Clinical Topic 2: Depression, Bipolar Flashcards
What screening tool is used to assess for post-natal depression?
Edinburgh Scale
What is the Edinburgh Scale?
Post-natal depression screening tool
What is the Monoamine Hypothesis? Which neurotransmitters do they refer to?
Patients with depressions have low levels of monoamines (serotonin, noradrenaline, dopamine) which are required for regulating mood. In depression, there is an increased density of MAO-A
Why are TCAs contraindicated in patients with a high suicide risk? What other conditions are they contraindicated in?
TCAs are the most toxic antidepressant, causing potentially fatal arrhythmias in overdose. Hence also contraindicated in heart failure
How long must symptoms persist before a diagnosis of Depression can be made?
At least 2 weeks
What is the difference between unipolar and bipolar depressive illness?
Unipolar: Illness only has depressive moods
Bipolar: Illness has depressive and manic moods
What is the lifetime risk of depression in males and females?
Males: 1 in 10
Females: 1 in 4
What are the three core symptoms of Depression?
- Low mood
- Anhedonia
- Anergia
What are the seven additional symptoms of Depression, aside from the core ones?
- Reduced concentration
- Feelings of guilt and shame
- Suicidal and self harm ideation
- Negative thoughts of future
- Sleep disturbances
- Appetite change
- Low self-esteem
How many Core and Additional symptoms are required for a diagnosis of Mild, Moderate and Severe depression?
Mild: 2 Core and 2 Additional
Moderate: 2 Core and 3 Additional
Severe: 3 Core and 4 Additional
In a patient with Psychotic Depression, what is common about their hallucinations and delusions?
Hallucinations - tend to be 2nd person auditory (derogatory, accusatory)
Delusions - tend to be persecutory, nihilistic
When taking anti-depressants for Depression, when do they start to work?
Starts working from 2nd week, but full effect starts from the 6th week
After a patient has remittance of Depressive symptoms, how long should they still be anti-depressants for?
Atleast 6 months
What is Antidepressant Discontinuation Syndrome? What are the symptoms? Give two drugs which patients taking may be at higher risk of ADS
Occurs when anti-depressants are abruptly stopped. Symptoms can be POOR BALANCE, SENSORY CHANGES flu-like, nausea, anxiety, difficulty sleeping
Antidepressants include those with a short-half life, i.e. Paroxetine, Venlafaxine
What is Serotonin syndrome?
Occurs when more than one Serotonin-blocking medication is used at the same time
If a patient is not responding to an anti-depressant for their depressive symptoms, how do they change to a different drug?
Withdraw the first drug, give a few days off without anti-depressant, then commence new drug
What is Treatment Resistant Depression defined as?
A patient with two therapeutic trials of anti-depressants from different classes of drug, for a minimum of 6-8 weeks and are still symptomatic
State the five classes of Antidepressant Medication
- Tricyclic Antidepressants (TCAs)
- Selective Serotonin Reuptake Inhibitors (SSRIs)
- Serotonin Noradrenaline Reuptake Inhibitors (SNRIs)
- Noradrenergic and Specific Serotonergic Antidepressants (NaSSA)
- Monoamine Oxidase Inhibitors (MOAs)
Give examples of four TCA medications. Give the names of two modified TCAs
Amitriptyline
Clomipramine
Imipramine
Dothiepin
Modified TCAs: Trazodone, Lofepramine
What is the Mechanism of Action of Tricyclic Antidepressants?
Prevents re-uptake of amines through competitive binding of amine transporter. This increases monoamines in synaptic cleft
In what patients are TCAs contraindicated?
Agranulocytosis, Severe liver damage, Glaucoma, Prostatic hypertrophy
What are the adverse side effects of TCAs?
- Toxicity in overdose (arrhythmias i.e. VT)
- Antimuscarinic (dry mouth, constipation, blurred vision, urinary retention, confusion)
- Antihistamine effect (sedation)
- a-Adrenoreceptor blocker (hypotension)
- Seizures
What medications should not be prescribed concurrently with TCAs?
