Mood Disorders Flashcards
Which SSRI is indicated for use in children and adolescents (with caution)?
Fluoxetine
Which are the currently preferred SSRIs?
Citalopram and fluoxetine.
Major side effect of citalopram?
Dose-dependent QT interval prolongation.
Can paroxetine be used in pregnancy?
Increased risk of congenital malformations, particularly in first trimester.
Describe symptoms of SSRI discontinuation syndrome
Dizziness, paraesthesia, anxiety, diarrhoea, vomiting, abdominal pain, insomnia, sweating, restlessness.
Describe symptoms of TCA overdose
Hypotension, drowsiness and seizures.
What are the differentials for depression?
Depressive episode linked to substance/medication use.
Bipolar affective disorder.
Premenstrual dysphoric disorder.
Bereavement.
Anxiety disorders.
Alcohol-use disorder.
Hypothyroidism.
Cushing’s.
Vitamin B12 deficiency.
How long should antidepressants usually be taken for?
For at least 6 months.
What is tangentiality?
Refers to wandering from a topic without returning to it, usually with loosely discernible links.
What is circumstantiality?
Patient gives unnecessary and excessive detail before finally answering the question.
What is flight of ideas?
Question answered first, then patient would jump from one topic to the next with discernible links. Also pressure of speech associated with this.
What is Knight’s move thinking?
Unexpected and illogical leaps from one idea to another. Also known as derailment of thoughts.
What are neologisms?
New word formations.
What are clang associations?
When ideas are related to each other only by the fact they sound similar or rhyme.
What is word salad?
Completely incoherent speech where real words are strung together into nonsense sentences.
What is preservation?
Repetition of ideas or words despite an attempt to change the topic.
What is echolalia?
Repetition of someone else’s speech, including the question when asked.
Flight of ideas is a feature of what?
Mania.
Which is the first line SSRI for depression in adults?
Sertraline.
What are the beneficial side effects of mirtazapine for the elderly?
Sedation and increased appetite.
MOA of mirtazapine?
Blocks alpha2-adrenergic receptors. Antidepressant.
What is cyclothymia?
Characterised by a persistent instability of mood involving numerous periods of mild depression and mild elation. They’re not severe or prolonged enough to diagnose bipolar disorder or recurrent depression.
Can steroids result in mania symptoms?
Yes.
What are the differential diagnoses considered in suspected bipolar disorder?
Schizoaffective disorder, frontal lobe pathologies (organic cause), psychotropic drug use, recurrent depression, borderline personality disorder, cyclothymia.
Define dysthymia
Chronic depression of mood which doesn’t fulfil the criteria for recurrent depressive disorder of mild/moderate severity.
How long do symptoms need to last for a depressive episode to be diagnosed?
2 weeks.
Name the 3 core symptoms of depression
Low mood, anhedonia, lack of energy.
List the somatic symptoms of depression
Lack of energy, weight change, sleep disturbance, psychomotor retardation, psychomotor agitation, decreased libido, loss of appetite, fatigue, lack of emotional reactivity, early morning wakening, diurnal mood changes.
List the mood symptoms of depression
Low mood, anhedonia, suicidal thoughts.
List the cognitive symptoms of depression
Worthlessness, feeling of guilt, decreased concentration, decreased attention, reduced self-esteem, reduced self-confidence, pessimism.
How is depression classified?
Mild: 2 core symptoms and 2 other, minor functional impairment.
Moderate: 2 core symptoms and 3 other, moderate functional impairment.
Severe: all 3 core symptoms and 4 other, significant functional impairment.
Severe depressive episode with psychotic symptoms.
Recurrent depressive disorder: 2+ depressive episodes.
Describe the psychotic symptoms of depression
Delusions - nihilistic, guilt, inadequacy.
Hallucinations - auditory, visual, olfactory.
Depressive stupor.
What is the prevalence of depression in UK?
4.5%
Name the risk factors for depression
FHx, neuroticism, chronic illness, serotonin imbalance, HPA axis, substance misuse, medications, anxiety, traumatic life events, childhood abuse, lack of support, low SES, unemployment, homeless, divorced, female, recent childbirth, bereavement.
Describe the management for depression
Mild: low intensity psychological interventions e.g. CBT, group therapies, mild fullness, counselling, sleep hygiene.
Moderate/severe: high intensity psychological interventions e.g. CBT, antidepressants e.g. SSRIs, antipsychotics (quetiapine, olanzapine), ECT.
Describe the symptoms of hypomania
Persistent mild elevation of mood, increased energy and activity, feelings of wellbeing, physical and mental efficiency, increased sociability, talkativeness and overfamiliarity, increased sexual energy, decreased need for sleep, irritability. These symptoms don’t lead to severe disruption of work or result in social rejection. They’re present for 3-4 days.
Describe the symptoms of mania
Elevated mood, increased energy and activity, flight of ideas, pressure of speech, decreased need for sleep, inability to maintain attention, self-esteem inflated with grandiosity, self-important and increased confidence, loss of social inhibitions, increased libido, extreme irritability and aggression, spend money recklessly, facetious in inappropriate situations.
