MOOD DISORDERS (BIPOLAR AND ECT) Flashcards
What is hypomania?
persistant mild elevation of mood, increased energy and activity, and usually marked feelings of well-being and both physical and mental efficiency.
Increased sociability, talkativeness, over-familiarity, increased sexual energy, and a decreased need for sleep are often present but not to the extent that they lead to severe disruption of work or result in social rejection.
Absence of psychotic symptoms
Requires symptoms to last 4 days
What is mania?
Mood is elevated out of keeping with the patient’s circumstances and may vary from carefree joviality to almost uncontrollable excitement.
Elation is accompanied by increased energy, resulting in overactivity, pressure of speech, and a decreased need for sleep.
Attention cannot be sustained, and there is often marked distractibility.
Self-esteem is often inflated with grandiose ideas and overconfidence.
Loss of normal social inhibitions may result in behaviour that is reckless, foolhardy, or inappropriate to the circumstances, and out of character.
Symptoms lasting 7 days
What psychotic symptoms typically occur in mania with psychotic symptos?
delusions (usually grandiose) or hallucinations (usually of voices speaking directly to the patient) are present, or the excitement, excessive motor activity, and flight of ideas are so extreme that the subject is incomprehensible or inaccessible to ordinary communication.
What is bipolar affective disorder?
A disorder characterized by two or more episodes in which the patient’s mood and activity levels are significantly disturbed, this disturbance consisting on some occasions of hypomania/mania and on others of depression. Repeated episodes of hypomania or mania only are classified as bipolar.
Episodes of depression are not required for a diagnosis of bipolar affective disorder but are common
What are symptoms and signs of BAD that distinguish it from depression?
Hypersomnia, lability, and weight instability - experienced by ~90% of people with bipolar disorder and ~50% of people with unipolar depression
Earlier age of onset (peak age 15 to 19 years)
Abrupt onset (possibly triggered by stressor).
More frequent episodes of shorter duration.
Comorbid substance misuse.
Higher post-partum risk.
Psychosis, psychomotor retardation, and catatonia.
Lower likelihood of somatic symptoms.
FHx is more likely in bipolar
What are the types of bipolar affective disorder?
Current episode hypomanic
Current episode manic without psychotic symptoms
Current episode manic with psychotic symptoms
Current episode mild or moderate depression
Current episode severe depression without psychotic symptoms
Current episode severe depression with psychotic symptoms
Current episode mixed
Currently in remission
Other bipolar affected disorders
Bipolar affected disorder unspecified
How do you treat bipolar affective disorder mania/hypomania?
Manage mania/hypomania by considering stopping antidepressants and offer an antipsychotic
If antipsychotic isnt suitable offer an alternative
If not suitable offer lithium
If not suitable offer valproate
If not suitable offer ECT
What proportion of those who have a manic episode go on to have further episodes?
> 90%
What is rapid cycling?
4 or more mood episodes within a year
What proportion of pt complete suicide?
10-15%
How do you treat BAD depressive episode?
Quetiapine alone, or
Fluoxetine combined with olanzapine, or
Olanzapine alone, or
Lamotrigine alone
Psychological treatment
How do you manage BAD in the long term,?
Start long-term treatment with lithium to prevent relapses, or
If lithium is not effective, valproate may be added to lithium treatment.
If lithium is poorly tolerated, valproate alone or olanzapine alone may be considered.
This is to prevent relapses and is indicated in those who have has more than 1 episode
Outline the care plan for BAD?
Clear, individualised social and emotional recovery goals.
An assessment of the person’s mental state.
A crisis plan, indicating early warning symptoms and triggers of both mania and depression relapse and preferred response during relapse, including liaison and referral pathways.
A medication plan with a date for review by primary care, frequency and nature of monitoring for effectiveness and adverse effects, and what should happen with medication in the event of a relapse.
An advance statement - a written statement, drawn up and signed when the person is well, which sets out if there are treatments that the person does not wish to receive if they lose their capacity to make decisions for themselves through illness.