Antihypertensives i.e. ACE, MAOs, Phenytoin, Adrenaline
State the name of some SSRI medications
Sertraline Fluoxetine Paroxetine Citalopram Escitalopram
Which SSRI medication is good to use in patients post-MI?
Setraline
Which SSRI medication is good to use in children?
Fluoxetine
Which two SSRI medications cause Long QT syndrome?
Citalopram
Escitalopram
State the main side-effects of SSRIs
- Increased risk of bleeding (especially when on NSAID, if so then prescribe a PPI)
- Tremor
- Hyponatraemia
Which electrolyte abnormality is associated with SSRIs?
Hyponatraemia
SSRIs interact with which three medications?
Monoamine Oxidase Inhibitors
Triptans
NSAIDs
What are the risks of an unborn child if its mother takes an SSRI?
First trimester: Congenital heart defects
Third trimester: Persistent pulmonary HTN
Give the names of two SNRI drugs?
Venlafaxine
Duloxetine
Give the names of a NaSSA drug? What are the main side-effects?
Mirtazepine
Increased appetite, weight gain, postural hypotension, peripheral oedema, sedation, tiredness, drowsiness
Give the names of two MOAI drugs? What is the MoA?
Phenelzine
Isocaboxazid
Irreversible inhibitor of mitochondrial MAO
What are the adverse side-effects of MOAI drugs?
- Weight gain
- Increased appetite
- Tremors
- Tyramine cheese reaction
What foods should be avoided in patients taking MAOI drugs
Most cheeses Meats (Bovril) Yeast (Marmite) Smoked + Pickled fish Hung poultry Game Red meats Some wines Some beers
What are the consequences of taking a MAOI drug and consuming excessive tyramine?
Hypertensive crises, leading to cerebral haemorrhage
What is PHQ9?
Patient Health Questionnaire - assesses severity of depression symptoms
What is the definition of Bipolar Affective Disorder?
Characterised by severe mood swings and changes in activity with complete recovery between episodes
What symptoms suggest a patient is having a manic episode?
- Increase in mood, where patient feels elated
- Increase in activities
- Grandiose delusions, with ideas of self-importance
What is the difference between mania and hypomania?
Mania interferes with a patient’s daily functioning, whereas Hypomania does not
What is a “Manic stupor”?
Manic stupor refers to immobility which has replaced the activity seen in manic patients. Patients also have reduced or absent speech
Which is a “Mixed affective state”?
Mixed affective state refers to when manic and depressive symptoms exist together
What is required for a diagnosis of Bipolar Affective Disorder?
Two episodes of mood disturbance, one of which must be mania, hypomania or mixed affective
Mania can only be present for how long in a single episode?
No more than 1 week
What is the life-time risk of Bipolar Affective Disorder?
How prevalent is it in males and females?
What is the age of onset?
Is there a heritability?
Lifetime risk: 1 in 100
Equal prevalence in males and females
Age of onset is early 20s, with a second peak in later life
15% inheritance from a 1st degree relative
Bipolar Affective Disorder is associated with which personality type?
Cyclothymic personality types
What are some triggers to a Manic episode? 5 examples
- Corticosteroids
- DOPA agonists i.e. Bromocriptine
- Cushing’s syndrome
- Hyperparathyroidism
- Abruptly stopping medications
What is Neuroleptic Malignant Syndrome?
What are the symptoms?
What is the treatment?
Fatal complication of antipsychotics, beginning in the first 10 days of treatment
Symptoms: Fluctuating consciousness, hyperthermia, muscular rigidity, rapidly fluctuating pulse / BP
Treatment: Cool the patient down, hydration, prevent secondary complications
Atypical Antipsychotics cause an increased risk of what in elderly patients? What is therefore done to prevent this?
VTE / Stroke
Hence only prescribe small dose (less than half)
State the name of 4 Typical Antipsychotics. What is their MoA?
- Haloperidol
- Chlopromazine
- Thiorizadine
- Sulpiridine
D2 receptor antagonist
What is the treatment for Acute Dystonic reactions seen when using Antipsychotics?
Anticholinergics i.e. Procyclidine, Benzotropine
What are some of the side-effects seen in Typical Antipsychotics?
