Management of Mood Disorders Flashcards by Joanne McEwan

what is inventory of depressive symptomatology ?

scale used to tell whether treatment is working for mood disorder
patient rated scale with 30 items

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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

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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

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what is the hospital anxiety and depression scale?

14 item self rated scale

easy to complete/administer

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what is the MADRS?

Montgomery-asberg rating scale
10 item observer rated scale
highly sensitive to change and more objective as mot self rated

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how can mood be monitored?

mood diary - on paper, website or app etc

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are antidepressants more effective in maintenance or in acute treatment?

maintenance

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what is ECT?

electro-convulsive therapy

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do antidepressants prevent relapse?

reduce chance of relapse by 70%

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how long are antidepressants effective for?

around 36 months

the longer you take them, the greater the relative reduction in relapse

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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

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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)

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what may cause medication not to work?

medication concordance 
is the diagnosis right?
substance misuse 
physical illness
any other predisposing, precipitating or prolonging factors

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what can you do if antidepressant isn’t working?

increase dose
swap
combine - usually SSRI/SNRI + mirtazapine
augment - antipsychotic or lithium first

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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?)

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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