Mood disorders

Question 1

What is bipolar disorder?

Answer 1

Episodes of mania and depression and periods in between in which the patient is normal. Patients may experiences one type more than the other

Question 2

What are the symptoms of mania?

Answer 2

- elated/expansive/irritable mood
and 3 other symptoms of the following:
- increased sex drive and loss of inhibition
- increased energy 
- reduced sleep 
- Grandiosity/increased self esteem 
- distractible
- pressure of speech 
- flight of ideas 
- social inhibitions lost 
- psychotic symptoms (hallucinations and delusions)

Question 3

What are the symptoms of hypomania

Answer 3

3 or more characteristic symptoms of mania for 4 days however not severe enough to interfere with social/occupational functioning

Question 4

What is a mixed episode

Answer 4

rapid alternation of manic and depressive symptoms
a period (at least 1 week) in which the criteria are met for a manic/hypomanic episode and at least 3 symptoms of depression for most of the days during the manic episode
OR
a period of major depression with at least 3 symptoms of manic/hypomannia present

Question 5

What is rapid cycling bipolar disorder

Answer 5

experience of at least 4 episodes of depression, mania. hypomania or mixed within a year

Question 6

How is bipolar classified

Answer 6

Bipolar I = 1+ manic episodes or mixed episodes without any depressive episodes
Bipolar II = 1+ depressive episode with at least 1 hypomanic episode

Question 7

What are the complications of bipolar disorder

Answer 7

SUICIDE and SELF HARM

• financial issues from overspending during mania
• STIs and unplanned pregnancies
• Damage to reputation, income, occupation and relationships
• self neglect, exhaustion, dehydration
• exploitation by others
• alcohol and substance misuse
• harm to others

Question 8

What are the differentials for bipolar

Answer 8

in some cases some of these diagnoses may coexist

• unipolar depression
• cyclothymia - chronic disturbance of mood, periods of hypomania and depression
• schizophrenia
• substance misuse
• organic brain disease
• metabolic disease -> thyroid, cushings
• personality disorder - mood changes are usually rapid and do not go in cycles

Question 9

What is the pharmacological management for bipolar disorder

Answer 9

Mood Stabilizers

• Lithium Carbonate - therapeutic range is 0.4-1 mmol/L
• Sodium valproate - not given to women of child bearing age
• Lamotrigine - use mainly for bipolar depression

Antipsychotics 
- haloperiodol 
- olanzapine 
- quetiapine 
if 2 antipsychotics do not work add Lithium or sodium valproate 

Avoid antidepressants as this can lead to an episode of mania

Question 10

What is the social management for bipolar

Answer 10

make patients aware of support groups and websites they can use for advice
help with getting back to work
entitlement to benefits
PIP
housing options
Driving - must not drive during acute mania - must inform DVLA
Carers care plan
Avoiding alcohol and substance misuse
Avoiding caffeine
smoking cessation
adequate amount of sleep and avoiding shift work

Question 11

What are the psychological management strategies for Bipolar

Answer 11

identify personal, social, occupational and environmental triggers
encourage compliance
Psychological interventions specifically for bipolar disorder
CBT to treat depression
Self monitoring of symptoms

Question 12

Which physical health checks are needed for patients with Bipolar Disorder?

Answer 12

Weight/BMI
Bp and Pulse
Metabolic - fasting blood glucose, HbA1c, lipid profile
LFTs
U+Es, TFTs, Calcium levels if on long term lithium

Question 13

What are the core symptoms of depression

Answer 13

Persistent low mood
lack of energy
lack of interest/pleasure

Question 14

What are the other symptoms of depression

Answer 14

Early morning wakening 
Diurnal variation 
Weight loss
Decreased appetite 
Decreased libido 
low self esteem 
worthlessness
hopelessness 
feelings of guilt 
psychomotor retardation
poor concentration

Question 15

What are the symptoms of psychotic depression

Answer 15

hallucinations - mainly auditory

delusions - mood congruent, guilt, nihilistic, persecutory, hypochondriasis

Question 16

Which investigations should be done if depression is suspected?

Answer 16

Used to exclude organic causes 
Bloods:
FBC - to rule out anaemia 
TFTs - rule out hypothyroidism 
LFTs 
U+Es 
Glucose 
Calcium - hypercalcaemia 
inflammatory markers 

HIV/syphilis test, drug screening - if evident from the history

Question 17

What are the differentials for depression

Answer 17

Bipolar disorder - ask about any periods where their mood was very high
Schizophrenia - may coexist
dementia - may occasionally present as dementia
Seasonal affective disorder
Bereavement
Organic cause e.g. hypothyroidism

Question 18

How is depression classified

Answer 18

Mild = 2 core + 2 other symptoms (still able to function)
Moderate = 2 core + 3 others
Severe = 3 core + 4 others
Also severe with psychotic symptoms

Question 19

What is atypical depression

Answer 19

Oversleeping 
Overeating 
Variably depressed mood
Extreme fatigue and heaviness in limbs 
Pronounced anxiety

Question 20

Which diseases are associated with depression?

Answer 20

Eating disorders 
Dysthymia 
Substance misuse
other psychiatric disorders may coexist 
PTSD
Parkinsons 
Cerebrovascular disease 
endocrine disorders 
Cancer esp Pancreatic 
autoimmune conditions

Question 21

What should be assessed when a patient presents with symptoms of depression

Answer 21

Full history
MSE
Risk assessment both to self and others and driving
Ask about organic causes for e.g. weight gain and hair loss for hypothyroidism
Establish onset, speed of onset and duration
Ask about social situation - job, relationship difficulties, housing, finance
Collateral hx from family/carer - idea of premorbid personality
Ask about premorbid personality
Past psychiatric hx
assess for psychotic symptoms

Question 22

What is the pharmacological management for depression

Answer 22

Moderate to severe depression antidepressants are used
1st line - SSRIs
e.g. sertraline, citalopram, fluoxetine (children and young people), paroxetine
try two SSRIs before SNRIs/TCAs
SNRIs = duloxetine and venlafaxcine
TCAs = amitryptaline and clomipramine

Question 23

What monitoring is needed when a patient first starts an SSRI

Answer 23

If not suicidal initial follow up after 2 weeks and 2-4 weeks monitoring
make patient aware of any side effects and that suicidal ideation may increase in first few weeks
If at risk of suicide see after 1 week, if very high risk only prescribe limited amount to reduce risk of OD.

Question 24

Which treatment is used in severe treatment resistant depression

Answer 24

ECT

Question 25

Which psychological treatment options can be offered to a patient with depression

Answer 25

Mild = low intervention treatment such as individual self facilitated CBT, computerized CBT, group CBT, group activity programmes
Moderate and severe cases = interpersonal therapy, CBT, behavioural activation and behavioural therapy for couples

Question 26

what are the complications of depression

Answer 26

impaired quality of life
increased mortality - men more at risk of suicide due to using more aggressive means
attempted suicide
increased levels of hopelessness
increased risk of developing and dying from coronary heart disease

Question 27

What are some social management options for patients with depression

Answer 27

Review of ADLs
Help with housing - social care 
lack of social support may require referral to support group 
may need carer support if a carer 
Financial support - DLA, benefits 
Courses at hospital 
General coping strategies

Question 28

What is post natal depression

Answer 28

Depression that occurs after a woman has had a child
10-15% of women within 6 months postpartum
Often have worries about baby’s health, feelings of unable to cope/not able to look after the child properly

Question 29

What are the risk factors for Post Natal Depression

Answer 29

family hx
old age 
unwanted pregnancy 
poor social support 
single mother