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Mental Health > Mood Disorders > Flashcards

Mood Disorders Flashcards

1
Q

Compare BIPOLAR 1 versus BIPOLAR 2 disorder.

A

BP1D - at least ONE episode of mania plus one episode of major depressive disorder (although not required for diagnosis)

BP2D - at least ONE episode of major depressive disorder plus one episode of hypomania

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2
Q

Define CYCLOTHYMIA

A

Cyclothymia is a condition in which an individual experiences cycles of hypomania and mild / moderate depression for at least TWO YEARS, although, symptoms never are severe enough to meet the criteria for bipolar depression (type 1 or type 2).

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3
Q

Outline DSM-V criteria for MANIA.

A

(A). Persistently elevated, expansive or irritable mood for at least one week in duration; most days of the week; most of the time.

(B). At least THREE of the following seven:
✔️ D - distractibility
✔️ I - insomnia
✔️ G - grandiosity
✔️ F - flight of ideas
✔️ A - activities increased
✔️ S - speech pressured / increased speech
✔️ T - thoughtless activities / risky behaviour

(C). Symptoms impair functioning / cause clinical impairment and distress.
(D). Symptoms not attributable to a substance or organic cause.

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4
Q

Define HYPOMANIA.

A

In HYPOMANIA, criteria (A) and (B) for mania are met, however, the symptoms are not significant enough to cause impairment in daily functioning.

The changes to mood and activities must be noticeable by other people.

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5
Q

Outline management of ACUTE MANIA.

A

Acute mania management involves second generation antipsychotic medications, specifically:
✔️ olanzapine
✔️ risperidone

Mood stabilising agents may be used, although, this is more common for maintenance therapy.
✔️ lithium carbonate
✔️ sodium valproate
✔️ carbamazepine

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6
Q

Define MOOD STABILISER.

A

By definition, a mood stabiliser is a drug that:

(1) . has efficacy in treating both manic / hypomanic and depressive symptoms
(2) . prevents recurrent of future episodes

Lithium is the only drug that fits this definition.

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7
Q

Outline the therapeutic ranges for lithium.

A

ACUTE MANIA - 0.8 to 1.0 mmol / L

MAINTENANCE THERAPY - 0.6 to 0.8 mmol / L

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8
Q

Identify how lithium is metabolised and adverse drug reactions.

A 
Lithium is metabolised by the kidney. Thus, any drugs that affect the kidney may also have implications for lithium metabolism. This includes: 
✔️ ACE-i and ARBs
✔️ thiazide or loop diuretics
✔️ dehydration / low fluid status
✔️ NSAIDs
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9
Q

Identify risk factors for lithium toxicity.

A 
✔️ dehydration
✔️ patient age > 50 years
✔️ impaired renal function / low eGFR
✔️ medications (e.g. thiazides, ACE / ARB, NSAIDs)
✔️ nephrogenic diabetes insipidus 
✔️ thyroid dysfunction
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10
Q

Outline side effects of lithium carbonate.

A

L - leucocytosis
I - insipidus (diabetes) –> polyuria, polydipsia, nocturia, fatigue
T - tremor and ataxia
H - hypothyroidism
I - increased weight
U - upset stomach (e.g. nausea, vomiting, diarrhoea)
M - mothers (teratogenic)
ECG - prolonged QTc, flattened T waves, conduction abnormalities, arrhythmia

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11
Q

Outline the plasma concentrations at which lithium toxicity occurs.

A
  1. 6 to 1.0 mmol / L –> toxicity may occur in elderly patients / those with renal impairment
  2. 0 to 1.4 mmol / L –> tremor, ataxia, nausea and vomiting, diabetes insipidus
  3. 4 to 2.0 mmol / L –> seizures

> 2.0 mmol / L –> renal failure, coma, death

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12
Q

Outline the investigations that should conducted to monitor lithium levels.

A 
✔️ serum lithium concentration
✔️ FBC and WCC
✔️ UECs
✔️ eLFTs
✔️ TFTs
✔️ ECG

Once plasma lithium levels have stabilised, the above parameters should be monitored every three months.

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13
Q

Identify four mood stabilising drugs, and what their main indications are.

A
  1. lithium carbonate - first line medication for bipolar disorder
  2. sodium valproate - indicated in rapid cycling illness
  3. lamotrigdine - indicated for where mood symptoms are predominant
  4. carbamazepine - indicated for rapid cycling illness; safe to use in pregnancy

Note that antidepressants should be avoided in patients with bipolar disorder, due to risk of inducing rapid cycling illness (>4 cycles per year).

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14
Q

Define MOOD DISORDER.

A

MOOD DISORDER - any psychiatric condition characterised predominately by mood symptoms.

