Management of Mood Disorders Flashcards
What scales can be used to assess patients mood to say that treatment is working?
- Inventory of Depressive Symptomatology (IDS 30 Qs)
- Quick Inventory of Depressive Symptomatology (QIDS 16 Qs)
- Hospital Anxiety and Depression Scale 14 Qs
- Montgomery-Asberg Rating Scale (MADRS) - 10 item observer rated scale
Why is it useful for people to use a mood diary?
Allows doctor to see how patient has been over the past months/weeks NOT just on the day of the consultation
Also allows patient to log their symptoms and exercise
What apps and websites can patients use to log their mood diary?
Medhelp.com survey
Daylio (App)
Bipolar Disorder Research Network- weekly QIDS and Altman surveys
What myths about antidepressants are held by the population?
- overprescribing
- addictive
- dont work - exercise/ eating well is better
All antidepressant drugs are favoured more than placebo on Forest Plot. TRUE/FALSE?
TRUE
=> they DO work
How effective are antidepressants for maintenance treatment versus acute treatments?
More effective for maintenance
Lithium is very effective for bipolar maintenance treatment. TRUE/FALSE?
TRUE
Relapse rate with antidepressants decreases. TRUE/FALSE?
TRUE
Why have SSRI antidepressants become more widely prescribed?
GPs more likely to prescribe them
Stigma for patients has decreased
side effect profile lower than other antidepressants
Why is sertraline used in older patients?
Cardiac safety
What are the main 2 side effects of mirtazapine, and why may they not be suitable for some depressive patients?
Sedation and weight gain
may not be suitable if patient is already excessively eating/sleeping
Why are venlafaxine and mirtazapine often given in combination?
Acute depression treatment
What questions should you be asking if medication is not working for a patient?
- Medication concordance?
- diagnosis right?
- Substance misuse
- Physical illness
- Address any other predisposing, precipitating and prolonging factors
What can doctors DO if the medication they have prescribed is not working?
Dose increase
Swap
Combine- most common is SSRI/SNRI plus mirtazapine
Augment- antipsychotic or lithium first
What should be done when starting a patient on a new antidepressant?
- Get ratings of depressive symptoms before and after trial of medication
- Warn patients about possible side effects
- Review after 1-2 weeks
- Change after 4-6 weeks
How long should an antidepressant be continued after the first major depressive episode ?
At least 6 months after full recovery
How long should treatment be continued after two or more major depressive episodes?
At least 1-2 years after full recovery without reducing dose
some patients may require lifelong
What are the main principles of acute hypomania/mania treatment?
- Increase to anti-manic dose if patient already on maintenance treatment
- Antidepressants should be discontinued
- Combination therapy
- Hospital admission if mania
What antipsychotics are first line in anti-mania prescribing?
olanzapine, quetiapine or risperidone
What agents other than antipsychotics can be used in acute mania prescribing?
lithium
valproate
carbamazepine
ECT
Medication should be oral if possible in acute mania prescribing. TRUE/FALSE?
TRUE
BUT if patient is detained under mental health act then IM medication may be needed
When are benzodiazepines used in acute mania?
For symptom control e.g. agitation and insomnia
What are the main 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 (particularly fluoxetine) preferable to other classes
Lithium is gold standard long term treatment for bipolar maintenance. TRUE/FALSE?
TRUE
What is meant by the recovery model?
Helping patients to make the most of life regardless of whether their mental health problems are present/absent
What seasons show a peak in mood disorders?
Spring and Autumn
What is meant by Rapid Cycling and what medication is best used to treat this?
4 different mood episodes in one year
SSRIs useful - escitalopram = purest form of SSRI
What should be monitored when a patient is on lithium?
Lithium levels U&Es ECG TFTs (check pt is not hypothyroid) Ca2+ (check pt is not hypoparathyroid) Check patient is not dehydrated
Name some of the common side effects of lithium
GI upset
Metallic taste
Tremor
Exacerbation of skin conditions
Why should tricyclics possibly be avoided in older patients?
Can decrease cognition
ALSO cause sedation (can precipitate falls)
What SSRI should be used if a patient is prone to falling?
Mirtazapine
as other SSRIs can cause postural hypotension
What types of drugs should lithium NOT be combined with?
NSAIDs
ACEi
What is electroconvulsive therapy?
Electrical shockwaves administered to brain whilst patient is under general anaesthetic and a muscle relaxant
Causes a 20-30 second seizure
Aims to decrease overactivity between limbic system and areas of the prefrontal cortex
What can be used to reverse an ECT seizure that continues for too long?
Midazolam
What condition is ECT used to treat most?
Recurrent Depressive Disorder without Psychosis
How often are patients usually treated with ECT?
Twice a week
6-12 sessions usually required for full effect
Is ECT conducted unilaterally or bilaterally?
Usually always bilaterally
When is ECT deemed to be “safer” than medications?
In an acute scenario where waiting on medications to work would take too long
ECT can cause cognitive side effects. TRUE/FALSE?
TRUE
- short term
- closer to time of treatment
How is a patient monitored during ECT?
EEG (to see start and end of seizure)
ECG
What are the ABSOLUTE contraindications for ECT?
- Recent MI (within last 3 months)
- Recent cerebrovascular accident
- Intracranial mass lesion
- Phaeochromocytoma
What other contraindications may be considered for ECT?
- Angina
- Congestive heart failure
- Severe pulmonary disease
- Severe osteoporosis
- Pregnancy
2/3 of patients experience at least 1 mild physical side effect after ECT. TRUE/FALSE?
TRUE
e.g. headache, memory loss etc
Give examples of “thinking errors” which Cognitive Behavioural Therapy attempts to overcome?
- Overgeneralising
- Dichotomous thinking (black and white thinking)
- Selective abstraction (Focus on one –ve detail)
- Personalisation (Relate events to self)
- Minimisation or magnification
- Arbitrary evidence
- Emotional Reasoning (I feel bad/guilty)
What is meant by “dysfunctional assumptions” which CBT attempts to overcome?
- Pt feels that accepting help makes them look weak
- “If i cant do something perfectly, why attempt it at all?”
What is the aim of Cognitive behavioural analysis system of psychotherapy (CBASP)?
Talking therapy like CBT
- Uses influential people to help patient learn from experiences with these people
- Situational analysis where patient was stressed/ upset, revisit and plan how patient would achieve their desired outcome
What is discussed during Interpersonal Therapy?
Focus on patients relationships
- if older, patient may have struggled with children leaving home
What is the aim of acceptance and commitment therapy?
Acceptance of unpleasant thoughts coming
Learning how to stand back and observe/ analyse these thoughts?
What should be considered when doing a risk assessment of a patient?
Suicide Self harm financial difficulty neglect not seeking attention for physical health problems inappropriate sexual behaviour
Why may patients who experience mania need a power of attorney?
Financial needs - incase they end up manically spending money
What are the predisposing factors for most mood disorders?
aka things from previously in life that may NOW play a part
Genetics
Disrupted parental attachments
Chronic health problems during childhood
Trauma as a child
What are the precipitating factors of mood disorders?
aka current factors which contribute to patients mood
Recent trauma
stress (moving house, changing job)
New medications
Sleep disturbance (night shift)
What prolonging factors can affect mood disorders?
aka things which occur during depressive episode that can make it last longer
- Distress whilst staying on ward
- detained under mental health act
- substance misuse during depressive episode
Who and what can act as support for patients with mood disorders?
Friends and family
Religion
Enjoyable activities
ECT can be given in an outpatient setting. TRUE/FALSE?
TRUE
- especially for patients requiring maintenance therapy but do not need admission to hospital
