Mood disorders (bipolar and depression) Flashcards
What is the timeframe for follow up for commencing <25 year old on sertraline?
1 week due to higher risk of suicidal ideation in first week
despite SSRI taking 4 weeks to be effective
For how long do you need depressive symptoms to be diagnosed with depression?
2 weeks
What is a quick way to screen for depression?
The following two questions can be used to screen for depression
‘During the last month, have you often been bothered by feeling down, depressed or hopeless?’
‘During the last month, have you often been bothered by having little interest or pleasure in doing things?’
A ‘yes’ answer to either of the above should prompt a more in depth assessment.
How would you know if someone is manic or hypomanic?
with mania, there is severe functional impairment or psychotic symptoms for 7 days or more
hypomania describes decreased or increased function for 4 days or more
from an exam point of view the key differentiation is psychotic symptoms (e.g.delusions of grandeur or auditory hallucinations) which suggest mania
Acronym to diagnose/screen for symptoms depression?
SADFACES
What are the components of SADFACES?
A = Appetite (Weight Change)
S = Sleep (Insomnia / Hypersomnia)
A = Anhedonia
D = Dysophria
F = Fatigue
A = Agitation / Retardation
C = Concentration Diminished
E = Esteem (Low) / Guilt
S = Suicide / Thoughts of Death
What is an acronym/mneumonic for screening for suicidality?
SADPERSONS
S: Male sex
A: Age (<19 or >45 years)
D: Depression
P: Previous attempt
E: Excess alcohol or substance use
R: Rational thinking loss
S: Social supports lacking
O: Organized plan
N: No spouse/support
S: Sickness
State two examples of negative symptoms of psychosis
anhedonia
amotivation
social withdrawal
blunt affect
List two positive symptoms of psychosis
delusions
hallucinations
thought disorder
disorganised behaviour
What are the three types of bipolar disorder?
bipolar 1= 1:1 depression and mania
bipolar 2= depression 5:1 mania
rapid cycling bipolar >4 mania + depression episodes
Why is it important to distinguish rapid cycling bipolar from bipolar disorder?
different treatment
Why is it important to distinguish rapid cycling bipolar from bipolar disorder?
different treatment
Is the treatment for bipolar and depression the same?
no!!!
List three factors that can precipitate bipolar event
life factors that lead to early morning waking
positive life events
negative life events
pregnany
steroids
stimulants
alcohol
cannabis
thyroid disease
list three clinical features of bipolar
mania
hypomania
irritable mood
increased feelings of self worth
inappropriate social behavior
delusions and hallucinations
heightened sense of abilities
altered perceptions
difference between mania and hypomania?
mania- psychotic symptoms 1–2 weeks
hypomonia- no psychotic symptoms >4 days
How is bipolar disorder diagnosed?
elated or irritable mood for >one week PLUS 3 of:
Inflated self esteem
Decreased need for sleep
Accelerated speech
Racing thoughts / flight of ideas
Distractibility (reported or observed)
Increased goal directed activity or psychomotor agitations
Excessive activity
Impaired social or occupational functioning
Episode not due to substance misuse or other organic cause
Differential diagnosis for bipolar?
depression
schizophrenia
BPD
Organic causes of mania
List three organic causes of mania
endocrine- thyroid and adrenal disorders
neuro- epilepsy, tumour, MS, CVA
Drugs- antidepressants, steroids, stimulants
What is the management of manic episode?
atypical antipsychotic- olanzapine, risperidone, clozapine
What is a serious complication of atypical antipsychotic?
agranulocytosis
What is the management of depressive episode in bipolar?
AVOID antidepressants!!!!!!??
atypical antipscyhotic- olanzapine
+ lithium or lamotrigine
Why are antidepressants avoided in depressive bipolar disorder?
they can induce rapid cycling mood
List three symptoms of mania
abnormally elevated mood
restlessness/increased activity
increased energy levels, no sleep without fatigue
poor concentration
impulsive behaviour
delusions
auditory hallucinations
which type of delusion is typically present in mania
grandiose
How long do symptoms need to persist for to diagnose mania
7 days
What is the management of acute mania?
stop any antidepressant medication
atypical antipscyhotic
add lithium
What must you assess before commencing antipsychotic
weight and BMI
pulse and BP
Fasting blood glucose Hba1C lipid profile
ECG for QTc
What is the long term treatment of bipolar disorder?
lithium
How is lithium extreted?
kidneys
When should you measure lithium levels?
