Affective Disorders (Depression/bipolar) Flashcards
A 46-year-old man presents to the Emergency Department with abdominal pain, diarrhoea and vomiting. He feels weak and reports a new-onset tremor. He has just come back from a cruise in the Caribbean. His only past medical history is bipolar disorder, for which he takes lithium and newly diagnosed hypertension, for which his GP has recently started him on ramipril.
What intervention should form the basis of your treatment?
A. Intravenous fluids
B. Oral doxycycline
C. Chelation therapy
D. Oral azithromycin
E. Intravenous lorazepam
A. Intravenous fluids
This patient is showing signs of lithium toxicity, for which intravenous fluids is the mainstay of treatment.
Common causes of lithium toxicity include dehydration, alcohol intake and angiotensin-converting enzyme inhibitors (ACE-i) such as ramipril as they reduce glomerular filtration rate (GFR) and enhance the tubular reabsorption of lithium (thus increasing plasma concentrations of lithium). In addition, the patient has recently been through a time zone change and therefore may have taken his medications at different times to his usual; therefore, one should be alert to the possibility of lithium toxicity
Not C: Chelation therapy
Chelation is a treatment for heavy metal poisoning, for example, with lead or mercury. It is not used in the treatment of lithium toxicity, and there is no evidence that this patient has come into contact with any heavy metals
common causes of lithium toxicity:
Common causes of lithium toxicity include dehydration, alcohol intake and angiotensin-converting enzyme inhibitors (ACE-i) such as ramipril as they reduce glomerular filtration rate (GFR) and enhance the tubular reabsorption of lithium (thus increasing plasma concentrations of lithium).
clinical features of lithium toxicity (mnemonic):
LITHIUM GAIN to remember the side effects and complications:
* Lethargy/drowsiness
* Insipidus (diabetes): polyria/polydipsia (increased thirst)
* Tremor (course)
* Hypothyroidism
* Insides (gastrointestinal)
* Urine (increased)
* Metallic taste/dry mouth
* Gain weight
- CNS disturbance including seizures, impaired co-ordination, dysarthria
- Arrhythmias
- Visual disturbance
management of lithium toxicity:
The management of lithium toxicity is largely supportive and requires specialist input.
- Maintaining electrolyte balance, monitoring renal function and seizure control are the main aims.
- IV fluid therapy and alkalisation of the urine are beneficial and enhance excretion of the drug. Benzodiazepines may be used to treat agitation and seizures in lithium toxicity.
- Haemodialysis can be required if the renal function is poor.
DSM-5 diagnostic criteria for depression:
Depression (SIGECAPS): >5/8 over 2 weeks for DSM-5 (including either low mood/anhedonia)
(vs In ICD-11, depression is defined as the presence of depressed mood (or irritable most of the day eg appears tearful) or diminished interest in activities occurring most of the day, nearly every day, for at least 2 weeks)
- Sleep: insomnia or hypersomnia
- Interest: reduced, with loss of pleasure (anhedonia)
- Guilt/worhlessness: often unrealistic
- Energy: mental and physical fatigue
- Concentration: distractibility, memory disturbance, indecisiveness
- Appetite: decreased or increased (or significant weight change 5%_
- Psychomotor: retardation or agitation
- Suicide: thoughts, plans, behaviours.
RFs for depression:
- Female gender
- Past history of depression
- Significant physical illness
- Other mental health problems
- Social issues (divorce, unemployment, poverty)
organic causes of depression:
e.g. thyroid function tests, full blood count, metabolic panel and brain imaging).
- Neurological disease such as Parkinson’s disease, dementia and multiple sclerosis
- Endocrine disorder, particularly thyroid dysfunction and hypo/hyperadrenalism (e.g. Cushing’s and Addison’s disease)
- Drugs (e.g. steroids, isotretinoin (roaccutane), alcohol, beta-blockers, benzodiazepines and methyldopa
- Chronic conditions such as diabetes and obstructive sleep apnoea. Additionally, long standing infections such as mononucleosis
- Neoplasms and cancers - pancreatic cancer is a notable example. However, low mood can theoretically be a presenting complaint in any cancer. It may be as a result of pro-inflammatory cytokines and immune system modulation.
psychiatric differentials for depression:
Bipolar disorder
Schizophrenia
Dementia
Seasonal affective disorder
Bereavement
Anxiety
depression in children presentation and management
presentation may be atypical eg irritability, temper tantrums, mood lability and low frustration tolerance, somatic symptoms (eg abdominal pain), and withdrawn behavior.
