Mood disorders Flashcards by sofia littlejohn

When is someone thought to have a mood disorder?

Disturbance in mood is severe enough to cause an impairment in the activites of daily living

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What are the different affective disorders?

Manic episode (including hypomania, mania with/without psychotic symptoms)

Bipolar affective disorder

Depressive disorder: including mild, moderate, severe and severe with psychotic symptoms

Recurrent depressive disorder

Persistent mood disorder (cyclothymia / dysthymia)

Other mood disorders

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What is a secondary mood disorder?

Mood disorder resulting from another medical condition

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What is depressive disorder?

Affective mood disorder characterized by a persistent low mood, loss of pleasure, and / or lack of energy accompanied by emotional, cognitive and biological symptoms

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What is the monoamine hypothesis of depression?

Deficiency of monoamines (noradrenaline, serotonin and dopamine) cause depression - supported by the fact that antidepressants increase conc of these neurotransmitters in the synaptic cleft

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What are some risk factors for depression?

FF AA PP SS

Female / Family history

Alcohol / Adverse events

Past depression / Physical co-morbidities

Social support / Socioeconomic status (poor)

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What is a mneumonic for the main symptoms of depression?

DEAD SWAMP

Depressed mood

Energy loss (anergia)

Anhedonia

Death thoughts (suicide)

Sleep disturbances

Worthlessness / guilt

Appetite or weight change

Mentation (concentration) reduced

Psychomotor retardation

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What are the core symptoms of depression?

Anhedonia
Low mood (2 weeks)
Anergia (low energy)

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What are the cognitive symptoms of depression?

Lack of concentration
Negative thuoughts
Excessive guilt
Suicidal ideation

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What are the biological symptoms of depression?

Diurnal variation in mood (low mood worse in morning)
Early morning wakening
Loss of libido

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What are the biological symptoms of depression?

Psychomotor retardation (slow speech / movement)
Weight loss and loss of appetite

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What are the psychotic symptoms of depression?

Hallucinations (usually 2nd person auditory)

Delusions (hypochondrial, guilt, nihilistic or persecutory)

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How is mild, moderate, servere and severe with pyschosis depression classified?

Mild = 2 core + 2 others

Moderate = 2 core + 3-4 others

Severe = 3 core + more than 4 others (and psychosis)

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What else to consider in depression history?

Thyroid dysfunction

Bipolar affective disorder

Secondary to psychoactive substance abuse

Secondary to other psychiatric disorder (psychotic disorders, anxiety disorders, adjustment disorder, eating disorder, dementia)

Normal bereavement

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What investigations can be used to rule out organic causes in depression?

Questionnaires (PHQ-9, HADS)
Bloods (FBC - anaemia, TFTs, U&Es, LFTs, calcium levels - biochemical abnormalities), glucose (diabetes can cause anergia)
Imaging (CT or MRI for personality changes or unexplained headache)

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Name some other depressive disorders?

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What is the biopsychosocial treatment of depression?

Biological = antidepressants, adjuvants (antipsychotics), ECT

Psychological = psychotherapies (CBT, IPT), physical acitvity, self-help programmes

Social = social support

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What is the management of mild-moderate depression?

Watchful waiting (2 weeks)

Self help programmes

Computerised CBT

Psychotherapy

(antidepressants often not first line, unless: hx of moderate-severe, failure of other interventions)

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How can moderate-severe depression be managed?

Suicide risk assessment
Psychiatric referral (suicide risk is high, recurrent depression, unresponsive to initial treatment)
Mental health act
Antidepressants (SSRIs e.g. citalopram, TCAs e.g. amitriptyline, MAOI) - continued for 6 months after resolution of symptoms for 1st depressive episode
Adjuvants: augmented with lithium or antipsychotics
Psychotherapy: CBT and interpersonal therapy
ECT (life-threatening depression, depression with psychotic features, failure of other treatments)

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What therapy is used to manage depression?

CBT: depression causes negative thoughts leading to negative behaviours, this is challenged, conducted in groups or individually

IPT: Helps to identify and solve relationship problems

Behavioural activation: encourages depressed patients to develop more positive behaviours

Psychodynamic therapy: explores the dynamics of a patient’s life which may have begun in childhood

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What is the monoamine hypothesis for bipolar affective disorder?

Elevated mood is a result of increased central monoamines (noradrenaline and serotonin)

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What are the risk factors for bipolar?

Aggressive Spenders

Age = early 20s

Anxiety disorders

After depression

Strong family Hx

Substance misuse

Stressful life events

(Male:Female ratio is 1:1)

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How is the severity of mania graded?

Hypomania

Mania without psychosis

Mania with psychosis

What are the symptoms of mania?

I DIG FASTER

Irritability

Distractibility / disinhibited (secual, social, spending)

Insight impaired

Grandiose delusions

Flight of ideas

Appetite increased

Sleep deprived

Talkative

Evelated mood

Reckless behaviour and spending

What is hypomania?

Mildly elevated mood present for **at least 4 days -** insight may be preserved

What is **mania without psychosis?**

Manic symptoms for at least 7 days with **complete distruption of work and social activites** Grandiose ideas, excessive spending, sexual disinhibition, reduced sleep may be present

What is the different between Bipolar I and Bipolar II?

