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Mood disorders and self-harm | Flashcards

1
Q

According to ICD-10, what are: 1. The 3 core symptoms of depression
2. 7 additional symptoms

A

Core:

  1. Low mood, present most of the day, nearly every day
  2. Loss of interest and enjoyment (anhedonia)
  3. Reduced energy (anergia)

Additional symptoms:

  1. Reduced concentration
  2. Reduced confidence and self-esteem
  3. Ideas of guilt and worthlessness
  4. Pessimism about the future
  5. Ideas/acts of self-harm/suicide
  6. Disturbed sleep
  7. Changes in appetite
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2
Q

According to the ICD-10 criteria, what is classified as:

  1. Mild depressive episode
  2. Moderate depressive episode
  3. Severe depressive episode
  4. Severe depressive episode with psychotic symptoms
A

Mild depressive episode

  • At least 2/3 core symptoms
  • Plus additional symptoms, giving a total of at least 4
  • With or without the somatic syndrome

Moderate depressive episode

  • At least 2/3 core symptoms
  • Plus additional symptoms, giving a total of at least 6
  • With or without the somatic syndrome

Severe depressive episode

  • All 3 core symptoms
  • Plus additional symptoms, giving a total of at least 8

Severe depressive episode with psychotic symptoms

  • All 3 core symptoms
  • Plus additional symptoms, giving a total of at least 8
  • Plus delusions, hallucinations or depressive stupor
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3
Q

According to ICD-10, what are 7 somatic symptoms of depression?

A
  1. Loss of emotional reactivity
  2. Diurnal mood variation (depression worse in the morning, improving throughout the day)
  3. Anhedonia
  4. Early morning wakening
  5. Psychomotor agitation or retardation
  6. Loss of appetite and weight
  7. Loss of libido
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4
Q

According to ICD-10, what are psychotic symptoms/features of depression?

  1. Delusions (7)
  2. Hallucinations (3)
A

Delusions

  1. Poverty
  2. Personal inadequacy
  3. Guilt over presumed misdeeds
  4. Responsibility for world events - accidets, natural disasters, war
  5. Deserving of punishement
  6. Other nihilistic delusions
  7. Persecutory delusion can also occur

Hallucinations

  1. Auditory - defamatory or accusatory voices, cries for help or screaming (2nd person)
  2. Olfactory - bad smells, such as rotting food, faeces, decomposing flesh
  3. Visual - tormentors, demons, the Devil, dead bodies, scenes of death or torture
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5
Q

What are the causes of depression?

  1. Biological
  2. Psychological
  3. Social
A

Biological

  1. Genetics
  2. Hormonal changes
  3. Substance misuse
  4. Serious illness

Psychological

  1. Negative thoughts
  2. Learned helplessness
  3. Psychodynamic defence mechanisms

Social

  1. Life events
  2. Social isolation
  3. Bereavement
  4. Loss
  5. Childhood abuse
  6. Social adversity
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6
Q

What is the ratio of depression in M:F?

A

1:2

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7
Q

What % is the lifetime prevalence of depressive symptoms?

A

10-20%

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8
Q

What is the point prevalence of major depressive illness?

A

5%

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9
Q

In terms of prognosis, what % of people with depression will recover within a year?

A

50-60%

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10
Q

In terms of prognosis, what % of people will have chronic depression (>2 years)?

A

10-25%

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11
Q

What % of people with depression will die by suicide?

A

5-10%

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12
Q

What are 5 risk factors for depression?

A
  1. Genetic
  2. Childhood experiences
    -Loss of a parent
    -Childhood sexual abuse
    -Lack of parental care
    -Parental alcoholism/antisocial traits
  3. Personality traits
    -Anxiety
    0Impulsivity
    -Obsessionality
  4. Social circumstances
    -Unmarried/divorced
    -Adverse life events
  5. Physical illness
    -Especially if chronic, severe or painful
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13
Q

According to ICD-10, how long do symptoms have to be present to count as depression?

A

> 2 weeks

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14
Q

What are ddx of depression?

  1. Other psychiatric disorders
  2. Neurological disorders
  3. Metabolic disorders
  4. Medication-related
  5. Substance misuse
A
  1. Other psychiatric disorders
    - Dysthymia
    - Anxiety disorders
    - Bipolar disorder
    - Negative symptoms of schizophrenia
    - Personality disorder
  2. Neurological disorders
    - Dementia
    - Parkinson’s doisease
    - Huntington’s disease
  3. Metabolic disorders
    - Hypoglycaemia
    - Thyroid and parathyroid disorders (esp hypothyroidism)
    - Cushing’s/Addison’s disease
  4. Medication-related
    - Anti-hypertensives
    - Steroids
    - H2 blockers
    - L-dopa
    - Opiates
  5. Substance misuse
    - Alcohol
    - Amfetamines
    - Cocaine
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15
Q

What are common comorbidities of depression?

