mood (affective) disorders Flashcards
most important question to ask in depression history
any prior manic, hypomania or mixed episodes that would indicate presence of bipolar disorder
mild vs moderate vs severe depression
domain = family, social, educational, occupationa etc
mild - difficultly continuing to function in 1 or more
mod - difficultly multiple domains
severe - most domains
ICD-11 classification of a depressive episode
a period of depressed mood or diminished interest in activities occurring most of the day, nearly every day lasting at least 2 weeks accompanied by other symptoms such as
o Difficulty concentrating
o Feelings of worthlessness or excessive or inappropriate guilt
o Hopelessness
o Recurrent thoughts of death or suicide
o Changes in appetite or sleep
o Psychomotor agitation or retardation
o Reduced energy or fatigue
cotard’s syndrome
More common in elderly
Often nihilistic (life in meaningless) delusions – I cant eat because my bowels have turned to dust
(type of psychotic depression)
depression severity scales
Hamiltons rating scale for depression (HRSD)
Montgomery-Asperg Depression rating scale (MADRS)
Beck depression inventory (BDI)
management of mild depression
Antidepressants not recommended initially
Watchful waiting, assess again in 2 weeks
Consider offering one or more low-intensity psychosocial interventions – CBT
management of moderate-severe depression
Offer antidepressant combined with high intensity psychological treatment - CBT or interpersonal therapy (IPT)
First line = SSRI – escitalopram, sertraline, mirtazapine
* No benefit felt by 6 weeks – change drug
2nd line = switch SSRI
3rd line = different class of antidepressant
* Venlafaxine (SNRI)
* Tricyclic antidepressant - cardiotoxic
* MAOI - phenelzine, moclobemide
Urgent psychiatric referral if suicidal ideas or plans (someone else at risk), psychotic, severely agitated or self-neglecting
o ECT (electroconvulsive therapy) is reserved for most severe cases - generalised seizure is induced
when a child responds to depression medication, how long should it be continued for?
6 months post remission
- response can take several weeks
if no response -> intensive psychological therapy
admnit if high risk of self harm, sicide, self-neglect, or safegaurding issue
management of mild depression in children
Watchful waiting for 2 weeks
Group IPT/CBT, non-directive supportive therapy for 2-3months
management of moderate to severe depression in children
Individual psychological therapy - CBT, IPT, family therapy, non-directive supportive – 4-6sessions
1st line = fluoxetine, 10mg to max of 20mg
2nd line = sertraline or citalopram
pathophysio of self harm
self-harm promotes release of endorphins
Brings temporary distress reduction – through negative reinforcement, these behaviours are repeated
biggest risk factor for suicide
most are attempts to maintain control in very stressful situations
Self harm scoring system
SAD PERSON
sex, age, depression, previous attempt, ethnol abuse, rational thinking loss, social supports lacking, organised plan, no spouse, sickness
guidelines for action with self harm scale
SAD PERSONS
0-2 send home with follow up
3-4 close follow up, consider hospitalisation
5-6 strongly consider hospitalisation
7-10 hospitalise or commit
what question is important to ask post self-harm?
feelings of hopelessness
no release of discomfort after self injury
intent to escape pain
“one way out”
define mania
severe functional impairment or psychotic symptoms for 7 days or more
- psychotic symptoms - delusions, auditory hallucinations
- euphoria, irritability
- pressure speech, increased self-esteem
- decreased need for sleep
difference between mania + hypomania
mania - >=7 days, psychotic symptoms, grandiosity
hypomania - <7days (3-4), no psychotic symptoms, no impairment of social or work capacity
difference between mania + hypomania
mania - >=7 days, psychotic symptoms(delusions, auditory hallucinations, grandiosity)
hypomania - <7days (3-4), no psychotic symptoms, no impairment of social or work capacity
types of bipolar
bipolar type I = mania or mixed + depression
bipolar type II = hypomania + depression
predictors of poor outcome in bipolar
early onset
low socioeconomic status
subsyndromal mood symptoms
rapid mood fluctuation
mixed presentations
cormorbid disorders
psychosis
acute manic episode management
1 - atypical antipsychotic (olanzapine, quetiapine, risperidone)
2 - valproate, lamotrigine
benzodiazepines or Z drugs can be used for symptoms control - agitation, insomnia
consider stopping antidepressant if takes
acute bipolar depression management
1 - atypical antipsychotic - quetiapine or olanzapine
antidepressant avoided - can cause mood cycling
fluoxetine may be suitable in some cases
bipolar maintenance management
lithium = gold standard, (mood stabiliser)
+ valporate if primarily manic/hypomanic
**must monitor ECG, U+Es, TFTs, calcium
if patient not want monitoring - combinations of valporate, quetiapine + olanzapine
lithium and pregnancy
Can continue if manic or depressive symptoms have not been stable
Risk of developing fetal abnormalities highest in first trimester
-> Ebsteins anomaly
mode of action of lithium (carbonate)
may block phosphatidylinositol or onhibot glycogen synthase kinase 3-beta or modulate NO signalling
interferes with inositol triphosphate formation
interferes with cAMP formation
how is lithium excreted?
RENALLY - liver is not involved
monitoring of lithium (narrow therapeutic index)
12hrs post dose bloods
target ranfe = 0.4-1 mmol/l with higher end of range being associated with better response
side effects of lithium
fine tremor
nephrotoxicity - polyuria, diabetes insipidus
thyroid enlargement - hypothyroidism
ECD - T wave flattening, inversion
weight gain
leucocytosis
hyperparathyroidism -> hypercalcaemia
dry mouth/strange taste
features of lithium toxicity
coarse tremor
hyperreflexia
polyuria
seizure, coma
confusion
which anticonvulsant causes neural tube defects
valproate
(lamotrigine - risk of stevensjohnson syndrome)
postpartume (peuerperal) psychosis
Severe mental illness that develops acutely in the early postnatal period, usually within the first month (2-3weeks) following delivery
o Acute sudden onset of psychotic, manic symptoms / disinhibition, confusion
o Psychiatric emergency – safeguarding risks
o different to post-natal depression
o 1 in 1000 births, presents between 2-4weeks postpartum
severe mood swings, disordered perception (auditory hallucinations)
25-50% risk of recurrence following future pregnancies
risk factors for postpartume (peuerperal) psychosis
- Previous mental illness
- Previous thyroid disorder
- Family history
- Being unmarried
- First pregnancy
- C-section
- Perinatal death
aeitiology of postnatal depression
- 1 in 10 women – same as depression
Opposed to postnatal blues – present in 50-75% of women - Usual onset 1-4weeks post partum
Cognitive behavioural therapy may be beneficial. Certain SSRIs such as sertraline and paroxetine* may be used if symptoms are severe
