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Psychiatry > Mood disorders > Flashcards

Mood disorders Flashcards

1
Q

What is the lifetime prevalence of depressive symptoms?

+ Prevalence of major depression (+ how many referred to outpts/hosp)

A

Lifetime prevalence = 10-20%

5% prevalence of major depression → 10% these to outpatients + 0.1% these hosp

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2
Q

What are some of the biological (4), psychological (3) + social (5) causes of depression?

A 
Bio:
Genetics
Hormonal changes
Substance misuse
Serious illness

Psycho:
-ve thoughts
Learned helplessness
Psychodynamic defence mechanisms

Social:
Loss / Bereavement
Life events
Childhood abuse
Social isolation
Social adversity
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3
Q

What is the prognosis like for depression?

What are the chances of relapse?

A

<2/3rd recover within a year
<1/3rd chronic depression (>2yr)
Rest % die by suicide

25% relapse within 1yr
75% relapse within 10yrs

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4
Q

What are the core (3) + additional (7) symptoms of depression?

A

CORE:
Low mood
Anhedonia
Anergia

ADDITIONAL:
Reduced concentration
Reduced appetite
Disturbed sleep
Self-harm/suicidal thoughts/acts
Psychomotor symptoms
Pessimism about future
Feelings of guilt/worthlessness
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5
Q

How long should depressive symptoms technically have been lasting for to be official ‘depressive symptoms’?

A

Symps >2wks

Can be shorter if rapid onset / severe symptoms

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6
Q

What are the biological symptoms (somatic syndrome) of depression? (5)

A 
Early morning awakening
Loss of appetite/ wt loss
Diurnal variation in mood
Psychomotor retardation/agitation
Loss of libido
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7
Q

Describe the delusions that may be experienced in severe depression (3)

A

Mood congruent
Nihilistic (self/others/world ceased to exist)
Persecutory

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8
Q

Describe the hallucinations that may be experienced in severe depression (2)

A

2nd person auditory - derogatory/accusatory

Olfactory - filth/rotting flesh

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9
Q

List the psychiatric DDx for depression (4)

A

Schizophrenia
Anxiety
Eating disorder
Dementia

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10
Q

List the organic DDx for depression (22) (surgical sieve)

A

Infection: HIV / Typhoid / EBV / Syphilis / Herpes
Iatrogenic: Opiates / Steroids / LDOPA
Immune: SLE / RA

Tumour: cerebral tumour / other malignancies (esp panc)
Trauma: head injury / SC injury

Endocrine: Thyroid/Para / Cushing / Addisons

Neuro: CVA / MS / Parkinsons/Huntingtons

Systemic: Renal failure / Porphyria

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11
Q

What drugs may precipitate Depression? (10)

A

Antihypertensives: B-blockers / methyldopa
Steroids: corticosteroids / oral contraceptive
Neuro: BZDs / LDOPA / anticonvulsants (pheny+carba)
Analgesics: opiates / certain NSAIDs (ibu/indo)
Psychiatric: antipsychotics

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12
Q

What physical Ix can be done into depression? (3)

A

Neuro + Endocrine examination
TFTs + Ca levels
LFTs, U+Es, FBC, ESR

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13
Q

What does Step 1 of NICE management of depression consist of? (5)

A

For all known/suspected presentations of Depression:

Assessment/active monitoring
Psychoeducation
Computerised CBT
Self-help guides
Sleep hygiene
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14
Q

What does Step 2 of NICE management of depression consist of? (3)

A

Mild/moderate:

Low intensity psychosocial interventions
Psychological interventions
Medication if moderate

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15
Q

What does Step 3 of NICE management of depression consist of? (3)

A

Moderate/severe unresponsive to Step 2:

Medication
High intensity psychological interventions
Consider secondary referral

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16
Q

What does Step 4 of NICE management of depression consist of? (5)

A

Severe complex / life threatening:

High intensity psychological interventions
MDT
Crisis team
ECT
Inpatient care
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17
Q

List some possible indications for antidepressants (10) (ACID NIMBI)

A 
Anxiety
Chronic fatigue syndrome
IBS
Depression (moderate/severe)
Narcolepsy (TCAs)
Insomnia
Migraines
Bulimia
Impulsivity
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18
Q

What are the SEs of SSRIs? (9) (SAD AND SIC)

A

Sexual Dysfunc (++++)
Apathy/fatigue
Diarrhoea

Akathesia
Nausea
Dizziness

Sweaty
Insomnia
Cardiac teratogenic (paroxetine)

(No weight gain)

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19
Q

When are SNRIs used?