  1. Psychiatric
  2. Organic
    - Neurological
    - Endocrine
    - Infections
    - Iatrogenic
A

Psychiatric:

  1. Psychosis
  2. Anxiety
  3. Suicide and self-harm
  4. Eating disorder
  5. Dementia
  6. Substance abuse

Organic

  1. Neurological
    - MS
    - Parkinson’s
    - Huntington
  2. Endocrine
    - Thyroid/parathyroid
    - Cushing’s/Addison’s disease
  3. Infections
    - HIV/AIDs
    - Syphilis
  4. Iatrogenic
    - 2o to opiates, L-dopa, steroids, anti-hypertensives
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16
Q

What are 5 physical effects of depression?

A
  1. Increases risk of CVD
  2. Sensations of aches and pains
  3. Shakes and tremors
  4. Dizziness
  5. Difficulty sleeping
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17
Q

What are 4 social effects of depression?

A
  1. Substance use and abuse
  2. Social and family withdrawal including loss of marriage
  3. Decreased performance at work or school
  4. Financial problems
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18
Q

According to the NICE stepped care model of the management of depression, what 6 things need to be done for all known and suspected presentations of depression regardless of severity?
Bio-psycho-social

A

Social

  1. Assessment
  2. Active monitoring

Psycho:

  1. Psychoeducation
  2. Computerized CBT
  3. Sleep hygiene
  4. Guided self-help
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19
Q

According to the NICE stepped care model, what is the management of mild/moderate depression or persistent subthreshold depressive symptoms?
Bio-psycho-social

A

Bio
1. Medication - 1st line is SSRI

Psycho

  1. Low-intensity psychological interventions
  2. Psychoeducation

Social
4. 1o care

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20
Q

According to the NICE stepped care model, what is the management of moderate/severe depression or persistent subthreshold depressive symptoms or mild to moderate depression with inadequate response to initial interventions?
Bio-psycho-social

A

Bio
1. Medication - 1st line SSRI

Psycho

  1. High-intensity psychological interventions e.g. CBT, ITP (interpersonal psychotherapy)
  2. Psychoeducation

Social

  1. Consider 2o care referral
  2. CPN and outpatient appointments to monitor symptoms, mood, mental state
  3. Support with regard to housing, benefits, education, training, employment
  4. Carer support
  5. Work around social inclusion
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21
Q

According to the NICE stepped care model, what is the management of severe complex depression/risk to life/severe self-neglect?
Bio-psycho-social

A

Bio

  1. Medication - other agents may be considered including:
    a. venlafaxine, an SNRI
    b. mirtazapine, a NASSA
    c. tricyclics, like imipramine
    d. MAOIs, like phenelzine
    e. Adjunctive medications, such as antipsychotics or lithium esp in treatment-resistant depression
  2. ECT

Psycho

  1. High-intensity psychological interventions e.g. CBT, interpersonal therapy
  2. Psychoeducation

Social

  1. Crisis Resolution and Home Treatment (CRHT)
  2. Multidisciplinary (MDT) approach
  3. Inpatient care
  4. CPN and outpatient appointments to monitor symptoms, mood, mental state
  5. Support with regard to housing, benefits, education, training, employment
  6. Carer support
  7. Work around social inclusion
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22
Q

How long do patients have to be on medication for to reduce risk of relapse?

  1. Following a single episode of depression
  2. Following recovery from recurrent depression
A
  1. Continued pharmacotherapy for 6 months

2. Continued pharmacotherapy for 2 years

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23
Q

What are 10 indications for antidepressants?

A
  1. Depressive illness (more effective in moderate and severe depression)
  2. Anxiety disorders
  3. Neuropathic pain
  4. Insomnia
  5. Bulimia nervosa
  6. Impulsivity
  7. Migraines
  8. Chronic fatigue syndrome
  9. Irritable bowel syndrome
  10. Narcolepsy
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24
Q

What is the mechanism of action of most anti-depressants including: SSRIs, TCAs and SNRIs?

A

Most inhibit the reuptake of serotonin, noradrenaline or both, resulting in the enhancement of neurotransmission

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25
Q

What is the 1st line medication for depression?

A

SSRIs

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26
Q

What are 6 SSRIs?

