Affective Mood Disorders Flashcards
1
Q
1 year prevalence of depression
A
5.3%
2
Q
Lifetime prevalence of depression
A
13%
3
Q
Mean age of onset of depression
A
30
4
Q
What % of primary care patients have symptoms of depression
A
30%
5
Q
core sx of depression
A
low mood
anhedonia
anergia
6
Q
list 3 categories of further depression Sx
A
biological
negative cognitions
psychotic
7
Q
list biological sx of depression
A
poor:
sleep
appetite
concentration
libido
8
Q
list negative cognitions sx of depression
A
hopelessness
helplessness
worthlessness
guilt
9
Q
list psychotic sx of depression
A
mood congruent delusions eg nilihistic
hallucinations
catatonia
10
Q
how long do symptoms have to be present for depression to be diagnosed
A
more than 2 weeks
11
Q
what is a nihilist
A
either believe their body doesn’t exist anymore or that their body is dead/dying
12
Q
define mild depression
A
2 core + 2 other
13
Q
define moderate depression
A
2 core + 3 others
14
Q
define severe depression
A
3 core + 4 others
15
Q
define immediate severe depression
A
3 core + 4 others + psychotic symptoms (delusions+/-hallucinations)
16
Q
atypical depression sx
A
increased appetitie, increased sleep, fatigue, leaden paralysis
17
Q
dysthymia sx
A
chronic low grade depression symptoms for 2+ years
18
Q
SAD sx
A
low mood related to the seasons
19
Q
tx of SAD
A
responds to light therapy
20
Q
How are the other types of depression treated first line
A
SSRIs
21
Q
what is the monoamine theory of depression
A
NA and serotonin are produced in locus coeruleus and raphe nucleus
NA and serotin descending tracts are involved in connections to stomachs / joints - can explain physical Sx
these are thought to be involved in mediating mood
22
Q
risk factors for depression
A
female 2:1
previous Hx of depression
significant physical illness - chronic / neuro esp
concurrent mental health issues - personality
Afro-Caribean, Asian, refugees/asylum seeker
poor social support system
unemployed
early maternal loss
>3 children
lack of confiding relationships
23
Q
DDx of depression
A
Medicatioms
substance misuse
psychiatric illness - bipolar, anxiety
neuro illness - dementia, PD, stroke
endocrine - hypoglycaemia, Addisons, Cushings
anaemia, menopause
24
Q
What medications cause depression
A
steroids
anti HTN - esp beta blockers
Histamine blockers
sedatives
sex hormones - oestrogen,
25
Ix for depression
Bloods: U&Es, LFTs, TFTs, CA, FBC
HIV, syphillis, tox screen
MRI head
26
how can you screen for depression in hospital
PHQ-9 (patient health questionnaire)
27
symptoms of mania
increased talkativeness/pressure speech
flight of ideas
increased self esteem / grandiosity
decreased need for sleep
distractibility
impulsive, reckless behaviour
increased sexual drive, sociability or goal directed activity
28
define bipolar affective disorder
at least 2 episodes of mood disturbance
- one of these is hypomanic/manic
29
2 types of bipolar
type 1 = mania +/- depression
type 2 = hypomania +/- depression
30
why is misdiagnosis of bipolar as depression be worrying
SSRIs is main stay of Tx of depression, but it can precipitate a manic episode in bipolar patients
31
define a manic episode
mood must be predominantly elevated, expansive or irritable, plus increased activity
>7 days (unless severe enough for hospital admission)
at least 3 of the key symptoms
32
define hypomania
>4 days
decreased degree of functional impairment compared to mania
all symptoms, just to a lesser extent
33
epidemiology of bipolar
1.5% point prevalance
15-18x higher suicide rate
34
mean age of onset
18-21
35
causes of secondary mania
organic brain damage
hyperthyroidism
36
Mx of BPAD
biological - medication
psychological - stress relief
37
risk factors for BPAD
greater incidence in the upper social classes compared to to other psychiatric illnesses - better adapted to their regular life
no difference in ethnicities or sexes
7x incidence in first degree relatives
38
what % of patients with depression as first Sx actually have bipolar
10% patients who present with depression go on to have mania within 10 years
39
what is the main psychological tx in NHS
CBT
40
what is CBT used for
lots of psychiatric disorders
41
list classifications of psychological therapy
individual
couples therapy
family therapy
