Management of Mood Disorders

Question 1

what is inventory of depressive symptomatology ?

Answer 1

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

Question 2

who is IDS best for?

Answer 2

treatment resistant
not so depressed that they cant find the energy to fill it out
determined to find help/cure

Question 3

what is QIDS?

Answer 3

quick inventory of depressive symptomatology
16 item self reporting scale for effectiveness of mood treatment
- like IDS but only the more important questions

Question 4

what is the hospital anxiety and depression scale?

Answer 4

14 item self rated scale

easy to complete/administer

Question 5

what is the MADRS?

Answer 5

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

Question 6

how can mood be monitored?

Answer 6

mood diary - on paper, website or app etc

Question 7

are antidepressants more effective in maintenance or in acute treatment?

Answer 7

maintenance

Question 8

what is ECT?

Answer 8

electro-convulsive therapy

Question 9

do antidepressants prevent relapse?

Answer 9

reduce chance of relapse by 70%

Question 10

how long are antidepressants effective for?

Answer 10

around 36 months

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

Question 11

how can you choose an antidepressants?

Answer 11

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

Question 12

what are the top 4 antidepressants?

Answer 12

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)

Question 13

what may cause medication not to work?

Answer 13

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

Question 14

what can you do if antidepressant isn’t working?

Answer 14

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

Question 15

how do you start antidepressants?

Answer 15

get ratings of symptoms
warn patents about side effects
review after 1-2 weeks
ensure adequate dose for adequate time (at least 6 weeks?)

Question 16

how long should antidepressants be given?

Answer 16

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

Question 17

how is acute mania/hypomania managed?

Answer 17

maximise antimanic dose if patient is already on maintenance treatment
stop antidepressants
may need combination therapy
hospital admission if needed

Question 18

prescribing in acute mania?

Answer 18

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

Question 19

what are the principles of acute bipolar depression management?

Answer 19

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

Question 20

what is prescribed in bipolar depression?

Answer 20

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

Question 21

what is the gold standard treatment for bipolar maintenance?

Answer 21

lithium

Question 22

what antipsychotic is used if primarily depressive or manic/hypomanic?

Answer 22

depressive = lamotrigine
manic = valproate

Question 23

lithium monitoring?

Answer 23

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

Question 24

how is ECT given?

Answer 24

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

Question 25

bilateral vs unilateral ECT?

Answer 25

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

Question 26

4 absolute contraindications to ECT?

Answer 26

recent MI
recent cerebrovascular accident
intracranial mass lesion
phaeochromocytoma

Question 27

relative contraindications to ECT?

Answer 27

angina
CHF
severe pulmonary disease
severe osteoporosis
pregnancy

Question 28

what are the risks in ECT?

Answer 28

cardio and pulmonary complications most common cause of death
but non-treatment can be more dangerous (suicide risk in severe, severe depression)

Question 29

physical side effects of ECT?

Answer 29

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

Question 30

cognitive side effects of ECT?

Answer 30

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

Question 31

why is it difficult to determine cognitive effects of ECT?

Answer 31

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

Question 32

how does ECT work?

Answer 32

63% overall and 85% of most severe patients showed at least 50% reduction in MADRS score after treatment
only 10% showed no improvement

Question 33

what is the most common form of psychotherapy?

Answer 33

cognitive behavioural therapy

Question 34

what 3 areas does CBT target?

Answer 34

altered thinking
altered feelings
altered behaviour

Question 35

examples of altered thinking (NATs)

Answer 35

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

Question 36

examples of psychotherapy?

Answer 36

behavioural activation
CBASP
interpersonal therapy
acceptance and commitment therapy
psychoeducation

Question 37

risk management in mood disorders?

Answer 37

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

Question 38

main effects of ECT on CNS?

Answer 38

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