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Medicine, Year 3, Mental Health > Clinical Topic 2: Depression, Bipolar > Flashcards

Clinical Topic 2: Depression, Bipolar Flashcards

1
Q

What screening tool is used to assess for post-natal depression?

A

Edinburgh Scale

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2
Q

What is the Edinburgh Scale?

A

Post-natal depression screening tool

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3
Q

What is the Monoamine Hypothesis? Which neurotransmitters do they refer to?

A

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

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4
Q

Why are TCAs contraindicated in patients with a high suicide risk? What other conditions are they contraindicated in?

A

TCAs are the most toxic antidepressant, causing potentially fatal arrhythmias in overdose. Hence also contraindicated in heart failure

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5
Q

How long must symptoms persist before a diagnosis of Depression can be made?

A

At least 2 weeks

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6
Q

What is the difference between unipolar and bipolar depressive illness?

A

Unipolar: Illness only has depressive moods
Bipolar: Illness has depressive and manic moods

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7
Q

What is the lifetime risk of depression in males and females?

A

Males: 1 in 10
Females: 1 in 4

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8
Q

What are the three core symptoms of Depression?

A
  1. Low mood
  2. Anhedonia
  3. Anergia
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9
Q

What are the seven additional symptoms of Depression, aside from the core ones?

A
  1. Reduced concentration
  2. Feelings of guilt and shame
  3. Suicidal and self harm ideation
  4. Negative thoughts of future
  5. Sleep disturbances
  6. Appetite change
  7. Low self-esteem
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10
Q

How many Core and Additional symptoms are required for a diagnosis of Mild, Moderate and Severe depression?

A

Mild: 2 Core and 2 Additional
Moderate: 2 Core and 3 Additional
Severe: 3 Core and 4 Additional

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11
Q

In a patient with Psychotic Depression, what is common about their hallucinations and delusions?

A

Hallucinations - tend to be 2nd person auditory (derogatory, accusatory)

Delusions - tend to be persecutory, nihilistic

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12
Q

When taking anti-depressants for Depression, when do they start to work?

A

Starts working from 2nd week, but full effect starts from the 6th week

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13
Q

After a patient has remittance of Depressive symptoms, how long should they still be anti-depressants for?

A

Atleast 6 months

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14
Q

What is Antidepressant Discontinuation Syndrome? What are the symptoms? Give two drugs which patients taking may be at higher risk of ADS

A

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

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15
Q

What is Serotonin syndrome?

A

Occurs when more than one Serotonin-blocking medication is used at the same time

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16
Q

If a patient is not responding to an anti-depressant for their depressive symptoms, how do they change to a different drug?

A

Withdraw the first drug, give a few days off without anti-depressant, then commence new drug

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17
Q

What is Treatment Resistant Depression defined as?

A

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

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18
Q

State the five classes of Antidepressant Medication

A
  • Tricyclic Antidepressants (TCAs)
  • Selective Serotonin Reuptake Inhibitors (SSRIs)
  • Serotonin Noradrenaline Reuptake Inhibitors (SNRIs)
  • Noradrenergic and Specific Serotonergic Antidepressants (NaSSA)
  • Monoamine Oxidase Inhibitors (MOAs)
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19
Q

Give examples of four TCA medications. Give the names of two modified TCAs

A

Amitriptyline
Clomipramine
Imipramine
Dothiepin

Modified TCAs: Trazodone, Lofepramine

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20
Q

What is the Mechanism of Action of Tricyclic Antidepressants?

A

Prevents re-uptake of amines through competitive binding of amine transporter. This increases monoamines in synaptic cleft

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21
Q

In what patients are TCAs contraindicated?

A

Agranulocytosis, Severe liver damage, Glaucoma, Prostatic hypertrophy

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22
Q

What are the adverse side effects of TCAs?

A
  • Toxicity in overdose (arrhythmias i.e. VT)
  • Antimuscarinic (dry mouth, constipation, blurred vision, urinary retention, confusion)
  • Antihistamine effect (sedation)
  • a-Adrenoreceptor blocker (hypotension)
  • Seizures
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23
Q

What medications should not be prescribed concurrently with TCAs?