Includes:
✔️ major depressive disorder (unipolar depression)
✔️ bipolar / manic depression
✔️ melancholic depression
✔️ psychotic depression
✔️ catatonic depression
✔️ atypical depression
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15
Q

Outline some risk factors for depression.

A

Risk factors for depression include:
✔️ certain personality traits
✔️ family history
✔️ coping mechanisms and resilience level
✔️ neurotransmitter imbalances
✔️ endocrine abnormalities (i.e. affecting serotonin, noradrenaline)
✔️ vascular changes
✔️ psychosocial stressors (e.g. work, family, relationships, finances)

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16
Q

Outline the monoamine hypothesis for depression.

A

The monoamine hypothesis states that there are three key neurotransmitters involved in the regulation of mood:

  1. serotonin
  2. dopamine
  3. noradrenaline

According to the hypothesis, elevated or depressed mood is attributed to changes in these neurotransmitter levels (either increased or decreased levels, respectively).

Pharmacotherapy helps to stabilise / regulate levels of these neurotransmitters.

17
Q

What are the symptoms of depression?

A 
S - sleep disturbances 
I - interest reduced
G - guilt
E - energy reduced
C - concentration reduced
A - appetite altered (increased or decreased)
P - psychomotor agitation
S - suicide / self-harm behaviour

PLUS LOW MOOD

18
Q

DSM-V criteria for MAJOR DEPRESSIVE DISORDER.

A

(A). Five or more of the following criteria present over a minimum of a two-week period (of which two of the symptoms must be either depressed mood or anhedonia):
✔️ low mood
✔️ sleep disturbance (increased or decreased)
✔️ reduced interest in pleasurable activities
✔️ feelings of guilt or worthlessness
✔️ energy reduced / easily fatigued
✔️ concentration reduced
✔️ appetite changed (increased or decreased)
✔️ psychomotor agitation
✔️ suicidal thoughts or self-harming behaviour
(B). Symptoms must impair functioning / be of clinical or significant distress
(C). Symptoms are not due to organic cause or withdrawal / intoxication from drugs

19
Q

Identify the severity classification for DEPRESSION.

A

Mild: 1 - 3 symptoms
Moderate: 4 - 6 symptoms
Severe: > 7 symptoms

20
Q

Identify two screening tools that can be applied clinically to rate the severity of depression.

A

K10 / K21

DASS

21
Q

MELANCHOLIC DEPRESSION
✔️ definition
✔️ key features

A

DEFINITION - a severe form of depression in which the patient “looks depressed…”

KEY FEATURES
✔️ pervasive low mood
✔️ anhedonia
✔️ fatigue upon waking
✔️ psychomotor agitation
✔️ diurnal variation (i.e. symptoms are worse in the morning and improve as the day progresses)
22
Q

PSYCHOTIC DEPRESSION
✔️ definition
✔️ key features

A

DEFINITION - a severe form of depression in which features of depression and psychosis co-exist (it is important to differentiate psychotic depression from schizoaffective disorder)

KEY FEATURES
✔️ derogatory hallucinations (usually auditory)
✔️ nihilistic delusions
✔️ delusions of guilt
✔️ delusions of poverty / poverty of affect

23
Q

ATYPICAL DEPRESSION
✔️ definition
✔️ key features

A

DEFINITION - persistent depressed mood, however, patient is intermittently and briefly able to experience positive mood

KEY FEATURES
✔️ increased appetite and weight gain
✔️ hypersomnia
✔️ heavy sensation in the limbs

24
Q

AGGITATED DEPRESSION
✔️ definition
✔️ key features

A

DEFINITION - major depression mixed with features of anxiety

KEY FEATURES
✔️ appears anxious
✔️ experiences panic attacks
✔️ psychomotor agitation

25
Q

POST NATAL DEPRESSION
✔️ definition
✔️ key features

A

DEFINITION - symptoms of depression that develop in the four months following pregnancy / birth

KEY FEATURES
✔️ low mood
✔️ loss of interest in pleasurable activities 
✔️ teary / emotional
✔️ expresses feelings of not coping
✔️ irritable
26
Q

CATATONIC DEPRESSION
✔️ defintion
✔️ key features

A

DEFINITION - severe form of depression characterised by catatonia as a major feature; requires ECT for treatment

KEY FEATURES
✔️ unable to speak / poverty of speech
✔️ unable to move
✔️ unable to eat

27
Q

DSM-V criteria for PERSISTENT DEPRESSION.

