Psych Written - Mood & Anxiety Flashcards
Specific antidepressant indications
Biological Sx e.g., lack of appetite, insomnia - Mirtazapine
Child/adolescent - Fluoxetine
IHD or other co-morbidity - Sertraline
Severe episode - paroxetine
Features of Severe psychotic depression
Delusions:
Nihilistic delusions - excessive guilty, punishment
Coutard syndrome - belief they are dead/ rotting
Hallucinations:
auditory - (2nd version usually) cries or screams for help, derogatory voices
visual - demons, ghosts, punishers
olfactory - faeces, rotting flesh
Catatonia & functional incapacity
Core depression sx
Low mood
Anhedonia
Anergia
Patient Health Questionnaire (PHQ) - 9 Scoring
Minimal 1-4 Mild 5-9 Moderate 10-14 Moderately severe 15-19 Severe 20-27
Hospital Anxiety & Depression scale (HADS) Scoring
Normal 0-7
Mild 8-10
Moderate 11-14
Severe 15-21
Criteria for admission or urgent referral to HTT (in depression)
Self-neglect Active suicidal ideas or plans Risk to others Poor social support Psychotic Sx Severe agitation Lack of insight Treatment resistant depression
Antidepressant medication approach
1st = SSRI
- e.g. sertraline, citalopram
- 2x trials before moving to next step
2nd = taper down SSRI + switch to SNRI
- e.g. venlafaxine, duloxetine
- NOTE: will not see effect until max dose reached
3rd = augment Tx
- antipsychotic e.g. quetiapine
- Lithium
- alternative antidepressant e.g. mirtazapine
ICD-10 Criteria for Bipolar Affective Disorder
2 or more episodes
- 1 must be manic associated (manic / hypomanic), the other can be depressive
- mania must last ~ 4 months
- depression lasts ~6 months
- complete recovery between episodes
Bipolar types
Type 1 = manic interspersed with depressive
Type 2 = recurrent depressive episodes, less prominent hypomanic episodes
Rapid cycling = 4+ episodes per year
Mania - definition
Distinct period of abnormally & persistently elevated, expansive or irritable mood
with 3 characteristics of mania
for at least 7 days.
Features of mania (MMSE)
Appearance & behaviour:
- excitable, easily distracted
- inappropriate clothing - flashy/extravagant
- catatonic stupor (Extreme cases)
Speech:
- pressures
- mutism (extreme cases, unusual)
Mood (& affect)
- increased self esteem
- labile mood
- irritable
- loss of inhibition
Thought:
- flight of ideas
- racing thoughts
Perception
- Schneider’s 1st rank Sx
- grandiose delusions
- paranoia
Insight: minimal - reckless behaviour
Cognition: no change
Risk
- suicidal ideation
- disinhibition –> sexual, financial exploitation from others
- aggression to others
Hypomania - definition
> 3 characteristic sx of mania
lasting 4+ days
Does NOT impair occupational/social functioning
No psychotic sx
Ix to consider in suspected BPAD
Collateral Hx!
Young Mania rating scale
Physical exam
Urine drug screen
Bloods - FBC, TSH, U&E, LFT
Management of first presentation ?BPAD
Refer to secondary care - cannot diagnose in GP!
- mania or severe depression –> urgent to CMHT / HTT / admission to ward
- hypomania –> routine referral to CMHT
Acute Mania Biological Management
Taper off & stop any antidepressant e.g. SSRI
Consider sedation e.g. clonazepam
If no existing Tx = stabilise
- 1st line = antipsychotic e.g. olanzapine
- 2nd line = switch antipsychotic e.g. haloperidol, quetiapine, risperidone
- 3rd line = + lithium or sodium valproate
Already on Tx = optimise
- check compliance
- check lithium levels
- add atypical antipsychotic
+ ECT if unresponsive to Tx
Acute Depression (in BPAD) Biological Management
Not already on Tx:
- 1st line = fluoxetine + olanzapine OR quetiapine only
- 2nd line = olanzapine or lamotrigine only
On lithium:
- check plasma lithium + increase dose if needed
- if at max lithium level = Tx as above
On sodium valproate:
- check levels + increase dose if needed
- max tolerated dose / top of therapeutic range = Tx as above
+ R/v within 4 weeks of resolution
Long term biological management of BPAD
1st line = lithium
- monitor for toxicity
- can take up to 5 weeks to titrate
Not effective = + Sodium valproate
Not tolerated = switch to sodium valproate ONLY or Olanzapine ONLY
Co-existing depression = antidepressant only if mood stabiliser also given
- 1st line = fluoxetine + olanzapine
- 2nd line = quetiapine only
- 3rd line = olanzapine ONLY or lamotrigine ONLY
Psychological management of BPAD
Offered after resolution of acute episode
Mainly CBT
- identify relapse indicators
- establish relapse prevention strategies
Psychodynamic psychotherapy if mood stable
DSM-V Definition of Generalised Anxiety Disorder
Excessive & uncontrolled worry
present for most days over 6 months
NOT triggered by specific stimulus (and disproportionate to any inherent risk)
that causes distress or imppairment
And is NOT due to other mental health disorder substance abuse or medical condition
Presentation of GAD
At least 3 of:
- restlessness / nervousness
- irritability
- muscle tension
- poor concentration
- sleep disturbance & fatigue
- coping mechanisms e.g. EtOH, substance
GAD-7 Scoring
Mild - 5
Moderate = 10
Severe = 15
Biological management of GAD
Education & Psych considered earlier in Tx.
1st line = SSRI
- NICE - sertraline
- licensed - paroxetine
2nd line = switch SSRI after 8 weeks
3rd line = venlafaxine extended release formulation
Adjuncts:
- pregabalin
- quetiapine (unclicensed)
- propanolol
Guidance for giving Benzodiazpines in GAD
Avoid if possible
Better for short term situations e.g. flight, blood test
Max duration of tx = 2-4 weeks (psych and physiological dependence)
Lorazepam = worst withdrawal risk as shortest half life
Agoraphobia definition
Cluster of phobias relating to being in situations where escape might be difficult or that help won’t be available if things go wrong
Often open or confined spaces
Central fear = inability to escape to safe place –> urge to return home to safety
