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1 - Y5 Psych > Gargi's & Emma's notes - Affective Disorders > Flashcards

Gargi's & Emma's notes - Affective Disorders Flashcards

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1
Q

What is an affective disorder?

Describe the features of affective disorders

A
  • Main feature is excessively high or low mood
  • Run a relapsing/remitting course
  • Unipolar – recurrent episodes of depression
  • Bipolar – recurrent episodes of mania and depression
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2
Q

Define the depression triad

A

Triad of

  1. low mood,
  2. anhedonia (loss of enjoyment in previously enjoyable activities),
  3. low energy/increased fatiguability.

Depression is a unipolar affective disorder

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3
Q

What are the causes of depression?

A
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4
Q

What are the risk factors for depression?

A
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5
Q

What is Beck’s cognitive triad?

A

negative views about self (worthlessness) = world (helplessness) = future (hopelessness)

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6
Q

What are the core features of depression (ICD-10)?

A

low mood, low energy, anhedonia lasting 2 or more weeks

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7
Q

What are the biological features of depression?

A
  • early morning wakening
  • diurnal variation (symptoms worse in the morning)
  • appetite change with weight change,
    • Usually decreased, can be increased (atypical)
  • Psychomotor retardation or agitation
    • Slow, monotonous speech, blunted affect, lack of emotional reactivity
    • Or inability to sit still, fidgeting, pacing or hand-wringing, rubbing/scratching skin/clothes
  • Marked loss of libido
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8
Q

What are some additional symptoms of depression?

A
  • decreased attention/concentration,
  • low self-esteem,
  • ideas of guilt,
  • hopelessness
  • pessimistic view of the future
  • ideas of self-harm/suicide
  • disrupted sleep,
  • Difficulty falling asleep (insomnia), hypersomnia (atypical)
  • early morning waking, insomnia,
  • loss of libido
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9
Q

How many symptoms are required for mild, moderate and severe depression?

A
  • MILD: 2 core + 2 bio
  • MOD: 2 core + 6 bio
  • SEVERE: more than 8 symptoms, including all 3 core
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10
Q

What else is required in a psych depression Hx?

A
  • Any psychotic symptoms (hallucinations, delusions)
  • Look out for suicidality, self-neglect, psychosis
  • Can be with or without somatic symptoms
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11
Q

What are the subtypes of depression?

A
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12
Q

What is the mneumonic for MMSE?

A

ASEPTIC

A ffect

S peech

E ffect

P sychosis

T houghts

I

C ognition

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13
Q

What must be asked/observed in the MMSE (ASEPTIC)?

A

A: signs of neglect, weight loss, dehydration, looks miserable, disinterested, anxious movements, poor eye contact, tearful, posture, tearful, agitated depression = increased activity (restless, pacing, hand-wringing)

S: slow, quiet, psychomotor retardation can make mute

E: restricted range of affect

P: severe = hallucinations, visuals of evil images, auditory with unpleasant derogatory voices, delusions – guilt, nihilistic (nothingness), persecutory

T: concerned about, pessimistic, guilt and worthlessness thoughts, nihilistic delusions worthlessness, helplessness, negative triad, suicidal thoughts

I: insight is usually good

C: psychomotor retardation may mimic cognitive impairment, poor concentration

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14
Q

What are the differential diagnoses for ?depression?

A
  • Physical causes – hypothyroid, head injury, cancer, quiet delirium, meds
  • Adjustment disorder – following life event but not as severe
  • Normal sadness – part of life
  • Bereavement – concern when grief (numbness, pining, depression, recover) is very intense, > 6 months or delayed
  • Chronic schizophrenia – blunt affect
  • Substance withdrawal
  • Bipolar disorder
  • Postnatal depression/puerperal illness
  • Dementia – changes from depression may mimic dementia, but dementia can start with affective changes
  • Dysthymia – low-intensity but chronic low mood
  • Can co-morbid with panic disorder, agoraphobia, OCD, eating/personality dis
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15
Q

What further investigations are required for ?depression?

