Management of Mood Disorders Flashcards
In IDS-30-SR, energy levels can be graded from 0-3. Outline this.
0 - there is no change in my usual level of energy
1 - I get tired more easily than usual
2 - I have to make a big effort to start and finish my usual daily activities (shopping, homework, cooking, going to work)
3 - I really cannot carry out most of my normal daily activities because I just don’t have the energy
What is QIDS?
Quick inventory of depressive symtoms
Outline the different categories of symptoms of QIDS.
- Sleep
- Sadness
- Appetite
- Weight
- Concentration
- View of self
- Suicidal thoughts
- General interests
- Energy
What scale is used for those in hospital?
Depression and Anxiety Scale
Continuing treatment of depression reduces the risk of relapse by __%
70%
How long do the treatment affects of antidepressants last?
36 months
The longer you take an antidepressant, the less likely you are to relapse
T
What drug class is usually first line in treating depression?
SSRI’s
Name the top 4 antidepressants.
- Escitalopram
- Sertaline
- Mitrazapine
- Venlafaxine
What does Mirtazapine promote that most other antidepressants don’t?
Promotes sleep and appetite/weight gain
What is good about Sertaline?
- Good cardiac safety profile
* Allows for good dose titration
Describe Venlafaxine.
- Shows a dose-response relationship but has more side effects
If 1 antidepressant is not working, what could you do?
COMBINE - SSRI/SNRI plus mirtazapine
If an antidepressant is not working, what are all the things you should consider?
- Medication concordance
- Is the diagnosis right?
- Substance misuse
- Physical illness
- Address any other predisposing, precipitating and prolonging factors
- Dose increase
- Swap
- Combine- most common is SSRI/SNRI plus mirtazapine
- Augment- antipsychotic or lithium first
Venlafaxine is an example of an SNRI
T
What should always be done before starting someone on an antidepressant?
** Get ratings of depressive symptoms before and after starting each drug **
After starting someone on an antidepressant, when should you review them?
1-2 weeks
What should you warn patients about before starting them on an antidepressant?
Side effects
After someone has a relapse of their depression, they should take an antidepressant for at least _ months after the episode
6
Antidepressants are not associated with addiction
T
Continue medication for at least 6 months after someone has a relapse
T
How is acute mania in bipolar disorder treated?
- Increase anti-manic drug dose
* Stop antidepressant
What antipsychotics are the first line for an acute manic episode in bipolar?
- Olanzapine
- Quetiapine
- Risperidone
Aside from antipsychotics, what else can be used to manage an acute manic episode in bipolar?
- Lithium
- Valproate
- Carbamazepine
- ECT
What symptoms are BZD’s and Z drugs useful for in an acute manic episode in bipolar?
- Agitation
* Insomnia
What should you always prescribe with an antidepressant in someone with an acute depressive episode in bipolar?
Antipsychotic
What antidepressant should be prescribed in someone with an acute depressive episode in bipolar?
SSRI’s (particularly Fluoxetine)
Describe the management of bipolar depression.
1st line – Antipsychotics
- Quetiapine
- Olanzapine
- Lurasidone
+ Antidepressants (to prevent mania)
- Lithium
- Valproate
Lithium is gold standard for long term bipolar management
T
Outline how bipolar is managed long term.
LITHIUM +
- Lamotrigine if primarily depressive
- Valproate if primarily manic/hypomanic
How is ECT usually given?
Bitemporal
How does ECT work?
A dose of electricity is titrated for each patient to achieve a seizure typically lasting 15-20 seconds
ECT is usually given once weekly
F - twice weekly
In which 4 situations should you NEVER give a patient ECT?
- Recent MI (within the last 3 months)
- Recent cerebrovascular accident
- Intracranial mass lesion
- Phaeochromocytoma
In which 5 situations should you be cautious about giving a patient ECT?
- Angina
- Congestive heart failure
- Severe pulmonary disease
- Osteoporosis
- Pregnancy
** The most common side effect of ECT is headaches ** - after this there is ….
- Memory problems
- Cognitive problems
- Muscle aches
- Confusion
- N+V
Short term memory impairment around the time of the course of ECT is uncommon
F - this is common
Memory loss is worst from the time period surrounding their ECT treatment
T
Memory loss after ECT recovers gradually
T
In a small number of patients, ECT can result in permanent memory loss
T :(
Patients with severe depression often have impaired cognitive function and memory from the depression and not the ECT
T
In Scotland you cannot give ECT to a person who has capacity and who is refusing the treatment, even if detained under the Mental Health (Care and Treatment) (Scotland) Act 2003
T
If capacity to give consent is impaired then an independent second opinion doctor is then required before ECT can go ahead (T3 form)
T
For life saving ECT treatment, a second opinion from a doctor is still needed
F - this is not required
63% of patients overall (and 86% of most severe) showed improvement of at least a 50% reduction in MADRS scores by the end of ECT treatment
T
Outline some reasons why ECT works by altering the CNS.
- Modulation of monoamines
- Potent anticonvulsant
- Effects the second messenger system
- Reduced hyperconnectivity in the frontal and limbic circuits
- Boosts neuronal survival
- Promotes production of new neuronal processes in areas involving cognitive and emotional function
Give examples of psychotherapy (other than medication) which can be used to treat patients with depression/bipolar.
- CBT
- Behavioural activation
- Interpersonal therapy
- Psychoeducation
- Cognitive behavioural analytic system of psychotherapy
Someone with mental health issues will often have alterations in what 4 domains?
- Thinking
- Physical symptoms
- Behaviour
- Feelings
What 3 things can CBT help to alter to improve someones QoL?
- Thinking
- Behaviour
- Feelings
Overgeneralising?
Rules from isolated incidents then applied in all cases
Dichotomous Thinking?
‘all or nothing’ or ‘black and white’ thinking
Selective Abstraction
Focusing on one negative detail of a whole experience
Selective Abstraction?
Focusing on one negative detail of a whole experience
Personalisation?
Relate external events to self without cause (or little cause)
Minimisation/Magnification?
- Overestimate magnitude of undesirable events
* Underestimate magnitude of desirable events
Arbitrary Evidence?
Draw a conclusion in context of no evidence of contrary evidence
Emotional reasoning?
I feel bad/guilty therefore I must be bad/ have something to feel guilty about
