Management of mood disorders Flashcards
What scales are used to assess depression?
IDS-30-SR (30 question patient related scale)
QIDS (shorter version of ADS-30-SR which assesses biological symptoms)
HADS
MADRS
Which is the best all round SSRI?
Escitalopram
Why is sertraline used in the older population?
Good cardiac safety profile
Easy dose titration
What are the benefits of mirtazapine?
Promotes sleep and appetite/weight gain
What should you think about if antidepressants aren’t working?
Medication concordance Right diagnosis? Substance misuse Physical illness Any other predisposing, precipitating and prolonging factors
What should be tried medication wise if antidepressants aren’t working?
Dose increase; there is a dose response relationship with ADs
Swap
Combine; SSRI/SNRI plus mirtazapine
Augment; antipsychotic or lithium
What should be assessed before ADs are started?
Ratings of depressive symptoms using clinical scales
Warn pts about side effects but the probability that they will be transient
Review after 1-2 weeks
What constitutes a trial of ADs?
6 weeks in adults
8 weeks in elderly
What is treatment resistant depression?
2 adequate trials of 2 different antidepressants
What treatment should be given to prevent relapse in the 1st episode of depression?
Continue AD fo at least 6 months after full recovery without reducing the dose
What should be done for relapse prevention after 2 or more depressive episodes?
Continue AD for at least 1-2 years after full recovery without reducing dose
What are the principles of managing acute mania/hypomania?
Maximise antimanic dose if already on maintenance
ADs should be discontinued
Combo therapy may be required
Hospital admission likely to be required if mania
What is 1st line in management of acute mania?
Antipsychotic; olanzapine, quetiapine or risperidone
What are 2nd line options in the management of acute mania?
Lithium
Valproate
Carbamazepine
ECT
When will benzodiazepines be used in acute mania?
Symptom control; agitation and insomnia
What are the principles of management of acute bipolar depression?
ADs should NOT be prescribed without an antimanic drug
Avoid ADs in those with a recent manic/hypomanic episode or history of rapid cycling
SSRIs (particular fluoxetine) preferable to other classes
What is the 1st line treatment for bipolar depression?
Antipsychotic; quitipanie, olanzapine or lurasidone
Can you prescribe an AD by itself in bipolar disorder?
No; can be used alongside an antipsychotic, lithium or valproate, lamotrigine, ECT (to prevent mania)
What is the gold standard for long term maintenance of bipolar disorder?
Lithium
When should you prescribe lamotrigine in bipolar maintenance?
If primarily depression
When should you prescribe valproate in bipolar maintenance?
If primarily manic
What needs to be done when patients are on lithium?
Monitor levels; very narrow therapeutic range U+Es ECG TFTs Calcium NEED to stay hydrated
What are common side effects of SSRIs?
Postural hypotension
Falls common
Which drugs are an absolute CI to the prescription of lithium?
NSAID
ACEi
What is the basis of ECT?
Under GA
Induces seizures for 20-30 seconds
If prolonged give midazolam
For what conditions is ECT indicated?
Bipolar depression
Bipolar mania
Resistant catatonia
How is ECT given?
Twice weekly
Bitemporal
Absolute CI to ECT?
Recent MI (within 3 months)
Recent cerebrovascular accident
Intracranial mass lesion
Pheochromocytoma
Relative CI to ECT?
Angina pectoris Congestive heart failure Severe pulmonary disease Severe osteoporosis Pregnancy
Physical side effect of ECT?
Headache Memory problems Cognitive problems Muscle aches Confusion Nausea Acute confusion Cardiovascular Manic mood swings Anaesthetic complication Prolonged seizure Cerebrovascular
How does ECT work?
Not sure
Turns down an overactive connection between the limbic system and the prefrontal cortex
Bolsters neuronal survival
Promotes a production of new neuronal processes in areas involving cognitive and emotional function
What are the different types of psycho behavioural therapy
CBT Cognitive Behavioural Analysis System of Psychotherapy Interpersonal therapy Acceptance and commitment therapy Psychoeducation
What are the risks associated with mood disorders?
Self harm and suicidal ideation Financial difficulties; erratic overspending; time off work Neglect Driving; can't drive if manic Aggression Sexual disinhibition if manic Child protection Criminal justice system Assaulted
What are predisposing factors to mood disorders?
Genetics Attachment problems as a child Sources of negative schema Childhood trauma TBI Intellectual disability
What are precipitating factors for mood disorders?
Recent trauma Positive change Stress Childbirth Hormonal imbalance New medications (never prescribe tramadol in elderly) Sleep disturbance Change of social rhythms
What are prolonging factors to mood disorders?
Illness related
Distressed as being held under MHA
Worried about job security
Substance misuse
What are protective factors to mood disorders?
Friends
Family
Religion
Meaningful activities