A
  • Collateral Hx
  • Physical exam to rule out organics
  • Bloods –
    • TFT - rule out hypothyroid
    • FBC - rule out anaemia
    • glucose/HBA1C – rule out diabetes
    • U&Es
    • LFTs (alcohol),
    • Ca
  • Assess severity on Becks Depression Inventory (BDI) or Hospital Anxiety and Depression Scale (HADS)
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16
Q

When must a depressed patient be referred to secondary psych?

A

high suicide risk, severe depression, unresponsive to tx

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17
Q

Which severity of depression requires Tx?

A

Depressive episodes don’t qualify as dx (subthreshold) or mild that do not need treatment

→ wait and watch, sleep hygiene advice, give information about depression and follow up in 2 weeks

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18
Q

When may in-patient admission necessary in patients with depression?

A
  • Highly distressing psychotic symptoms
  • Active suicidal ideation or planning
  • Extreme self-neglect (e.g. dehydration, starvation)
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19
Q

What lifestyle advice may be given to patients with depression?

A
  • Avoid alcohol and substance use
  • Eat healthily
  • Exercise regularly
  • Good sleep hygiene (avoid caffeine and smoking in the evenings, do not nap, don’t use bedroom for TV etc.)
  • Minimise adverse life events where possible
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20
Q

How do you treat persistent subthreshold symptoms/mild-moderate depression?

A

low intensity psycho-social interventions (CBT, computerised CBT, structured group physical activity programme)

  • Do not use antidepressants routinely in subthreshold/mild-mod depression because of poor risk/benefit ratio*
  • But consider for people with PMH of mod/severe depression, 2 years subthreshold/mild persisting after other interventions*
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21
Q

How do you treat persistent subthreshold symptoms/mild-moderate depression that is unresponsive to 1st line Tx?

A

If not responsive: consider

(1) high-intensity therapy (individual CBT, interpersonal therapy, couple behavioural therapy, behavioural activation) OR
(2) antidepressant
* SSRI – fluoxetine, sertraline, paroxetine, citalopram, escitalopram

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22
Q

How do you treat the initial presentation of severe depression?

A

= high intensity therapy AND antidepressant,

treat until no longer depressed

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23
Q

What must be done if there is no positive impact of antidepressants?

A

check compliance, SE before changing

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24
Q

What are the side effects of SSRIs?

A
  • D/V,
  • weight change,
  • blurred vision,
  • anxiety,
  • agitation,
  • insomnia,
  • tremor,
  • dizziness,
  • headache,
  • sweating
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25
Q

What must be prescribed in older patients who are on aspirin or NSAIDs?

A
  • gastroprotective (PPI) - risk of GI bleeding
  • also risk in older patients
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26
Q

Must antidepressant Tx be continued after symptom remission?

A

yes (6 months)

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27
Q

What are some psychotic symptoms seen in depression?

A
  • Delusions and hallucinations are normally mood-congruent à irrational guilt, nihilistic delusions, accusatory voices
  • In severe cases, psychomotor retardation may progress to depressive stupor à unresponsiveness, lack of voluntary movement (akinesis), mutism
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28
Q

What are the complications of depression?

A
  • Social isolation, unemployment
  • Self-harm, suicide
  • Substance misuse
  • SEs of antidepressants (incl unmasking mania)
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29
Q

What is the prognosis of depression?

A
  • Lifetime suicide is 15% (20x higher than general population)
  • Initial episode usually lasts 6 months – 1 year
  • 80% have further episode (risk increases with each relapse)
    • 10% have chronic unremitting course
  • Pharmacological treatment failure is usually due to inadequate dose, duration or poor adherence
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30
Q

When is pscychological advice indicated in depressed patients?

A
  • 1st line for mild depression,
  • In combination with drug treatments for moderate-severe depression
31
Q

Which psychological Txs are useful in depression?

A
  • CBT (may be self-help or individual, depending on severity)
  • Mindfulness-based cognitive therapy
  • Interpersonal therapy
  • Family and marital therapy
  • Psychodynamic therapy
32
Q

When is drug Tx required in depression?

