Mood disorders Flashcards
1
Q
What are poor prognostic factors with schizophrenia?
A
- strong family history
- gradual onset
- low IQ
- premorbid history of social withdrawal
- lack of obvious precipitant
2
Q
PTSD management
A
- following a traumatic event single-session interventions (often referred to as debriefing) are not recommended
- watchful waiting may be used for mild symptoms lasting less than 4 weeks
- trauma-focused cognitive behavioural therapy (CBT) or eye movement desensitisation and reprocessing (EMDR) therapy may be used in more severe cases
- drug treatments not first-line. If used then paroxetine or mirtazapine are recommended
3
Q
PTSD features (things you must always ask about in an anxiety history)
A
- re-experiencing: flashbacks, nightmares, repetitive and distressing intrusive images
- avoidance: avoiding people, situations or circumstances resembling or associated with the event
- hyperarousal: hypervigilance for threat, exaggerated startle response, sleep problems, irritability and difficulty concentrating
- emotional numbing - lack of ability to experience feelings, feeling detached
4
Q
What are some organic causes of anxiety?
A
Organic causes of anxiety such as anxiety induced by medications and underlying physical causes such as hyperthyroidism and cardiac disorders
5
Q
What is the management for bulimia
A
- Specialist care referral
- Bulimia-nervosa-focused guided self-help for adults. If unacceptable, contraindicated, or ineffective after 4 weeks of treatment, eating-disorder-focused cognitive behavioural therapy (CBT-ED)
- Children family therapy (FT-BN)
- Fluoxetine has been described but lacking evidence
6
Q
How long does SIGE CAPS + libido + low mood have to be there for?
A
2 weeks
7
Q
How should you start of the depression screen>
A
‘During the last month, have you often been bothered by feeling down, depressed or hopeless?’
‘During the last month, have you often been bothered by having little interest or pleasure in doing things?’
8
Q
What 5 things must you always check inn a depression history
A
SPADD
Suicide and self harm, psychosis, anxiety, depression and drugs
9
Q
What is behavioural activation therapy?
A
Encourages depressed indiciduals to develop more positive behaviour, or activities they will usually avoid
10
Q
What is psychodynamic therapy
A
Aims to understand the dynamics and difficulties of a patiens life, which may have started in childhood. Can be done alongside counselling
11
Q
What SSRI prolongs the QT interval
A
Citalopram
12
Q
What are some SE of SSRIs
A
They cause long QT (citalopram), lower seizure threshold, and increase risk of bleeding (can give PPI). Can also increase suicidal thoughts which is another reason we monitor you. It can cause GI upset, apetite change, and weight gain or loss. ALSO ANORGAASMIA
13
Q
What situations should you be careful in giving SSRIs
A
- Epilepsy
- In the elderly it causes hyponatraemia
- Ulcers
- Metabolised by liver so careful if disease
14
Q
What receptors do TCAs block
A
- H1 (sedation)
- A1 and A2 (hypotension)
- D2 (breast changes and sexual dysfunction)
15
Q
How does venlaflaxine work
A
Venflalxine- SNRI. It is also a weak antagonist of muscarinic and histamine receptors. Not as crayy as TCA
16
Q
How does mirtazapine work?
A
It traps inhibitory pre synaptic a-2 receptors
17
Q
What is the only anti-depressant for under 18
A
Fluoxetine
18
Q
What is the best SSRI if there is IHD
A
Sertraline
19
Q
Management of bipolar
A
Hypomania-routine referral to CMHT
Mania or severe depression- urgent referral to the CMHT
20
Q
Hypomania
A
Decreased or increased function for 4 days or more. No psychosis
21
Q
Mania
A
Severe functional impairment or psychotic symptoms for 7 days or more with psychosis
22
Q
What is rapid cycling in bipolar
A
More than 4 mood swings in 12 month period with no intervening asymptomatic periods
23
Q
What is cyclothymia
A
Mood cycling over a year. Dysthymia is more persistent depression over 2 years
24
Q
How would you manage a bipolar person in an OSCE
A
First I would like to risk assess the patient to determine the urgency of referral to social services and consider admitting under the MHA if aggressive or at risk to self or others. I would enquire about driving as they will need to DVLA inform and not drive for possible 3 months.
