Mood Disorders Flashcards
Image showing possible symptoms of major depressive disorder
What are the 2 most common mood disorders?
The two most common mood disorders are major depressive disorder and bipolar affective disorder (manic depressive illness).
Definition of major depressive disorder
Period of low mood lasting over 2 weeks that is characterised by a mixture of core, biological and cognitive symptoms. Core symptoms: low mood, anhedonia and fatigue.
Core symptoms of depression
Anhedonia
Anergia
Apathy
Biological symptoms of depression
Sleep disturbance; Appetite/weight disturbance; Low libido; Disturbed sleep (particularly early morning waking); Psychomotor agitation or retardation
Cognitive symptoms of depression
Impaired memory; Reduced concentration and attention; Guilt and worthlessness; Low self-esteem and confidence; Bleak view of the future; Ideas or acts of self-harm or suicide
What symptoms may patients develop in severe depression?
patients may develop delusions and hallucinations (psychotic depression). These are congruent to their mood e.g. nihilistic delusions.
Investigations for depression
Collateral history
Physical examination
Bloods: FBC, TFT, U&E
Rating Scale: PHQ9, HAD, CDI (children)
Risk Assessment
What must you always do in depression?
RISK ASSESS
PACES: What rating scales can be used for depression?
PHQ9, HAD, CDI (children)
What subtypes of depression exist?
Seasonal – worse in winter
Psychotic – with psychotic features
Atypical – mood reactivity is core feature, hyperphagia, hypersomnia, leaden feeling in limbs, hypersensitivity to rejection
Management of mild to moderate depression
Sleep hygiene
Arrange further assessment within 2 weeks
Low-Intensity Psychosocial Intervention (ALWAYS CBT)
NOTE: Do NOT routinely consider MEDICATION unless:
Past history of moderate or severe depression
Symptoms have been present for a long time (> 2 years)
Symptoms persist despite other interventions
NOTE: Do NOT recommend St. John’s wort but warn patients about uncertainty in dosing and drug interactions
Should you consider medication in mild to moderate depression?
Do NOT routinely consider MEDICATION unless:
Past history of moderate or severe depression
Symptoms have been present for a long time (> 2 years)
Symptoms persist despite other interventions
NOTE: Do NOT recommend St. John’s wort but warn patients about uncertainty in dosing and drug interactions
What does management of moderate to severe depression involve?
Provide a combination of:
Antidepressant medication
High-intensity psychological intervention (CBT or interpersonal therapy (IPT))
1st line medication for moderate to severe depression
SSRI (e.g. sertraline)
Best antidepressant for young people
Fluoxetine
Which drug class pose a risk of bleeding?
SSRIs, need to give PPI if they need NSAIDs
What drugs are at high risk of interactions?
Fluoxetine, parocetine
What drug is at high risk of discontinuation symptoms?
Paroxetine
What drug causes death from overdose?
Venlafaxine
What drug class often causes overdoses?
TCAs
What drugs are often stopped due to side effecgts?
Venlafaxine, duloxetine, TCAs
Which drug needs BP to be monitored?
Venlafaxine
Which drugs cause worsening hypertension?
venlafaxine, duloxetine
Which drugs cause postural hypertension and arrhythmia?
TCA
How often should medication be monitored in moderate to severe depression?
After starting antidepressant medication, review after 2 weeks for side-effects, then every 2-4 weeks thereafter for 3 months
Patients < 30 years or at increased risk of suicide should be followed-up after 1 week
Review response to treatment after 3-4 weeks
When should caution be exercised when switching antidepressants? Why?
From fluoxetine to other antidepressants (fluoxetine = long half-life)
From fluoxetine or paroxetine to a TCA (both drugs inhibit TCA metabolism so a lower starting dose may be needed)
To a new SSRI, SNRI or MAOI (risk of serotonin syndrome)
From non-reversible MAOI: a 2-week washout period is required (other antidepressants should not be prescribed during this period)
Important note when swithcing fluoxetine to other antidepressants
Fluoxetine has a long half life
Important note when switching from fluoxetine or paroxetine to a TCA
both drugs inhibit TCA metabolism so need a lower starting dose
Important note when switching to a new SSRI, SNRI, or MAOI
RISK OF SERETONIN SYNDROME
Important note when switching from non-reversible MAOI
a 2-week washout period is required (other antidepressants should not be prescribed during this period)
Management of complex and severe depression
Use crisis resolution and home treatment teams to manage crises
Develop a crisis plan that identified potential triggers and strategies to manage triggers (share with the GP and any other people involved in the patient’s care)
Consider inpatient treatment if significant risk of suicide, self-harm or self-neglect
Consider ECT for acute treatment of severe depression and when a rapid response is required
PACES: Who should be used to manage crises in complex and severe depression?