A

Antihypertensives i.e. ACE, MAOs, Phenytoin, Adrenaline

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24
Q

State the name of some SSRI medications

A 
Sertraline
Fluoxetine
Paroxetine
Citalopram
Escitalopram
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25
Q

Which SSRI medication is good to use in patients post-MI?

A

Setraline

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26
Q

Which SSRI medication is good to use in children?

A

Fluoxetine

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27
Q

Which two SSRI medications cause Long QT syndrome?

A

Citalopram

Escitalopram

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28
Q

State the main side-effects of SSRIs

A
  • Increased risk of bleeding (especially when on NSAID, if so then prescribe a PPI)
  • Tremor
  • Hyponatraemia
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29
Q

Which electrolyte abnormality is associated with SSRIs?

A

Hyponatraemia

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30
Q

SSRIs interact with which three medications?

A

Monoamine Oxidase Inhibitors
Triptans
NSAIDs

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31
Q

What are the risks of an unborn child if its mother takes an SSRI?

A

First trimester: Congenital heart defects

Third trimester: Persistent pulmonary HTN

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32
Q

Give the names of two SNRI drugs?

A

Venlafaxine

Duloxetine

33
Q

Give the names of a NaSSA drug? What are the main side-effects?

A

Mirtazepine

Increased appetite, weight gain, postural hypotension, peripheral oedema, sedation, tiredness, drowsiness

34
Q

Give the names of two MOAI drugs? What is the MoA?

A

Phenelzine
Isocaboxazid

Irreversible inhibitor of mitochondrial MAO

35
Q

What are the adverse side-effects of MOAI drugs?

A
  • Weight gain
  • Increased appetite
  • Tremors
  • Tyramine cheese reaction
36
Q

What foods should be avoided in patients taking MAOI drugs

A 
Most cheeses
Meats (Bovril)
Yeast (Marmite)
Smoked + Pickled fish
Hung poultry
Game
Red meats
Some wines
Some beers
37
Q

What are the consequences of taking a MAOI drug and consuming excessive tyramine?

A

Hypertensive crises, leading to cerebral haemorrhage

38
Q

What is PHQ9?

A

Patient Health Questionnaire - assesses severity of depression symptoms

39
Q

What is the definition of Bipolar Affective Disorder?

A

Characterised by severe mood swings and changes in activity with complete recovery between episodes

40
Q

What symptoms suggest a patient is having a manic episode?

A
  • Increase in mood, where patient feels elated
  • Increase in activities
  • Grandiose delusions, with ideas of self-importance
41
Q

What is the difference between mania and hypomania?

A

Mania interferes with a patient’s daily functioning, whereas Hypomania does not

42
Q

What is a “Manic stupor”?

A

Manic stupor refers to immobility which has replaced the activity seen in manic patients. Patients also have reduced or absent speech

43
Q

Which is a “Mixed affective state”?

A

Mixed affective state refers to when manic and depressive symptoms exist together

44
Q

What is required for a diagnosis of Bipolar Affective Disorder?

A

Two episodes of mood disturbance, one of which must be mania, hypomania or mixed affective

45
Q

Mania can only be present for how long in a single episode?

A

No more than 1 week

46
Q

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?

A

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

47
Q

Bipolar Affective Disorder is associated with which personality type?

A

Cyclothymic personality types

48
Q

What are some triggers to a Manic episode? 5 examples

A
  • Corticosteroids
  • DOPA agonists i.e. Bromocriptine
  • Cushing’s syndrome
  • Hyperparathyroidism
  • Abruptly stopping medications
49
Q

What is Neuroleptic Malignant Syndrome?
What are the symptoms?
What is the treatment?

A

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

50
Q

Atypical Antipsychotics cause an increased risk of what in elderly patients? What is therefore done to prevent this?

A

VTE / Stroke

Hence only prescribe small dose (less than half)

51
Q

State the name of 4 Typical Antipsychotics. What is their MoA?