- depression can be managed with watchful waiting and advice about healthy habits
-The Severity Measure for Depression—Child Age 11–17 (adapted from PHQ-9 modified for Adolescents [PHQ-A]
-Consider referral to CAMHS for children with moderate to severe depression. Treatment options include:
1. Full assessment
2. Psychological therapy (first line)
3. Fluoxetine (first line antidepressant in children; followed by Sertraline and Citalopram)
4. Admission may be required if there is high risk of self harm, suicide or self-neglect
mania definition & features (mnemonic( :
The DSM defines mania as a “distinct period of abnormally and persistently elevated, expansive, or irritable mood.” The episode must last at least a week. The mood must have at least three of the following symptoms: (mnemonic, DIGFAST):
D - Distractibility.
I - Indiscretion (impaired judgement)
G - Grandiosity/elevated self-esteem
F - Flight of ideas.
A - Activity increased/increased interest in goals
S - Sleep decreased.
T - Talkativeness.
-Psychomotor agitation (pacing, hand wringing etc.)
-Increased pursuit of activities with a high risk of danger
hypomania definition:
“the episode (should not be) severe enough to cause marked impairment in social or occupational functioning, or to necessitate hospitalisation, and there are no psychotic features”
treatment for acute mania with/without agitation/acute depression
Acute mania with agitation: patients will typically require IM therapy, either a neuroleptic or a benzodiazepine. They may need urgent admission to a secure unit.
Acute mania without agitation: oral monotherapy can be attempted with an antipsychotic. Sedation and a mood stabilizer such as lithium can be added if necessary.
Acute depression: mood stabilizer and/or atypical antipsychotic and/or antidepressant with appropriate psychosocial support.
ECT (electroconvulsive therapy) contraindications
What forms part of the long-term management of a bipolar patient with multiple suicide attempts?
Comprehensive psychosocial assessment of needs & risks (eg identify dynamic risk factors which can be modified & managed)
A 33-year-old, 60kg woman is being treated in the coronary care unit following an acute coronary syndrome. She has a past medical history of bipolar affective disorder and takes lithium 1000mg every night. After being stable for the first few days of her admission, the cardiology team decide to start her on ramipril 5mg. The following week, she is found to be very confused on the ward round. It was noted that she had vomited several times and suffered a 4 minute self-terminating seizure overnight. On examination, she has a coarse tremor and is ataxic. She is oliguric, having only passed 100ml of urine in the last 24 hours. Her serum lithium level is 7.5mmol/L.
What is the most appropriate treatment for her presentation?
A. Discharge the patient and arrange follow up for serum lithium levels
B. Haemodialysis
C. Glyceryl trinitrate
D. Sodium bicarbonate
E. Fluid resuscitation
B. Haemodialysis
Ramipril is an ACE Inhibitor which increases serum lithium level. This patient is displaying symptoms of severe lithium toxicity after starting ramipril. These include CNS disturbances (confusion, poor coordination, seizure, ataxia, tremor), GI disturbances (vomiting) and kidney injury (oliguria.) UpToDate and many other guidelines recommend dialysis for asymptomatic patients if the lithium is >4mmol/L, or >2.5mmol/L with renal dysfunction, or otherwise on a case by case basis depending on presence of symptoms.
Not D: Sodium bicarbonate
Sodium bicarbonate alkalinizes urine, promoting lithium excretion. However, it is not routinely recommended due to risk of hypokalemia and fluid overload. Moreover, the patient has only produced 100ml of urine in 24 hours. She is oligouric and possibly has an acute kidney injury. Her renal function is poor and she will struggle to eliminate lithium through her kidneys. She has also developed severe signs of neurotoxicity, and given the extreme levels of her blood lithium, dialysis would be indicated.
Not E: Fluid resuscitation
The mainstay of treatment for lithium toxicity is IV fluid therapy. This helps to enhance lithium clearance. However, as the patient has only produced 100ml of urine in 24 hours, she is oliguric and possibly has an acute kidney injury. Her renal function is poor and she will struggle to eliminate lithium through her kidneys. She has also developed severe signs of neurotoxicity, and given the extreme levels of her blood lithium, dialysis would be indicated.
Oliguria is defined as urinary output less than 400 ml per day or less than 20 ml per hour and is one of the earliest signs of impaired renal function.
Normal urine output: 800-2000ml/day (with a normal fluid intake of about 2 liters per day)