A
  1. Fluoxetine
  2. Paroxetine
  3. Citalopram
  4. Sertraline
  5. Fluvoxamine
  6. Escitalopram
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27
Q

How long does it usually take for SSRis to work roughly?

A

1-6 weeks

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28
Q

What are 3 more common side effects of SSRIs on initiation, and 8 other possible side-effects?

A

Common:

  1. Transient nausea on starting
  2. Transient exacerbation of anxiety on starting
  3. Reports of increased suicidal ideation with starting

Others:

  1. Insomnia
  2. Apathy and fatigue
  3. Diarrhoea
  4. Dizziness
  5. Sweating
  6. Restlessness (akathesia)
  7. Sexual dysfunction
  8. Cardiac defects with 1st trimester exposure (Paroxetine)
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29
Q

What is the 2nd most commonly prescribed anti-depressant?

A

Serotonin-noradrenaline reuptake inhibitor (SNRI)

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30
Q

What are 2 SNRIs?

A
  1. Venlafaxine

2. Duloxetine

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31
Q

What are the side effects of SNRIs? How do they compare to SSRIs?

A
  1. Similar to SSRIs
    - Transient nausea on starting
    - Transient exacerbation of anxiety on starting
    - Reports of increased suicidal ideation with starting
    - Insomnia
    - Apathy and fatigue
    - Diarrhoea
    - Dizziness
    - Sweating
  2. Greater sedation than SSRIs
  3. Greater discontinuation symptoms when stopped than SSRIs
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32
Q

Why are SSRIs and SNRIs more preferable to TCAs?

A

Better side-effect profile

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33
Q

What must you be careful of with TCAs?

A

They are toxic in overdose - take into consideration a person’s risk of suicide when deciding on an appropriate antidepressant
-Lofepramine is less toxic

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34
Q

When are TCAs indicated as 1st line?

A

In pregnancy - they are not associated with teratogenic effects

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35
Q

What are 5 TCAs?

A
  1. Amitriptyline
  2. Imipramine
  3. Clomipramine
  4. Dosulepin
  5. Lofepramine
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36
Q

What is the main mode of action causing side effects of TCAs? What side effects do they cause?

What other side effects do they cause?

A

Anti-muscarinic:

  1. Dry mouth
  2. Blurred vision
  3. Constipation
  4. Urinary retention

Other:

  1. Sedation
  2. Weight gain
  3. Dizziness
  4. Hypotension
  5. Delirium
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37
Q

Why are monoamine oxidase inhibitors (MAOIs) less commonly used now?

A

Significant risk of serious drug/food interactions - cheese reaction

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38
Q

What are 2 indications for MAOIs?

A
  1. Resistant depression

2. Atypical depression

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39
Q

What are 4 MAOIs?

A
  1. Phenelzine
  2. Tranylcypromine
  3. Isocarboxazid
  4. Moclobemide (reversible MAOI)
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40
Q

What are the 5 most common side effects of MAOIs?

A
  1. Dry mouth
  2. Nausea, diarrhea or constipation
  3. Headache
  4. Sleep disturbance
  5. Postural Hypotension
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41
Q

What is an example of a noradrenergic and specific serotonergic antidepressant (NaSSA)?

A

Mirtazapine

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42
Q

What are 2 indications for a NaSSA?

A
  1. Mirtazapine can be combined with other antidepressants in treatment resistant depression
  2. For anxiety
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43
Q

What are 4 side effects of the NaSSA mirtazapine?

A
  1. Weight gain and increased appetite
  2. Drowsiness
  3. Dizziness
  4. Headache
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44
Q

What is an important thing to consider when initiating someone on antidepressants

A

Select a medication a patient is likely to tolerate and is effective

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45
Q

How long should you try an antidepressant for before deciding if a treatment has failed?

A

At least 3-4 weeks at an effective dose

If partial improvement has occurred by 4 weeks it is advisable to continue treatment for another 2 to 4 weeks, before considering alternative treatments

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46
Q

How long should you continue antidepressants for?

A

6 months following resolution of symptoms

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47
Q

What are 12 possible withdrawal symptoms of antidepressants?

A
  1. Dizziness
  2. Numbness
  3. Tingling
  4. Nausea
  5. Vomiting
  6. Headache
  7. Sweating
  8. Anxiety
  9. Sleep disturbance
  10. Strange dreams
  11. Shaking
  12. Electric-shock like sensations
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48
Q

Which 2 antidepressants have bigger withdrawal effects?

A

Paroxetine

Venlafaxine

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49
Q

What are the 4 main mood stabilisers?

A
  1. Lithium
  2. Valproate
  3. Lamotrigine
  4. Carbamazepine
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50
Q

What are 4 indications of mood stabilisers?

