Mood disorders Flashcards
What is the lifetime prevalence of depressive symptoms?
+ Prevalence of major depression (+ how many referred to outpts/hosp)
Lifetime prevalence = 10-20%
5% prevalence of major depression → 10% these to outpatients + 0.1% these hosp
What are some of the biological (4), psychological (3) + social (5) causes of depression?
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
What is the prognosis like for depression?
What are the chances of relapse?
<2/3rd recover within a year
<1/3rd chronic depression (>2yr)
Rest % die by suicide
25% relapse within 1yr
75% relapse within 10yrs
What are the core (3) + additional (7) symptoms of depression?
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
How long should depressive symptoms technically have been lasting for to be official ‘depressive symptoms’?
Symps >2wks
Can be shorter if rapid onset / severe symptoms
What are the biological symptoms (somatic syndrome) of depression? (5)
Early morning awakening Loss of appetite/ wt loss Diurnal variation in mood Psychomotor retardation/agitation Loss of libido
Describe the delusions that may be experienced in severe depression (3)
Mood congruent
Nihilistic (self/others/world ceased to exist)
Persecutory
Describe the hallucinations that may be experienced in severe depression (2)
2nd person auditory - derogatory/accusatory
Olfactory - filth/rotting flesh
List the psychiatric DDx for depression (4)
Schizophrenia
Anxiety
Eating disorder
Dementia
List the organic DDx for depression (22) (surgical sieve)
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
What drugs may precipitate Depression? (10)
Antihypertensives: B-blockers / methyldopa
Steroids: corticosteroids / oral contraceptive
Neuro: BZDs / LDOPA / anticonvulsants (pheny+carba)
Analgesics: opiates / certain NSAIDs (ibu/indo)
Psychiatric: antipsychotics
What physical Ix can be done into depression? (3)
Neuro + Endocrine examination
TFTs + Ca levels
LFTs, U+Es, FBC, ESR
What does Step 1 of NICE management of depression consist of? (5)
For all known/suspected presentations of Depression:
Assessment/active monitoring Psychoeducation Computerised CBT Self-help guides Sleep hygiene
What does Step 2 of NICE management of depression consist of? (3)
Mild/moderate:
Low intensity psychosocial interventions
Psychological interventions
Medication if moderate
What does Step 3 of NICE management of depression consist of? (3)
Moderate/severe unresponsive to Step 2:
Medication
High intensity psychological interventions
Consider secondary referral
What does Step 4 of NICE management of depression consist of? (5)
Severe complex / life threatening:
High intensity psychological interventions MDT Crisis team ECT Inpatient care
List some possible indications for antidepressants (10) (ACID NIMBI)
Anxiety Chronic fatigue syndrome IBS Depression (moderate/severe) Narcolepsy (TCAs) Insomnia Migraines Bulimia Impulsivity
What are the SEs of SSRIs? (9) (SAD AND SIC)
Sexual Dysfunc (++++)
Apathy/fatigue
Diarrhoea
Akathesia
Nausea
Dizziness
Sweaty
Insomnia
Cardiac teratogenic (paroxetine)
(No weight gain)
When are SNRIs used?
How do SEs compare to SSRIs?
2nd/3rd line
Same SEs as SSRIs but more discontinuation symptoms + more sedation
What receptors do TCAs work on? (5)
Why are they less used now?
Serotonin Dopamine (lesser extent) Noradrenaline Alpha-adrenoceptors Histaminergic
Less SEs + toxic in overdose
However TCAs 1st line in pregnancy as not teratogenic
What are the SEs of TCAs? (SW ADHD) (6)
Sedation Weight gain (++)
Antimuscarinic (dry mouth, blurred vision, urinary retention, constipation)
Diarrhoea
Hypotension
Delirium
Give some egs of MAOIs (3)
When are MAOIs used?
Why are they rarely used now?
Phenylazine, moclobemide (reversible), tranylcypromide
Used in treatment-resistant/ atypical
Rarely used due to tyramide (cheese) interaction
What are the SEs of MAOIs (6)
Dry mouth Nausea/Diarrhoea/Constipation Postural hypotension Sleep disturbances Headaches Cheese reaction
What is the main NaSSA used? (Noradrenaline + Selective Serotonin Antidepressant)
What are the advantages over SSRIs
Why still used less than SSRIs?
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
What are the SEs of NaSSA/Mirtazapine (5)
Weight gain (+++) / Increased appetite
Drowsiness
Dizziness
Headache
How long is needed when trialling antidepressants before deciding if failed?