Crisis resolution and home treatment teams
When to consider inpatient treatment in depression?
if significant risk of suicide, self-harm or self-neglect
When is ECT used in depression?
If tretment regractory
What can ECT cause?
retrograde amnesia
Can ECT be used in depression?
Yes
Management of catatonic depression
Consider ECT for acute treatment of severe depression and when a rapid response is required
Definition of BPAD
A disorder characterised by 2 or more episodes in which the patient’s mood and activity levels are significantly disturbed, this disturbance consisting on some occasions of an elevation of mood and increased energy and activity (hypomania or mania) and on others of a lowering of mood and decreased energy and activity (depression).
How many episodes of mood disturbances are needed in order to diagnose BPAD?
2 or mroe
What are episodes of hypomania or mania without depression classified as?
bipolar
Types of BPAD
Bipolar I Disorder
At least ONE manic episode
Depressive episodes are common but are NOT necessary to make the diagnosis
Bipolar II Disorder
At least ONE hypomanic episode
At least ONE major depressive episode
Cyclothymia
History of hypomanic episodes with periods of depression that do not meet the criteria for major depressive disorder
Requirements for diagnosis for type 1 BPAD
At least ONE manic episode
Depressive episodes are common but are NOT necessary to make the diagnosis
Requirements for diagnosis of type 2 BPAD
At least ONE hypomanic episode
At least ONE major depressive episode
Requirements for diagnosis of cyclothymia
History of hypomanic episodes with periods of depression that do not meet the criteria for major depressive disorder
What does BPAD typically manifest as?
a cyclical pattern of mania or hypomania and depression
Signs of a manic episode
THINK: DIG FAST
Distractibility
Irresponsibility
Grandiosity
Flight of ideas
Agitation
Less sleep
Talking too much (pressured speech)
How long does a manic episode last?
Lasts at least a week
Classic features of a manic episode
disinhibition and irresponsibility - spends money, goes out naked, increased self-esteem and confidence, gambling life-savings
Typical case of a manic episode
a patient with a sudden change in mood to an elevated state, no sleeping, doesn’t go to work, altered behaviour
Is social functioning distrubed in mania?
Yes
Is social functioning distrubed in hypomania
Little or no impairment in social functioning
Difference ebtween manic and hypomanic episodes
Mania has delusions of grandeur
Psychotic Symptoms in mania
Impairment of social functioning
How long does a hypomanic episode need to last?
At least 4 days
Investigations for BPAD
Collateral history
Physical examination (establish baseline state)
Bloods: FBC, TSH, U&E, LFT, ECG
Urine drug screen
Rating scale: Young Mania Rating Scale
Risk assessment
PACES: What rating scale is used in BPAD?
Young Mania Rating Scale
What is the mainstay of management in BPAD? What are the main drugs?
Mood stabilisers
Main drugs:
Lithium
Sodium valproate
Carbamazepine
What is the therapeutic range of Lithium? When does it become toxic?
Therapeutic range: 0.6-1.0 mmol/L, becomes toxic >1.2 mmol/L
How often should Lithium levels be monitored?
Lithium levels should be checked 1 week after starting or changing dose and monitored weekly until a steady therapeutic level is achieved
It should be monitored every 3 months from then on
What blood test results should be monitored in Lithium use? How often? Why?
U&E and TFTs should be monitored every 6 months (can cause renal impairment and hypothyroidism)
When does lithium toxicity occur?
Level > 1.2 mmol/L
How does Lithium toxicity present?
GI disturbance; polyuria/ polydipsia; sluggishness; giddiness; ataxia; gross tremor; seizures; renal failure
NOTE: It is life threatening
What triggers lithium toxicity?
Salt balance changes (e.g. dehydration, D&V)
Drugs interfering with lithium excretion via the kidneys (e.g. diuretics)
Accidental or deliberate overdose
How is lithium toxicity managed?
Check lithium level
Stop lithium. WARNING: stopping lithium abruptly could precipitate symptoms of mania/depression)
Transfer for medical care (rehydration, osmotic diuresis). If overdose is severe, the patient may need gastric lavage or dialysis.
What type of drug is Sodium Valproate? What does it treat in BPAD?
Anticonvulsant
Treats acute mania
Prophylaxis in BPAD
NOTE: Plasma levels do not need monitoring. Dose-related toxicity is NOT usually an issue
What type of drug is carbamezapine? What issues can it cause in management of BPAD?