A
  1. Prophylaxis for bipolar disorder
    - Single manic episode associated with significant risk
    - Illness with significant impact on functioning
    - Two or more acute episodes
  2. Treatment of an acute mania/hypomania
  3. Treatment of bipolar depression - generally not first line
  4. Augmentation for antidepressants in treatment-resistant depression
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51
Q

What is the mechanism of action of lithium?

A

Unclear

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52
Q

What are 4 indications of lithium?

A
  1. Acute mania/hypomania (good evidence)
  2. Prophylaxis in bipolar disorder
  3. Bipolar depression
  4. Treatment-resistant depression

-reduces risk of both attempted and completed suicide by 80%

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53
Q

What are 7 common side effects of lithium?

A
  1. GI upset
  2. Fine tremor
  3. Polyuria
  4. Polydipsia
  5. Metallic taste in mouth
  6. Weight gain
  7. Oedema
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54
Q

What are 7 symptoms of lithium toxicity?

A
  1. Diarrhoea
  2. Course tremor
  3. Ataxia
  4. Dysarthria
  5. Nystagmus
  6. Confusion
  7. Convulsions
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55
Q

What plasma concentration of Lithium leads to toxicity?

A

Over 1.5 mmol/L

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56
Q

Why do you need to be careful with administering Lithium?

A
  1. Narrow therapeutic range - need to titrate dosing and monitor levels
  2. Can be nephrotoxic and thyrotoxic so need to monitor:
    - Lithium level (once every 3 months)
    - Urea and Electrolytes (once every 6 months)
    - Thyroid function test (once every 6 months)
  3. Known teratogen with increased risk of major congenital malformations - recommend that Lithium should be withdrawn prior to conception
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57
Q

What are the 2 preparations that valproate comes in?

A
  1. Sodium valproate

2. Valproate semi-sodium (Depakote)

58
Q

What are 2 indications of valproate?

A
  1. Acute mania/hypomania

2. Prophylaxis in bipolar disorder (weaker evidence than lithium)

59
Q

What is the mechanism of Valproate?

A

Unclear

-don’t need to know side effects

60
Q

What do you need to consider when prescribing valproate to a female?

A

Teratogenic

  • adequate contraception is essential when prescribing
  • Valproate should be withdrawn prior to conception
61
Q

What are 3 indications for lamotrigine?

A
  1. Bipolar depression
  2. Prophylaxis in bipolar disorder (limited evidence)
  3. Augmentation of antidepressants in treatment-resistant depression
62
Q

What are side effects of Lamotrigine?

A
  1. Generally well-tolerated but needs to be titrated due to concerns of development of Stevens-Johnson Syndrome
  2. Least teratogenic of the mood stabilisers, but increased risk of cleft lip/palate with 1st trimester exposure
63
Q

What is the mechanism of action of carbamazepine?

A

Blocks voltage-dependent sodium channels

64
Q

What are 3 indications of carbamazepine?

A
  1. Acute mania/hypomania (weaker evidence than lithium or valproate)
  2. Prophylaxis in bipolar disorder (weak evidence)
  3. Bipolar depression
65
Q

What are 4 indications of ECT?

A
  1. Treatment-resistant depression
  2. Life-threatening severe depression
  3. Treatment-resistant mania
  4. Catatonia
66
Q

How many sessions of ECT do patients usually receive and how often?

A

4-12

Occurs twice a week

67
Q

What is the mechanism of action of ECT?

A

Unclear, but probably a mix of:

  1. Modulation of neurotransmitter functioning
  2. Changes in regional blood/activity
  3. Modulation of neuronal connectivity
  4. Alterations of neuronal structures, including hippocampal neurogenesis
68
Q

What is an absolute contraindication of ECT?

A

Cochlear implant

69
Q

What are 5 relative contraindications of ECT?

A
  1. Raised intracranial pressure
  2. Intracranial aneurysm
  3. History of cerebral haemorrhage
  4. Recent myocardial infarction (less than 3 months)
  5. Aortic aneurysm
70
Q

What are 4 common side effects of ECT?

A
  1. Headache
  2. Confusion
  3. Impaired cognitive function
  4. Temporary retrograde and anterograde amnesia
71
Q

What is a possible longer-term side effect of ECT?

A

There may be some loss of retrograde autobiographical memories

72
Q

What are 7 symptoms of hypomania?

A
  1. Mild elevation or instability of mood
  2. Increased energy
  3. Mild overspending, risk-taking
  4. Increased sociability, overfamiliarity
  5. Distractibility
  6. Increased sexual energy
  7. Decreased need for sleep
73
Q

How long to symptoms need to be present for to justify a diagnosis of hypomania?