A statement of wishes and feelings as to how they would prefer to be treated (or not treated) if they were to become ill in the future, who would be told about the illness or anything else of importance such as financial affairs, care of pets or at-risk relatives (but this is not binding with respect to children).
Key clinical contacts in case of emergency or impending crisis.
Whats the estimated lifetime risk of bipolar in the general public if a first-degree relative suffers from the condition.
5-10 times greater
What do twin studies show about the aetiology of BAD?
monozygotic twin studies show there is a 40-70% risk of developing bipolar if the other sibling suffers from the disorder.
What are the main features of mania?
Elevated mood
Extreme irritability and/or aggression
Increased energy
Restlessness
Decreased need for sleep
Flight of ideas
Racing thought
Pressure of speech
Increase libido and disinhibition
Distractibility, poor concentration
Psychotic features: delusions (fixed belief contradictory to reality or rational argument) or hallucinations
What are the main features of hypomania?
Elevated mood
Irritability
Increased energy
Feeling of physical and/or mental efficiency
Increased sociability
Talkativeness
Over-familiarity
What is a mixed episode in BAD/
rapid alternating between manic and depressive symptoms, or criteria for mania/hypomania and at least three symptoms of depression for ≥1 week, or criteria for a depressive episode and at least three mania/hypomania symptoms for ≥ 2 weeks.
How does ICD10 diagnose BAD?
at least two mood episodes, one of which must be mania or hypomania.
What psychological therapies are offered for BAD?
CBT
What proportion of BAD patients will attempt suicide at least once?
56%
What are complications of BAD?
Suicide
Impaired social functioning e.g. financial difficulties,
Disinhibition e.g. sexual issues, substance misuse
When is ECT used in depression?
For acute treatment of severe depression
When is ECT used in catatonia and mania?
It is recommended that electroconvulsive therapy (ECT) is used only to achieve rapid and short-term improvement of severe symptoms after an adequate trial of other treatment options has proven ineffective and/or when the condition is considered to be potentially life-threatening, in individuals with:
• catatonia
• a prolonged or severe manic episode.
What should you consider when thinking about using ECT for treating depression?
Risks associated with general anaesthetic
Current medical comorbidities
Potential adverse events, notably cognitive impairment
Risks associated with not receiving ECT
What group of people have greater risk of ECT?
Older people
Whats the difference between unilateral and bilateral ECT?
bilateral ECT is more effective than unilateral ECT but may cause more cognitive impairment
with unilateral ECT, a higher stimulus dose is associated with greater efficacy, but also increased cognitive impairment compared with a lower stimulus dose.
Outline the monitoring for ECT?
Assess clinical status after each ECT treatment amd stop treatment when remission has been achieved or sooner if SE outweigh the potential benefits
Assess cognitive function before first ECT teatment and monitor every 3-4 treatments and at the end of a course of treatment
If there is evidence of significant cognitive impairment at any stage consider, in discussion with the person with depression, changing from bilateral to unilateral electrode placement, reducing the stimulus dose or stopping treatment depending on the balance of risks and benefits.
What are the advantages of ECT?
Effective when other treatments dont work
Most effective with most severe illness
What are the disadvantages of ECT?
Multiple brief anaesthetics
Acute confusional states
Memory impairment
What is the seizure threshold?
defined as the minimum amount of electrical energy that is required to induce cerebral seizure activity of a defined length
Which groups of people is the seizure threshold higher in?
Men
Older people
What medicines interfere with ECT?
Anticonvulsants and lithium
What are short-term adverse effects of ECT?
Headache
Muscle aches
Nausea
Fuzzy head
Distressed, tearful, frightened
Temporary loss of memory
Confusion
Damage to tongue/teeth/lips due to contraction of jaw muscles
Whats the risk of death per course of treatment of ECT>
1 in 10,000
What are the long-term effects of ECT?
