Psychiatry Flashcards
What are mood disorders?
Disorders of mental status and function where altered mood is the major feature
List three important mood disorders
Depression
Mania
Bipolar disorder
A useful mnemonic for the diagnosis of depression is DEADSWAMP. It outlines the major depression criteria.
Depression Energy (low)/Fatigue Anhedonia Death thoughts (self-harm or suicide) Sleep (insomnia or hypersomnia
Depression can be transient (not abnormal) or it can be the principal sign of an abnormal mood disorder. How do psychiatrists determine abnormal depression from normal variation in emotion?
Psychiatry emphasises:
- Persistence of symptoms
- Pervasiveness of symptoms
- Degree of impairment
- Presence of specific symptoms or signs ( other diagnostic features)
Symptoms of depression occur in three distinct categories. List some psychological symptoms
Change in mood: Depression, anxiety, perplexity, anhedonia
Change in thought content: guilt, hopelessness, worthlessness, delusions/hallucinations
Symptoms of depression occur in three distinct categories. List some physical symptoms
Change in bodily function: energy, sleep, appetite, libido, constipation, pain
Change in psychomotor function: agitation, retardation
Symptoms of depression occur in three distinct categories. List some social symptoms
Loss of interests Irritability Apathy Withdrawal Loss of confidence Indecisiveness Loss of concentration/memory
What is the definition of agitation?
A state of restless overactivity, aimless ineffective
What is the definition of anhedonia?
Loss of ability to derive pleasure from experience
What is the definition of apathy?
Loss of interest in own surroundings
What is the definition of anxiety?
An unpleasant emotion in which thoughts of apprehension or fear predominate
What is the definition of depression?
An unpleasant emotion in which sadness or unhappiness predominates
What is the definition of retardation?
A slowing of motor responses including speech
What is the definition of stupor?
A state of extreme retardation in which consciousness is intact.
The patient stops moving, speaking, eating and drinking.
On recovery can describe clearly events which occurred whilst
stuporous
Outline the general criteria for the diagnosis of depression
Symptoms lasting for at least two weeks
No episodes of mania/hypomania in lifetime
Not attributable to psychoactive substance or organic mental disorder
Exclusion of psychotic disorders e.g. schizophrenia
What is somatic syndrome?
A form of depression with a predominance of physical symptoms (e.g. loss of appetite, weight loss, loss of libido, anhedonia, psychomotor retardation/agitation
How is the severity of depression characterised?
General criteria with additional major and minor criteria
Mild depression requires general criteria, two major criteria and four minor ones.
Moderate requires additional two more criteria
Severe requires all criteria to be met
List some differential diagnoses of depression
Normal reaction to life event Bipolar Hypothyroidism Addison's disease Infections (infectious mononucleosis, hepatitis, HIV/AIDS) Drugs
How is depression treated?
Antidepressants - SSRIs, TCAs, MAOIs
Psychological treatments - CBT, IPT
Physical treatments - ECT, Psychosurgery, DBS
List some tools for measuring/screening for depression
SCID (Structured interview for DSM Disorders)
SCAN (Schedules for clinical assessment in neuropsychiatry)
HDRS (Hamilton Depression Rating Scale)
BDI-II (Beck Depression Inventory-II)
HADS (Hospital anxiety and depression scale)
PHQ-9 (Patient health questionaire-9)
What is mania?
A term used to describe a state of feeling, or mood, that can range from near-normal to severe and life-threatening illness
How is mania measured?
SCID (Structured interview for DSM Disorders)
SCAN (Schedules for clinical assessment in neuropsychiatry)
YMRS (Young Mania Rating Scale)
How is mania treated?
Antipsychotics (olanzapine, risperidone, quetipine)
Mood stabilisers (sodium valproate, lamotrigine, carbamazepine)
Lithium
ECT
What is bipolar disorder?
A disorder consisting of repeated episodes of depression and mania/hypomania
How long does the typical major depression episode last for?
4-6 months
What percentage of major depressive patients recover at 26 weeks?
54%
What percentage of major depression patients don’t recover?
12%
What percentage of major depression patients go on to have another episode?
> 80%
What percentage of major depressive patients die y suicide?
15%
Outline cognitive behavioural therapy
Short-term, problem-based and goal orientated therapy which looks at the relationship between thoughts and feelings and how these affect behaviour.
Outline behavioural activation therapy
Focuses on avoided activities. Patients are taught to analyse unintended consequences of their way of responding.
Outline interpersonal therapy
Useful for the treatment of depression and anxiety
Focuses on an area(s) where the depressive symptoms link to an interpersonal event(s) - works to reduce symptomology
Outline motivational interviewing
Promotes behaviour change in a wide range of healthcare settings
Used where behaviour change is being considered, when a patient may be unmotivated or ambivalent to change
Outline the five stages of change
- Pre-contemplation - no desire to change
- Contemplation - thinking about change
- Planning/determination - options for change/building confidence
- Action - implement strategies
- Maintenance - coping strategies, address weak points etc.
List some indications for the prescription of antidepressants
(5)
Unipolar/bipolar depression Organic mood disorders Schizoaffective disorders Anxiety disorders (OCD, panic, social phobia) Premenstrual dysphoric disorder
How long does it take for antidepressants to improve symptoms?
Delay of two to four weeks after the therapeutic dose is achieved before symptoms improve
What is the indicated course of antidepressants after a first depressive episodes?
6 months to a year
What is the indicated course of antidepressants after a second depressive episodes?
2 years
What is the indicated course of antidepressants after a third depressive episodes?
Lifelong
List the classes of antidepressants
Tricyclics (TCAs)
Monoamine oxidase inhibitors (MAOIs)
Selective Serotonin Reuptake Inhibitor (SSRIs)
Serotonin/Norepinephrine Reuptake Inhibitors (SNRIs)
Novel agents
Why are tricyclic antidepressants not first line?