- Acute dystonia (Torticollis; tongue protrusion; grimacing; blepharospasm; arching of the spine; oculogyric crises)
- Tardive dyskinesia (chewing, pouting, sucking movements; grimacing, akasthesia)
- Akasthesia (need to keep moving)
- Parkinsonism (stooped posture, muscle rigidity, course tremor)
- Hormonal (gynaecomastia, raised prolactin, amenorrhoea, galactorrhoea)
State the names of some Atypical Antipsychotics
Olanazapine
Respirodone
Clozapine
Quetiapine
Clozapine is used for two main indications. What are they?
Treatment resistant Schizophrenia
Psychosis in Parkinson’s Disease
What is the most significant side-effect which patients complain of when using Atypical Antipsychotics?
Weight gain
What is the monitoring required for patients on Clozapine?
FBC:
Once a week for 18 weeks,
Once a fortnight for 1 year
Once a month after that
What are some side-effects of Clozapine?
- Weight gain / hyperlipidaemia / hypercholestolaemia
- Hypotension
- Epilepsy
- Bed-wetting
- Agranulocytosis
- Myocarditis / cardiomyopathy
- Hypersalivation
- GI obstruction
How often is ECT given to patients with severe depression?
Twice a week for 3-6 weeks
For patients with poor compliance to Antipsychotic medication or at high risk of relapse, how can drugs be administered?
Depot intramuscular injection, every 2-4 weeks
How long should Benzodiazepines be tapered off for when discontinuing the medication?
Tapered off for 6-8 weeks
What is the monitoring required for Lithium?
Weekly monitoring of Lithium blood levels until dose correctly titrated, followed by 3 monthly after. Renal and thyroid function should also be assessed every 6 months
Monitoring due to narrow therapeutic index
What are some side-effects of Lithium?
Nausea/vomiting, diarrhoea
Fine tremor
Nephrotoxicity: polyuria, secondary to nephrogenic Diabetes insipidus
Thyroid enlargement, may lead to hypothyroidism
ECG: T wave flattening/inversion
Weight gain
Idiopathic intracranial hypertension
What are the guidelines in managing Bipolar patients who are currently in a manic and hypomanic state?
Mania - Refer urgently to community mental health team
Hypomania - Refer routinely to community mental health team
Dopamine blockade can affect which three Dopamine pathways?
Mesolimbic pathway
Nigrostiatral pathway
Tuberoinfundibular pathway
Blockade of the Tuberoinfundibular pathway causes what symptoms?
Hormonal: Galactorrhoea, Amenorrhoea, Gynaecomastia, Infertility
Blockade of the Nigrostrial pathway causes what symptoms?
Extrapyraminal: Dystonia, Akasthesia
Blockade of the Mesolimbic pathway causes what symptoms?
Apathy, sedation, decreased initiative
Which anti-psychotic drug should be used if required in a patient with pre-existing Parkinson’s disease?
Quetiapine
What medication is used to treat Tardive Dyskinesia?
Tetrabenazine
Tetrabenazine is used to treat what?
Tardive dyskinesia
What is the mechanism of action of Atomoxetine?
SNRI
What four medications cause Serotonin syndrome?
SSRIs, MAOIs, Esctasy, Methamphetamines
What are the symptoms of Serotonin syndrome?
Hyperreflexia, myoclonus, rigidity, hyperthermia
What is the time of onset for:
Post-natal blues?
Post-natal depression?
Post-natal psychosis?
Post-natal blues - Day 3-4 post birth
Post-natal depression? - Month 2 post birth
Post-natal psychosis? - Week 2 post birth
What is the treatment for:
Post-natal blues?
Post-natal depression?
Post-natal psychosis?
Post-natal blues - No treatment, reassurance
Post-natal depression? - Psychosocial support, medication
Post-natal psychosis? - Hospitalisation, supervision, medication
What medication is used to treat Serotonin syndrome?
Benzodiazepines and IV fluids
Extreme cases:
Cyproheptadine
Chlorpromazine
What is the mechanism of action of Benzodiazepines?
Potentiation of GABAergic transmission
