Mood disorders + Depression Flashcards

Question

If patients suggests suicidal ideation/ activity what should you do?

Answer 1

*If the patient suggests that they are actively suicidal, you must carry out a full risk assessment

Answer 2

Appearance Signs of self-neglect, thin, unkempt, depressed facial expression, tearful. Behaviour Poor eye contact, tearful, psychomotor retardation, slow movements, slow responses, may sometimes present with psychomotor agitation. Speech May be slow, non-spontaneous, reduced volume and tone. Mood Low (subjectively) and depressed (objectively). Thought Pessimistic, guilty, worthless, helpless, suicidal, delusions (if psychotic). Perception Second person auditory hallucinations (often derogatory). Cognition Impaired concentration. Insight Usually good.

Answer 3

Diagnostic questionnaires: e.g. PHQ-9, HADS and Beck’s depression inventory. 59 Blood tests: FBC (e.g. to check for anaemia), TFTs (e.g. to test for hypothyroidis m), U&Es, LFTs, calcium levels (biochemical abnormalities may cause physical symptoms which can mimic some depressive symptoms), glucose (diabetes can cause anergia). Imaging: MRI or CT scan may be required where presentation or examination is atypical or where there are features suspicious of an intracranial lesion e.g. unexplained headache or personality change.

Answer 4

Other mood disorders: Bipolar affective disorder, other depressive disorders (see Key facts 1). Secondary to physical condition e.g. hypothyroidism (see Overview of mood disorders, Section 3.1). Secondary to psychoactive substance abuse. Secondary to other psychiatric disorders: Psychotic disorders, anxiety disorders, adjustment disorder, personality disorder, eating disorders, dementia. Normal bereavement. Grief Acute reaction to life event eg bullying Anxiety – affects sleep, concentration, can cause fatigue PTSD- affects sleep, concentration, can lead to loss of interest

Answer 5

Post traumatic Stress disorder Eating disorder Anxiety Disorder Drugs and Alcohol misuse

Answer 6

Recurrent depressive disorder: A recurrent depressive episode refers to when a patient has another depressive episode after their first. Seasonal affective disorder: Characterized by depressive episodes recurring annually at the same time each year, usually during the winter months. Masked depression: A state in which depressed mood is not particularly prominent, but other features of a depressive disorder are, e.g. sleep disturbance, diurnal variation in mood. Atypical depression: This typically occurs with mild–moderate depression with reversal of symptoms e.g. overeating, weight gain and hypersomnia. There is a relationship between atypical depression and seasonal affective disorder.

Answer 7

Dysthymia: Depressive state for at least 2 years, which does not meet the criteria for a mild, moderate or severe depressive disorder and is not the result of a partially-treated depressive illness. Cyclothymia: Chronic mood fluctuation over at least a 2-year period with episodes of elation and of depression which are insufficient to meet the criteria for a hypomanic or a depressive disorder. Baby blues: Seen in around 60–70% of women, typically 3–7 days following birth, and is more common in primiparae. Mothers are anxious, tearful and irritable. Reassurance and support is all that is required. Postnatal depression: Affects approximately 10% of women. Most cases start within a month and typically peak at 3 months. Clinical features are similar to depression seen in other circumstances.

Answer 8

Watchful waiting: Should be considered and reassess the patient again in 2 weeks. Antidepressants: Not recommended as a first-line therapy for mild depression unless: (1) depression has lasted a long time; (2) past history of moderate–severe depression; (3) failure of other interventions; (4) or the depression complicates the care of other physical health problems. Self-help programmes: Patient works through a self-help manual with a healthcare professional providing support and checking progress. Computerized cognitive behavioural therapy (CBT): Based on conventional CBT, involves a computer programme educating them about depression and challenging negative thoughts. Physical activity programme: Exercise has been shown to benefit mental health. Group exercise class under the supervision of a qualified trainer may be recommended. Psychotherapies (see Key facts 2): If the options above fail, psychotherapies can be tried.

