Mood disorders Flashcards
What are the two broad categories of mood disorder?
Depressive disorders
Bipolar disorders
What are six disorders that can involve depression?
Unipolar depression Dysthymia Seasonal affective disorder Atypical depression Postnatal depression Psychotic depression
What are some general symptoms of depression?
Mood- Depressed/irritable
Talk- Slow and impoverished
Energy- Lethargic
Ideas- Futility, guilt, unworthiness
Cognition- Impaired learning
Physical- Insomnia, poor appetite, loss of libido
Behaviour- Agitation, lack of movement/expression
Hallucinations- Auditory, often hostile
Endocrine- Increased ACTH, cortisol and TRH secretion
How do you diagnose depression
Clinical
How long do you need symptoms to diagnose depression?
2 weeks
What must you not have for it to be depression?
No hypo/mania
What are the three categories of core depression symptoms?
Mood
Enjoyment
Energy
How does mood change in depression?
Depressed to abnormal for most of day and uninfluenced by circumstances
How does enjoyment change in depression?
Loss of interest/pleasure in normally pleasurable activities
How does energy change in depression?
Lack of energy
What are some additional symptoms in depression?
Loss of confidence Excessive guilt Suicidal thoughts/behavior Reduced concentration/indecisiveness Psychomotor changes- agitation or retardation Sleep disturbances Appetite and weight changes
What are the three severities of unipolar depression?
Mild
Moderate
Severe
What features do you need for mild depression?
2 core
2 additional
What features do you need for moderate depression?
2 core
4 additional
What features do you need for severe depression?
3 core
5 additional
How do you treat mild depression?
Self-resolve
CBT
Psychosocial interventions
How do you treat moderate depression?
CBT
Psychosocial interventions
Antidepressants
How do you treat severe depression?
CBT
Psychosocial interventions
Antidepressants
Electroconvulsive therapy
What is dysthymia?
Mild/moderate loss of tiredness, low mood and low self-esteem
What is the time scale of dysthymia?
> 2 years
Several weeks well then longer periods of depression
What is Seasonal affective disorder?
Recurrent episodes of depressive illness occurring during the winter months in the northern hemisphere
What are some symptoms of seasonal affective disorder?
Hypersomnia
Increased appetite
Fatigue
How do you treat seasonal affective disorder?
Bright light in the mornings
SSRI
What is atypical depression?
Depression but with mood brightness in response to positive events.
What are some symptoms of atypical depression?
- Increased appetite or significant weight gain
- Hypersomnia (excessive sleepiness)
- Leaden paralysis (heavy, leaden feeling in arms or legs)
- Long standing pattern of interpersonal rejection sensitivity (not limited to episodes of mood disturbance) that results in significant social or occupational impairment
What are some forms of postnatal depression?
Maternity blues
Postpartum psychosis
Non-psychotic postnatal depressive disorders
Describe maternity blues
2-3 days post partum Resolve in a few days Emotional lability Irritability Tearfulness
Describe postpartum psychosis
Onset <2 weeks postpartum
Psychosis- May attempt to kill child or self
Confusion
Disorientation
Describe Non-psychotic postnatal depressive disorders
Occurs in first year post parum
Risk factors: First pregnancy, Poor relationship
Can cause lack of mother/baby bonding
How do you treat postnatal depression?
Most self-resolve however treat anyway
Short term: CBT, Fluoxetine
How can psychotic depression present?
Often paranoid or hypochondria
Can be nihilistic
What other conditions can cause depression?
Recurrent depressive disorder Bipolar disorder Schizo-affective disorder Schizophrenia Dementia Delirium Substance misuse
What are some differentials for depression?
Alcohol Amphetamines Borderline personality disorder Dementia Delirium Schizophrenia Grief Cushing's syndrome Thyroid disease Hyperparathyroidism
What are some non-pharma treatments for depression?
Exercise Electroconvulsive therapy CBT Interpersonal psychotherapy Couples and family therapy
What are the indications for electroconvulsive therapy?