group therapy
counselling
behavioural
cognitive
psychodynamic
other - CAT, IPT, MBT, DBT
42
who is DBT useful for
BPD patients
43
what is behavioural therapy
arose in 1950s based on the idea that maladaptive behaviour is learned, therefore adaptive behaviour can also be learned
44
what is operant conditioning
behaviour modified by consequence (rewards)
45
what is classical conditioning
behaviour modified by antecedent (stimulus/response)
46
what is reciprocal inhibition conditioning
counter conditioning
change a bad response to a stimulus to a good response to the same stimulus
47
what is systematic desensitisation
using hierarchy to overcome fears by replacing anxiety feelings with relaxation
start with imagining the feared stimulus then relaxing after each exposure, increasing the intensity of stimulus each time
48
what is systematic desensitisation used for
simple phobias and OCD
49
what can get in the way of habituation of anxiety
safety behaviours - escape/avoidance/resassurance
50
key features of exposure therapy
hirearchies
gradual exposure
habituation
extinction
watching out for safety behaviours
51
what is systematic desensitisation not useful for
anxiety and depression
52
who is aaron beck
founding father of CBT
53
what is the negative cognitive triad
negative view of yourself, the world and the future
54
why are TCAs not used for depression as much as they had been in the past
dangerous in overdose
55
what is the difference between CBT and behavioral therapy
CBT includes thoughts to link the event to behavioural emotion
56
what is the ABC of CBT
a = activating event
b = beliefs
c = consequences
a --> b --> c
different thoughts give rise to different emotions
57
why do people have different Bs and Cs of ABC of CBT
previous experiences
your general mood that day
58
what is formulation
rationale for patient's problems
- origin
- current status
- maintenance
59
how is formulation carried out in CBT
in COLLABORATION with patient
60
types of formulation
longitudinal
hot cross buns
61
describe longitudinal formulation
early experience --> core beliefs --> rules and assumptions --> critical incident --> create negative thoughts to emotions to sensations to mood
62
What is in a CBT session
agenda
progress and homework from last week
specific
homework for next week
63
list types of cognitive distortion
all or nothing thinking
over generalising
mental filter
disqualifying the positive
jumping to conclusions - eg mind reading
magnification (catastrophising) and minimising
64
how can we challenge the thought distortion
tools/techniques - thought record
guided discovery - socratic questioning
65
what is the use of thought record
analyse what the evidence for a thought is, what alternative thoughts are, what is the effect on me of the thought
66
list elements of CBT
developing a therapeutic relationship
empathic and collaborative
socratic questioning
time-limited
agenda setting / goals
formulation
homework
relapse prevention
67
when should CBT be used in depression
first line !!
68
when should CBT be used in anxiety
ALL anxiety disorders - social anxiety, PTSD, OCD
69
what is third wave CBT
3rd generation of CBT
target the process of thoughts rather than their content
mindfulness based
70
how can CBT be used in physical illness
adherence to Tx
illness behaviour that can maintain illness
concurrent psychiatric illness
71
what is ECT
passage of small electric current through the brain with a view to inducing a generalise fit which is therapeutic
72
which part of ECT is therapeutic
the seizure activity in brain - maybe the actual passing of current through brain too
73
indications for ECT
severe depressive illness only if life threatening situation: poor food intake, suicidal, Tx resistant
uncontrolled mania
catatonic
74
can you refuse ECT?
informal patient with capacity - can refuse
lack capacity - MHA to give up to 2 Tx
75
what is the modified ECT procedure
use anaesthetic and muscle relaxant
NBM 8 hours prior to reduce aspiration
medical monitoring prior, during and after
76
side effects of ECT
common (80%): confusion, muscle pain, headache, nausea
cognition effect: retrograde/anterograde memory loss, resolves after 6 months
rare to have long term complications
anaesthetic risks
77
What is bilateral ECT?
