Mental Health: Affective disorders 2 Flashcards
What is depression?
A mental disorder characterised by low mood and low energy levels
What criteria is used to diagnose depression?
DSM-IV criteria
true or false: most cases of depression will eventually resolve themselves?
true
How many of the DSM-IV criteria must be met for a depression diagnosis to be made?
5 of the 9
for more than 2 weeks
what to look out for and what to screen when diagnosing depression?
weight, changes, physical activity, energy changes, tiredness, feelings of worthlessness/ guilt, poor concentration, more indecisive than usual.
screen for conditions that may mimic/ coexist with depression: substance misuse/ medical/ psychiatric conditions/ life changing event or bereavement causing particular episode of depression.
What are the psychosocial interventions available for depression?
- CBT
- counselling
- mindfulness
- self-help
- exercise
- mental health apps
What are the basic principles of prescribing for depression?
- discuss w px: choice of drug/non-pharmacological options
- ensure effective dose following titration
- withdraw antidepressants gradually
How long should the first episode of drug treatment continue?
6-9 months
what should hcps discuss choice of with the patient alongside choice of drug?
alternative non pharmacological option
are relief of symptoms from treatment quick or gradual over a few weeks?
gradual
Px who’ve had multiple episodes of depression:
Treatment recommended for how long, and when to re-evaluate?
2 years but no upper limit set. Re-evaluate after 2 years with px: age, co-mobidities, other factors, if circumstances changed since diagnosis
How do antidepressants compare in terms of efficacy?
equal
What governs the antidepressant choice?
SE profile
What are the different anti-depressant classes?
- SSRIs
- tricyclics
- NARIs, NASSAs, SNRIs
- MAOIs
- St Johns Wort
- Lithium
all antidepressants are equal in terms of efficacy and side effect profile governs choice of drug. Which drug class is well tolerated and safer in overdose and associated with a reduction in sodium?
SSRIs
first line antidepressants: SSRIs. what do they have a risk of? and what to do about this?
Risk of bleeding! Prescribe GI protective drug: PPI (lansoprazole) in older px who take NSAID or aspirin. But PPI also associated with hyponatraemia = compounding effect of two together so rinetidine may be better.
SSRIs are Less sedating and fewer anti muscarinic effects.
give 2 example drugs
o Citalopram
o Sertraline
What electrolyte can SSRIs affect and how?
lowers Na, risk of hyponatraemia
What ADR are SSRIs associated with, who is it more risky in and what is the management?
- increased risk of bleeding
- elderly, NSAID/aspirin
- prescribe PPI
What is negative about SSRIs?
- toxicity in overdose
- cardiovascular effects
What antidepressants are reserved for specialist initiation for depression? and have drug interactions
MAOIs
tricyclics are toxic in overdose and have effects in which body system?
cardiovascular.
Mirtazapine: new drug, noradrenergic specific serotonergic antidepressant. (Tetracyclic antidep)
why is it taken at night?
Causes drowsiness
benefit of new drug mirtazapine vs SSRIs?
doesn’t have same negative effects on sodium :) thus electrolyte neutral and wont cause hyponatraemia like SSRIs. = good alternative option if px not tolerated SSRI
What can antidepressants cause upon stopping?
discontinuations symptoms - explained by ‘receptor rebound’ theory
what is the receptor rebound theory?
caused by stopping antidep suddenly
‘withdrawal’
Brain’s response to sudden absence of increased serotonin levels from when px on antidepressant
What discontinuation symptoms result from tricyclic antidepressants? TCAs
- cholinergic rebound
- insomnia
What discontinuation symptoms result from SSRIs?
- flu-like symptoms
- shivers ‘electric shocks’
- dizziness
higher risk of receptor rebound in what sort of drugs and why? think PK
drugs with short half life… cleared quicker = get more symptoms of discontinuation with missed doses
how to switch/swap antidep drugs to prevent intense receptor rebound/ discontinuation symptoms?
Cross-tapering recommended if switching is required
-When ineffective/ poorly tolerated drug is gradually withdrawn whilst new one is introduced
BIPOLAR DISORDER……………
What is bipolar disorder?
extreme shifts in mood/energy/behaviour from highs of mania at 1 extreme to lows of depression at other
How do bipolar depressive episodes compare to unipolar depression episodes?
- more rapid in onset
- more frequent
- more severe
- shorter
- more likely to involve delusions
what is the term given to when a person has had at least one episode of mania which has lasted longer than a week and experience depressive episodes ?
bipolar i
what is the term given when a person has had at least one episode of severe depression and symptoms of hypomania?
bipolar II
What are the 2 classifications of bipolar disorder?
bipolar I and II
what is the term given to:
elated mood, overactivity often unproductive, irritable. Also disinhibition may -> excessive spending sprees, inappropriate sexual activity, other high risk behaviours.
Driving can be dangerous
Racing thoughts, fast speech may stop abruptly, exaggerated and overthought ideas, flamboyant clothing
hypomania
What are the 2 types of interventions made for bipolar disorder?
- psychosocial
- pharmacological (severe/moderate)
What is first-line pharmacologically for bipolar disorder?
lithium
What is second-line pharmacologically for bipolar disorder?
valproate added to lithium
how does Li treat BPD?
Long term treatment strategy
reduces severity + frequency of mania + relives + prevents BPD symptoms, reducing suicide risk
Why can lithium affect a wide range of body processes?
body handles it in a similar way to sodium
Lightest metal, so induces multiple biochemical and molecular effects on neurotransmitters, receptor mediated signalling, signal transduction cascades, hormonal and circadian regulation, ion transport and gene expression
-Effects associated with neurotrophic pathways, involved in pathophysiology of BPD
What is the suggested mechanism of action of lithium?
