Choosing the right treatment

Question 1

What is the treatment for mild depression?

Answer 1

Low intensity psychological interventions 
NO ANTIDEPRESSANTS (unless 8+ wks or previous depression)

Question 2

What is the treatment for moderate depression?

Answer 2

ANTIDEPRESSANT + high-intensity psych intervention

Question 3

What is the treatment for severe depression?

Answer 3

Rapid specialist mental health assessment

Question 4

What are the 3 steps before starting antidepressants?

Answer 4

1-discuss choice of pharmacological/non-pharmacological therapy
2-S/E
3-Assess after 4wks

Question 5

What things can the patient do themselves to improve their depression?

Answer 5

Exercising
Engaging in productive activity
Socializing
Improve sleep
Relaxation
"self-soothing" techniques

Question 6

What are usually 1st line in treating depression?

Answer 6

SSRIs

Question 7

How does the dose change if the patient is old?

Answer 7

Half the adult dose to start with

then titrate up as with anyone

Question 8

What two drug types are combined in psychotic depression?

Answer 8

Antidepressants

Antipsychotics

Question 9

How long does antidepressants take to work? If needing a quicker response?

Answer 9

Normally take 2-6wks to work

If needing quicker response- ECT

Question 10

How long should antidepressants be continued?

Answer 10

6-12 months after full resolution of 1st episode
12-24 months for a recurrence
After 3rd episode consider indefinetly

Question 11

What is non-response defined as?

Answer 11

No response/inadequate response after 6wks at the max BNF dose or highest tolerated dose

Question 12

TRUE/FALSE

If switching antidepressants one needs to be stopped before another one is started

Answer 12

Kinda
Doses should be cross tapered
If MAOI need a washout period of 2 weeks
Moclobemide washout period of 24h

Question 13

What is gold standard in treatment of bipolar disorder?

Answer 13

Lithium

Question 14

Lithium is safe to use in pregnant TRUE/FALSE

Answer 14

FALSE

Ebstein’s abnormality, floppy baby _ thyroid abnormalities

Question 15

Why should you not change brands when prescribing lithium?

Answer 15

Different lithium salts have different bioavailability

Question 16

Lithium has a narrow therapeutic index so therefore needs to be montiored. How is it monitored?

Answer 16

12h post dose blood and U+E every 5 days
Every 6 months - TFTs
+ lithium level/ U+E if dehydrated from physical illness, generally unwell or signs of toxicity

Question 17

If you get hypothyroidism when on treatment of lithium for bipolar disorder what is done?

Answer 17

Treated with levothyroxine rather than stopping lithium

Question 18

If lithium levels are progressively rising what should be suspected?

Answer 18

Progressive nephrotoxicity

Question 19

What does lithium cessation precipitate in up to 50% of patients?

Answer 19

acute mania

discontinuation gradual over 2-4wks

Question 20

If one family member responds well to treatment others will benefit from the same one TRUE/FALSE

Answer 20

TRUE

Question 21

What are the common SE of lithium?

Answer 21

Dry mouth/strange taste
GI upset
Polyuria and polydipsia, neurogenic DI
Tremor, Hypothyroidism, Wt gain
Long term reduced renal function

Question 22

What are lithium toxicity signs?

Answer 22

Vomiting
Black diarrhoea
Ataxia/coarse tremor
Drowsiness
Convulsions
Coma

Question 23

When should lithium be taken?

Answer 23

At night due to sedation

Question 24

What two things should be checked before the initiation of anticonvulsants?

Answer 24

Platelet count

LFTs

Question 25

Name 4 side effects of Carbamazepine (Tegretol)?

Answer 25

Drowsiness Ataxia Cardiovascular effects Induced liver enzymes

Question 26

Why is sodium valproate not used in women of child brearing age?

Answer 26

Risk of neural tube defects in child | If you do use then make sure they have effective contraception

Question 27

What is the risk associated with lamotrigine?

Answer 27

Stevens-Johnsons syndrome

Question 28

What is 1st line in bipolar disorders in mania?

Answer 28

``` Atypical antipsychotics (as mood stabilisers) e.g. Quetiapine, Aripiprazole, Olanzapine, Lurasidone ```

Question 29

What are the side effects of Atypical antipsychotics?

Answer 29

Sedation Wt gain ( a couple of stone) Metabolic syndrome

Question 30

TRUE/FALSE | Antidepressants can be used short term in severe depressive episodes but should never be used without a mood stabiliser

Answer 30

TRUE

Question 31

What can be used an an emergency first line in depression?

Answer 31

ECT

Question 32

With ECT the more depressed the more effective it is TRUE/FALSE

Answer 32

TRUE

Question 33

With ECT how many treatments are usually given as part of the course?

Answer 33

9 treatments

Question 34

Is unilateral or bilateral ECT more effective?

Answer 34

Bilateral more common, works quicker and more likely to give cognitive effects

Question 35

What are absolute CI to ECT?

Answer 35

Recent MI (last 3 months) Recent cerebrovascular accident Intracranial mass lesions OR pheochromocytoma

Question 36

What are the side effects of ECT?

Answer 36

Often a short lived tension headache, memory and cognitive problems

Question 37

TRUE/FALSE In Scotland you cannot give ECT to a person who has capacity and is refusing treatment even if they are detained under the MHA

Answer 37

TRUE

Question 38

How does ECT work?

Answer 38

It causes a seizure in the brain Almost resets the brain (disrupts the hyper connectivity between various areas of the brain that maintain depression) which allows your brain to grow, sprout new neuron connections and increase volume of hippocampus

Question 39

What is behavioural activation?

Answer 39

Doing things that they enjoy

Question 40

What is interpersonal therapy?

Answer 40

Concentrates on relationships with people and their complications

Question 41

What is CBT based on?

Answer 41

Identifying an individuals automatic thoughts, cognitive bias and schemas. It helps to identify that which perpetuates the anxiety/depression