Management of Mood Disorders Flashcards
what is inventory of depressive symptomatology ?
scale used to tell whether treatment is working for mood disorder
patient rated scale with 30 items
who is IDS best for?
treatment resistant
not so depressed that they cant find the energy to fill it out
determined to find help/cure
what is QIDS?
quick inventory of depressive symptomatology
16 item self reporting scale for effectiveness of mood treatment
- like IDS but only the more important questions
what is the hospital anxiety and depression scale?
14 item self rated scale
easy to complete/administer
what is the MADRS?
Montgomery-asberg rating scale
10 item observer rated scale
highly sensitive to change and more objective as mot self rated
how can mood be monitored?
mood diary - on paper, website or app etc
are antidepressants more effective in maintenance or in acute treatment?
maintenance
what is ECT?
electro-convulsive therapy
do antidepressants prevent relapse?
reduce chance of relapse by 70%
how long are antidepressants effective for?
around 36 months
the longer you take them, the greater the relative reduction in relapse
how can you choose an antidepressants?
go back to the same drug if they have responded to that particular drug in the past (or a particular class - SSRIs etc)
match side effects to symptoms
patient preference
what are the top 4 antidepressants?
escitalopram - best all round SSRI
sertraline - good cardiac safety and easy dose titration (good for older people)
mirtazapine - promotes sleep and appetite/weight gain (good for certain people)
venlafaxine (good dose-response relationship but higher adverse effects)
what may cause medication not to work?
medication concordance is the diagnosis right? substance misuse physical illness any other predisposing, precipitating or prolonging factors
what can you do if antidepressant isn’t working?
increase dose
swap
combine - usually SSRI/SNRI + mirtazapine
augment - antipsychotic or lithium first
how do you start antidepressants?
get ratings of symptoms
warn patents about side effects
review after 1-2 weeks
ensure adequate dose for adequate time (at least 6 weeks?)
how long should antidepressants be given?
after first episode - continue until full recovery for at least 6 months
2nd or more episode - continue until well for at least 1-2 years
how is acute mania/hypomania managed?
maximise antimanic dose if patient is already on maintenance treatment
stop antidepressants
may need combination therapy
hospital admission if needed
prescribing in acute mania?
1st line = antipsychotic (olanzapine, quetiapine or risperidone)
other options = lithium, valproate, carbamazepine, ECT (but more for maintenance)
should be oral if possible but IM if needed
benzodiazepines can be used for symptoms control
what are the principles of acute bipolar depression management?
antidepressants should not be prescribed without anti-manic drug
avoid antidepressants in those with recent manic/hypomanic episode or history of rapid cycling
SSRIs probably best
what is prescribed in bipolar depression?
1st line = antipsychotic (quetiapine, alanzapine, lurasidone)
antidepressants can be used alongside antipsychotic, lithium or valproate
lamotrigine can be used but takes time to titrate
ECT
lithium
what is the gold standard treatment for bipolar maintenance?
lithium
what antipsychotic is used if primarily depressive or manic/hypomanic?
depressive = lamotrigine manic = valproate
lithium monitoring?
lithium level (weekly until titrated, then 3 monthly) check cardiac, renal, thyroid function, BMI, elctrolytes and FBC before starting treatment) check eGFR, electrolytes, thyroid function and BMI every 6 months
how is ECT given?
usually given twice weekly in the UK
most people are inpatients at time of treatment
majority receive bilateral ECT but it can also be given unilaterally
dose of electricity is titrated to each patient to achieve a seizure lasting typically 15-20 seconds
quick recovery - within mins
bilateral vs unilateral ECT?
bilateral = more common, quicker, more effective but more likely to cause cognitive problems unilateral = more difficult, lower doses needed, high dose unilateral can be as effective as bilateral
4 absolute contraindications to ECT?
recent MI
recent cerebrovascular accident
intracranial mass lesion
phaeochromocytoma
relative contraindications to ECT?
angina CHF severe pulmonary disease severe osteoporosis pregnancy
what are the risks in ECT?
cardio and pulmonary complications most common cause of death
but non-treatment can be more dangerous (suicide risk in severe, severe depression)
physical side effects of ECT?
most have at least 1 physical side effect but generally mild, self limiting and respond to symptomatic treatment
e.g headache, muscle aches, nausea, cardio etc
cognitive side effects of ECT?
short term memory impairment
memory loss most accentuated for time period closest to treatment (sparing of remote memories)
no effect on ability to learn new information
no effect on non-cognitive memory
memory recovers in most at around 2 months but some have permanent memory loss
why is it difficult to determine cognitive effects of ECT?
as the depressive illness itself can cause cognitive effects
- I.e patients with severe depressive illness have impaired cognition on recovery from illness even if not treated with ECT
memory problems are just as likely to be due to ongoing psychiatric disturbance
how does ECT work?
63% overall and 85% of most severe patients showed at least 50% reduction in MADRS score after treatment
only 10% showed no improvement
what is the most common form of psychotherapy?
cognitive behavioural therapy
what 3 areas does CBT target?
altered thinking
altered feelings
altered behaviour
examples of altered thinking (NATs)
overgeneralising
dichotomous thinking (all or nothing/black and white)
selective abstraction (focus on one -ve detail)
personalisation (relate external events to self)
minimisation/magnification
arbitrary evidence
emotional reasoning
shoulds and musts
examples of psychotherapy?
behavioural activation CBASP interpersonal therapy acceptance and commitment therapy psychoeducation
risk management in mood disorders?
self harm/suicide finances vulnerability to be taken advantage of etc driving (cant drive if manic) risk taking behaviour patient's own dependants (children etc) diet/nutrition self care
main effects of ECT on CNS?
modulation of monoamines
potent anticonvulsant effects
second messenger systems
reduces hyperconnectivity in frontal and limbic circuits
bolsters neuronal survival
promotes production of new neuronal processes in areas involving cognitive and emotional function
