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Psychiatry > Mood disorders > Flashcards

Mood disorders Flashcards

1
Q

When is someone thought to have a mood disorder?

A

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

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2
Q

What are the different affective disorders?

A

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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3
Q

What is a secondary mood disorder?

A

Mood disorder resulting from another medical condition

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4
Q

What is depressive disorder?

A

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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5
Q

What is the monoamine hypothesis of depression?

A

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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6
Q

What are some risk factors for depression?

A

FF AA PP SS

Female / Family history

Alcohol / Adverse events

Past depression / Physical co-morbidities

Social support / Socioeconomic status (poor)

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7
Q

What is a mneumonic for the main symptoms of depression?

A

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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8
Q

What are the core symptoms of depression?

A
  • Anhedonia
  • Low mood (2 weeks)
  • Anergia (low energy)
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9
Q

What are the cognitive symptoms of depression?

A
  • Lack of concentration
  • Negative thuoughts
  • Excessive guilt
  • Suicidal ideation
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10
Q

What are the biological symptoms of depression?

A
  • Diurnal variation in mood (low mood worse in morning)
  • Early morning wakening
  • Loss of libido
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11
Q

What are the biological symptoms of depression?

A
  • Psychomotor retardation (slow speech / movement)
  • Weight loss and loss of appetite
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12
Q

What are the psychotic symptoms of depression?

A

Hallucinations (usually 2nd person auditory)

Delusions (hypochondrial, guilt, nihilistic or persecutory)

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13
Q

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

A

Mild = 2 core + 2 others

Moderate = 2 core + 3-4 others

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

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14
Q

What else to consider in depression history?

A

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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15
Q

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

A
  • 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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16
Q

Name some other depressive disorders?

A
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17
Q

What is the biopsychosocial treatment of depression?

A

Biological = antidepressants, adjuvants (antipsychotics), ECT

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

Social = social support

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18
Q

What is the management of mild-moderate depression?

A

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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19
Q

How can moderate-severe depression be managed?

A
  • 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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20
Q

What therapy is used to manage depression?

A

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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21
Q

What is the monoamine hypothesis for bipolar affective disorder?

A

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

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22
Q

What are the risk factors for bipolar?

A

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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23
Q

How is the severity of mania graded?

A

Hypomania

Mania without psychosis

Mania with psychosis

24
Q

What are the symptoms of mania?

A

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

25
Q

What is hypomania?

A

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

26
Q

What is mania without psychosis?

A

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

27
Q

What is the different between Bipolar I and Bipolar II?

A

Bipolar II is a milder form of mood elation

28
Q

What is rapid cycling bipolar?

A

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

29
Q

How to diagnose bipolar affective disorder?

A

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

30
Q

What tests to perform in a patient presenting with mania?

A
  • 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)
31
Q

What are some differentials for patients with mania?

A
  • 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
32
Q

What is the biopsychosocial management of bipolar?

A

Bio = mood stabalizers, benzodiazepines, antipsychotics, ECT for severe uncontrolled mania

Psycho = psychoeducation, CBT

Social = Social support groups, self-help groups

33
Q

What are the steps in managing bipolar?

A

CALMER

Consider hospitalization

Antipsychotics

Lorazepam

Mood stabalizers

ECT

Risk assess (suicide, spending, driving)

34
Q

What medication should be used in acute manic episode?

A
  • 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
35
Q

What is the pharma management of bipolar depressive episode?

A
  • 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)
36
Q

What should be tested before lithium treatment commences?

A
  • U&Es (lithium has renal excretion)
  • TFTs
  • Pregnancy status
  • Baseline ECG

Lithium has a narrow therapeutic window

37
Q

What are the side effects of lithium?

A
  • 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)
38
Q

What are some signs of lithium toxicity?

A
  • N+V
  • Coarse tremor
  • Ataxia
  • Muscle weakness
  • Apathy
39
Q

What are some signs of severe toxicity from lithium?

A

> 2.0 mmol/L

  • Nystagmus
  • Dysarthria
  • Hyperreflexia
  • Oliguria
  • Hypotension
  • Convulsions and coma
40
Q

When should lithium levels be checked?

A

12 hours following first dose

Weekly until therapeutic level (0.5-1.0 mmol/L) for 4 weeks

Then every 3 months

41
Q

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

A

6 months

42
Q

How often should TFTs be checked after lithium initiated?

A

Every 12 months

43
Q

Name a MAOI? Why are they no longer used as much?

How do they work?

What should not be eaten when taking?

A

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

44
Q

What class of drug does mirtazapine belong to?

A

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

45
Q

What is a side effect of Mirtazapine?

A

Increase in appetite (subsequent weight gain), drowziness

46
Q

What is another indication of mirtizapine?

A

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

47
Q

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

A

SNRI

Duloxetine

48
Q

How to switch SSRIs?

A

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)

49
Q

Name some side effects of SSRIs?

A
  • Abdo cramping, diarrhoea and vomiting
  • Hyponatraemia
50
Q

What antidepressants are associated with QT elongation?

A

Citalopram and escitalopram

51
Q

When should SSRIs be used with caution?

A

Patients on NSAIDs (prescribe PPI)

Warfarin / heparin (instead use mirtazapine)

52
Q

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

A

Anticholinergic effects e.g. urinary retention, tachycardia, dry mouth, mydriasis

(Used less commonly for depression due to side-effects and toxicity in overdose)

53
Q

When is amitriptyline now normally used?

A

Neuropathic pain

Prophylaxis of headache (both tension and migraine)

54
Q

What is the SSRI of choice in children and adolescents?

A

Fluoxetine

55
Q

What SSRI is best post MI?

A

Sertraline

56
Q

How long should SSRIs be continued for?

A

At least 6 months

57
Q

How long should a normal grief reaction last for?

A

Less than 6 months

Psychiatry (13 decks)

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