Memory problems 1/10
Personality changes
Who is ECT likely to help?
Severe depression that is life-threatening
Resistant mania
Catatonia
Can ECT be given without permission?
Not usually even under MHA
It may only happen when you do not have capacity to consent - legal provisions for this differ throughout the UK
How is ECT given?
An anaesthetic and muscle relaxant are given
An electrical current is passed across the brain from a special ECT machine which produces muscle spasms that are small, rhythmic movements in arms, legs and body for 20-50 seconds
Outline how the monoamine theory is applicable to the manic episodes in bipolar affective disorder?
Manic episode are thought to be associated with increased central noradrenaline or serotonin
Who should you not prescribe lithium to?
People with cardiac disease associated with rhythm disorders
Clinically significant renal impairment
Untreated hypothyroidism
Brugada syndrome
Hyponatraemia
Addison’s disease
Why is lithium contraindicated in Addison’s disease?
Lithium blocks the mineralocorticoid action of fludrocortison
What are initial adverse effects of lithium?
Nausea
Diarrhoea
Vertigo
Muscle weakness
Dazed feeling
Find hand tremors, polyuria and polydipsia may persist
What are longer term adverse effects of lithium?
Hypothyroidism
Hyperthyroidism
Hyperparathyroidism
Nephrotoxicity
Renal tumours
Rhabdomyolysis
What are the key drug interactions of lithium?
Diuretics - reduce renal clearance of lithium
NSAIDs - increase serum lithium levels
Haloperidol - severe neurotoxicity
Carbazmazepine - neurotoxic reactions
Dapagliflozin - increases lithium renal clearance
Antidepressants with serotonergic action increase incidence of CNS toxicity
ACEi decreased excretion and preciptate renal failure
Drugs that prolong QT interval
Drugs that cause hypokalaemia - increased risk of torsades de points
How do you monitor someone taking lithium?
Before starting check U&Es and TFTs
Measure lithium levels one week after staring treatment, every week after changing dose and then weekly until levels are stable; then check every 3 months
Measure BMI, eGFR, calcium and TFTs every 6 months
ECG before treatment begins if risk factor/existing CVD
Why is it important to monitor lithium ?
Narrow therapeutic index = easy to get lithium toxicity
What are signs of lithium toxicity?
increasing diarrhoea, vomiting, anorexia, muscle weakness, lethargy, dizziness, ataxia, lack of coordination, tinnitus, blurred vision, coarse tremor of the extremities and lower jaw, muscle hyper-irritability, choreoathetoid movements, dysarthria, and drowsiness.
Severe - hyper-reflexia and hyperextension of limbs, syncope, toxic psychosis, seizures, polyuria, renal failure, electrolyte imbalance, dehydration, circulatory failure, coma, and occasionally death.
At what concentration does lithium toxicity occur?
1.5 mmol/L and above
Severe >2
What is done if lithium toxicity is suspected?
Urgent lithium level immediately and seek specialist advice
No specific antidote so treatment is supportive and lithium levels checked every 6-12 hours
Osmotic or forced alkaline diuresis may be required. Peritoneal or haemodialysis may be used if levels >3
What advice should be given to someone taking lithium?
People taking lithium should be advised:
To carry a lithium card.
That regular blood tests are important and the results should be recorded in their lithium record booklet.
About what adverse effects to expect.
How to recognize the symptoms of lithium toxicity.
Not to take over-the-counter nonsteroidal anti-inflammatory drugs.
That episodes of diarrhoea or vomiting, or any form of dehydration, will lead to sodium depletion and therefore increased plasma lithium levels.
To maintain their fluid intake, particularly after sweating (for example, after exercise, in hot climates, or if they have a fever), if they are immobile for long periods, or if they develop a chest infection or pneumonia.
That if a dose is missed they should take it as soon as possible; but if yesterday’s dose was missed then they should not double today’s dose.
Not to stop taking lithium abruptly, and that non-compliance may lead to a relapse.