Not responding to treatment
Psychotic
Need for swift control of symptoms: Very suicidal, Not drinking
How does electroconvulsive therapy work?
Induce epileptic fit
How often is electroconvulsive therapy given?
Twice a week for 3-6 weeks
What are some side effects of electroconvulsive therapy?
Transient headache
Transient confusion
Transient amnesia
What must you inform patients of before administering electroconvulsive therapy?
- Minor memory loss (lasts up to a few days)
- Tachycardia
- Increased BP
- Small risk of MI, PE, cerebral haemorrhage
- It is done twice a week, for a period of 6-8 weeks. -Should notice change in 2-5 weeks
What does CBT target?
Negative thoughts associated with: self, situation and future
How does CBT work?
Combat/question negative thoughts
When is CBT given?
All depression
As good as antidepressants in mild unipolar depression
Is CBT better in groups or individually?
Individually
What is interpersonal psychotherapy good for?
Mild/moderate depression
Who does interpersonal psychotherapy work?
Focus on patients interpersonal relationships that affect illness
What should you stop in depression?
Alcohol
Recreational drugs
What should you reduce in depression?
Depression causing prescriptions such as steroids
Give six classes of antidepressants
SSRI TCA SNRI Noradrenergic and specific serotonergic antagonists (NSSA) Noradrenaline reuptake inhibitor (NaRI) Monoamine oxidase inhibitors (MAOIs)
Give three examples of SSRIs
Citalopram
Fluoxetine
Sertraline
What are some side effects of SSRIs?
'Hangover'- N+V, diarrhea, dry mouth, headache Insomnia Agitation on starting Erectile dysfunction/loss of libido Hyponatremia- Rare
What are some side effects of sudden withdrawal of an SSRI?
Shivering Anxiety Dizziness 'Electric shocks' Headache Nausea
What are some benefits of SSRIs?
Given once daily
Fewer side effects
How do SSRIs work?
Inhibit 5-HT reuptake therefore increase conc.
How do TCAs work?
Inhibit reuptake of monoamines: NA and serotonin
Give some examples of TCAs
Amitriptyline
Clomipramine
Give some examples of TCA side effects
- Weight gain
- Antimuscarinic: Dry mouth, Constipation, Tremor, Blurred vision, Urinary retention
- Cardiovascular: QT prolongation, Arrhythmias, Postural hypotension
- Lowers seizure threshold
- Mania
Should TCA be given to those with suicidal intentions?
Not directly as toxic in OD.
Give to responsible 3rd party
Give an example of an SNRI
Venlafaxine
What are some benefits of venlafaxine?
Once daily
Less muscarinic effects
Less sedation
What are some side effects of venlafaxine?
Nausea
Hypertension
Do NOT give to those with hypertension or arrhythmias
Give an example of a Noradrenergic and specific serotonergic antagonists (NSSA)
Mirtazapine
What are some side effects of mirtazapine?
Sedation
Agranulocytosis
Give an example of an Noradrenaline reuptake inhibitor (NaRI)
Reboxetine
What are some side effects of reboxerine?
Dry mouth Insomnia Constipation Urine hesitance Tachycardia
What does monoamine oxidase do?
Metabolise monoamines: NA and serotonin
What is a major side effect of Monoamine oxidase inhibitors (MAOIs)?
Dangerous hypertension when consume tyramine or dopamine: Cheese Pickled herring Yeast Game Broad beans
What is a dangerous condition associated with a combination of some antidepressants?
Toxic hyperserotonergic state
What can cause Toxic hyperserotonergic state?
Can be caused by 2+ drugs that increase serotonin levels
What are some symptoms of toxic hyperserotonergic state?
Agitation Confusion Tremor Diarrhoea Tachycardia Hypertension Hyperthermia Support
How should antidepressant dose be altered in the elderly?
Half the dose
How should antidepressant dose be altered in pregnancy/breastfeeding?