Answer 9

Suicide risk assessment: Should be performed on all patients. Psychiatry referral: Indicated if: (1) suicide risk is high; (2) depression is severe; (3) recurrent depression; (4) or unresponsive to initial treatment. Mental Health Act: Implementation may become necessary in some cases. Antidepressants: First-line antidepressants are selective serotonin reuptake inhibitors (SSRIs) e.g. citalopram. Other antidepressants include tricyclic antidepressants (TCAs), serotonin noradrenaline reuptake inhibitors (SNRIs) and monoamine oxidase inhibitors (MAOIs can only be 61 prescribed by specialists). Should be continued for 6 months after resolution of symptoms for first depressive episode, 2 years after resolution of second episode, and long term in individuals who have had multiple severe episodes. Adjuvants: Antidepressants may be augmented with lithium, or antipsychotics. Psychotherapy: Refer for CBT and interpersonal therapy (IPT). Social support: Engaging with activities in the community that the individual is avoiding or attending social support groups with others. ECT: Indications specific to depression include: (1) acute treatment of severe depression which is life-threatening; (2) rapid response required; (3) depression with psychotic features; (4) severe psychomotor retardation or stupor; (5) or failure of other treatments.

Answer 10

CBT: Depression causes negative thoughts, which can lead to negative behaviours. CBT allows people to identify and tackle negative thoughts; conducted in groups or individually. IPT: Helps to identify and solve relationship problems, whether it is with family, partners or friends. Behavioural activation: Encourages depressed patients to develop more positive behaviour or activities that they would usually avoid. Counselling: Enables patients to explore their problems and symptoms. Counsellors offer support and guide patients to help themselves for a particular focus, e.g. bereavement or relationship counselling. Psychodynamic therapy: Aim is to explore and understand the dynamics and difficulties of a patient’s life, which may have begun in childhood.

Answer 11

may not be able to describe depression and present as irritable, temper tantrums, refusing to go to school and clingy to Mum. Rating scales eg CDI can be very helpful if young person finds it difficult to explain

Answer 12

A 15 year old presents with tearfulness , difficulty sleeping , feeling down, doesn’t want to go out with her freinds and has recently had suicidal thoughts

Answer 13

Bipolar affective disorder (previously known as ‘manic depression’) is a chronic episodic mood disorder, characterized by at least one episode of mania (or hypomania) and a further episode of mania or depression Either one can occur first but the term bipolar also includes those who at the time of diagnosis have suffered only manic episodes, as all cases of mania will eventually develop depression.

Answer 14

Genetic: Monozygotic twins: 40-70% concordance rate, strong family history Neurochemical: Inc Dopamine, Inc serotonin Endocrine: Inc cortisol, Inc aldosterone, Inc Thyroid

Answer 15

Adverse life events, exams, post partum period, loss of loved ones

Answer 16

The lifetime risk of developing BPAD is 1–3%. The mean age of onset is 19 years of age. 63 In the UK, the incidence of bipolar disorder is higher in black and other minority ethnic groups than in the white population. The male to female affected ratio is 1:1.

Answer 17

Age in early-20’s Strong Family Hx Anxiety disorders Substance misuse After depression Stressful life events

Answer 18

Irritability Activity/Appetite increased Distractibility/Disinhibited (sexual, social, spending) Sleep decreased Insight impaired/Increased libido Talkative – pressure of speech Grandiose delusions Elevated mood/Energy increased Flight of ideas Reduced concentration/Reckless behaviour and spending

Answer 19

Mildy elevated mood or irritable mood present >4 days Symptoms of mania are to a lesser extent than true mania Considerable interference with work and social life but not severe disruption Partial insight may be preserved

Answer 20

As with hypomania but to a greater extent Symptoms present for >1 week with complete disruption of work and social activities Grandiose ideas and excessive spending could lead to debts Sexual disinhibition and reduced sleep may lead to exhaustion

Answer 21

Severely elevated or suspicious mood with addition of psychotic features such as grandiose or persecutory delusions and auditory hallucinations that are mood congruent Aggression

Answer 22

Bipolar 1: Involves periods of severe mood episodes from mania to depression. Bipolar 2: Milder form of mood elevation, involving milder episodes of hypomania that alternate with periods of severe depression. Rapid cycling: More than four mood swings in a 12-month period with no intervening asymptomatic periods. Poor prognosis.

Answer 23

Mania requires 3/9 symptoms to be present: (1) Grandiosity/inflated self-esteem; (2) Decreased sleep; (3) Pressure of speech; (4) Flight of ideas; (5) Distractibility; (6) Psychomotor agitation (restlessness); (7) Reckless behaviour, e.g. spending sprees, reckless driving; (8) Loss of social inhibitions (leading to inappropriate behaviour); (9) Marked sexual energy.