3-4wks (continue even if partial improvement by then)
upto 12wks in elderly
70% respond to first medication
Which antidepressants commonly experience withdrawal/discontinuation symptoms? (2)
What are the possible Sx (8)
Paroxetine + Venlafaxine
Anxiety + sweating Nausea + vom Tingling + shaking Dizziness Headache Numbness Sleep disturbance/ strange dreams Electric-shock like sensations
What other biological treatments can be used in depression? (4)
Augmentation with treatment-resistant:
Lithium
Atypical antipsychotics
T3 (triiodothyronine)
ECT
What psychological interventions are used in Depression? (4)
Self-help materials
Psychoeducation
CBT
Interpersonal Therapy (IPT)
What social interventions are used in Depression (5)
Work around social inclusion Housing/benefits support Employment/education support Carer support CPN + Outpt appts (for more severe)
What are the indications for ECT (4)
Treatment-resistant depression
Life-threatening depression
Treatment-resistant mania
Catatonia
What are the possible MOAs of ECT
Modulation of NTs
Modulation of neuronal connectivity
Modulation of neuronal structure (inc hippocampal neurogenesis)
Changes in regional blood/activity
List the contraindications to ECT (1 absolute + 9 relative)
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
What are the SEs of ECT? (4)
Headache
Confusion
Impaired cognitive function
Temporary retrograde/anterograde amnesia
(+poss long term but inconsistent evidence)
Where are the electrodes placed in ECT?
Mid-point b/wn lateral angle of eye + external auditory meatus
What are the organic DDx of bipolar disorder (5)
Hyperthyroidism (v severe) Metabolic disorders Epilepsy Space-occupying lesions (SOL) - esp frontal lobe Substance misuse (inc. steroids)
What is the lifetime risk of developing bipolar disorder?
M:F ratio?
Usual age of onset
1% lifetime risk
Males+Females equal
Usually late teens/early 20s
What are the 3 etiological factors of bipolar?
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
What is the prognosis like in bipolar disorder?
≥90% have further episodes + req >25yr FU
20-30x more likely to die by suicide
What factors may contribute to relapse in bipolar disorder (6)
Natural/idiopathic Non-concordance with medication Substance misuse Life events/stressors Disruption of circadian rhythm Childbirth
List the ICD-10 Dx criteria for Hypomania (7)
Mild mood elevation Distractibility Mild overspending/risk-taking Sociability/overfamiliarity Increased energy Increased sexual energy Decreased need for sleep
List the ICD-10 Dx criteria for Mania (9)
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
How many mood disturbance episodes defines Bipolar?
= at least 2 episodes severe mood disturbance
≥1 of those being mania/hypomania
What are the 3 phases of bipolar disorder?
Acute mania
Bipolar depressive phase
Maintenance phase (remission/ req relapse prevention)
Describe the biopsychosocial management of acute mania (4:1:4)
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
Describe the biopsychosocial management of bipolar depressive phase (3:2:3)
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
Describe the biopsychosocial management of the maintenance phase of bipolar (relapse prevention) (3:3:3)
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
What physical health monitoring must be done in Bipolar? (5)
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
List the mood stabilisers available (7 - 3 of which antipsychotics)
Lithium
Valproate
Lamotrigine
Carbamazepine
Quietiapine
Olanzapine
Aripiprazole
What is another indication for mood stabilisers other than bipolar?
Augmentation for antidepressants in treatment-resistant
What is the lithium level range that is aimed for?
What level is assoc w. toxicity?
Aim for 0.4-1.2 mmol/L
>1.5 = toxicity >2.5 = serious toxicity medical emergency
List the common SEs of lithium (6)
G Will Make-sure Finances On PPoint
GI upset Wt gain Metallic taste in mouth Fine tremor Oedema Polyuria/dipsia
What congenital defects are assoc w. lithium in pregnancy?
What is incidence (% risk)
ASD/VSD
Ebstein’s anomaly (tricuspid abn)
6% risk major malformations
What congenital defects / effects are assoc w. valproate in pregnancy? (4)
What is incidence (% risk)
Low verbal IQ 30%
Autism 6%
Congenital malformations 10%
Neural tube defects 3%
What congenital defects may be seen with lamotrigine?
What is one of the rare/serious SEs with lamotrigine?
Least teratogenic but cleft lip/palate (if in 1st T)
Steven-Johnson Syndrome
What factors must be considered/discussed when choosing a mood stabiliser (5)
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