A
  • For moderate-severe depression
  • OR milder depression not responsive to psychological therapy alone
33
Q

What must patients be warned/counselled of before starting SSRIs?

A
  • anxiety/suicidal thoughts at first
  • Warn patients of gradual development of full anti-dep effect
  • Continue treatment after remission
  • Non-addictive
34
Q

What should be prescribed next if there is no response to SSRIs for depression?

A
  • Change to another SSRI
  • try TCA/different class
  • augment another antidepressant/antipsychotic (e.g. quetiapine)/lithium
35
Q

What may be prescribed prophylactically if there are multiple episodes of depression?

A

SSRIs

36
Q

What should a depressed patient be prescribed if they express psychotic symptoms?

A

antipsychotics

37
Q

When is ECT indicated in depression?

A
  • Poor response or intolerance to antidepressants
  • Severe suicidal ideation, psychotic features, psychomotor retardation or stupor
  • Severe self-neglect (poor fluid and food intake)
  • Previous good response to ECT
38
Q

What is the Tx for initial presentation of moderate depression?

A

high-intensity therapy (individual CBT, interpersonal therapy, couple behavioural therapy, behavioural activation

39
Q

What is the Tx for initial presentation of severe depression?

A

high-intensity therapy (individual CBT, interpersonal therapy, couple behavioural therapy, behavioural activation) AND antidepressant,

treat until no longer depressed

40
Q

What must you do if patient is non-responsive to antidepressant?

A
  • check compliance & SE
  • before changing
41
Q

Can antidepressants be stopped suddenly?

A
  • Antidepressants cannot be stopped suddenly
  • need to wean over weeks
42
Q

When is a secondary care pscyh referral indicated?

A
  • high suicide risk
  • severe depression
  • unresponsive to tx
43
Q

What is the definition of bipolar affective disorder?

A
  • At least 2 episodes, one must be hypomania or mania or mixed (other can be depressive) with complete recovery between 2 episodes + depressive episodes
  • Mania lasts 2w-4m, depression longer
44
Q

Name the types of BAD

A
  • Type 1
  • Type 2
  • Rapid-cycling
  • repeated episodes of mania/hypomania (with no depression)
45
Q

What is Type 1 BAD?

A
  • manic episodes interspersed with depressive episodes
  • At least 1 manic episode
46
Q

What is Type 2 BAD?

A
  • mainly recurrent depressive episodes, with less prominent hypomanic episodes
    • Never had a full manic episode; at least 1 hypomanic episode and 1 depressive episode
47
Q

What is Rapid-cycling BAD?

A

4 or more affective episodes in a year

48
Q

What is a mixed episode of BPAD?

A

manic/hypomanic and depressive symptoms in a single episode,

present every day for at least 1 week

49
Q

What is Ultra rapid cycling BPAD?

A

fluctuations over days or even hours

50
Q

Are repeated episodes of mania/hypomania (with no depression) also classified as BAD?

A

Yes

51
Q

What is the biological aetiology of BAD?

A
  • Genetics
    • Strong genetic component –> 80% heritability
    • 10% risk in 1st degree relatives (also higher risk of depression and schizophrenia/schizoaffective disorder)
    • Due to multiple alleles in genes related to neuronal development, DA/5-HT metabolism and ion channels
  • Neurobiology:
    • Due to structural and functional abnormalities in brain regions linked to emotion (esp hippocampus)
    • Decreased activation and reduced grey matter in areas controlling emotional regulation, increased activity in ventral limbic areas that mediate and generate emotional responses
    • Multiple NTs have been implicated –> may be due to DA overactivity
  • Substance use (incl antidepressants) can trigger mania
52
Q

What is the biological cause of mania?

A
  • Increased adrenaline, NA, dopamine, serotonin → mania
53
Q

What are the risk factors for rapid cycling BAD?

A

female sex

54
Q

What is the social aetiology of BAD?

A
  • Most important environmental RF is childbirth –> 50% risk of mania post-partum in untreated bipolar
  • Stress can trigger manic episodes
55
Q

What is the epidemiology of BAD?

