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