Mood disorders Flashcards

Question

What initial monitoring is required in managing MDD?

Answer 1

1. Those newly on ADs should be reviewed after 1 – 2 weeks and then 2 – 4 weekly for early response, S/Es and adherence. - Always enquire specifically about these three factors. 2. Further monitoring depends on case complexity, medical/psychiatric comorbidity, suicide/other risk, depression severity, and degree of functional impairment. -Always watch for a manic switch.

Answer 2

1. The STAR * D trial showed that 28% of individuals achieve complete remission after the first AD. 2. An additional 25% of the remaining individuals achieve remission after the second trial (i.e., 53% in remission after 2 x sequential AD trials). 3. Thereafter, switching vs augmenting didn’t really change the likelihood of remission (a further +/- 18%). 4. The more trials needed, the less likely to achieve remission (about 10.3% at the 4th trial). 5. There is no way to predict who will respond at what point.

Answer 3

1. Discuss common and serious side effects/adverse effects. 2. Will need to take the medication for 2-4 weeks or longer before she experiences a change in her mood. 3.She will need regular follow-up after starting the AD; more regularly if any suicidality. -Most SSRIs and SNRIs have similar efficacy; SSRIs tend to be better tolerated. Therefore, you decide together that citalopram 20mg will be an appropriate agent to start.

Answer 4

The use of electrical currents or magnetic fields applied to the brain to cause stimulation of the neurons. Include: -Electroconvulsive therapy (ECT). -Repetitive transcranial magnetic stimulation (rTMS). -Deep brain stimulation (DBS). -Vagal nerve stimulation (VNS).

Answer 5

- Application of electrical current to the brain to induce a therapeutic seizure. -Use of informed consent (if capacity), and anaesthesia and muscle relaxant medication to prevent a motor seizure. -Indications: highly effective in MDD – 80-90% remission; 50-60% remission in treatment-resistance + it works quickly. - The main side effects are antero- and retrograde amnesia, nausea and headache. -Therefore, reserved for life-threatening depression (psychotic depression, suicidality, catatonia/unable to care for self), those with a prior good response to ECT/patient preference, and treatment-resistant depression.

Answer 6

-Uses a magnetic field to induce electrical currents in the brain. -Main difference to ECT – can target specific brain regions, does not cause memory impairment, does not require anesthetic. -But: not as effective as ECT (25-30% response rate) As it is better tolerated but less effective than ECT, it is second-line for treatment-resistant MDD

Answer 7

DBS is invasive, requires surgery. Both are experimental still and rarely used. Complimentary and alternative medications (CAMs): healthy diet, exercise, and sleep schedule should be encouraged in all individuals.

Answer 8

Bipolar 1 disorder – manic episode(s) (usually also hypomanic and depressive episode(s)) Bipolar 2 disorder – hypomanic and depressive episode(s)

Answer 9

-Lifetime prevalence 0.7 – 1% -M=F -Mean age of onset 30s (wide range) -Commoner in those with a higher SES -Comorbidity is common and worsens the prognosis

Answer 10

1. A specific period of persistent and abnormal change in mood (elevated/expansive/irritable) AND increased energy/activity lasting at least ONE WEEK (or any period if hospitalization required) 2. During this period, THREE of the following must be present (FOUR if mood is only irritable): Mneumonic: DIG FAST. -Distractibility (poor attention) -Indiscretion (in spending, sexual activity, etc.) -Grandiosity (inflated self-esteem) -Flight of ideas (racing thoughts) -Activity increased (GDA or agitation) -Sleep need decreased (NOT insomnia) -Talkativeness increased

Answer 11

1. Symptoms are severe enough to cause marked impairment in functioning, or require hospitalization, or there is psychosis. 2. Not due to a substance or another medical condition.

Answer 12

1. A specific period of persistent and abnormal change in mood (elevated/expansive/irritable) AND increased energy/activity lasting at least FOUR DAYS 2. During this period, THREE of the following must be present (FOUR if mood is only irritable): Mneumonic: DIG FAST. -Distractibility (poor attention) -Indiscretion (in spending, sexual activity, etc.) -Grandiosity (inflated self-esteem) -Flight of ideas (racing thoughts) -Activity increased (GDA or agitation) -Sleep need decreased (NOT insomnia) -Talkativeness increased

Answer 13

-There is a definite change in functioning for that person. -The change in mood and functioning is observable by others. -The episode is NOT severe enough to cause marked impairment in functioning, or require hospitalization. -If there is psychosis – it is a manic episode. -The change is not due to substances or another medical condition.

Answer 14

-Characterized by recurrent mood episodes. -The mood is often described as euphoric, excessively happy, high, excited, fantastic, “up”, “on top of the world”, or else is predominantly irritable (easily angered). -The mood is often infectious to those around the patient (including the clinician) – a helpful clue. -Rapid mood shifts often occur (from euphoric to irritable to dysphoric). -The individual often feels as if he/she can accomplish anything and often engages in multiple overlapping tasks that are rarely completed, often through the night. -Insight is usually very poor

Answer 15

-About 75% of bipolar 1 disorders start with a depressive episode. -Most patients experience both manic and depressive episodes; 10 – 20% experience only manic episodes. -Manic episodes tend to have a rapid onset (hours to days), but may evolve over a few weeks. -Untreated manic episodes tend to last about 3 months. -After an index manic episode, 90% will go on to have a second episode. -The prognosis is poorer than in MDD – a third of patients will have chronic symptoms and significant social decline.

Answer 16

-For acute severe mania: a second-generation antipsychotic or a mood stabiliser or both (preferably). -SGA options: risperidone, olanzapine, quetiapine, aripiprazole, (haloperidol). -Mood stabiliser options: lithium, valproate. -If there is no/a poor response over 1-3 weeks, switch the mood stabilizer or the antipsychotic. - If no/poor response to 4-6 different treatment combinations, consider ECT or clozapine (either clozapine monotherapy or clozapine + lithium/valproate). -Treat agitation and lack of sleep with benzodiazepines temporarily, while giving the treatment time to work e.g., clonazepam or lorazepam.

Answer 17

-Psychopharmacology is the cornerstone of treatment, often with adjunct psychotherapy. -Antidepressants are often unhelpful and may cause rapid cycling and/or manic switch. -First line: quetiapine monotherapy. -Second line (if no/poor response or poorly tolerated): Olanzapine + fluoxetine Valproate Quetiapine + lithium/valproate Lithium + valproate/lamotrigine