Anticonvulsant
Can cause toxicity at high doses
Induces liver enzymes (check for drug interactions before prescribing)
What must be checked before prescription of carabamazepine? Why?
Drug interactions, it induceds liver enzymes
Risks of mood stabilisers in pregnancy
Mood stabilisers are teratogenic
Risk of harm should be weighed against harm of manic relapse
Lithium - Ebstein’s anomaly
Valproate + carbamazepine - spina bifida
PACES: Advice to give women of childbearing age on mood stabilisers
Women of childbearing age should be given contraceptive advice and prescribed a folate supplement if using valproate
What does Lithium cause in pregnancy?
Ebstein’s anomaly
What does Valproate and carbamazepine cause in pregnancy?
Spina bifida
Besides mood stabilisers, what other drugs can be used for management of BPAD?
Antipsychotics (e.g. olanzapine)
Usually atypical (e.g. olanzapine, risperidone, quetiapine) because of fewer side-effects
Anticonvulsants
Lamotrigine is 2nd line for prophylaxis in BPAD type II
What is the acute treatment of mania or hypomania?
Stop medications that may induce symptoms (e.g. antidepressants, drugs of abuse, steroids and dopamine agonists)
Monitor food and fluid intake to prevent dehydration
If treatment free:
Give an antipsychotic OR mood stabiliser (can be given together if not responding)
A short course of benzodiazepines may be added for sedation (sleep deprivation can exacerbate mania)
If already on treatment
Optimise the medication; check compliance; adjust doses
Consider adding another agent (e.g. antipsychotic as well as mood stabiliser)
Short-term benzodiazepines may help
After stopping medications that may induce symptoms, what is the acute treatment of mania or hypomania if treatment free?
Give an antipsychotic OR mood stabiliser (can be given together if not responding)
A short course of benzodiazepines may be added for sedation (sleep deprivation can exacerbate mania)
Why might a short course of benzodiazepines be added in the acute treatment of mania or hypomania?
A short course of benzodiazepines may be added for sedation (sleep deprivation can exacerbate mania)
After stopping medications that may induce symptoms, what is the acute treatment of mania or hypomania if already on treatment?
Optimise the medication; check compliance; adjust doses
Consider adding another agent (e.g. antipsychotic as well as mood stabiliser)
Short-term benzodiazepines may help
How to treat depression in BPAD?
DIFFICULT because antidepressants can cause a switch to mania
To reduce this risk, antidepressants should only be given with a mood stabiliser or antipsychotic
1st line: fluoxetine + olanzapine/quetiapine
2nd line: lamotrigine
Why is it difficult to treat depression in BPAD?
antidepressants can cause a switch to mania
What must antidepressants be given with in the treatment of depression in BPAD? Why?
antidepressants should only be given with a mood stabiliser or antipsychotic
1st line: fluoxetine + olanzapine/quetiapine
2nd line: lamotrigine
Because antidepressants can cause a switch to mania
What psychological therapy is used in BPAD?
CBT
What medication should you consider stopping during an acute manic episode?
During an acute manic episode, consider stopping antidepressant (if the patient is on one)
What is the antidepressant of choice in the management of depression in BPAD? What must it be given with?
fluoxetine is the antidepressant of choice (given with olanzapine or quetiapine)
How should primary care refer people with BPAD?
Symptoms of hypomania 🡪 routine referral to CMHT
Symptoms of mania or severe depression 🡪 urgent referral to CMHT
PACES: Important questions to ask when risk assessing those with depression
Have you ever thought about/attempted to end your life?
Have you ever purposefully hurt yourself or want to hurt yourself?
PACES: Important things to explore if patient has displayed thoughts or intent of harming themselves
Before – trigger, planned/impulsive, intoxication, preventing discovery
During – Method (cutting, OD, burning, hitting oneself), thoughts during act, where were they
After – who called for help, current mood, regret, would they do it again, will they accept treatment
Suicide risk factors
THINK: SAD PERSONS
S - sex (male)
A - age (young, elderly)
D - depression
P - previous attempt (highest risk factor)
E - ethanol or drug use
R - rational thinking loss (psychosis)
S - sickness (medical illness)
O - organised plan
N - no social support
S - states future intent
Protective factors against suicide
family support
having children at home
religious belief
What are some factors that suggest increased risk of completed suicide?
efforts to avoid discovery
planning
leaving a written note
final acts such as sorting out finances (e.g. sorting a will)
violent method
Beck’s cognitive triad of depression