A

4 days

74
Q

What are 9 symptoms of mania?

A
  1. Mood is elevated, expansive, irritable
  2. Increased activity
  3. Reckless behaviour
  4. Disinhibition
  5. Marked distractibility
  6. Markedly increased sexual energy
  7. Sleeve severely impaired or absent
  8. Grandiosity
  9. Flight of ideas
75
Q

How long do symptoms need to be present for it to be classed as mania?

A
  1. A week

2. Or severe enough to necessitate inpatient admission

76
Q

In mania with psychotic symptoms, what are additional symptoms to the ones for mania?

A

Presence of delusions

  1. Often mood congruent
  2. Inflated self-esteem and ideation can develop into fully-formed grandiose beliefs
  3. Irritability and suspiciousness can develop into delusions of persecution

Hallucinations occur less frequently
4. Where present, they are likely to be mood congruent, and often take the form of second person auditory hallucinations

77
Q

What are the diagnoses for the following episodes?

  1. One episode of mania
  2. Two episodes of mania
  3. One episode of mania, one episode of depression
  4. Two episodes of depression
A
  1. Acute mania
  2. Bipolar affective disorder
  3. Bipolar affective disorder
  4. Recurrent depressive disorder
78
Q

What are 4 important things in the assessment of bipolar affective disorder?

A
  1. History - often requiring collateral
  2. Organic differentials - substance misuse (including steroids), hyperthyroidism (very severe), space-occupying lesion (especially frontal lobe), metabolic disorders, epilepsy
  3. Use of the Mental Health Act as part of assessment process is common
  4. Level of care - secondary mental health services, such as community mental health team, crisis team, early intervention in psychosis (EIP). Inpatient admission may be indicated
79
Q

What is the lifetime risk of bipolar affective disorder?

A

1%

80
Q

What is the prevalence of bipolar affective disorder among men and women?

A

Equal

81
Q

At what age does bipolar affective disorder usually start?

A

Late teenage to early twenties

82
Q

What are 3 causes of bipolar affective disorder?

A
  1. Genetics
    - More likely if they have relatives with bipolar disorder/ other types of mood disorders
  2. Life events
    - prolonged stressful circumstances or vulnerability factors can predispose to or preciptate episodes of affective disturbance
  3. Substance misuse
    - often thought to be a precipitating factor in episodes of illness
83
Q

What is the average length of a manic episode in bipolar affective disorder in both treated or untreated people?

A

6 months

84
Q

Following a manic episode, what % will have a further episode of mood disturbance?

A

at least 90%

85
Q

What is the short and long term prognosis of bipolar affective disorder?

A

Short term - recovery is good

Long term - poor prognosis

86
Q

What % of people with bipolar affective disorder achieve a period of 5 years of clinical stability, with good social/occupational performance?

A

<20%

87
Q

What % more likely are people with bipolar affective disorder to die by suicide compared to the general population?

A

20-30%

88
Q

What are 6 causes of relapse of bipolar?

A
  1. Non-concordance with medication
  2. Life events, social stressors
  3. Disruption of circadian rhythm
  4. Substance misuse
  5. Childbirth (puerperal psychosis)
  6. Natural course of the illness
89
Q

How could you ask a patient about bipolar?

A

Have you ever had lows as well as highs?

90
Q

What are 7 ddx of bipolar disorder?

A
  1. Schizophrenia, schizoaffective disorder, delusional disorder, other psychotic disorders
  2. Anxiety disorders/PTSD
  3. Circadian rhythm disorder
  4. ADHD/conduct disorder
  5. Alcohol or drug misuse
  6. Physical illness
    - Hyper/hypothyroidism
    - Cushing’s syndrome
    - SLE
    - MS
    - HIV
  7. Other antidepressant treatment or drug-related causes
91
Q

What is the ICD-10 diagnostic classification of bipolar affective disorder?

A
  1. Requires at least 2 episodes, one of which must be hypomanic, manic or mixed, with recovery, usually complete between episodes.
  2. Criteria for depressive episodes are the same as unipolar depression
92
Q

What are standard investigations of depression/bipolar (8)?

A
  1. FBC
  2. ESR
  3. B12/folate
  4. U&Es
  5. LFTs
  6. TFTs
  7. Glucose
  8. Ca2+
93
Q

Other investigations that can be done for depression/bipolar if indicated in hx and/or physical signs?

