(PM3B) Depression + Bipolar Disorder Flashcards
In psychiatric terms, what is ‘affect’?
An objective description of a person’s emotional behaviour
In psychiatric terms, what is ‘mood’?
An individual’s prevailing subjective emotional state
What are some examples of affective disorders?
(1) Unipolar depression/ major depressive disorder
(2) Bipolar disorder
(3) Dysthymia (subthreshold depression)
(4) Cyclothymia
What is classification of affective disorders usually based on?
(1) Severity
(2) Presence/ absence of physical features (physical/ somatic)
(3) Presence/ absence of psychotic features
(4) Course (duration + recurrence)
(5) Presence/ absence of intervening manic phases
What is the system in the UK for classification of mood disorders?
(1) ICD-10
OR
(2) DSM-V
What is depression?
(1) Depressed mood
(2) Loss of pleasure in activities
(3) Definition relies on what a normal response to a situation should be (socially + culturally)
What percentage of the population have major depression?
~5%
What percentage of suicides are males?
~75%
What main groups of factors may give rise to depression?
(1) Brain regional changes
(2) Genes + environment
(3) Medical conditions + medications
(4) Biochemical
What effect can genes and environment have on causation of depression?
(1) Family history is common
(2) Genetic/ environmental factors
(3) Changes in temperament/ personality
What effect can biochemistry have on causation of depression?
(1) Reserpine (antihypertensive) reported to cause depression
(2) No reliable metabolic/ biochemical markers for depression
How can depression be diagnosed?
(1) ICD-10 – must exhibit ≥2 key symptoms
(2) DSM-V – must exhibit ≥1 key symptoms
Key symptoms are
- Low mood
- Loss of interest/ pleasure
- Loss of energy (ICD-10 only)
What is the NICE guideline preference of depression diagnosis system?
DSM-V
Has more evidence
What scales are often used to formalise a potential diagnosis of depression?
(1) Hamilton Depression Scale Rating
(2) Beck Depression Inventory
What are two vitally important questions for a healthcare professional to ask a patient potentially suffering from depression?
(1) During the last month, have you often been bothered by feeling down, depressed, or hopeless?
(2) During the last month, have you often been bothered by having little interest/ pleasure in doing things?
What are some examples of important depression questionnaires?
(1) HADS
(2) BDI-II
(3) PHQ-9
What are the key/ core symptoms for DSM-V?
(1) Depressed mood (self-report or other’s observation
(2) Loss of interest or pleasure
What are they key/ core symptoms for ICD-10?
(1) Depressed mood
(2) Loss of interest
(3) Reduced energy
How many symptoms present does DSM-V require to diagnose depression?
5 out of 9 symptoms present
1 of 2 KEY symptoms must be present
How many symptoms present does ICD-10 require to diagnose depression?
4 out of 10 symptoms
2 of 3 KEY symptoms must be present
What are the 10 symptoms used to categorise depression in ICD-10?
(1) Depressed mood
(2) Loss of interest
(3) Reduced energy
(4) Loss of confidence/ self-esteem
(5) Inappropriate guilt/ self-reproach
(6) Recurrent thoughts of death/ suicide
(7) Diminished ability to think/ concentrate (indecisiveness)
(8) Change in psychomotor activity with agitation/ retardation
(9) Sleep disturbance
(10) Change in appetite + weight change
What are the 9 symptoms used to categorise depression in DSM-V?
(1) Depressed mood (self-report or other’s observation
(2) Loss of interest or pleasure
(3) Fatigue/ loss of energy
(4) Worthlessness/ inappropriate or excessive guilt
(5) Recurrent thoughts of death/ suicidal thoughts/ suicide attempts
(6) Diminished ability to think/ concentrate (indecisiveness)
(7) Psychomotor agitation/ retardation
(8) Insomnia/ hypersomnia
(9) Significant appetite/ weight loss
How is sub-threshold depression diagnosed using the DSM-V or ICD-10 scale?
(1) DSM-V: 2-5 symptoms (inc. 1 core)
(2) ICD-10: Cannot be diagnosed
How is mild depression diagnosed using the DSM-V or ICD-10 scale?
(1) DSM-V: >5 symptoms
(2) ICD-10: 4 symptoms
How is moderate depression diagnosed using the DSM-V or ICD-10 scale?
(1) DSM-V: Between mild + severe
(2) ICD-10: 5-6 symptoms
How is severe depression diagnosed using the DSM-V or ICD-10 scale?
(1) DSM-V: Several in excess of 5
(2) 7+ symptoms
What are the treatment aims for treatment of depression?
(1) Prevent suicide
(2) Identification of possible primary causes
(3) Provide symptomatic therapy
(4) Investigate adverse social, domestic, financial circumstances + provide support
(5) Initiate long-term therapy to prevent relapse/ recurrence
What are the 3 principle divisions of treatment for depression?
(1) Pharmacological
(2) Psychological
(3) Psychosocial
What is the stepped care model?
Helps with diagnosis + management of depression
Begins at Step 1 and increases with severity
(1) Assessment, support, monitoring, psychoeducation + referral for further assessment
(2) For patients diagnosed with persistent sub-threshold depressive symptoms – low intensity psychosocial + psychological interventions + medications + further assessment + interventions
(3) For persistent sub-threshold/ mild-moderate depression who have not responded to Step 2 interventions OR moderate-severe depression – medication + high-intensity psychological interventions + combined treatments + collaborative care
(4) For severe + complex depression + risk to save life (severe self-neglect) – medication + high-intensity psychological interventions + combined treatments + multi-professional and inpatient care + crisis service
What is low-intensity psychosocial care?
