Depression, Mania and Bipolar Flashcards
What are the risk factors of depression?
1) Female gender
2) Genetics
3) Social Isolation
4) Early life experience
5) Illness
6) Acute stress
7) Family History
8) Past History
Clinical Presentation of depression?
Core symptoms:
1) Depressed mood - little variation, or can be diurnal mood variation that is worst in the mornings improving as day progresses.
2) Anhedonia - Loss of interest/pleasure in daily life things previously enjoyed.
3) Fatigue - lack of energy that pervades life.
Typical Symptoms: Biological - 1) Decreased libido 2) Poor appetite with marked weight loss 3) Psychomotor retardation or agitation 4) Sleep problems
Cognitive - 1) Decreased consciousness and memory
2) Low self-esteem, guilt and hopelessness
3) Suicide thoughts
Psychotic - 1) Delusions
2) Hallucinations - visual, olfactory and auditory
3) Catatonic symptoms - waxy flexibility, stupor, opposition and aversion
What is the diagnostic criteria, and 3 screening tools for depression?
Symptoms must be present every day for over 2 weeks, and represent a change of normal personality that causes significant distress/impairs social function, and is not secondary to alcohol/drugs, bereavement or other medical disorders.
Mild - 2 core, 2 typical
Moderate - 2 core, 3+ typical
Severe - all 3 core, 4+ typical
Screening tools:
1) Patient health questionnaire (PHQ-9) - 9 item questionnaire to help diagnose and assess severity of depression.
2) Hospital anxiety and depression scale (HAD) - assesses both anxiety and depression.
3) Becks Depression Inventory (BDI) - assesses severity of depression.
Treatment of depression?
1) Lifestyle - Avoid smoking, alcohol, eat well, exercise and sleep well.
2) Psychological - Charities, CBT, specialist health professionals.
3) Biological - usually take antidepressants for 6 months after resolution of symptoms then stop.
Medication:
1st line: SSRI - Citalopram (ECG needed - QT change), Sertraline, Fluoxetine (only one licensed for use in children).
2nd line: alternative SSRI
3rd line: SNRI (Venlafaxine), NaSSA (Mirtazapine), TCA (Amitriptyline)
ECT:
Electrical conductivity interrupts the hyperactivity between areas of the brain that maintain depression. Indications: poor response to treatment, prolonged/severe depression and mania (manic episode).
Contraindications: general anaesthesia used, caution in recent subdural/subarachnoid bleeds, stroke, MRI, arrhythmia, vascular abnormalities.
Name some risks and side-effects to antidepressant treatment?
1) Takes 6 weeks to generate full effect and in early stages it can increase suicide risk as it increases motivation to patients to act upon their thoughts.
2) Seretonin syndrome - neuromuscular hyperactivity (Brisk reflex, clonus, rigidity, tremor), autonomic dysfunction (tachcardya, hyperthermia, sweating, shivering, diarrhoea, and altered mental state,
3) Hypernatraemia associated mostly with SSRI
4) GI bleeding
Withdrawal - tingling, numbness, GI disturbance after antidepressant treatment.
How does Mania present?
A distinct period (>1 week) of persistently elevated, expansive or irritable mood that is disruptive it impairs social/occupational function.
1) Mood - Irritability, euphoria, elevated
2) Cognition - Poor concentration/distracted, flight of ideas/racing hyperactivity, grandiosity, lack of insight.
3) Behavioural - lack of sleep, pressure of speech, hyperactivity, hyper sexuality, extreme risk taking behaviours.
4) Psychotic - Delusions, hallucinations, tangentiality, circumstantiality
How does hypomania differ?
Lasts 4 or more days but not severe enough to interfere with social/occupational function, require hospital admission and has no psychotic features.
Bipolar summary:
Depression + hypomania/mania = bipolar. It is an episodic illness that is chronic. Bipolar I involves both mania and depression, Bipolar II involves mainly depression but mild hypomania. Peak prevalence between 15-19yrs in women and 20-24 in men. Family history link with schizophrenia, schizoaffective disorder and bipolar.
How does Bipolar present?
Manic phase - mood - euphoric/elevated/irritable, cognitive - poor concentration/hyperactivity+racing of ideas/grandiosity/lack of insight, behavioural - no need for sleep, hypersexual, risky behaviours, pressure of speech, psychotic - delusion, hallucination, tangentiality, circumstantiality. (3 or more episodes for a week - mania, less would be hypomania)
Depressive phase - anhedonia, fatigue, low mood, low libido, poor appetite and WL, psychomotor retardation and agitation, sleep problems, decreased consciousness and memory, low self esteem/guilt/hopeless, suicide thoughts, delusion, hallucination, catatonic behaviours.
Differential diagnosis for Bipolar?
1) Other causes for mania: Steroids inducing psychosis and depression, Cushing’s, hyperthyroidism, illicit substances such as amphetamines and cocaine, excess antidepressants (increase in serotonin and dopamine), infection/stroke/neoplasm/epilepsy.
2) Schizophrenia
3) Schizoaffective disorder
4) ADHD in young people
Diagnosing Bipolar disorder?
1) Clinical - 2 or more episodes or mood changes, 1 of which must be mania/hypomania.
2) Bipolar I - Both mania (>1 week) + depression (sometimes only mania)
Bipolar II - Mainly depression and mild hypomania (>4 days)
3) Urine - drug screen, TFT’s to exclude hyperthyroidism, ESR/CRP to exclude infection, CT/MRI to exclude brain pathology.
Treatment for Bipolar - acute mania or acute depressive episode?
Acute Mania: Admit if severe + consider detaining under MHA if suicide risk. Stop all drugs that may cause symptoms - steroids and antidepressants, and give short term Benzes for sedative effect.
1) Start SGA - olanzapine, riesperidone, quetiapine (S/e weight gain + hyperglycaemia).
2) If ineffective raise dose or start mood stabiliser - Lithium or Valproate.
3) Combine and if still ineffective ECT.
Acute depression:
1) Mood stabiliser - raise dose
2) add antipsychotic
3) add antidepressant instead of antipsychotic
4) ECT
Prophylaxis of Bipolar disorder?
Mood stabilisers Lithium or Valproate (Lithium most effect long-term and decreases suicide risk)
1) Check Lithium levels weekly until dose has been constant for 4 weeks - check monthly for 6 months than 3-monthly if stable.
2) NSAIDs, diuretics and ACE-i patients need to be monitored closely as those increase Lithium - can lead to toxicity.
3) Kidney and thyroid function need to be monitored - processed through kidneys (can cause diabetes insidious) or cause hypo/hyperthyroid.
4) DO NOT GIVE LITHIUM OR VALPROATE TO pregnancy women.
Other forms of management:
1) Advice - psychoeducation, avoid overstimulation such as TV, lively conversations, maintain routine and all environment. Avoid drugs and alcohol, and walk/exercise to use up energy.
2) Psychointervention - CBT, psychoeducation, therapy and support groups.
3) Hospital admission - if episode is severe, suicide risk, inappropriate behaviour, lacks capacity or support.
What are the features of lithium toxicity?
Caused by: depleted fluid levels, changes in salt, reduced renal function, drugs - NSAIDs, ACE-i, diuretics.
Symptoms: Nausea, vomitting, diarrhoea, confusion, excessive sleep and coarse tremor.