A
  1. Urine or blood toxicology
  2. Breath or blood alcohol
  3. ABG
  4. Thyroid antibodies
  5. Antinuclear antibody
  6. Syphilis serology
  7. Additional electrolytes
  8. Dexamethasone suppression test (Cushing’s disease)
  9. Cosyntrophin stimulation test (Addison’s disease)
  10. LP
  11. CT/MRI/EEG
94
Q

What are the common co-morbidities of bipolar disorder?

  1. Psychiatric
  2. Organic
A

Psychiatric

  1. ADHD
  2. Anxiety/panic disorders
  3. Substance misuse
  4. Suicide and self-harm

Organic

  1. CVD
  2. Obesity
  3. Metabolic syndrome
95
Q

What is cyclothymia?

A

A milder mood disorder - ups and downs but they never reach the extremes seen with bipolar

96
Q

What are physical symptoms associated with bipolar?

  1. Mania
  2. Depressive
A

Mania:

  1. Distraction
  2. Inability to concentrate
  3. Rapid speech
  4. Restlessness
Depressive;
1. Anhedonia
2. Fatigue
3. Difficulty concentrating
4. Change in sleep/eating
(same as depression)
97
Q

What are 5 social affects of bipolar?

A
  1. Substance use and abuse
  2. Social and family withdrawal including loss of marriage
  3. Decreased performance at work or school
  4. Financial problems
  5. Becoming lost in delusional worlds
98
Q

What are the 3 phases of bipolar disorder that need to be considered in the management?

A
  1. Acute manic phase
  2. Bipolar depressive phase
  3. Bipolar in remission but requires prevention of relapse (sometimes called maintenance phase)
99
Q

What are 6 key principles in managing bipolar affective disorder?

A
  1. As depression, treatment also depends on severity of the depressive episode
  2. Consider possible organic causes (remember hypothyroidism in long term lithium use)
  3. Avoid routine use of antidepressants unless with an anti-manic agent
  4. Consider increase dose of mood stabiliser
  5. Consider psychological treatment early if possible
  6. Consider intervention to reduce social stressors
100
Q

What is the management of acute mania according to the bio-psycho-social model?

A

Bio

  1. Stop any prescribed antidepressants
  2. Offer an antipsychotic: quetiapine (1st line), haloperidol, olanzapine or risperidone
  3. Consider lithium or valproate (or adjust dose if already on these medications)
  4. Consider benzodiapines, like lorazepam or diazepam for behavioural disturbance

Psycho

  1. Psychoeducation
  2. Formal psychological approaches are unlikely to be appropriate in the acute phase

Social

  1. Consider inpatient admission
  2. Consider a calming, low-stimulus environment
  3. Consider the use of the Mental Health Act
  4. Advise not to make serious decisions whilst unwell
  5. Advise to maintain relationships with carers
101
Q

What is the management of bipolar depression according to the bio-psycho-social model?

A

Bio

  1. Antidepressant (usually SSRI) can be used but needs to be with an anti-manic agent
  2. Consider mood stabiliser (lithium, valproate, lamotrigine) or optimise the dose
  3. Consider 2nd generation/atypical antipsychotic (quetiapine, olanzapine, )

Psycho

  1. Psychoeducation
  2. CBT especially if it is a mild to moderate depressive episode

Social

  1. Consider inpatient admission if risk indicates
  2. Work around social inclusion
  3. Support with regard to education, training, employment
  4. Carer support
102
Q

What is the prevention of relapse in bipolar affective disorder according to the bio-psycho-social model?

A

Bio

  1. Avoid use of antidepressants. Never prescribe an antidepressant ‘unopposed’ (i.e. without a mood stabiliser)
  2. Give lithium
  3. If Lithium ineffective or intolerable, consider adding or replacing (respectively) with valproate or olanzapine
  4. If woman of child-bearing age, consider antipsychotic as first-line mood stabiliser as lithium and valproate are associated with foetal abnormalities

Psycho

  1. Psychoeducation
  2. Offer a structured psychological intervention to prevent relapse or manage residual symptoms e.g. CBT
  3. Offer a family intervention e.g. family therapy

Social

  1. CPN and outpatient appointments to monitor symptoms, mood, mental state
  2. Support with education, training, employment, housing, benefits
  3. Carer support
  4. Work around social inclusion
103
Q

What monitoring do people with bipolar affective disorder need?

A
  1. Weight and other cardiovascular and metabolic indicators of morbidity should be monitored, at least annually
  2. Some medications have their own monitoring requirements (e.g. lithium - levels weekly whilst initiating and after any dose change and every 3 months thereafter; also need to check U&E and TFT every 6 months)
104
Q

What other advice do people with biopolar affective disorder need?