Typically for persistent sub-threshold or mild to moderate depression
(1) Guided self-help
(2) Group physical activity programmes
What is group CBT?
Alternative to low-intensity psychosocial
Used when low-intensity psychosocial interventions have been refused OR are not suitable
What is high-intensity psychological care?
For persistent sub-threshold/ mild-moderate depression
(1) Where low-intensity psychosocial has failed
OR
(2) For use in moderate-severe depression (in combination with antidepressant)
What are some examples of high-intensity psychological care?
(1) Individual cognitive behavioural therapy – CBT
(2) Interpersonal therapy
(3) Behavioural couples therapy
Name 4 types of antidepressants.
(1) Monoamine oxidase inhibitors (MAOIs)
(2) Inhibitors of monoamine uptake
- Selective Serotonin
Reuptake Inhibitors (SSRIs)
- Tricyclics (TCAs)
(3) Modulators of serotonin (5HT) receptors and other NT receptors
(4) St John’s Wort
What is the typical first line medication given for treatment of depression?
Selective serotonin reuptake inhibitors (SSRIs)
What are SNRIs?
Serotonin and noradrenaline reuptake inhibitors
What are NaSSas?
Noradrenergic and specific serotonergic antidepressant
What are SARIs?
Serotonin antagonist and reuptake inhibitor
What are SMSs?
Serotonin modulator and stimulator
e.g. vortioxetine – inhibits reuptake serotonin (SERT) + modulates many 5HT receptors
What are NRIs?
Noradenaline reuptake inhibitor
e.g. reboxetine
Give some examples of SSRIs.
(1) Sertraline
(2) Fluoxetine
(3) Paroxetine
(4) Citalopram
(5) Escitalopram
Why are SSRIs the preferred first line medication for the treatment of depression?
(1) Fewer side effects
(2) No anticholinergic
(3) Lack of toxicity in overdose
(4) Less sedating than TCAs
What is venlafaxine?
SNRI
Serotonin and noradrenaline reuptake inhibitor
What is mirtazapine?
Fewer interactions
Fewer adverse events
What is trazodone?
Only if sedation required
What is the treatment course for sertraline to treat depression?
50-200 mg per day
What is the treatment course for citalopram to treat depression?
20-40 mg per day
What is the treatment course for escitalopram to treat depression?
10-20 mg per day
What is the treatment course for fluoxetine to treat major depression?
20-60 mg per day
What is the treatment course for paroxetine to treat major depression?
20-50 mg per day
What is the treatment course for venlafaxine to treat major depression?
75-375 mg per day
What is the treatment course for mirtazapine to treat major depression?
15-45 mg per day
What are RIMAs?
Subclass of MAOI
Reversible inhibitor MAO-A
Safer + fewer side effects than other MAOIs
e.g. moclobemide
What is electroconvulsive therapy?
Associated with neuronal death – specific mechanism unknown
For severe psychotic depression + bipolar disorder with psychotic symptoms
What is the important information for a patient when initiating therapy for depression?
(1) Full antidepressant effect takes time (e.g. 2-4 weeks)
(2) Important to take as prescribed and continue after remission (e.g. 6 months+)
(3) Possible side-effects
(4) Potential interactions
(5) Antidepressants are not addictive
(6) Risk and nature of discontinuation symptoms with all antidepressants
What is the follow-up following initiation of therapy for depression?
Typically see patient after 2 weeks of initiation
Every 2-4 weeks after for 3 months (may then extend)
What is mania?
Severe + recurrent psychotic affective disorder
(1) Abnormally elevated mood, unwarranted optimism, exuberance, over-confidence, inflated self-esteem, hyperactivity, excessive libido and little sleep
(2) Increased drive and extrovert behaviour but often socially tactless
(3) Makes compliance problematic
(4) Attacks last ≥1 week
What lasts longer, manic or depressive episodes?
Usually depressive
What are the classifications of bipolar?
(1) Bipolar I disorder – more severe mania
2) Bipolar II disorder – less severe mania (hypomania
What are the aims of treatment of bipolar disorder?
(1) Control manic and depressive attacks
(2) Minimise recurrence and stabilise mood
How are manic attacks normally controlled?
Sedative anti-psychotics
What is the long-term treatment for prophylaxis of bipolar disorder?
(1) Lithium
(2) Anticonvulsants – e.g. sodium valproate
(3) Other anticonvulsants – lamotrigine/ carbemazepine
(4) Atypical antipsychotics – olanzapine or quetiapine
(5) Benzodiazepines may be used short-term
Antidepressants are not normally used
Why does lithium in the treatment of bipolar disorder require very careful monitoring?
Very narrow therapeutic window
Why are antipsychotics given in the treatment of bipolar disorder and mania?
Can give control of mania + some help to prevent relapse
Mood stabiliser
What are some examples of antipsychotics given in the treatment of bipolar disorder and mania?
(1) Olanzapine
(2) Quetiapine
(3) Haloperidol
(4) Risperidone
What are some antiepileptics and anticonvulsants given in the treatment of bipolar disorder and mania?
(1) Valproate – possible effects at voltage-gated sodium channels + GABA signalling
(2) Carbamazepine – patients unresponsive to lithium
(3) Lamotrigine – prophylaxis of bipolar disorder + depression (NOT mania)
