Mood disorders Flashcards
What are possible differentials for a depressive picture?
Depression (try and classify) BPAD (if mania sx) Dementia (if old) / mild cognitive defect Seasonal affective disorder Dysthymia Postnatal depression (if perinatal) Generalised anxiety disorder Bereavement reaction
Non psych: Vitamin D deficiency, hypercalcaemia, hypothyroidism, hypoglycaemia, neurological disease, hypo/hyperadrenalism, steroid, alcohol, beta-blockers, benzodiazepines, chronic conditions, long-standing infections
What are the Ix for depression?
Bedside: Finish MSE, Neurological exam
Bloods: Blood gluose, U&Es, LFTs, TFTs, Ca2+ levels, FBC, CRP, Mg2+ levels, HIV, syphilis, drug tox
Imaging: CT head/MRI brain
Other: Patient Health Questionnaire - 9 (PHQ-9_
Hospital anxiety + depression scale (HADS)
Generalised Anxiety Disorder - 7 scale (GAD-7)
What is the Mx for mild/mod depression?
CONSERVATIVE: Watchful waiting and assess 2 weeks later -> may then offer BIO: medications
PSYCHOSOCIAL: Low intensity -> guided self help, internet resources, computerised CBT, Relaxation therapy, brief psychological interventions (6-8weeks) - problem solving, brief CBT, counselling
What is the Mx for mod/severe depression?
1) Urgent psych referral if pt active suicidal ideas/plans or psychotic/severely agitated/ self neglecting -> community mental health services/ sectioning
BIO: Anti-depressants - SSRI - sertraline, SNRI - duloxetine/venlafaxine
PSYCH: High intensity psychological tx - CBT or IPT
ECT for severe/life threatening depression
SOCIAL: Social groups, social supports
What is the Ix for schizophrenia?
Bedside: finish MSE, physical examinations - neurological, cardiac, respiratory if signs of infection
Bloods: FBC, U&Es, HbA1c, TFTs, PTH, Testosterone, cortisol, vitD, ACTH, prolactin, estrogen etc, lipids
Imaging: MRI/CT head
Special: EEG
What is the Mx for schizophrenia?
BIO: Anti-psychotic medication - Typical (chlorpromazine, haloperidol) or Atypical (olanzapine, risperidone, aripiprazole) or clozapine
PSYCHO: CBT for psychosis (16+ 1-2-1 sessions over 6 months), psychosocial rehab - care coordination, supported accommodation, assertive outreach, early interventions, recovery
SOCIAL: Family interventions - 10 group sessions over 6-12 months
What is the Ix for hypomania/mania?
Bedside: Finish MSE, thyroid exam
Bloods: TFTs
Imaging: CT/MRI brain
Special: Urine drug toxicity test - see what happens when drug wears off!
What is the management for hypomania/mania?
BIO: If on anti-depressants - stop anti-depressants, lower levo-dopa, corticosteroids Mood stabiliser drug - Lithium, valproate (prophylactic and long term), acutely can give antipsychotic medication. Acutely can give benzodiazepine - lorazepam
PSYCH: Psychoeducation, family therapy, individual/group psychology
SOCIAL: Supported employment programmes, adaptation in education systems, care coordinator, regular engagement/follow up
- If pregnant, get obstetrician and psychiatrist*
- Consider hospital admission
When should lithium levels be monitored for bipolar disorder?
NICE: ‘Lithium levels are normally measured one week after starting treatment, one week after every dose change, and weekly until the levels are stable. Once levels are stable, levels are usually measured every 3 months. Lithium levels should be measured 12 hours post-dose.’
What is the most useful antidepressant in a patient that also has had 2 heart attacks in the past?
Sertraline
What is the difference between type 1 and type 2 bipolar affective disorder?
Type 1 is associated with mania and type 2 is associated with hypomania.
What is the difference between a mood disorder such as mania and schizoaffective disorder?
Whilst mania may also be associated with features of psychosis (such as grandiose beliefs), the psychotic symptoms in schizoaffective disorder are seen outside of the mood symptoms. In patients who have psychosis in association with a mood disorder, the symptoms are only seen during episodes of the mood disorder.
What is the referral pattern for severe mood disorder if seen at the GP?
Primary care referral
if symptoms suggest hypomania then NICE recommend routine referral to the community mental health team (CMHT)
if there are features of mania or severe depression then an urgent referral to the CMHT should be made
A 14 year old girl, who has been doing very well at school and had been physically well, presents to A&E with new onset seizures and her family have noticed that she does not seem to know where she is or what she is doing for some of the days of the last week and she cannot remember simple things. She can switch from crying to laughing within the space of minutes for no apparent reason.
She has never had mental health problems and neither has anyone in her family. She has no history of epilepsy or febrile seizures and regains full consciousness between seizures. After full neurological examination and a normal MRI brain, lumbar puncture shows increased lymphocytes in the cerebrospinal fluid. She is started on intravenous methylprednisolone and intravenous immunoglobulin.
Over the next few days she does not appear to respond to this therapy and becomes increasingly agitated.
What is the most appropriate pharmacotherapy to manage her agitation?
Risperidone or quetiapine (as she is displaying signs of autoimmune encephalitis).
