Mood disorders Flashcards
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
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
What is a secondary mood disorder?
Mood disorder resulting from another medical condition
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
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
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)
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
What are the core symptoms of depression?
- Anhedonia
- Low mood (2 weeks)
- Anergia (low energy)
What are the cognitive symptoms of depression?
- Lack of concentration
- Negative thuoughts
- Excessive guilt
- Suicidal ideation
What are the biological symptoms of depression?
- Diurnal variation in mood (low mood worse in morning)
- Early morning wakening
- Loss of libido
What are the biological symptoms of depression?
- Psychomotor retardation (slow speech / movement)
- Weight loss and loss of appetite
What are the psychotic symptoms of depression?
Hallucinations (usually 2nd person auditory)
Delusions (hypochondrial, guilt, nihilistic or persecutory)
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)
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
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)
Name some other depressive disorders?
What is the biopsychosocial treatment of depression?
Biological = antidepressants, adjuvants (antipsychotics), ECT
Psychological = psychotherapies (CBT, IPT), physical acitvity, self-help programmes
Social = social support
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)
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)
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
What is the monoamine hypothesis for bipolar affective disorder?
Elevated mood is a result of increased central monoamines (noradrenaline and serotonin)
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)
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
Consider hospitalization
Antipsychotics
Lorazepam
Mood 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