A
  1. Offered a healthy eating/physical activity programme
  2. Provide advice with regard to contraception and folic acid if lithium, valproate, carbamazepine are prescribed to women of childbearing age
105
Q

What is the rationale behind CBT?

A
  1. Based on the rationale that a patient’s thoughts, feelings and actions are interdependent on one another
  2. Attention is directed towards the patient’s current thoughts and behaviours which are closely examined and challenged, with a view to modification to improve symptoms.
106
Q

What disorders have CBT been applied to (7)?

A
  1. Mild-moderate depression
  2. Anxiety disorders including OCD
  3. Eating disorders
  4. More recently, psychotic disorders
  5. Personality disorders
  6. Bipolar disorder (reduce risk of relapse)
  7. Substance abuse disorders
107
Q

When are psychotherapies contraindicated?

A
  1. Acute psychosis (due to increasing expressed emotion and the inherent neuropsychological deficits associated with this mental state)
  2. Severe depressive illness (because of psychomotor retardation)
  3. Dementia/delirium (where treatment of organic pathology is first line)
  4. Where there is an acute suicide risk
108
Q

What are the modes of delivery of CBT?

A
  1. Individual
  2. Groups
  3. Self-help via books
  4. Computer programs (including online)
109
Q

What is the rationale for Interpersonal psychotherapy (ITP)?

A

Emotional disturbance (e.g. depression) tends to be associated with ‘here and now’ deficits in interpersonal functioning. Life events related to illness development include: grief, interpersonal disputes, change of role and interpersonal deficits. The events are not viewed as directly causing the episode of illness but helping the patient to understand their role in the evolution of illness and resolving the interpersonal problem is seen as a route to recovery

110
Q

How does ITP work?

A

Patient and therapist meet weekly for 12-16 hour-long individual sessions. It involves educating them about the depressive illness, ascribing their symptoms to the current episode of depression, offering appropriate treatment and giving the patient responsibility for change

111
Q

What are indications for ITP (3)?

A 
Non-psychotic depressive disorders
-Panic disorder
-Bipolar affective disorder
-Dysthymic disorder
etc
112
Q

What is psychoeducation?

A

An evidence-based therapeutic intervention for patients and their loved ones that provides information and support to better understand and cope with illness

113
Q

What is family therapy?

A

A therapist (or pair of therapists) works with the whole family. The therapist explores their views and relationships to understand the problems the family is having. It helps family members communicate better with each other.

Sessions can last from 45 minutes to an hour-and-a-half, and usually take place several weeks apart

114
Q

What are social interventions?

A
  1. CPN and outpatient appointments to monitor symptoms, mood, mental state
  2. Support with education, training, employment, housing, benefits
  3. Carer support
  4. Work around social inclusion
  5. Consider 2o care referral
  6. Crisis Resolution and Home Treatment (CRHT)
  7. Multidisciplinary (MDT) approach
115
Q

What is the male to female ratio of self-harm?

A

1:2

116
Q

What are the 2 most common methods of self-harm?

A

Overdosing

Cutting

117
Q

What age group do 2/3rds of people who harm themselves fall under?

A

> 35 years

118
Q

What are 4 categories of causes of self-harm?

A
  1. Biological
  2. Psychological
  3. Social
  4. Spiritual
119
Q

What are predisposing, precipitating and perpetuating biological causes of self-harm?

A

Predisposing biological

  1. Genetics
  2. Substance misuse
  3. Age - more common in teenagers/young adults

Precipitating and perpetuating biological
1. Substance misuse

120
Q

What are predisposing, precipitating and perpetuating psychological causes of self-harm?

A

Predisposing, precipitating, perpetuating psychological

  1. Sexual, physical, emotional abuse
  2. Bullying
  3. Bereavement
  4. Relationship breakdown
  5. Difficult feelings
  6. Endings/change
121
Q

What are predisposing, precipitating and perpetuating social causes of self-harm?

A

Predisposing social

  1. Having friends who self-harm
  2. Housing concerns
  3. Money worries

Precipitating social

  1. Having friends who self-harm
  2. Housing concerns
  3. Money worries
  4. Work/school pressures
  5. Endings/change

Perpetuating social

  1. Have friends who self-harm
  2. Housing concerns
  3. Work/school pressures
  4. Money worries
  5. Isolation, loneliness
122
Q

What are predisposing, precipitating and perpetuating spiritual causes of self-harm?

A

Crisis of faith

123
Q

What are 5 factors precipitating repetition of self-harm?

A
  1. Number of previous episodes
  2. A diagnosis of personality disorder
  3. History of violence
  4. Alcohol misuse/dependence
  5. Being unmarried
124
Q

How much more likely are people who self-harm to die by suicide?