2 electrodes are placed over 2 hemispheres
+ effective at threshold, more efficacious, quicker
78
What % of people respond to ECT
80%
79
How long does the ECT seizure last
15 - 25 seconds
80
contraindications of ECT
Technically NO absolute contraindications as its a life saving procedure
heart disease / stroke
pace maker
raised ICP
anaesthetics contraindications
risk of cerebral bleeding - HTN/stroke
pregnant
81
what is TMS
intermediate step between treatment resistance and ECT
82
step 1 of depression tx
watch and wait
83
step 2 of depression tx
CBT +/- SSRIs
84
factors necessitating admission
self neglect
risk of suicide / self harm
risk to others
poor social support
psychotic Sx
lack of insight
Tx resistance
85
how do SSRIs work
block serotonin pump
86
when are SSRIs indicated
1st line drug Tx for depression
87
side effects of SSRIs
headache
GI disturbance
sleep disturbance / vivid dreams
sexual dysfunction
rare increased risk of suicide
88
complications of SSRIs
hyponatraemia
GI bleeding
89
examples of SSRIs
citalopram
sertraline
fluoxetine
90
how long should pt take sertraline for
6-12 months once well
2 years for those greater risk of relapse
91
when do you review someone on sertraline
after 2 weeks then regularly after
92
what drug is preferred in children for depression
fluoxetine
93
what are TCAs
serotonin and NA re-uptake inhibitors
94
side effects of TCAs
dry mouth, blurred visions, constipation, urinary retention
cardiotoxic - QT prolongation, ST elevation, AV block
anti-histaminergic - sedation, postural hypotension, weight gain
95
examples of TCAs
amytriptilyin
nortripyline
clomipramine
lofepramine
96
discontinuation Sx of TCAs
flu like Sx, headaches, dizziness, trouble sleeping, anxiety
97
what is the key problem with TCAs
lethal in overdose
98
what are MAOIs
increase availability of serotonin and NA in synapse
99
contrast older and newer MAOIs
newer are reversible, others are irreversible
100
what is the key interaction in MAOIs & what should they avoid
Tyramine reaction - cheese / dairy / smoked meats / red wine / soy sauce / high caffeine / chocolate
101
what drug is mirtazipine
NaSSA - blocks presynaptic alpha 2 adrenergic Rs
102
side effects of NaSSA
drowsiness, increased appetite, weight gain
103
what drug is venlafaxine / duloxetine
SNRI - serotonin and NA reuptake inhibitor
104
side effects of SNRI
same as SSRIs
105
risks of SNRI
HTN
106
what are NRIs
NA reuptake inhibitor
107
example of NRIs
reboxetine
108
SARI example
trazodone
109
side effects of trazodone
sedation, arrhytmia, hypotension, priapism
110
risks of agomelatine
sedation and sleep disorder
111
vortioxetine benefits
improves cognition so better in older people
112
options for refractory depression
1. check adherence / side effects / optimal dose
2. switch drug to one of same class
3. change class of drug
4. combinations ? augmentation with Lithium/antipsychotic ? ECT?
113
serotonin syndrome
altered mental state - agitation, confusion, coma
neuromuscular changes - hypotonia, tremor, clonus
autonomic dysfunction - high HR, temp, RR
114
what is serotonin syndrome
excessive serotonin in synapses of brain
115
incidence of serotonin syndrome
<1%
116
risk factors for serotonin syndrome
increased antidepressant use
combinations of antidepressants
overdose of antidepressants
lithium use
ECT
opiates, anti emetics, illicit drugs
117
complications of serotonin syndrome
DIC
rhabdomyolysis
renal failure
metabolic acidosis
seizures
118
Mx of serotonin syndrome
admit
stop offending medication
119
list 3 classes of mood stabilisers
lithium
anti epileptics
atypical antipsychotics
120
what is the gold standard mood stabiliser
lithium
121
benefits of lithium
good anti suicidal effects
122
uses of lithium
BPAD
schizoaffective disorder
depression (recurrent / Tx resistant)
123
complications of lithium use
teratogen
arrhytmia
CKD
hypothyroidism
124
common adverse effects of lithium
fine tremor
mild GI upset
metallic taste in mouth
sedation
125
LI toxicity adverse effects
**********************************
126
Li consultation
Purple book - register pt on purple book
PRE LI
baseline bloods - FBC, U&Es, Ca, TFTs,
ECG
DURING LI
monitor monthly
stay hydrated
3 monthly repeat bloods
go to A&E with febrile illness
avoid NSAIDs / diuretics
do not suddenly stop taking it
127
give a type of anti psychotic
olanzipine - zyprexa (brand name)
128
use of olanzapine
acute mania and prophylaxis
129
beneift of olanzapine
rapid effect
130
how does olanzapine work
blocks dopamine Rs
has effect on other neurotransmitter too
131
side effects of olanzapine
dizziness
restlessness
difficulty walking
constipation
difficulty going to / staying asleep
132
example of anti convulsants
sodium valproate (epilim)
carbamezapine
lamotragene
133
use of sodium valproate
acute mania and prophylaxis
IM option - for poor compliance pts
134
side effects of sodium valproate
PCOS
teratogenic
135
MOA for sodium valproate
increased cytochrome P450 to increase enzyme synthesis
136
use of sodium valproate
used for prophylaxis
137
what Ix do you monitor for sodium vaproate
FBC - leucopenia / thrombocytopenia
138
lamotrogine use
prophylaxis for Bipolar
139
side effects of lamotrogine
NV, rash, aggression
Steven Johnson - blistering of mucous membranes, painful, coryzal prodrome
140
drugs causes of steven johnson syndrome
phenytoin
lamotragine
carbamazepine
141
acute mania Mx
if 1st episode: antipsychotics +/- Li if ineffective alone
stop antidepressant if they are on one, or add antipsychotic
if already on mood stabilisers: optimise the dose and add antipsychotic
often add benzodiazepine on top
142
long term Mx of mania
Lithium
+/- valproate / olanzepine
143
Mx of bipolar depression
dont use SSRI alone - augment it with antipsychotic or mood stabiliser
olanzapine + fluoxetine / lamotragine