- people w bipolar have high intracellular [Na]
- lithium can reduce this
What are indications for lithium?
- prophylaxis of bipolar affective disorder
- augmentation of antidepressant in severe depression
What makes lithium so pharmacologically problematic?
NTI
- dose differences between brands
- slow onset of action
- several drug interactions
- toxicity
What are the key drug interactions of lithium?
- loop/thiazide diuretics
- iodides
- ACEis
- SSRIs
- carbamazepine
- NSAIDs
What must patients on lithium carry with them at all times?
purple lithium alert card
What are patients on lithium provided along w a lithium alert card?
purple lithium booklet
if a person develops moderate or severe bipolar depression and is not taking a drug to treat it what can be offered depending on the persons preference and response to treatment?
fluoxetine combined with olanzapine
or quetiapine
what might you offer a patient who does not tolerate lithium for long term control of their bipolar because they do not want to undergo routine blood monitoring?
valproate or olanzapine or quetiapine
Depression WS: Amy
All women have postpartum check at X weeks and to check mothers physical and mental health and baby
6
what other risk must you consider during postnatal depression screening?
suicide
- look at wider body language and pauses, allow px to elaborate
what happens at a post natal check?
asked how shes feeling
had any vaginal discharge and whether still have period since bith
contraception
weight loss advice if obese
T/F
diagnosis of post natal depression is clear if got 5/9 symptoms present?
true
caution with new mother on fluoxetine?
present in breat milk, avoid
consider alt: paroxetine and sertraline
why are paroxetine and sertraline safe than fluoxetine in post natal?
short half life = reduced effect of any potential transfer to baby
what does SSRI choice depend on for mother?
if shes breastfeeding
SSRIs better tolerated and safer BUT fluox present in milk, avoid
SSRIs better tolerated and safer BUT caution in <30y why?
increased risk of suicidal behaviour
who can provide details of attending local mother and baby groups for additional support and access to various support websites? 3
GP, midwife or health visitor
All infants with mother on fluoxetine should be monitored for what? (SPS)
drowsiness, poor feeding, irritability/ restlessness
you change amy form fluox -> parox/ sertraline.
what should you discuss?
Reason for change (safety profile in breastfeeding)
Infants exposed to SSRIs via milk must be monitored for sedation, poor feeding, behavioural effects
Antidepressants balance mood-altering chemicals in brain to work. Can help ease symptoms of low mood, irritability, lack of conc and sleeplessness -> function normally and help you cope better with your new baby
Antidepressants take at least a week before benefit felt, so important to keep taking even if don’t notice improvement straight away.
usually need to take them for around 6 months after you start to feel better.
what general SEs may Amy experience which should pass once body gets used to med?
o feeling sick,
o blurred vision,
o dry mouth,
o constipation,
o dizziness
o feeling agitated or shaky
Depression WS: Alison
core symptoms to ask when making a formal depression diagnosis using DSM V diagnostic tool?
During last months have you often been bothered by feeling down, depressed, or hopeless
Do you have little interest/ pleasure in doing things
..
disturbed sleep
diff appetite/ weight
fatigue/ loss of energy
poor conc
suicidal
GP decides to start Alison on citalopram. After 2 months treatment Alison shows a poor response to treatment – what are the options?
Assess reason for why antidepressants not working effectively
If no obvious cause found/ resolved, further treatment options:
- Switch to alt psychological treatment
- Add SSRI to physiological therapy
- Switch to an SSRI alone
GP wants to change Alison’s treatment from Citalopram to Mirtazipine and asks you for advice on how to switch. She currently takes 20mg mane, what would you advise and what is your rationale for recommending this?
SPS: cross-tapering of both.
Decrease Citalopram dose and slowly introduce Mirtazapine alongside and continue changing doses until Citalopram ended.
Due to serotonin levels being high then may fall if stopped.
T/F:
Drug discontinuation symptoms =withdrawal.
false
by how many mg should you
- reduce citalopram
- inc mirtazapine?
- 40mg -> 20, 10, 5, 0
- 0mg -> 15, 30, 30, 45
2 months later on picking up her repeat Rx Alison says she’s feeling a lot better now and says she’s going stop taking them in a few weeks’ time but plans to keep the other 2 weeks’ just in case’ – what would you advise?
advise Alison against stopping her medication abruptly, as -> withdrawal symptoms/ relapse of depression.
GP could discuss importance of continuing treatment for the recommended duration, and monitor Alison closely for any signs of relapse or adverse effects.
Over the following years Alison’s depression worsened, she was hospitalised on a number of occasions. On this admission she is diagnoses with ‘recurrent depressive disorder’; the medical team and Alison agree to start Lithium treatment.
What routine monitoring will she require?
For depression px taking Li, assess the following BEFORE treatment
* Weight
* Renal function
* Thyroid function
* Calcium levels
Monitor at least every 6 months during/ more often if evidence of significant renal impairment
Whilst in hospital she is stabilised on 800mg nocte prior to discharge.
been having swallowing difficulties for many months and has been complaining of a ‘lump’ in her throat. GP refereed her to the local hospital for investigations, the hospital have diagnosed her with ‘Benign oesophageal stricture’ narrowing of oesaphagus.
GP asked you to advise on how to switch her lithium (Priadel® 800mg NOCTE) to a liquid form. What do you recommend?
dose will need to be adjusted based on BA and dosing instructions of new formulation
Monitor closely for signs of AEs/ changes in therapeutic response during transition