A

66x

125
Q

What 6 factors indicate suicidal intent?

A
  1. Precautions to avoid intervention (e.g. isolation, timing)
  2. Planning
  3. Leaving a suicide note
  4. Anticipatory acts (e.g. leaving a will, settling debts)
  5. Use of violent methods
  6. Perceived lethality by the patient
126
Q

What is the ratio of M:F in suicide?

A

3:1

127
Q

What are 4 particularly vulnerable groups to suicide?

A
  1. Prisoners
  2. Asylum seekers
  3. People from LGBTQ and backgrounds
  4. Veterens
128
Q

What is self-halm?

A

A deliberate, non-fatal act of injuring oneself, done in the knowledge that it is potentially harmful

129
Q

What is suicide?

A

The act of intentionally killing oneself with primary aim of dying

130
Q

What is the management of self-harm (3)?

A
  1. Assessment
    - They should be cared for with compassion and the same respect and dignity as any service user
    - Have an initial assessment of physical health, mental state, safeguarding concerns, social circumstances and risks of repetition or suicide
    - Receive a comprehensive psychosocial assessment
  2. Appropriate environemnt
    - They should receive the monitoring that they need while in the healthcare setting, in order to reduce the risk of further self‑harm
    - They should be cared for in a safe physical environment while in the healthcare setting, in order to reduce the risk of further self‑harm
  3. Care and forward planning
    - They should Receive appropriate physical treatment for their injuries
    - Be referred for specialist psychosocial assessment of their needs (secondary mental health services)

If the person who has self-harmed is already involved with mental health services, they should:

  • Have a collaboratively developed risk management plan
  • Have a discussion with their lead healthcare professional about the potential benefits of psychological interventions specifically structured for people who self‑harm
131
Q

How would you explain to a patient/carer the aetiology of depression?

A

There isn’t a clear cause, but there are various risk factors:
Bio - illness, genetics
Psycho - e.g. their own psychological defense mechanisms
Social - life events

132
Q

How would you explain to a patient/carer the management of depression?

A

Treatment varies according to severity, but there are 3 groups of treatment:

  1. Bio - Medication i.e. antidepressants, or ECT for severe
  2. Psycho - Talking therapies
  3. Social - Nurses to help in the community, as well as help with education/work/housing etc
133
Q

How would you explain to a patient/carer the prognosis of depression?

A

50-60% of people with one episode of depression will recover within a year

134
Q

How would you explain to a patient/carer the aetiology of bipolar affective disorder?

A

We are not certain, but we think it is multifactorial:

  1. Genetics
  2. Life events
  3. Substance misuse
135
Q

How would you explain to a patient/carer the management of bipolar affective disorder?

A

It depends on the phase of bipolar: acute mania, depression, or when they are better, to prevent another episode

Acute mania:

  1. Bio - Stop antidepressants, give anti-psychotics and mood stabilisers
  2. Social - admit them to hospital, keep them in a calming, low-stimulus environment

Bipolar depression:

  1. Bio - Give antidepressants, anti-psychotics and mood stabilisers
  2. Psycho - CBT
  3. Social - consider admission to hospital, help with job/education/carer etc

Prevention of relapse
1. Bio - Most will need mood stabilizer + low-dose anti-psychotic or mood stabiliser + antidepressant

136
Q

What is the prognosis of bipolar?

A

Recovery in short term is good
But long term is poor - less than 20% will achieve a period of 5 years of clinical stability, with good social/occupational performance

137
Q

What are risk factors for self-neglect (6)?

A
  1. Mental illness
    - Depression
    - Psychosis
  2. Dementia
  3. Cognitive impairment
  4. Alcohol and substance misuse
  5. Social isolation and poor social support
  6. Old age
138
Q

What are risk factors for harm to others (7)?

A
  1. Psychosis
    - Persecutory delusion
    - Violent thoughts
    - Command hallucinations
  2. Impulsivity
  3. Hx of violence to others
  4. Access to weapons
  5. Substance abuse/withdrawal
  6. Unstable accommodation/unemployed
  7. Poor compliance with medication
139
Q

Start an interview with:

A

Hello, my name is …, what is your name?

So i’m going to be asking you quite a lot of qs with regards to your mental health etc

140
Q

When a patient doesn’t want to talk to you about something, what could you say to explore further?

A

I don’t need you to tell me about it, but I just need to know about the impact it has had on you because it is relevant to your mental health, and i need to get an idea of whats going on in your life.
Was that a very traumatic experience for you then? And how has it affected you since?

aaa (8 decks)

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