25
How would you investigate a patient with possible bipolar
I'd first like to take a further history and consider a collateral. I'd offer the patient an objective mood quesionnaire. I'd like to do basic tests like FBC, U+E if lithium and LFT, calcium and glucose. Also a urine and blood test for any drugs and finally a CT head to rule out SOL.As there is often high comorbidities, I will also like to address comorbidies, so diabetes, COPD, CVD
26
What is the management of an acute manic episode
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Consider hospitalisation
Atypical antipsychotics like olanzapine for rapid effect
Lorazepam
Mood stabilisers like lithium
ECT
Risk assessment
```
27
What is the long term management of bipolar affective disorder
4 weeks after the acute episode has resolved, lithium first line to prevent relapse. If ineffective consider adding valporate
28
What is the management of a bipolar depressive episode?
Atypical antipsychotics are first line like olanzapine combined with fluoxetine, olanzapine alone or quietapine. Add a mood stabiliser like lamortrigine or lithium. ALWAYS AVOID PLAIN ANTIDEPRESSANT as if depression is main feature can induce mania (hence why you give mania cover)
29
What monitoring must you do in a patient with lithium?
FBC, U&Es, TFTs, βHCG, ECG. Check lithium level 12 hours after the first dose, everyweek until stable for 4 weeks, then every 3 months. Also check during any acute illness
30
What level is lithium toxixity at?
Toxic levels are > 1.5 mmol/L
31
What level is severe lithium toxicity at?
>2.0 mmol/L
32
What are signs of lithium toxicity?
GI disturbances, Leukocytosis, Impaired renal function, Tremor (fine)/Teratogenic/Thirst(polydipsia), Hypothyroidism/Hair loss, Increased weight and fluid retention, Urine increase (polyuria), Metallic taste. (LITHIUM)
33
What drugs must you avoid before giving lithium?
Before start treatment avoid NSAIDS, TFT, pregnancy, do U+E and eGFR
34
What is the over-arching method of the management of GAD which is then replicated in primary care:?
Anxiety is managed using the bio-psycosocial model, in a stepped wise approach starting with recognition and diagnosis and treatment in primary care and ending with care in specialist mental health services.
35
How is anxiety managed in primary care specifically?
Biological- SSRI (sertaline first as anxiolytic too) and if this doesn't help then SNRI like venlaflaxine and duloxetine. Avoid benzodiazepine long term as increased dependence risk. Psychological including psychoeducational groups (low intensity) and CBT and applied relaxation techniques (high intensity) and social including support groups. The comorbid depression and substance use must also be treated.
36
What are some differentials for anxiety?
```
Acute stress reaction
PTSD
OCD
Depression + secondary anxiety
Specific phobias- agoraphobia,
Panic attacks
Anxious/avoidant personality disorder
Hyperthyroidism, hypoglycaemia, phaeochromocytoma, caffeine
Intoxication
```
37
How long do GAD symptoms need to be for it to be diagnosed?
6 months
38
What are the phobic anxiety disorders?
Agoraphobia
Social phobia
Specific phobia
39
What is agoraphobia
Marked and consistence fear and avoidance of one of 2 of crowds, public spaces, travelling alone and travelling away from home. They fear the openness
40
What is social phobia?
Marked fear of being the focus of attention including blushing, fear of vomitting, urgency or fear of micturition/defecation. They fear they will act in a way that is embarassing or humiliating
41
What is specific phobia?
Marked fear or avoidance of a specific objection or situation
42
When must PTSD symptoms occur?
Within 6 months of the event and can involve reliving the event, avoidance, hyperarousal, emotional numbing
43
How do you manage PTSD
It depends on if it is within or 3 months or after 3 months from the trauma. If it is within 3 months, watchful waiting, trauma focused CBT, short term drug treatment in the acute phase for sleep disturbamce and risk assessment
44
How is PTSD managed > months after trauma
Trauma focused psychosocial intervention. The psychological trreatment is CBT and eye movement desentisization EMDR. The EMDR helps reduce distress in the shortest period of time. Drug treatment last line if all else fails with paroxetine, mitrazapine (trapped in PTSD), paroxetine being the weaker
45
What are protective factors for GAD
Aged 16 - 24 AND Being married or cohabiting
46
What is the antidepressant of choice in children
Fluoxetine
47
What do you need to conscious about in the GI with SSRIs
Increased risk of gastrointestinal bleeding in patients taking SSRIs. A proton pump inhibitor should be prescribed if a patient is also taking a NSAID
48
SSRI in pregancy
1st trimester gives a small increased risk of congenital heart defects. Paroxetine has an increased risk of congenital malformations, particularly in the first trimester
3rd trimester can result in persistent pulmonary hypertension of the newborn
49
Citalopram and QT
Citalopram and escitalopram are associated with dose-dependent QT interval prolongation and should not be used in those with: congenital long QT syndrome; known pre-existing QT interval prolongation; or in combination with other medicines that prolong the QT interval
50
What is the only SSRI that you don't need to stop over 4 weeks
This not necessary with fluoxetine due to its longer half-life.
