Management of Mood Disorder Flashcards
what are the four scales used to assess progress in mood disorders
inventory of depressive symptomatology self report 30 (IDS-30-SR): patient rated, very detailed
quick inventory of depressive symptomatology self report (QIDS): shorter more simple questions
hospital anxiety and depression scale: 14 items, easy to complete
montgomery- asberg rating scale (MADRAS): 10 items, observers rated, objective (good if patient cant communicate/ complete form/ lacks insight)
(can also use symptom diaries)
are antidepressants addictive
no
are antidepressant effective
yes
does continued antidepressant use reduce relapse rates
yes
this isnt a question by If someone has responded to a particular type of drug (e.g. SSRI), stick to that class
:)
what is sertraline and what is it good for
SSRI
has good cardiac safety - give if patient has/ is prone to heart problems (old)
what is mirtazapine and what is it good for
atypical antidepressant (mixed receptor effect) promote sleep and appetite/ weight gain
what is venlafaxine and what is it good/ bad for
SNRI
high rate of adverse effects but may be slightly more effective
what are the top 4 antidepressants
escitalopram (SSRI)
sertraline (SSRI)
mirtazapine (atypical)
venlafaxine (SNRI)
what should you consider if antidepressents dont work
concordance right diagnosis? substance missuse physical illness address other predisposing, precipitating and prolonging factors
what pharmacological changes can you make if an antidepressant doesnt work
increase dose
swap
combine- SSRI/SNRI plus mirtazapine (atypical)
augment- antipsychotic/ lithium first
what are the features of good antidepressant prescribing
Get ratings of depressive symptoms before and after each trial (e.g. PHQ-9)
Warn patients about possible side effects and the probability that they will be transient
Review after 1-2 weeks
Ensure adequate dose for adequate time
how do you prevent depression relapse after first episode
continue antidepressant for at least 6 months after full recovery without reducing dose
how do you prevent depression relapse after second episode/ more
continue antidepressant for at least 1-2 years after full recover without reducing dose
what is the treatment principles for acute mania/hypomania
maximise antimanic dose if patient already on them
stop antidepressants
combination therapy may be required
hospital admission likely to be required in mania
medication should be oral if possible
what is the treatment for acute mania
1st line= antipsychotic: olanzapine, quetiapine or risperidone
other options: lithium, valproate, carbamazepine, ECT
benzodiazepines/ Z drugs for symptoms control (agitation and insomnia)
what are the principles of treating acute bipolar depression
antidepressants should not be prescribed without an antimanic drug
avoid antidepressants in those with a recent manic/ hypomanic episode or history of rapid cycling
SSRIs (esp fluoxetine) are preferable
what is rapid cycling
at least 4 episodes per year (bi polar disorder)
what treatment for acute bipolar depression
antipsychotic 1st line: quetiapne, olanzapine
antidepressants can be used alongside antipsychotic, lithium or valproate to prevent mania
lamotrigine (needs to be titrated)
ECT
lithium
what is gold standard for long term bipolar maintenance
lithium
what are the other options (other than lithium) for bipolar maintenance
antipsychotics,
lamotrigine (if primarily depression),
valproate (if primarily manic/ hypomanic)
psychoeducation important
psychological therapies
what do you need to measure when prescribing lithium
lithium levels in blood U&Es ECGs TFTs calcium
what do you need to consider in prescribing for the elderly
want to preserve cognition
prevent falls- least sedative/ postural hypotension causing (mirtazopine)
sodium (SSRIs and SNRIs lower sodium) (mirtazopine good at not doing this aswell)
polypharmacy- lithium cannot be given with an NSAID or an ACEi)
start slow and titrate up
what does ECT do
induces seizures causes release of NTs and causes brain growth anticonvulsant effects reduces hyper-connectivity
what is patient given during ECT
under GA and given a muscle relaxant
given medazolam if seizure lasts too long
what is ECT used to treat
#1 depression bipolar disorder, mania, catatonia
how is ECT given
twice weekly
80% bilateral
seizures last 15-30 seconds
recovery is within minutes
what are the absolute and relative contraindications to ECT
absolute: recent MI (last 3 months), recent cerebrovascular accident, intracranial mass lesion, phaeochromocytoma
relative:
angina, congestive HF, severe pulmonary disease, severe osteoporosis, pregnancy
what most likely causes death in ECT
very rare
cardio/ pulmonary complications
what are the side effects of ECT
usually mild, self limiting and respond to symptomatic treatment
- HA
- memory problems (short term, time before treatment, small number have permanent memory loss)
- cognitive problems
- muscle aches
- confusion
- nausea
in pyschological therapies what are examples of thinking errors
Overgeneralising
Rules from isolated incidents then applied in all cases
Dichotomous thinking
“all or nothing” or “black and white thinking”
Selective abstraction
Focus on one –ve detail; colours entire experience
Personalisation- Relate external events to self without cause (or little cause)
Minimisation or magnification- overestimate magnitude of undesirable events (or opposite)
Arbitrary evidence- Draw a conclusion in context of no evidence or contrary evidence
Emotional Reasoning-I feel bad/guilty/therefore I am bad/have something to feel guilty about
Shoulds and musts
what are examples of pyschological therapies
behavioural activation (more you do the better youll feel- meaningful activities)
cognitive behavioural analysis system of pyschotherapy (impact of three people on your life)
interpersonal therapy
acceptance and commitment therapy
psychoeducation
what are the risks associated with mood disorders
suicide financial difficulties driving aggression sexual disinhibition self harm neglection of personal health vulnerable to exploitation
what symptoms are SNRIs good for
biological symptoms- anergia, sleep, libido
why are tricyclics unpopular
anticholinergic side effects
risk of overdose
what is the order of prescribing antidepressants
fluoxetine 1st line (SSRI) (only licensed antidepressant for young people)
other SSRI
after 2 SSRIs SNRI
then tricyclic
what is a bad quality of fluoxetine
long half life, if coming off because of SEs will have them for ages after
when should you start to feel effects of antidepressants
within 10 days/ 2 weeks
max effect at 4 weeks
what is the maximum dose of fluoxetine
60 mg
if <18 then 20 mg
what are points of good sleep hygiene
routine- always go to bed at same time, avoid caffeine, alcohol, cigarettes, hot chocolate
what can you combine antidepressants with to treat depression
SSRI/ tricyclic + SNRI
or antidepressant with atypical antipsychotic
what is the last resort treatment for depression
ECT
if lithium is not tolerated for bi polar what else can given
Antipsychotics (quetiapine, olanzapine (significant weight gain), lurasidone, aripiprazole),
anticonvulsants:
lamotrigine (if primarily depression), valproate (if primarily manic/hypomanic- but teratogenic), carbamazepine