A
  • 1% prevalence
  • Average age of onset is 20yo; usually presents with mania
  • M:F equal
    • Rapid cycling BAD is more common in F
56
Q

What are the symptoms of BAD?

A
  • mania/hypomania episodes
  • depressive episodes
57
Q

What is mania?

A
  • Elevated mood (or irritability) lasting >1wk duration with complete disruption of work and social life
58
Q

What are the signs and symptoms of mania?

A

Appearance/behaviour

  • Excitement, irritable, aggro
  • Increased energy, over-active, reduced concentration, increased distractibility, over familiarity, self-neglect
  • reduced sleep

Speech

  • Pressured speech → can lead to loosening of associations

Emotion –

  • mood/affect → increased self esteem

Perception

  • grandiose delusions, paranoia, catatonic behaviour (manic stupor)

Thought

  • flight of ideas, racing thoughts, overoptimistic ideation
  • May have psychotic symptoms: grandiosity, auditory hallucination

Cognition

  • risk taking behaviour: Excessive expenditure (debts), Sexual disinhibition, Alcohol/drug use

Insight

  • Can be minimal, totally lost with psychotic symptoms
  • Reckless behaviour – spending, promiscuity, driving, violence ▪ Biological – reduced need for sleep and food
  • Difficulty completing tasks
  • Significant disruption to work, family life
59
Q

What is hypomania?

A
  • Persistent mild elevation of mood (>3d)
  • More than 3 characteristic symptoms of mania lasting at least 3/4 days, not clearly different from normal mood (collateral hx)
60
Q

What are the signs and symptoms of hypomania?

A
  • Persistent mild elevation of mood (>3d)
  • Patient can usually still function reasonably normally
  • Increased activity and energy
  • Decreased sleep
  • Talkative, overfamiliarity
  • Increased libido
61
Q

What is a major difference between mania and hypomania (with the exception of intensity of symptoms)?

A
  • mania can have psychotic symptoms
  • once a hypomanic patient has pscyhotic symptoms. the diagnosis becomes mania
62
Q

Describe the MSE of someone in a BPAD manic episode

A
  • A: inappropriate/bright/outlandish, may be neglect of personal hygiene
  • B: increased psychomotor activity, overfamiliar, flirtatious, distractible
  • S: loud, pressure of speech, uninterruptible, flight of ideas, puns and rhymes, circumstantiality/tangentiality
  • M: elated, can quickly turn to irritability/anger
  • T: grandiose delusions (sometimes persecutory), thought disorder
  • P: auditory hallucinations, often mood-congruent
  • C: impaired attention and concentration
  • I: poor
63
Q

What investigations are required for ?BPAD?

A
  • Thorough Hx and MSE
    • Previous depression/mania
    • Risk –> suicide, spending money, promiscuity, substance misuse, self-neglect
    • Assess whether psychotic or affective symptoms are predominant (could be schizoaffective disorder)
    • Various screening tools can be used
      • Patient health questionnaire (PHQ-9) –> screen for depression
      • Mood disorder questionnaire (MDQ) –> screen for Hx of mania/hypomania
  • Exclude other causes for manic episode
    • FBC, TFTs, CRP, glucose (hyperthyroid, infection, renal failure, SLE, vit B12 and niacin deficiency)
    • UDS (substance misuse)
    • CT/MRI if indicated (trauma, SOL)
  • Pregnancy test/STI screen if necessary
64
Q

What are the differential diagnoses for acute mania?

A
  • Schizophrenia, schizoaffective, delusional disorder, psychotic disorders
  • Anxiety, PTSD
  • Circadian rhythm disorder
  • ADHD/conduct disorder
  • ETOH/Drug misuse
65
Q

What is the Tx setting for acute mania?

A
  • Usually needs inpatient admission, often under MHA
    • Esp if reckless behaviour, significant psychotic symptoms, excessive psychomotor agitation, thoughts of harm to self/others
66
Q

What is the pharmacological Tx for an acute manic episode?