Answer 24

Bipolar affective disorder requires at least two episodes in which a person’s mood and activity levels are significantly disturbed – one of which MUST be mania or hypomania. ICD-10 divides bipolar disorder into five states: (1) Currently hypomanic; (2) Currently manic; (3) Currently depressed; (4) Mixed Disorder; (5) In remission.

Answer 25

‘How would you describe your mood?’ (elevated, depressed or irritable mood). ‘Have you ever felt on top of the world?’ (elevated mood). ‘Do you feel that you have too much energy compared to those around you?’ (↑ energy). 65 ‘Are you able to concentrate on routine activities?’ (↓ concentration). ‘Do you find yourself needing less sleep but not getting tired?’ (↓ sleep and ↑ energy levels). ‘Has your interest in sex changed?’ (↑ libido). ‘Have you had any new interests or exciting ideas lately?’ (delusions/overvalued ideas). ‘Do you have any special abilities that are unique to you?’ (grandiose delusions). ‘Are you afraid that someone is trying to harm you?’ (persecutory delusions). Also ask about family history of bipolar affective disorder and substance misuse. Pressure of speech and flight of ideas can be assessed from the conversation

Answer 26

Appearance Flamboyant/unusual combination of clothing heavy makeup and jewellery. Personal neglect when condition is severe. 66 Behaviour Overfamiliar, disinhibited (flirtatious, aggressive), increased psychomotor activity, distractible, restless. Speech Loud, ↑ rate and quantity, pressure of speech, uninterruptible, puns and rhymes, neologisms. Mood Elated, euphoric, and/or irritable. Thought Optimistic, pressured thought, flight of ideas, loosening of association, circumstantiality, tangentiality, overvalued ideas, grandiose/persecutory delusions. Perception Usually no hallucinations. Mood-congruent auditory hallucinations may occur. Cognition Attention and concentration often impaired. Fully oriented. Insight Generally very poor.

Answer 27

Self-rating scales: e.g. Mood Disorder Questionnaire. Blood tests: FBC (routine), TFTs (both hyper/hypothyroidism are differentials), U&Es (baseline renal function with view to starting lithium), LFTs (baseline hepatic function with view to starting mood stabilizers), glucose, calcium (biochemical disturbances can cause mood symptoms). Urine drug test: Illicit drugs can cause manic symptoms. CT head: to rule out space-occupying lesions (can cause manic symptoms such as disinhibition).

Answer 28

Mood disorders: hypomania, mania, mixed episode, cyclothymia. Psychotic disorders: schizophrenia, schizoaffective disorder. Secondary to medical condition: hyper/hypothyroidism, Cushing’s disease, cerebral tumour (e.g. frontal lobe lesion with disinhibition), stroke. 67 Drug related: illicit drug ingestion (e.g. amphetamines, cocaine), acute drug withdrawal, side effect of corticosteroid use. Personality disorders: histrionic, emotionally unstable.

Answer 29

Full risk assessment is vital including suicidal ideation and risk to self (e.g. financial ruin from overspending). This will determine the urgency of referral to specialist mental health services. Remember to ask about driving. The DVLA has clear guidelines about driving when manic, hypomanic or severely depressed. The Mental Health Act is needed if the patient is violent or a risk to self. Hospitalization will be required if there is: (1) reckless behaviour causing risk to patient or others; (2) significant psychotic symptoms; (3) impaired judgement; (4) or psychomotor agitation.

Answer 30

First-line: offer an antipsychotic such as olanzapine, risperidone or quetiapine (haloperidol is also effective). They have a rapid onset of action compared to mood stabilizers and are therefore used in severe mania. If the first antipsychotic is not effective or poorly tolerated then a second is usually offered. Mood stabilizers namely lithium or if not suitable, valproate should be added as second-line treatment (see Mood stabilizers, Section 12.4). Benzodiazepinesmay further be required to aid sleep and reduce agitation. Rapid tranquilization may be required with haloperidol and/or lorazepam.

Answer 31

Atypical antipsychotics are effective in bipolar depression. Options include olanzapine (combined with fluoxetine), olanzapine alone or quetiapine alone. Mood stabilizer option is lamotrigine. Lithium is also effective. Antidepressants alone are usually avoided – if used, they should be used with care in BPAD, even if depression is the main feature, as they have the potential to induce mania. They should be prescribed in conjunction with the cover of antimanic medication.

