Mood disorders

Question 1

two questions screen for depression

Answer 1

‘During the last month, have you often been bothered by feeling down, depressed or hopeless?’
‘During the last month, have you often been bothered by having little interest or pleasure in doing things?’

Question 2

screening tool depression, how work

Answer 2

Patient Health Questionnaire (PHQ-9)
asks patients ‘over the last 2 weeks, how often have you been bothered by any of the following problems?’
9 items which can then be scored 0-3
includes items asking about thoughts of self-harm
less severe - <16
more severe - same or >16

Question 3

criteria to grade depression

Answer 3

DSM-IV

Question 4

criteria grades depression how work

Answer 4

1. Depressed mood most of the day, nearly every day
2. Markedly diminished interest or pleasure in all, or almost all, activities most of the day, nearly every day
3. Significant weight loss or weight gain when not dieting or decrease or increase in appetite nearly every day
4. Insomnia or hypersomnia nearly every day
5. Psychomotor agitation or retardation nearly every day
6. Fatigue or loss of energy nearly every day
7. Feelings of worthlessness or excessive or inappropriate guilt nearly every day
8. Diminished ability to think or concentrate, or indecisiveness nearly every day
9. Recurrent thoughts of death, recurrent suicidal ideation without a specific plan, or a suicide attempt or a specific plan for committing suicide
   MILD - >5 for diagnosis (otherwise subthreshold)
   MOD
   SEV -> most sx, interfere with functioning, with or without psychosis

Question 5

anhedonia

Answer 5

lack of interest/enjoyment

Question 6

sx depression
core, somatic, cognitive

Answer 6

core - lack of energy, anhedonia
somatic - loss of libido, early morning waking, diurnal variation of mood, agitation
cognitive - low self esteem , guilt, suicidal, hypochondral

Question 7

psychotic depression

Answer 7

hallucinations - usually auditory
delusions - hypochondrical, guilt, nihilstic, persecutory

Question 8

delusions

Answer 8

not based on reality, or individual’s cultural or religious background

Question 9

less severe management depression

Answer 9

less severe - avoid antidepressant meds unless person’s preference
1st line -> guided self help, CBT, BA, individual CBT, BA, group exercises, mindfulness, IPT, SSRI, counselling, STPP (most ->least)

Question 10

more severe management depression

Answer 10

1st line - individual CBT + antidepressant
then individual BA, individual problem solving, counselling, STPP, IPT, guided self help, group exercise

Question 11

switching antidepressants guidlines

Answer 11

Switching from citalopram, escitalopram, sertraline, or paroxetine to another SSRI
the first SSRI should be withdrawn* before the alternative SSRI is started

Switching from fluoxetine to another SSRI
withdraw then leave a gap of 4-7 days (as it has a long half-life) before starting a low-dose of the alternative SSRI

Question 12

depression over dementia

Answer 12

short history, rapid onset
biological symptoms e.g. weight loss, sleep disturbance
patient worried about poor memory
reluctant to take tests, disappointed with results
mini-mental test score: variable
global memory loss (dementia characteristically causes recent memory loss)

Question 13

prevalence depression

Answer 13

lifetime prevalence 10-20%

Question 14

depression risk factors

Answer 14

female
chronic physical health conditions

Question 15

sx of hypomania

Answer 15

interference for at least several days ->
- mildly elevated mood
- increased energy
- increased self esteem
- sociabke, talkative
- increased sex drive
- reduce need for sleep
- difficulty in focussing on one task alone

Question 16

sx of mania

Answer 16

• elevated mood
• increased energy, agitated
• gradiosity
• pressure of speech (not make sense)
• flight of ideas
• distractible
• reduced need for sleep
• increased libido
• social inhibitions lost
• psychotic sx

Question 17

mania v hypomania

Answer 17

mania - at least 7 days, severe functional impairment, require hospitalisation, psychotic sx
hypomania - lesser version, <7 days, high functioning, no psychotic sx or hospitalisation

Question 18

BPD ddx

Answer 18

-> cyclothymia - mild episodes of elation/depression
early onset, chronic course
common in relatives of BPD
-> emotionaly unstable personality disorder

Question 19

depression ddx

Answer 19

dysthymia - chronic low mood, not fulfil criteria of depression

Question 20

define mixed affective state

Answer 20

mixture or rapid alternation of hypomanic, manic and depressive sx

Question 21

bipolar disorder define

Answer 21

chronic mental health disorder characterised by periods of mania/hypomania alongside episodes of depression

