Mood disorders (bipolar/depression)

Question 1

DSM 5 criteria for MAJOR DEPRESSIVE EPISODE

Answer 1

1) Depressed mood (subjective or objective): most of the day, nearly everyday
2) ‘Anhedonia” -Loss of interest or pleasure
3) Change in weight (5% change over 1 month) or appetite
4) Insomnia or hypersomnia
5) Psychomotor agitation or retardation
6) Loss of energy or fatigue
7) Worthlessness or guilt
8) Impaired concentration or indecisiveness
9) Recurrent thoughts of death or suicide ideation or any suicide attempt

Question 2

DSM 5 for PERSISTENT DEPRESSIVE DISORDER (DYSTHYMIA)

Answer 2

• poor appetite or overeating
• insomnia/hypersomnia
• ↓energy/fatigue
• low self esteem
• poor concentration or difficulty making decisions
• feelings of hopelessness

Question 3

Mx of DEPRESSION

Answer 3

IMMEDIATE:
Perform a RISK ASSESSMENT (to determine the appropriate setting for treatment)
- can they be managed in the community or do they require an inpatient admission?
- Risk Management/Safety Plan
- regular followup essential

SHORT TERM:
for all severities of depression, patients require
- close monitoring
- education
- lifestyle review (good hygiene/nutrition/exercise/smoking/EtOH)
- supportive counselling

1) PSYCHOEDUCATION for patient (and significant others as indicated)
- info giving RE: symptoms, causes, treatment options
- discuss availability of supports/community resources

2) Mental Health Care Plan ( up to 10 visits to psychologist)

MID to LONG TERM

3) PSYCHOTHERAPY (CBT)
- structured problem solving: identify stressors and help patient find their own solutions to problems
- cognitive reframing: identifying, addressing and challenging negative thinking patterns
- relaxation therapy
- activity scheduling

4) Consider antidepressant medication
1st line:
• SSRIs: sertraline (safe in pregnancy, BF, adolescents), citalopram, escitalopram, fluoxetine (adolescents) etc
• Mirtazipine (good for sleep disturbance, but weight gain)
• Agomelatin (good for sleep disturbance but not PBS)

5) Arrange REGULAR FOLLOW-UP

Question 4

Indications for inpatient admission for patient with depression

Answer 4

• significant risk of self-harm or homicidal risk
• psychotic depression
• unable to cope at home/significantly physically unwell
• complicated & treatment-resistant depression

Question 5

What things are important to ascertain in a RISK ASSESSMENT?

Answer 5

1) SUICIDALITY/SELF-HARM
- thoughts
- plans (+ lethality of plans)
- access means
- any last acts e.g.: will, suicide note
- Help seeking behaviour vs attempts to conceal intentions/actions from others
- desire to die vs call for help?
- Past Hx of self-harm or prev. suicide attempts?
- FHx or suicide of a peer

2) HARM TO OTHERS
[esp. mothers → harm to baby]
- thoughts & precipitating events
- degree of planning and premeditation 
- severity of intended injury (lethality)
- access means
- capacity for restraint

RFs

• male > female
• younger (peaks in teens and early 20s)
• Prev Hx violence
• active substance use ( drugs, EtOH)
• psychosis: command hallucinations, thought insertion, delusions of persecution or grandiosity, morbid jealousy
• personality: anti-social

3) HARM FROM OTHERS
- at immediate risk? do they feel safe?
- PHx
- access to services
- contingency/safety plan?
- do they have somewhere to go? access to finances?

4) PROTECTIVE FACTORS & VULNERABILITIES
- employment/financial status
- marital/relationship status
- support networks (friends, family, community)
- living status (by self etc)
- physical illness
- co-morbid mental illness
- substance use (smoking, EtOH, illicit drugs)
- personality: ?impulsive?

FROM THIS:
• SCREENING TOOLS: eg: K10, DASS21, Edinburgh PND
• CREATE A SAFETY PLAN
- written list of prioritised contacts and resources as well as coping strategies for patient to utilise

Question 6

Principles of commencing SSRI Therapy

Answer 6

PRINCIPLES
• “start low and go slow”
• Allow 4-6 weeks for response (although some improvement in first 1-2 weeks)
• Response rate: 70-80% (no differences between classes, but differing side effect profiles)
• Monitor for:
○ Side effects: N&V, GI upset, headache/dizziness, restlessness, sedation, insomnia
○ Suicidal TPI ( esp. in the first month
• Warn RE: effects of abrupt cessation
○ Discontinuation sx:
• Regular review

CONTINUING Rx

• Monitor for:
○ Side effects
○ Relapse & recurrence of condition, as measured by:
- Patient recovery goals
- EWS eg: sleep distrubance
- Concurrent factors (eg: psychosocial issues, medical condition)
- Adherence to medication

Question 7

Duration of Rx for DEPRESSION

Answer 7

1st episode: 6-12 mths

Recurrent episodes: minimum 12 months, usually 2-3 years

Question 8

Principles of CEASING SSRI Rx &; what happens if abrupt discontinuation?

Answer 8

• Taper dose gradually
• Abrupt cessation = associated with unpleasant discontinuation symptoms
- N&V
- Insomnia
- Flu-like symptoms
- Imbalance/ dizziness
- Sensory disturbances
- Hyperarousal (agitation, irritability)
NB: lasts 1-2 weeks, rapidly ceased with reinstitution of Rx