Gargi's & Emma's notes - Affective Disorders Flashcards
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
2
Q
Define the depression triad
A
Triad of
- low mood,
- anhedonia (loss of enjoyment in previously enjoyable activities),
- low energy/increased fatiguability.
Depression is a unipolar affective disorder
3
Q
What are the causes of depression?
A
4
Q
What are the risk factors for depression?
A
5
Q
What is Beck’s cognitive triad?
A
negative views about self (worthlessness) = world (helplessness) = future (hopelessness)
6
Q
What are the core features of depression (ICD-10)?
A
low mood, low energy, anhedonia lasting 2 or more weeks
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
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
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
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
11
Q
What are the subtypes of depression?
A
12
Q
What is the mneumonic for MMSE?
A
ASEPTIC
A ffect
S peech
E ffect
P sychosis
T houghts
I
C ognition
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
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
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)
16
Q
When must a depressed patient be referred to secondary psych?
A
high suicide risk, severe depression, unresponsive to tx
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
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)
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
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*
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
22
Q
How do you treat the initial presentation of severe depression?
A
= high intensity therapy AND antidepressant,
treat until no longer depressed
23
Q
What must be done if there is no positive impact of antidepressants?
A
check compliance, SE before changing
24
Q
What are the side effects of SSRIs?
A
- D/V,
- weight change,
- blurred vision,
- anxiety,
- agitation,
- insomnia,
- tremor,
- dizziness,
- headache,
- sweating
25
What must be prescribed in older patients who are on aspirin or NSAIDs?
* **gastroprotective (PPI)** - risk of GI bleeding
* also risk in older patients
26
Must antidepressant Tx be continued after symptom remission?
yes (6 months)
27
What are some psychotic symptoms seen in depression?
* 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
28
What are the complications of depression?
* Social isolation, unemployment
* Self-harm, suicide
* Substance misuse
* SEs of antidepressants (incl unmasking mania)
29
What is the prognosis of depression?
* 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
30
When is pscychological advice indicated in depressed patients?
* 1st line for mild depression,
* In combination with drug treatments for moderate-severe depression
31
Which psychological Txs are useful in depression?
* CBT (may be self-help or individual, depending on severity)
* Mindfulness-based cognitive therapy
* Interpersonal therapy
* Family and marital therapy
* Psychodynamic therapy
32
When is drug Tx required in depression?
* For moderate-severe depression
* OR milder depression not responsive to psychological therapy alone
33
What must patients be warned/counselled of before starting SSRIs?
* anxiety/suicidal thoughts at first
* Warn patients of gradual development of full anti-dep effect
* Continue treatment after remission
* Non-addictive
34
What should be prescribed next if there is no response to SSRIs for depression?
* Change to another SSRI
* try TCA/different class
* augment another antidepressant/antipsychotic (e.g. quetiapine)/lithium
35
What may be prescribed prophylactically if there are multiple episodes of depression?
SSRIs
36
What should a depressed patient be prescribed if they express psychotic symptoms?
antipsychotics
37
When is ECT indicated in depression?
* 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
What is the Tx for initial presentation of moderate depression?
**high-intensity therapy** (individual CBT, interpersonal therapy, couple behavioural therapy, behavioural activation
39
What is the Tx for initial presentation of severe depression?
**high-intensity therapy** (individual CBT, interpersonal therapy, couple behavioural therapy, behavioural activation) AND **antidepressant**,
## Footnote
*treat until no longer depressed*
40
What must you do if patient is non-responsive to antidepressant?
* check compliance & SE
* before changing
41
Can antidepressants be stopped suddenly?
* Antidepressants cannot be stopped suddenly
* need to wean over weeks
42
When is a secondary care pscyh referral indicated?
* high suicide risk
* severe depression
* unresponsive to tx
43
What is the definition of bipolar affective disorder?
* 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
Name the types of BAD
* Type 1
* Type 2
* Rapid-cycling
* *repeated episodes* o*f mania/hypomania (with no depression)*
45
What is Type 1 BAD?
* manic episodes interspersed with depressive episodes
* At least 1 manic episode
46
What is Type 2 BAD?
* 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
What is Rapid-cycling BAD?
4 or more affective episodes in a year
48
What is a mixed episode of BPAD?
manic/hypomanic and depressive symptoms in a single episode,
present every day for at least 1 week
49
What is Ultra rapid cycling BPAD?
fluctuations over days or even hours
50
Are repeated episodes of mania/hypomania (with no depression) also classified as BAD?
Yes
51
What is the biological aetiology of BAD?
* **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
What is the biological cause of mania?
* Increased adrenaline, NA, dopamine, serotonin → mania
53
What are the risk factors for rapid cycling BAD?
female sex
54
What is the social aetiology of BAD?
* Most important environmental RF is **childbirth** --\> 50% risk of mania post-partum in untreated bipolar
* **Stress** can trigger manic episodes
55
What is the epidemiology of BAD?
* 1% prevalence
* Average age of onset is 20yo; usually presents with mania
* M:F equal
* Rapid cycling BAD is more common in F
56
What are the symptoms of BAD?
* **mania/hypomania** episodes
* **depressive** episodes
57
What is mania?
* Elevated mood (or irritability) lasting \>1wk duration with complete disruption of work and social life
58
What are the signs and symptoms of mania?
**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
What is hypomania?
* 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
What are the signs and symptoms of hypomania?
* Persistent mild elevation of mood (\>3d)
* Patient can usually still function reasonably normally
* Increased activity and energy
* Decreased sleep
* Talkative, overfamiliarity
* Increased libido
61
What is a major difference between mania and hypomania (with the exception of intensity of symptoms)?
* mania can have psychotic symptoms
* once a hypomanic patient has pscyhotic symptoms. the diagnosis becomes mania
62
Describe the MSE of someone in a BPAD manic episode
* 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
What investigations are required for ?BPAD?
* **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
What are the differential diagnoses for acute mania?
* Schizophrenia, schizoaffective, delusional disorder, psychotic disorders
* Anxiety, PTSD
* Circadian rhythm disorder
* ADHD/conduct disorder
* ETOH/Drug misuse
65
What is the Tx setting for acute mania?
* Usually needs **inpatient admission**, often under MHA
* Esp if reckless behaviour, significant psychotic symptoms, excessive psychomotor agitation, thoughts of harm to self/others
66
What is the pharmacological Tx for an acute manic episode?
* 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
When should a manic patient be admitted to secondary care?
* high risk of suicide/homicide,
* severe psychotic/mania/depressive symptoms,
* severe cycling,
* catatonic symptoms
68
What is the pharmaceutical Tx for a severe behavioural disorder in BPAD?
haloperidol and clonazepam
69
What is the Tx for Treatment of acute depression in the context of bipolar?
* 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
What is the Prophylactic Tx for BPAD?
* *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
What are the complications of BPAD?
* 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
What is the prognosis of BPAD?
* \>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
What is cyclothymia? Describe it
* 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
What is dysthymia? Describe it
* 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