51
How long do symptoms have to be present before a diagnosis of depression
Minimum duration of the whole episode is about 2 weeks
52
What are differentials for OCD
Hypochondrial and anakastic personality disorder (characterized by a general pattern of concern with orderliness, perfectionism, excessive attention to details, mental and interpersonal control, and a need for control over one's environment, at the expense of flexibility, openness to experience)
53
How do you manage OCD
SSRI - fluoxetine, paroxetine, sertaline
54
What are risk factors for suicide (4)
MODE- Male, Older, Drugs, Ethanol. Also chonic illness and current mental illness and family history
55
Biological- SSRI (sertaline first as anxiolytic too) and if this doesn't help then SNRI like venlaflaxine and duloxetine. Avoid benzodiazepine long term as increased dependence risk. Psychological including psychoeducational groups (low intensity) and CBT and applied relaxation techniques (high intensity) and social including support groups. The comorbid depression and substance use must also be treated is the management of what?
Generalised anxiety disorder
56
How often do you need to follow up patients on an SSRI?
NICE recommend you warn patients of the increased risk of suicidal thinking and self-harm. Weekly follow-up is recommended for the first month
57
What is the management of panic disorder?
NICE recommend either cognitive behavioural therapy or drug treatment
SSRIs are first-line. If contraindicated or no response after 12 weeks then imipramine or clomipramine should be offered
58
If CBT or drug therapy isn't working after twelve weeks in treating panic disorder, what does NICE recommend?
Imipramine or clomipramine [tricyclics]
59
Imipramine or clomipramine are only given twelve weeks later after what has been tried?
SSRIs
60
How long should a patient with panic disorder be trialled on SSRIs before switching to another drug class?
12 weeks. if no improvement switch to imipramine or clomipramine
61
What are some psychological interventions used in the management of GAD
Psychological including psychoeducational groups (low intensity) and CBT and applied relaxation techniques (high intensity) and social including support groups.
62
What must you always do before you start to manage an anxiety/panic disorder patient
Always look for a potential physical cause when considering a psychiatric diagnosis. In anxiety disorders, important alternative causes include hyperthyroidism, cardiac disease and medication-induced anxiety (NICE)
63
What are some anxiety inducing medication?
Salbutamol, theophylline, corticosteroids, antidepressants and caffeine
64
Salbutamol, theophylline, corticosteroids, antidepressants and caffeine are examples of what?
Anxiety inducing medications
65
What is the first line SSRI for anxiety?
Sertaline [good in IHD]
66
What are the high intensity methods of managing GAD
CBT and applied relaxation techniques [practicing techniques that lead to muscular or bodily relaxation, which can be applied to situations that trigger anxiety or worry
67
What are some social methods of managing GAD
Self help methods like keeping a journal of anxious or worrying thoughts and analysing them objectively and support groups. Exercise should also be encouraged and comorbid depression and substance misuse should be treated
68
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S leep changes: increase during day or decreased sleep at night
I nterest (loss): of interest in activities that used to interest them
G uilt (worthless): depressed elderly tend to devalue themselves
```
E nergy (lack): common presenting symptom (fatigue)
C ognition/C oncentration: reduced cognition &/or difficulty concentrating
A ppetite (wt. loss); usually declined, occasionally increased
P sychomotor: agitation (anxiety) or retardations (lethargic)
S uicide/death preocp and sex
```
S leep changes: increase during day or decreased sleep at night
I nterest (loss): of interest in activities that used to interest them
G uilt (worthless): depressed elderly tend to devalue themselves
```
E nergy (lack): common presenting symptom (fatigue)
C ognition/C oncentration: reduced cognition &/or difficulty concentrating
A ppetite (wt. loss); usually declined, occasionally increased
P sychomotor: agitation (anxiety) or retardations (lethargic)
S uicide/death preocp and sex
69
How would you explain depression to a patient
The word depressed is a common everyday word. People might say "I'm depressed" when in fact they mean "I'm fed up because I've had a row, or failed an exam, or lost my job", etc. These ups and downs of life are common and normal. Most people recover quite quickly. With true depression, you have a low mood and other symptoms each day for at least two weeks. Symptoms can also become severe enough to interfere with normal day-to-day activities.