How do SEs compare to SSRIs?

A

2nd/3rd line

Same SEs as SSRIs but more discontinuation symptoms + more sedation

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20
Q

What receptors do TCAs work on? (5)

Why are they less used now?

A 
Serotonin
Dopamine (lesser extent)
Noradrenaline
Alpha-adrenoceptors
Histaminergic

Less SEs + toxic in overdose
However TCAs 1st line in pregnancy as not teratogenic

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21
Q

What are the SEs of TCAs? (SW ADHD) (6)

A 
Sedation
Weight gain (++)

Antimuscarinic (dry mouth, blurred vision, urinary retention, constipation)
Diarrhoea
Hypotension
Delirium

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22
Q

Give some egs of MAOIs (3)
When are MAOIs used?
Why are they rarely used now?

A

Phenylazine, moclobemide (reversible), tranylcypromide

Used in treatment-resistant/ atypical
Rarely used due to tyramide (cheese) interaction

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23
Q

What are the SEs of MAOIs (6)

A 
Dry mouth
Nausea/Diarrhoea/Constipation
Postural hypotension
Sleep disturbances
Headaches
Cheese reaction
24
Q

What is the main NaSSA used? (Noradrenaline + Selective Serotonin Antidepressant)
What are the advantages over SSRIs
Why still used less than SSRIs?

A

Mirtazapine

Poss more effective in depression + anxiety
Can use in combo w. other antidepressants

Some pts get signif sedation/weight gain even on low doses

25
Q

What are the SEs of NaSSA/Mirtazapine (5)

A

Weight gain (+++) / Increased appetite
Drowsiness
Dizziness
Headache

26
Q

How long is needed when trialling antidepressants before deciding if failed?

A

3-4wks (continue even if partial improvement by then)
upto 12wks in elderly

70% respond to first medication

27
Q

Which antidepressants commonly experience withdrawal/discontinuation symptoms? (2)
What are the possible Sx (8)

A

Paroxetine + Venlafaxine

Anxiety + sweating
Nausea + vom
Tingling + shaking
Dizziness
Headache
Numbness
Sleep disturbance/ strange dreams
Electric-shock like sensations
28
Q

What other biological treatments can be used in depression? (4)

A

Augmentation with treatment-resistant:
Lithium
Atypical antipsychotics
T3 (triiodothyronine)

ECT

29
Q

What psychological interventions are used in Depression? (4)

A

Self-help materials
Psychoeducation
CBT
Interpersonal Therapy (IPT)

30
Q

What social interventions are used in Depression (5)

A 
Work around social inclusion
Housing/benefits support
Employment/education support
Carer support
CPN + Outpt appts (for more severe)
31
Q

What are the indications for ECT (4)

A

Treatment-resistant depression
Life-threatening depression
Treatment-resistant mania
Catatonia

32
Q

What are the possible MOAs of ECT

A

Modulation of NTs
Modulation of neuronal connectivity
Modulation of neuronal structure (inc hippocampal neurogenesis)
Changes in regional blood/activity

33
Q

List the contraindications to ECT (1 absolute + 9 relative)

A

Absolute: cochlear implant

Relative:
Raised ICP
Intracranial aneurysm
H/o cerebral haemorrhage

DVT
Recent MI
Aortic aneurysm
Cardiac arrhythmias (uncontrolled)
Cardiac failure (decompensated)
Acute resp inf
34
Q

What are the SEs of ECT? (4)

A

Headache
Confusion
Impaired cognitive function
Temporary retrograde/anterograde amnesia
(+poss long term but inconsistent evidence)

35
Q

Where are the electrodes placed in ECT?

A

Mid-point b/wn lateral angle of eye + external auditory meatus

36
Q

What are the organic DDx of bipolar disorder (5)

A 
Hyperthyroidism (v severe)
Metabolic disorders
Epilepsy
Space-occupying lesions (SOL) - esp frontal lobe
Substance misuse (inc. steroids)
37
Q

What is the lifetime risk of developing bipolar disorder?
M:F ratio?
Usual age of onset

A

1% lifetime risk
Males+Females equal
Usually late teens/early 20s

38
Q

What are the 3 etiological factors of bipolar?