A

(A). Depressed mood for most of the day, more days than not, for > 2 years.
(B). Presence, whilst depressed, of at least TWO of the following:
✔️ increased or decreased appetite
✔️ increased or decreased sleep
✔️ low energy / fatigue
✔️ feelings of worthlessness / low self-esteem
✔️ feelings of hopelessness
(C). During the total period, patient has not been without symptoms for more than 2 months.
(D). Criteria for Major Depressive Episode has been met for a period > 2 years.
(E). Symptoms cause significant distress and impact on functioning.
(F). Not due to another disorder or physiological effects of a drug / substance.
(G). Patient has never experienced a manic or hypomanic episode.

28
Q

Outline the protocol for managing MAJOR DEPRESSIVE DISORDER.

A

The management options for major depressive disorder depend on the severity of the condition.

MILD DEPRESSION: psychotherapy > pharmacotherapy
MODERATE DEPRESSION: psychotherapy = pharmacotherapy
SEVERE DEPRESSION: pharmacotherapy > psychotherapy

29
Q

Identify the four components of COGNITIVE BEHAVIOURAL THERAPY (CBT).

A
  1. understanding thoughts, feelings and emotions
  2. identifying / monitoring for unhelpful thoughts and emotions
  3. challenging unhelpful thoughts
  4. pleasant event scheduling
30
Q

Outline some factors that influence / impact the choice of pharmacotherapy for depression.

A

✔️ patient age and gender
✔️ previous response to certain medications
✔️ patient preference
✔️ drug profile + side effects
✔️ risk of interaction with current medications
✔️ antidepressant safety in overdose
✔️ comorbidities

31
Q

Counsel a patient on antidepressant therapy.

A

✔️ antidepressants are a group of medications that alter the chemical signals in the brain, to help improve / stabilise negative emotions
✔️ all antidepressants take 1 - 2 weeks to work
✔️ sometimes maximum response is not achieved for 4 - 6 weeks
✔️ in the acute initiation period, it is normal to have an increase in anxious / depressed thoughts
✔️ antidepressants should be continued for a MINIMUM of 6 months (preferably 12)
✔️ all medications come with their side effects; side effects of antidepressants depend on the individual drug, but can include GI upset (e.g. nausea, vomiting, diarrhoea), weight gain, sedation, sexual dysfunction
✔️ antidepressant medications should never be ceased immediately due to risk of “discontinuation syndrome…”
✔️ wean medications gradually over 1 - 2 weeks and monitor for symptoms of discontinuation syndrome

32
Q

Outline the symptoms of discontinuation syndrome.

A 
Discontinuation syndrome occurs when antidepressant medications are ceased abruptly. Symptoms include: 
✔️ flu-like symptoms
✔️ fever
✔️ nausea
✔️ postural imbalance
✔️ hyperarousal

To avoid discontinuation syndrome, patients should gradually reduce the dosage of antidepressant over 1 - 2 weeks.

33
Q

Features of lithium toxicity at MILD, MODERATE AND SEVERE levels.

A 
MILD (1.0 to 1.4 mmol / L)
✔️ nausea and vomiting
✔️ diarrhoea 
✔️ diabetes insipidus
✔️ proximal muscle weakness
✔️ poor memory
✔️ flu-like symptoms
MODERATE (1.5 to 2.0mmol / L)
✔️ nausea and vomiting
✔️ diarrhoea 
✔️ blurred vision
✔️ proximal muscle weakness
✔️ ataxia
✔️ hypotension
✔️ ECG changes (eg. QTc prolongation, T wave flattening, U waves)
SEVERE (>2.0 mmol / L)
✔️ seizure
✔️ coma
✔️ death
✔️ hyperreflexia
✔️ myoclonus
✔️ coarse tremor 
✔️ dysarthria
34
Q

Outline the three-stage management of lithium toxicity.

A

NOTE - most patients with lithium toxicity do not require any specific management, other than serial monitoring of plasma lithium levels.

Where specific management is required, the three steps are:

  1. optimum circulation - IV saline appropriate in patients with adequate renal function
  2. decontamination - indicated if > 50g ingested; whole bowel irrigation
  3. optimum elimination - renal dialysis until < 1.0 mmol / L
35
Q

Side effects for SSRIs?

A
  • GI disturbances (eg nausea and vomiting, diarrhoea)
  • sedation
  • erectile dysfunction / reduced libido
  • weight gain
  • transient increase in depression / anxiety / suicide risk in the first 2 weeks
  • discontinuation symptoms if ceased abruptly (eg. flu-like symptoms, low grade fever, postural hypotension)
36
Q

What is the monitoring regime for starting someone on lithium carbonate?

A
  • lithium levels monitored every 3 months
  • UECs and TFTs monitored every 6 months
  • UECs, TFTs and ECG should be collected at baseline prior to commencing treatment

Mental Health (10 decks)

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