A
  • Antipsychotics
    • 1st line: Olanzapine, aripiprazole, quetiapine, risperidone
    • For rapid control of acute behavioural disturbance
    • IM for agitation; oral if milder
  • Benzodiazepine e.g. lorazepam
    • Adjunct for agitation
  • Mood stabilisers e.g. lithium
    • Take longer (3-7d) to achieve therapeutic effect
  • Discontinue antidepressants (may need to be gradual) – as they can cause mania
67
Q

When should a manic patient be admitted to secondary care?

A
  • high risk of suicide/homicide,
  • severe psychotic/mania/depressive symptoms,
  • severe cycling,
  • catatonic symptoms
68
Q

What is the pharmaceutical Tx for a severe behavioural disorder in BPAD?

A

haloperidol and clonazepam

69
Q

What is the Tx for Treatment of acute depression in the context of bipolar?

A
  • Co-prescribe antidepressants with anti-manic agent to avoid precipitating a manic episode
  • Only prescribe antidepressants for moderate-severe episodes
  • Start dose low and increase gradually
  • SSRIs are first line, quetiapine can be considered if not already on an antipsychotic
  • Long-term antidepressants should be avoided à gradual discontinuation once depression has been in remission for 8 weeks
70
Q

What is the Prophylactic Tx for BPAD?

A
  • Most clinicians think that one episode of mania is an indication for prophylactic treatment; others treat if manic episode had severe consequences or patient has also had another disordered mood episode
  • Mood stabilisers:
    • Treatment for at least 2yrs is recommended
    • Lithium and sodium valproate are the main treatments
      • Contraception for females; valproate is the most teratogenic (avoid if possible in females)
      • Monitoring (lithium levels, hepatic/renal function in valproate)
      • Rapid-cycling bipolar responds better to valproate than lithium
      • If ineffective, consider switching (or trying olanzapine)
      • NB lithium can be harmful if taken for <2yrs (discontinuation can cause mania) à not advisable to start in patients who are unlikely to adhere to long-term treatment
    • Olanzapine is being increasingly used for prophylaxis
      • Monitor for metabolic syndrome
    • Carbamazepine
      • Can be used as an adjunct if above are not effective
    • Lamotrigine
      • 1st line if depression is the more predominant feature
    • ECT
      • If no response to pharmacotherapy or very severe depressive symptoms or mixed states
      • May precipitate mania
    • Regular monitoring and enhancing adherence
71
Q

What are the complications of BPAD?

A
  • Suicide (10%)
  • Alcohol and substance misuse
  • Non-compliance with prophylaxis
    • Often due to SEs or prolonged period of well-being
    • Abrupt withdrawal of a mood stabiliser has a high risk of mania/depression à 50% relapse within 5 months if lithium is stopped
  • 5-15% develop rapid-cycling à poor prognosis
72
Q

What is the prognosis of BPAD?

A
  • >90% of patients who have a single manic episode go on to have future episodes
  • Most relapses are related to poor compliance
  • Predictors of poor outcome: early onset of illness, poor compliance, persistent depressive symptoms, severe mania, co-morbid personality disorder, substance misuse, rapid-cycling
73
Q

What is cyclothymia? Describe it

A
  • Persistent instability of mood involving numerous periods of depression and mild elation, none of which is sufficiently severe or prolonged to justify a diagnosis of bipolar or recurrent depressive disorder
  • Lifetime risk 0.5-1%; M=F; average onset is adolescence/early adulthood
  • Common in relatives of people with BAD
  • Management:
    • May benefit from same treatment as bipolar
    • Use antidepressants with caution (risk of mania)
    • Psychological therapy
74
Q

What is dysthymia? Describe it

A
  • Chronic depression of mood, lasting several years, which is not sufficiently severe or individual episodes are not sufficiently prolonged to justify a diagnosis of recurrent depressive disorder
  • Lifetime risk of 3-6%; M>F; onset in childhood/adolescence/early adulthood
  • Management:
    • Similar to depression
    • Psychological therapy

1 - Y5 Psych (23 decks)

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