1 week after starting lithium (12 hours post dose)
measure 1 week after dose change
What is the monitoring for lithium?
FBC
U+Es
TFTs
caclium
ECG
Once lithium levels are stable, do you need to measure levels still?
measure once a month and then every 3 months
also need TFTs urea calcium every 6 months
List two side effects of lithium
GI upset
fine tremor
hypothyroidism
peripheral oedema
metallic taste in mouth
thirst polyuria weight gain tiredness
Two signs of lithium toxicity?
confusion
visual disturbances
loss of appetite
seizures
coarse tremor
ataxia
paraesthesia
Name one drug that interacts with lithium and can lead to toxicitity
NSAIDs and ACEi
How should you stop lithium/how to ween off?
reduce dose gradually 4weeks- 3months. Close monitoring after weened off lithium for mania
Which birth defect is associated with lithium?
ebstein’s anomaly= congenital heart defect
Aside from lithium and antipsychotics, name one other drug in the treatment of bipolar disorder
sodium valproate
lamotrigine
What to look out for in appearance section of MSE for depressed patient
self harm scars
weight
personal hygiene
clothing
Behaviour?
engagement and rapport
eye contact
movement/postures
restlessness or agitation
How to assess thought content?
are you worried about anything?
do you have thoughts that life isn’t worth living?
do you feel that people are out to harm you?
do you have thoughts that others don’t share with you?
What are the three core symptoms of depression?
anhedonia
low mood
reduced energy
For how long must depressive symptoms be present for to be diagnosed?
two weeks
State one somatic symptom of depression
sleep disturbance
loss of appetite or weight loss
loss of libido
List two cognitive symptoms of depression
decreased concentration
impaired memory
nihilistic thinking
suicidal thoughts
pessimistic thinking
feelings of worthlessness
List three differentials for depression
anxiety
depressive episode of bipolar disorder
premenstrual dysphoric disorder
organic: anaemia, alcohol use, cushing’s syndrome, hypothyroidism
What is the treatment for mild depression
group CBT
avoid antidepressants
low intensity psychosocial intervention
What is the treatment for moderate depression?
antidepressant and high psychological intervention
Which antidepressants should be avoided in history of overdose?
TCA and venlafaxine
What is the first line antidepressant?
SSRI
Two examples of SSRI
sertraline, fluoxetine, citalopram
Name two side effects of SSRIs
nausea vomiting
insomnia
increased risk of suicidality in young
loss of libido
What is a major complication of SSRI use
serotonin syndrome
what are the features of serotonin syndrome
confusion
agitation
sweating
diarrhoea
muscle twitching
Features of severe serotonin syndrome?
fever
seizures
arrhythmia
loss of consciousness
myoclonus
Treatment for serontonin syndrome
stop all medication
IV fluids
propranolol
cryheptadine- block serotonin production
What is MOA of venlafaxine?
SNRI
Example of TCA
amitriptyline
imipramine
What are the side effects of TCAs?
dry mouth constipation confusion in elderly
tachy hypotension arrhtyhmias prolonged QTc
toxic in overdose
Which antidepressants are not toxic in overdose?
SSRIs- generally safe in overdose
Which antidepressants are toxic in overdose?
TCAs and SNRI (venlafaxine)
Which antidepressants can cause hypertensive reaction?
MAOIs
Why does hypertensive reaction arise?
MAOIs inhibit tyramine breakdown
Which foods are rich in tyramine?
cheese, smoked or pickled fish
List two indications for ECT
life threatening depression- not eating or drinking
resistant depressive disorder following failure with antidepressants
catatonia
List three risk factors for suicide
previous suicide
active mental illness
male
unemployed
lives alone
unmarried
drug/alcohol dependence