Answer 32

4 weeks after an acute episode has resolved, lithium should be offered first-line to prevent relapses. If lithium is ineffective consider adding valproate. Olanzapine or quetiapine are alternative options.

Answer 33

For bipolar depression, offer a high-intensity psychological intervention (e.g. CBT). ECT is not first-line, but it can be used when antipsychotic drugs are ineffective and the patient is so severely disturbed that further medication or awaiting natural recovery is not feasible. Patients who present with an acute episode should be followed-up once a week initially and then 2–4 weekly for the first few months.

Answer 34

Biological: Mood stabilisers, benzodiazepines, antipsychotics ECT: for severe uncontrolled mania Psychological: Psychoeducation, CBT Social: Social support groupsm self- help groups, encourage calming activities

Answer 35

Lithium is the standard long-term therapy in bipolar affective disorder. It minimizes the risk of relapse and improves quality of life. Before lithium treatment is started U&Es (lithium has renal excretion), TFTs, pregnancy status and baseline ECG should be checked. Lithium has a narrow therapeutic window and so drug levels should be closely monitored and patients should be informed of potential side effects and toxicity. Side effects include: polydipsia, polyuria, fine tremor, weight gain, oedema, hypothyroidism, impaired renal function, memory problems and teratogenicity (in 1st trimester). Signs of toxicity (1.5–2.0 mmol/L): N+V, coarse tremor, ataxia, muscle weakness, apathy. Signs of severe toxicity (>2.0 mmol/L): nystagmus, dysarthria, hyperreflexia, oliguria, hypotension, convulsions and coma. Due to its side effect profile and risk of toxicity lithium is strictly regulated: Lithium levels – 12 hours following first dose, then weekly until therapeutic level (0.5–1.0 mmol/L) has been stable for 4 weeks. Once stable check every 3 months. U&Es – every 6 months; TFTs – every 12 months. A combination of lithium and sodium valproate is first-line treatment for rapid cycling.

Answer 36

AMH Individual Focused Family History = of mental illness CAMHS Young person as part of family system Family History = of mental illness and life events Developmental stage essential in process of assessment and diagnosis

Answer 37

Their Role in Assessment, Cause and Treatment of Mental Illness

Answer 38

Parents Carer Often siblings

Answer 39

High expressed emotion in Family ( or clinical environment) study in 1976 by Vaughn and Leff Overcritical or overinvolved significantly increased risk of relapse 92% non med and HighEE, 53% non med and low EE 15% medn and low EE

Answer 40

Child Family School and Community

Answer 41

Very different from adult mental health – Focus on system round young person as this is needed for change Interview the family together – to gather history - to understand relationships /environment for child Speak to young person on own – important as crucial information they will not give you with rest of family present eg self harm/ child protection Challenge – family may feel vulnerable ‘it’s not about us’ – can be expressed as anger – want you to sort child Opportunity - family provide safety network around the young person

Answer 42

Schools can give you a very good insight into how the young person is managing socially and academically You must obtain permission from the young person and family before contacting school Challenge - Schools vary in their understanding of mental illness in young people Opportunity - Most CAMHS services have link workers to schools who are very helpful Intervention Address bullying

Answer 43

Developmental Disorders Conduct Disorders Emotional Disorders Eating Disorders Psychoses

Answer 44

Triad of Poor concentration, overactivity and inattention Diagnosed over 6years old Treated with parenting advice and stimulant medication

Answer 45

Triad of difficulties in social understanding, rituals and preoccupations and language difference Multidisciplinary assessment Treatment is support in schools and to parents

Answer 46

Developmental disorders Attachment to primary caregiver is essential for: Safety Food Emotional development Physical development 4 subtypes

Answer 47

Description of young person with behavioural presentation eg tantrums, breaking things, disruptive in school , in trouble with police. > Controversial as a medical diagnosis as describes breaking social norms

Answer 48

PTSD Self Harm Depression Anxiety disorders OCD

Answer 49

Eating disorders Psychoses

Answer 50

Key symptoms same as adults Specific diagnoses less clear Delusions Ideas of reference Most common - Hallucinations Most common onset late teens but can occur in childhood Thought disorder unusual

Answer 51

DELUSION A false unshakeable belief out of keeping with cultural background HALLUCINATION A Hallucination is when you perceive something without an object Hallucination is a disturbance of any of our senses It has not been willed and cannot readily be controlled Its like a real perception located in outer objective space