Question 22

epidemiology BPD

Answer 22

late teens
2%
M=F

Question 23

2 types of bipolar

Answer 23

type I disorder: mania and depression (most common)
type II disorder: hypomania and depression

Question 24

ICD classification bipolar

Answer 24

> 2 episodes, one of which must be hypomanic, manic or mixed episode

Question 25

BPD management

Answer 25

psychological interventions lithium - 1st line episode of mania/hypomania - consider stopping antidepressant if on one, start antipsychotic - olanzapine, haloperidol episodes of depression - talking therapies, fluoxetine

Question 26

BPD co-morbidites

Answer 26

2-3x increased risk of DM, CVD, COPD

Question 27

BPD primary care referral

Answer 27

hypomania - routine referral to CMHT mania or severe depression - urgent referral

Question 28

electroconvulsive therapy indication

Answer 28

severe depression that is treatment resistant - most common prolonged, severe manic episode high suicide risk caratonia stupor psychmotor retardation

Question 29

short and long term side effects electroconvulsive therapy

Answer 29

headache nausea short term memory impairment memory loss of events prior to ECT cardiac arrhythmia some patients report impaired memory

Question 30

ECT mechanism

Answer 30

electric current through brain to trigger epileptic seizure

Question 31

rTMS

Answer 31

repetitive transcranial magentic stimulation - repetitive pulses of magnetic energy at a fixed frequency

Question 32

tDCS

Answer 32

transcranial direct current stimulation = constant low strength current

Question 33

avoid BPD

Answer 33

antidepressants

Question 34

BPD prognosis

Answer 34

80% relapse after first episode within 5-7 years esp if severe episodes or early onset

Question 35

nature of ECT

Answer 35

small dose of electric current to induct seizures under anaesthetic and given muscle relaxant - propofol and suxamethonium frontotemporal region uni or bilateral cerebral blood flow increases, hormone changes neurotransmitter hypothesis - balancing chemical changes in mental illness. increase serotinergic and noradrenergic unsure tho monitor Hamilton Depression Rating Scale and Montreal Cognitive Assessment before and after ECT

Question 36

indications ECT

Answer 36

severe depression catatonia mania schizophrenia

Question 37

s/e ECT

Answer 37

memory loss, confusion, headache, status epilepticus, stroke, PE, broken teeth, body aches risks of anaesthesia - Mi, arrthymias, aspiration pneumonia, nausea

Question 38

c/i ECT

Answer 38

raised ICP, cerebral aneurysm - absolute MI within 3 mths unstable angina acute resp infection pregnancy unstable fractures etc

Question 39

grief reaction

Answer 39

denial anger bargaining depression acceptance

Question 40

atypical grief reaction

Answer 40

delayed grief: sometimes said to occur when more than 2 weeks passes before grieving begins prolonged grief: difficult to define. Normal grief reactions may take up to and beyond 12 months

Question 41

insomnia define

Answer 41

difficulty initiating or maintaining sleep, or early-morning awakening that leads to dissatisfaction with sleep quantity or quality. This is despite adequate time and opportunity for sleep and results in impaired daytime functioning.

Question 42

chronic insomnia criteria

Answer 42

at least 3 nights per week for 3 months or longer

Question 43

sx of insomnia

Answer 43

decreased daytime functioning, decreased periods of sleep (delayed sleep onset or awakening in the night) or increased accidents due to poor concentration

Question 44

insomnia risk fx

Answer 44

Female gender Increased age Lower educational attainment Unemployment Economic inactivity Widowed, divorced, or separated status Alcohol and substance abuse Stimulant usage Medications such as corticosteroids Poor sleep hygiene Chronic pain Chronic illness: patients with illnesses such as diabetes, CAD, hypertension, heart failure, BPH and COPD have a higher prevalence of insomnia than the general population. Psychiatric illness: anxiety and depression are highly correlated with insomnia. People with manic episodes or PTSD will also complain of extended periods of sleeplessness.

Question 45

insomnia investigations

Answer 45

sleep diaries and actigraphy polysomnography

Question 46

management insomnia

Answer 46

identify causes advise driving advice sleep hygeine only consider hypontics if daytime impairment severe (zopiclone)

Question 47

seasonal affective disorder

Answer 47

escribes depression which occurs predominately around the winter months. SAD should be treated the same way as depression, therefore as per the NICE guidelines for mild depression, you would begin with psychological therapies and follow up with the patient in 2 weeks to ensure that there has been no deterioration. Following this an SSRI can be given if needed.