A
  • Haloperidol
  • Chlopromazine
  • Thiorizadine
  • Sulpiridine

D2 receptor antagonist

52
Q

What is the treatment for Acute Dystonic reactions seen when using Antipsychotics?

A

Anticholinergics i.e. Procyclidine, Benzotropine

53
Q

What are some of the side-effects seen in Typical Antipsychotics?

A
  • 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)
54
Q

State the names of some Atypical Antipsychotics

A

Olanazapine
Respirodone
Clozapine
Quetiapine

55
Q

Clozapine is used for two main indications. What are they?

A

Treatment resistant Schizophrenia

Psychosis in Parkinson’s Disease

56
Q

What is the most significant side-effect which patients complain of when using Atypical Antipsychotics?

A

Weight gain

57
Q

What is the monitoring required for patients on Clozapine?

A

FBC:

Once a week for 18 weeks,
Once a fortnight for 1 year
Once a month after that

58
Q

What are some side-effects of Clozapine?

A
  • Weight gain / hyperlipidaemia / hypercholestolaemia
  • Hypotension
  • Epilepsy
  • Bed-wetting
  • Agranulocytosis
  • Myocarditis / cardiomyopathy
  • Hypersalivation
  • GI obstruction
59
Q

How often is ECT given to patients with severe depression?

A

Twice a week for 3-6 weeks

60
Q

For patients with poor compliance to Antipsychotic medication or at high risk of relapse, how can drugs be administered?

A

Depot intramuscular injection, every 2-4 weeks

61
Q

How long should Benzodiazepines be tapered off for when discontinuing the medication?

A

Tapered off for 6-8 weeks

62
Q

What is the monitoring required for Lithium?

A

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

63
Q

What are some side-effects of Lithium?

A

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

64
Q

What are the guidelines in managing Bipolar patients who are currently in a manic and hypomanic state?

A

Mania - Refer urgently to community mental health team

Hypomania - Refer routinely to community mental health team

65
Q

Dopamine blockade can affect which three Dopamine pathways?

A

Mesolimbic pathway
Nigrostiatral pathway
Tuberoinfundibular pathway

66
Q

Blockade of the Tuberoinfundibular pathway causes what symptoms?

A

Hormonal: Galactorrhoea, Amenorrhoea, Gynaecomastia, Infertility

67
Q

Blockade of the Nigrostrial pathway causes what symptoms?

A

Extrapyraminal: Dystonia, Akasthesia

68
Q

Blockade of the Mesolimbic pathway causes what symptoms?

A

Apathy, sedation, decreased initiative

69
Q

Which anti-psychotic drug should be used if required in a patient with pre-existing Parkinson’s disease?

A

Quetiapine

70
Q

What medication is used to treat Tardive Dyskinesia?

A

Tetrabenazine

71
Q

Tetrabenazine is used to treat what?

A

Tardive dyskinesia

72
Q

What is the mechanism of action of Atomoxetine?

A

SNRI

73
Q

What four medications cause Serotonin syndrome?

A

SSRIs, MAOIs, Esctasy, Methamphetamines

74
Q

What are the symptoms of Serotonin syndrome?

A

Hyperreflexia, myoclonus, rigidity, hyperthermia

75
Q

What is the time of onset for:
Post-natal blues?
Post-natal depression?
Post-natal psychosis?

A

Post-natal blues - Day 3-4 post birth
Post-natal depression? - Month 2 post birth
Post-natal psychosis? - Week 2 post birth

76
Q

What is the treatment for:
Post-natal blues?
Post-natal depression?
Post-natal psychosis?

A

Post-natal blues - No treatment, reassurance
Post-natal depression? - Psychosocial support, medication
Post-natal psychosis? - Hospitalisation, supervision, medication

77
Q

What medication is used to treat Serotonin syndrome?

A

Benzodiazepines and IV fluids

Extreme cases:
Cyproheptadine
Chlorpromazine

78
Q

What is the mechanism of action of Benzodiazepines?

A

Potentiation of GABAergic transmission

Medicine, Year 3, Mental Health (10 decks)

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