Manic episodes should last 7 days and have significant negative functional effects on work and social activities.
Describe the psychotic symptoms of mania
Grandiose delusions, persecutory delusions, religious delusions, 2nd person auditory hallucinations.
Describe the management for a manic episode
Antipsychotics: haloperidol, olanzapine, quetiapine, risperidone.
Lithium (3rd line).
Remove antidepressants.
Benzodiazepines for sleep disturbance and overactivity.
Which antipsychotic is used in young people with a manic episode?
Aripiprazole.
Bipolar 1 vs bipolar 2
Bipolar 1: at least one episode of mania.
Bipolar 2: at least one episode of hypomania (never mania) and one depressive episode.
What is the prevalence of bipolar affective disorder in the UK?
1%
Explain the aetiological factors contributing towards bipolar disorder
Genetics: strong genetic component, genetic overlap between bipolar disorder and schizophrenia.
Environmental: negative life events, trauma, abuse.
Neurobiological: increased dopamine in mania, HPA axis.
Describe the management of bipolar disorder
Mania: antipsychotics, stop antidepressants.
Depression: fluoxetine + olanzapine, quetiapine, olanzapine, lamotrigine.
Long-term: lithium, sodium valproate (2nd line), CBT.
What are the advantages and disadvantages of ECT?
Advantages: effective when other treatments don’t work, most effective with the most severe illness.
Disadvantages: multiple brief anaesthetics, acute confusional states, memory impairment.
What is seasonal affective disorder?
Depression which predominately occurs around the winter months.
The long term use of lithium can result in…
Hyperparathyroidism and resultant hypercalcaemia.
Once lithium concentrations are stable how often should lithium blood levels be checked?
Every 3 months.
How often should thyroid and renal function be checked in patients taking lithium?
Every 6 months.
Which antidepressants have an increased risk of GI bleeding?
SSRIs.
Describe presentation of serotonin syndrome
Rigidity, hyperreflexia and autonomic dysfunction. Can be treated with benzodiazepines.
- Neuromuscular excitation: hyperreflexia, myoclonus, rigidity.
- Autonomic nervous system excitation: hyperthermia, sweating.
- Altered mental state: confusion.
Are SSRIs associated with hyponatraemia?
Yes.
What are the anticholinergic effects of TCAs?
Tachycardia, dry mouth, mydriasis, blurred vision, constipation and urinary retention.
What is the risk associated with using SSRIs in the 3rd trimester?
Persistent pulmonary hypertension.
What is the risk associated with using SSRIs in 1st trimester?
Congenital heart defects.
What are the 5 stages of the grief reaction?
Denial, anger, bargaining, depression and acceptance.
What are the indications for ECT?
Treatment-resistant depression, catatonic schizophrenia and severe mania.
What is the only absolute contraindication for ECT?
Raised intracranial pressure.
What are the short-term and long-term side effects of ECT?
Short-term: headache, nausea, short term memory impairment, memory loss of events prior to ECT, cardiac arrhythmia.
Long-term: impaired memory (rare).
Which drugs interact with SSRIs?
NSAIDS, warfarin/heparin, aspirin, triptans (increased risk of serotonin syndrome), MAOIs (increased risk of serotonin syndrome).
When checking lithium levels, when should the sample be taken post dose?
12 hours.
How long after remission should antidepressants be continued for to reduce the risk of relapse?
6 months.
When stopping SSRIs over what period of time should it be gradually reduced?
Over a 4 week period.
What should all patients have monitored at initiation and each dose titration of venlafaxine?
BP - SNRIs are associated with development of hypertension.
Describe the adverse effects of lithium
N+V, diarrhoea, fine tremor, nephrotoxicity, thyroid enlargement, T wave fattening/inversion, weight gain, idiopathic intracranial hypertension, leukocytosis, hyperparathyroidism, hypercalcaemia.
Why should SSRIs and MAOIs never be combined?
As there is a risk of serotonin syndrome.
After a change in lithium dose, when should the levels be re-checked?
1 week later, the weekly until levels are stable.
How is lithium excreted?
Renally
Which drugs in particular interact with lithium?
Diuretics, ACEi, ARBs, NSAIDs.
Overdosage usually produces symptoms when the serum lithium concentrations rise above what?
1.5 mmol/L
Why are SSRIs the generally preferred antidepressants?
Fewer adverse effects and safer in overdose.
Lithium is known to cause what disturbance of sodium?
Hypernatraemia
What factors might precipitate lithium toxicity?
- Dehydration.
- Renal failure.
- Drugs: diuretics (especially thiazides), ACEi/ARBs, NSAIDs and metronidazole.
Describe the features of lithium toxicity
- Coarse tremor (a fine tremor is seen in therapeutic levels).
- Hyperreflexia.
- Acute confusion.
- Polyuria.
- Seizure.
- Coma.
Management of lithium toxicity
- Mild-moderate: volume resuscitation with normal saline.
- Severe: haemodialysis.
