
Q

Because of lithium’s narrow therapeutic index, interactions with other drugs can be very important. The most commonly encountered interactions are with:

A 
Diuretics 
 Nonsteroidal anti-inflammatory drugs (NSAIDs) 
 Haloperidol 
 Carbamazepine 
 Antidepressants
 ACE inhibitors 
 Drugs that prolong the QT-interval 
 Drugs that cause hypokalaemia
57
Q

Lithium levels monitoring

A

1.Lithium levels are normally measured one week after starting treatment.
2.One week after every dose change, and weekly until the levels are stable.
3.Once levels are stable, levels are usually measured every 3 months.
Lithium levels should be measured 12 hours post-dose.

58
Q

When should lithium level be measured?

A

Lithium levels should be measured 12 hours post-dose.

59
Q

Why is valproate not good for children of child bearing age?

A

Valproate is a teratogen and can cause physical birth defects and developmental disorders in children exposed in utero.

60
Q

Valproate metabolism (increased levels)

A

Valproate is highly protein-bound (up to 94%), is metabolized by the liver, so drugs that inhibit CYP450 enzymes (for example erythromycin, fluoxetine, and cimetidine) can increase valproate levels.

61
Q

Valproate can increase the plasma levels of some drugs…

A

Valproate can increase the plasma levels of some drugs, possibly by inhibition of their metabolism (for example tricyclic antidepressants, particularly clomipramine).

62
Q

When should Valproate not be prescribed?

A

Not be prescribed to female children, female adolescents, women of childbearing potential, or pregnant women to treat bipolar disorder unless the illness is very severe and there is no effective alternative option. (MHRA)

63
Q

Blood disorders symptoms

A

any unexplained bleeding, bruising, purpura, sore throat, fever, or malaise that occurs during treatment

64
Q

Before starting valproate treatment (4)

A
  1. A full blood count, baseline liver function tests (LFTs), and body weight or body mass index (BMI) are usually measured.
    Advise the person and their carers how to recognize the signs and symptoms of:
    2.Blood disorders
    3.Liver disorders
    4.Pancreatitis
    Inform them that they should seek immediate medical help if these develop.
65
Q

Liver disorders symptoms

A

sudden onset of weakness, malaise, anorexia, lethargy, oedema, and drowsiness [which are sometimes associated with repeated vomiting and abdominal pain], and jaundice

66
Q

Pancreatitis symptoms

A

abdominal pain, nausea, and vomiting

67
Q

Antipsychotics

A

Antipsychotics can cause a wide range of adverse effects. The risk varies with the type of antipsychotic (first-generation or second-generation) and the individual drug.

68
Q

The following interactions are common to all antipsychotics: Drugs with a sedative action

A

Drugs with a sedative action (such as alcohol, analgesics, tricyclic antidepressants, and sedating antihistamines) will enhance the sedative effects of antipsychotics.

69
Q

The following interactions are common to all antipsychotics: Drugs with a hypotensive effect

A

Drugs with a hypotensive effect (for example antihypertensives) will enhance the hypotensive effect of antipsychotics.

70
Q

The following interactions are common to all antipsychotics: Diuretics

A

Diuretics may cause hypokalaemia, which may increase the risk of arrhythmias; monitor potassium levels in people taking diuretics.

71
Q

The following interactions are common to all antipsychotics: Others

A

Drugs that prolong the QT interval Azole antifungals
Carbamazepine.
Grapefruit juice
Selective serotonin reuptake inhibitors (SSRIs)
Stopping smoking

72
Q

What should happen in female of childbearing age is on valproate?

A

Females of childbearing potential taking valproate should be enrolled in a pregnancy prevention plan.
Or gradually stop

Stage 3 Case 2 (7 decks)

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