Avoid as far as possible
If needed TCA best
What herbal medication should be avoided when taking antidepressants?
St John’s Wort
What is bipolar disorder?
Two or more episodes in which the patient’s mood and activity levels are significantly elevated.
Give five forms of bipolar disorder
Bipolar 1 Bipolar 2 Rapid cycling Mixed affective state Cyclothymia
What is Cyclothymia?
Hypomania and mild depression not serious enough to be classed as bipolar
What is bipolar 1?
Mania and depression
What is bipolar 2?
Hypomania and depression
Which is more common: bipolar 1 or 2?
Bipolar 2
How long does untreated mania tend to last?
~2 months
How long must mania be sustain to diagnose?
Must be maintained for 7 days or be hospitalized to diagnose
Give some symptoms of mania
-Mood- Elevated or irritable
-Speech- fast, pressurized, flight of ideas
-Energy- Excessive
-Ideas- Grandiose, self-confident, delusions of wealth, power, influence or religious significance, sometimes persecutory
-Cognition- Disturbance of registration of memories
-Physical- Insomnia, mild to moderate weight loss, increased libido
-Behaviour- Disinhibition, increased sexual activity, excessive drinking or spending
-Hallucinations- Fleeting auditory
Lack insight
How long must hypomania be sustained to diagnose?
4 days
Give some symptoms of hypomania
Same as mania but less severe and maintain insight or psychosis
What is rapid cycling?
Frequent swings from one mood state to another
What is mixed effective state?
Features of mania and depression in same episode
What serious condition can bipolar increase?
Suicide
What is the differential for bipolar?
Intoxication
Long term cannabis use
Cushing’s syndrome- Can cause mania
Dopamine agonists
What is the pathology of bipolar?
Strong genetic link
Serotonin increases in mania
Tricyclic antidepressants can cause manis
What should you do in a first hypo/manic presentation?
CT head
EEG
Drug screen
How should you treat acute mania?
Stop antidepressants
Give antipsychotics: Sodium valproate, Li, Olanzapine
How do you treat acute hypomania?
Valproic acid
Describe prophylaxis for bipolar?
Mood stabilisers
Give some examples of mood stabilisers
Li Carbonate
Olanzapine
Valproic acid
How is Li Carbonate absorbed?
GI
How is Li Carbonate excreted?
Renal
What should you screen for before starting Li Carbonate?
Thyroid disease
Renal disease
What are you looking for when screening for thyroid disease?
TSH
fT4
Thyroid antibodies
Why must you screen for thyroid disease before starting Li Carbonate?
Because because it can cause hypothyroidism
Why must you screen for renal disease before starting Li Carbonate?
Because it can cause:
Reduced glomerular function
Nephrogenic DI
What are you looking for when screening for renal function?
Serum urea and creatinine
What is the therapeutic range for Li Carbonate?
0.5-1mmol/l
What is the toxic threshold for Li Carbonate?
1.5mmol/l
What are some symptoms of Li Carbonate toxicity?
Drowsiness
N+V
Blurred vision
What can Li Carbonate interact with?
NSAIDs
Diuretics
What are some side effects of Li Carbonate?
N+D Tremor Polyurea and polydipsia Increased appetite Mania if abrupt stop
What can happen if you abruptly stop Li Carbonate?
Mania
How long should you treat a first presentation of depression for?
6-12 months after resolution
How long should you treat a second presentation of depression for?
12-24 months after resolution
How long should you treat a third presentation of depression for?
Indefinitely
What is the definition of non-response to antidepressants?
No or inadequate response in 6 weeks
How do cortisol levels change in unipolar depression?
Raised
Why are cortisol levels raised in unipolar depression?
No negative feedback of cortisol
What do the increased levels of cortisol in depression do?
Increased flight or fight
Brain damage
What test can you do for cortisol in depression?
Dexamethasone test
What does dexamethasone do in depression?
Sweet fuck all
What happens to the adrenal glands in depression?
Hypertrophy
What is another name for mood disorders?
Affective disorders