A

Genetics: relatives of bipolar have higher risk bipolar/unipolar dep/schizoaffective (but not other way round with unipolar dep)

Life events: prolonged stresses/ vulnerability

Substance misuse

39
Q

What is the prognosis like in bipolar disorder?

A

≥90% have further episodes + req >25yr FU

20-30x more likely to die by suicide

40
Q

What factors may contribute to relapse in bipolar disorder (6)

A 
Natural/idiopathic
Non-concordance with medication
Substance misuse
Life events/stressors
Disruption of circadian rhythm
Childbirth
41
Q

List the ICD-10 Dx criteria for Hypomania (7)

A 
Mild mood elevation
Distractibility
Mild overspending/risk-taking
Sociability/overfamiliarity
Increased energy
Increased sexual energy
Decreased need for sleep
42
Q

List the ICD-10 Dx criteria for Mania (9)

A 
Marked mood elevation/ agitation
Marked distractibility
Reckless behaviour
Disinhibition
Grandiose
Flight of ideas
Marked increase in sexual energy
Increased activity
Absent/severe probs with sleep
43
Q

How many mood disturbance episodes defines Bipolar?

A

= at least 2 episodes severe mood disturbance

≥1 of those being mania/hypomania

44
Q

What are the 3 phases of bipolar disorder?

A

Acute mania
Bipolar depressive phase
Maintenance phase (remission/ req relapse prevention)

45
Q

Describe the biopsychosocial management of acute mania (4:1:4)

A

1st line = Antipsychotic
Consider lithium/val (or adjust)
Stop any antidepressants
BZDs in behav disturbance

Psychoeducation (other interventions will be useless)

Consider MHA/inpatient
Consider calm/low-stim environment
Advise not to make serious decisions whilst unwell
Advise to maintain relationships with carers

46
Q

Describe the biopsychosocial management of bipolar depressive phase (3:2:3)

A

Consider atypical
Consider lithium/val (or adjust)
Consider SSRI (only with mood stabiliser)

CBT
Psychoeducation

Support re: social inclusion / employment / education
Carer support
Consider inpatient if at risk

47
Q

Describe the biopsychosocial management of the maintenance phase of bipolar (relapse prevention) (3:3:3)

A 
Lithium +/or valproate (+ if ineffective // or if intolerable)
Antipsychotic 1st line in child-bearing
Avoid antidepressant (NB never w/o stabiliser)

Family therapy
CBT
Psychoeducation

Support re: social / employment / housing / benefits
Carer support
CPN/outpt appts to monitor

48
Q

What physical health monitoring must be done in Bipolar? (5)

A

Healthy eating / physical exercise programme
CV/Metabolic/Weight monitoring (annually)
Mood stabiliser levels (e.g. lithium weekly then 3m)
U&E + TFTs every 6m (with lithium)
Contraception/folic acid for childbearing age

49
Q

List the mood stabilisers available (7 - 3 of which antipsychotics)

A

Lithium
Valproate
Lamotrigine
Carbamazepine

Quietiapine
Olanzapine
Aripiprazole

50
Q

What is another indication for mood stabilisers other than bipolar?

A

Augmentation for antidepressants in treatment-resistant

51
Q

What is the lithium level range that is aimed for?

What level is assoc w. toxicity?

A

Aim for 0.4-1.2 mmol/L

>1.5 = toxicity
>2.5 = serious toxicity medical emergency
52
Q

List the common SEs of lithium (6)

G Will Make-sure Finances On PPoint

A 
GI upset
Wt gain
Metallic taste in mouth
Fine tremor
Oedema
Polyuria/dipsia
53
Q

What congenital defects are assoc w. lithium in pregnancy?

What is incidence (% risk)

A

ASD/VSD
Ebstein’s anomaly (tricuspid abn)

6% risk major malformations

54
Q

What congenital defects / effects are assoc w. valproate in pregnancy? (4)
What is incidence (% risk)

A

Low verbal IQ 30%
Autism 6%
Congenital malformations 10%
Neural tube defects 3%

55
Q

What congenital defects may be seen with lamotrigine?

What is one of the rare/serious SEs with lamotrigine?

A

Least teratogenic but cleft lip/palate (if in 1st T)

Steven-Johnson Syndrome

56
Q

What factors must be considered/discussed when choosing a mood stabiliser (5)

A

Choose in conjunction w. pt
Evaluate evidence / explain best option for pt as indiv
Special consideration in childbearing
Explain to childbearing women all are teratogens
Adequate contraception essential

Psychiatry (11 decks)

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