Bipolar II is a milder form of mood elation

What is rapid cycling bipolar?

More than 4 mood swings in 12 month period with no intervening asymptomatic periods - prognosis is poor

How to diagnose bipolar affective disorder?

At least 2 episodes of mood disturbance - **one must be mania or hypomania**

What tests to perform in a patient presenting with mania?

- **Self rating scales** e.g. mood disorder questionnaire - **Blood tests:** FBC (routine), TFTs, U&Es and LFTs (baseline before lithium), glucose, calcium - **Urine drugs test** (illicit drugs can cause manic symptoms) - **CT head** (rules of space occupying lesions)

What are some differentials for patients with **mania**?

- **Mood disorders** e.g. hypomania, mania, mixed episode, cyclothymia - **Psychotic disorders** e.g. schizophrenia, schizoaffective disorder - **Organic** e.g. hyperthyroidism, Cushing's disease, cerebral tumour - frontal lobe lesion with disinhibition - **Drug related**: amphetamines, cocaine, acute drug withdrawal - **Personality disorder** e.g. emotionally unstable

What is the **biopsychosocial** management of **bipolar**?

**Bio** = mood stabalizers, benzodiazepines, antipsychotics, ECT for severe uncontrolled mania **Psycho** = psychoeducation, CBT **Social** = Social support groups, self-help groups

What are the steps in managing bipolar?

CALMER **C**onsider hospitalization **A**ntipsychotics **L**orazepam **M**ood stabalizers **ECT** **Risk assess** (suicide, spending, driving)

What medication should be used in **acute manic episode**?

- **Antipsychotic** e.g. olanzapine, risperidone, quetiapine (rapid onset compared to mood stabalizers) - **Mood stabilizer** e.g. lithium or valporate - **Benzodiazepine** for sleep and reduce agitation - **Rapid tranquilization** with haloperidol / benzo

What is the **pharma** management of **bipolar depressive episode**?

- **Atypical antispychotics** e.g. olanzapine (maybe with fluoxetine) or quetiapine - **Mood stabilizers** e.g. Iamotrigine / lithium - **Antidepressants** (used in caution, as they can induce mania)

What should be tested before lithium treatment commences?

- **U&Es** (lithium has renal excretion) - **TFTs** - **Pregnancy status** - **Baseline ECG** Lithium has a narrow therapeutic window

What are the **side effects** of **lithium**?

- Polydipsia - Polyuria - **Fine** tremor - **Leucocytosis** (WBCs - also caused by cortocosteroids and BBs) - Weight gain - Oedema - Hypothyroidism - Impaired renal function - Memory problems - Teratogenicity (in 1st trimester)

What are some signs of **lithium toxicity**?

- N+V - **Coarse** tremor - Ataxia - Muscle weakness - Apathy

What are some signs of **severe toxicity** from **lithium**?

\> 2.0 mmol/L - Nystagmus - Dysarthria - Hyperreflexia - Oliguria - Hypotension - Convulsions and coma

When should lithium levels be checked?

**12 hours** following first dose **Weekly** until therapeutic level (0.5-1.0 mmol/L) for 4 weeks Then **every 3 months**

How often should U&Es be checked after lithium started?

6 months

How often should TFTs be checked after lithium initiated?

Every **12 months**

Name a **MAOI**? Why are they **no longer used as much?** How do they work? What should not be eaten when taking?

Used in atypical depression Selegiline, phenelizine - side effects Serotonin and noradrenaline are **metabolised by monoamine oxidase in the presynaptic cell** Cheese, Bovril, marmite e.g. tyramine containing foods - causes hypertensive crisis

What class of drug does mirtazapine belong to?

**Noradrenergic and specific serotonergic antidepressant** which increase release of neurotransmitters by blocking **alpha-2-adrenoceptors**

What is a side effect of Mirtazapine?

**Increase in appetite** (subsequent weight gain), **drowziness**

What is another indication of mirtizapine?

Older people with **insomnia and poor appetite** (taken in evening as can be sedative)

What is the mechanism of action of venlafaxine? Give another example?

SNRI Duloxetine

How to switch SSRIs?

**Between SSRIs** = stopped and new one started From **fluoxetine** to another SSRI = leave gap of 1 week as **_flipping_** long **half life** **SSRI to TCA** = **cross-tapering** (with exception of fluoxetine which should be withdrawn)

Name some side effects of SSRIs?

- Abdo cramping, diarrhoea and vomiting - **Hyponatraemia**

What antidepressants are associated with QT elongation?

Citalopram and escitalopram

When should SSRIs be used with caution?

Patients on NSAIDs (prescribe PPI) Warfarin / heparin (instead use mirtazapine)

What are the side effects of TCA e.g. amitriptyline?

**Anticholinergic** effects e.g. urinary retention, tachycardia, dry mouth, mydriasis (Used less commonly for depression due to side-effects and toxicity in overdose)

When is amitriptyline now normally used?

Neuropathic pain Prophylaxis of headache (both tension and migraine)

What is the SSRI of choice in children and adolescents?

Fluoxetine

What SSRI is best post MI?

**Sertraline**

How long should SSRIs be continued for?

**At least 6 months**

How long should a normal grief reaction last for?

Less than 6 months