Unacceptable side effect profile (long QT) and can overdose lethally with a one week supply
What are the two different types of tricyclic antidepressant?
Tertiary and secondary TCAs
What is the action of monoamine oxidase inhibitors?
Bind irreversibly to monoamine oxidase. Thereby preventing the activation of amines such as norepinephrine and dopamine.
What are MAOIs particularly useful for?
Treating resistant depression
List some side effects of MAOIs
Orthostatic hypotension Weight gain Dry mouth Sexual dysfunction Sleep disturbance
What can occur if MAOIs are taken concurrently with tyramine rich foods/sympathomimetics
Cheese reaction - a hypertensive crisis
What is serotonin syndrome?
A reaction that can occur when taking multiple serotinergic drugs (e.g. MAOIs) causing abdominal pain, diarrhoea, tachycardia and hypertension.
Can ultimately lead to CVS shock, hyperpyrexia and death
What is the action of SSRIs?
Block the presynaptic serotonin reuptake
List some side effects of SSRIs
GI upset Sexual dysfunction Anxiety Restlessness Nervousness Insomnia
What is it important to warn a patient of before they start SSRIs?
Activation syndrome (acute increase in serotonin)
Lasts 2-10 days
Causes nausea, increased anxiety, panic and agitation
What is the risk when stopping SSRIs?
Discontinuation Syndrome - causes agitation, nausea, disequilibrium and dysphoria
More common in shorter half life drugs
List some examples of SSRIs
Fluoxetine
Citalopram/escitalopram
Sertraline
Fluvoxamine
What are the pros and cons of choosing fluoxetine in the treatment of depression?
Pro - long half-life therefore low risk of discontinuation syndrome
Con - contraindicated in liver disease due to active metabolites and P450 interactions
What are the pros and cons of choosing citalopram in the treatment of depression?
Pro - low P450 inhibition, therefore, fewer drug interactions
Con - QT prolongation and both sedating/GI side effects
What are the pros and cons of choosing sertraline in the treatment of depression?
Pro - short half-life
Con - commonly causes GI upset
What are the pros and cons of choosing escitalopram in the treatment of depression?
Pro - more effective than citalopram in acute response and remission induction
Con - QT prolongation
What are the pros and cons of choosing fluvoxamine in the treatment of depression?
Pro - shortest half-life (can be pro or con)
Con - GI distress, headaches, sedating
What is the action of SNRIs?
Inhibit both serotonin and noradrenaline reuptake (like TCAs) but dont have any anti-histamine, androgenic and cholinergic effects
Give two examples of SNRIs
Venlafaxine
Duloxetine
List some examples of novel antidepressant agents
Mirtazapine
Buproprion
What are the current indications for novel antidepressant agents?
Good for augmentation adjunct to SSRI/SNRI therapy
Treatment-resistant depression is common. What therapies are indicated in this case?
Combination of SSRI/SNRI with mirtazapine
Adjunctive treatment with lithium
Adjunctive treatment with atypical antipsychotic e.g. olanzapine
ECT (Electro-convulsive therapy)
What classes of drugs are categorised as mood stabilisers?
Lithium
Anti-convulsants
Anti-psychotics
Anxiolytics
List some indications for mood stabilisers
Bipolar
Cyclothymia
Schizoaffective disorders
What is the main indication for the use of lithium?
Effective in long term prophylaxis of both mania and depressive episodes in over 70% of cases
What factors predict a positive response to lithium?
Prior long-term response or family member with good response
Classic pure mania
Mania followed by depression
What baseline investigations need to be done before commencing lithium therapy
Baseline U/Es and TSH
Pregnancy check (association with Ebstein’s anomaly)
What monitoring is required for patients on long term lithium therapy?
Steady-state achieved after 5 days
TSH checked at three months
Creatinine levels at six months
Blood level between 0.6-1.2mmol\L
List some common side effects of lithium
Common GI upset Thyroid abnormalities Interstitial renal fibrosis (polyuria/polydipsia) Reduces seizure threshold Cognitive slowing
Lithium toxicity can be either mild, moderate or severe.
Outline the symptoms and signs of each
Mild - vomiting, diarrhoea, ataxia, nystagmus
Moderate - clonic limb movements, delirium
Severe - convulsions, oliguria and renal failure
List some commonly used anticonvulsants
Lamotrigine
Valproic acid
Carbemazapine
What are the indications of the use of valproic acid?
Effective in mania prophylaxis (not for depression) and has better tolerance than lithium
What investigations are required before valproic acid is commenced?
LFTs and pregnancy test
What is the side effect profile of valproic acid?
Thrombocytopenia Sedation Tremor Increased risk of NTD Alopecia
What are the indications of carbamazepine?
First-line agent for acute mania and mania prophylaxis
What is the action of typical anti-psychotics?
D2 dopamine receptor antagonist
List some typical antipsychotics (list both high potency and low potency types)
High potency - haloperidol, fluphenazine, pimozide
Low potency - chlorpromazine, thioridazine
What is the difference between high and low potency typical antipsychotics
High potency typical antipsychotics bind to D2 with high affinity. Low potency have low affinity
Outline the action of atypical antipsychotics
Serotonin-dopamine 2 antagonists
Give examples of commonly used atypical antipsychotics
Risperidone
Clozapine
Aripiprazole
Olanzapine
What are the three main adverse effects of antipsychoitcs?
Tardive dyskinesia
Neuroleptic malignant syndrome
Extrapyramidal side effects
Outline the presentation of tardive dyskinesia
Involuntary muscle movements
Outline the presentation of neuroleptic malignant syndrome
Muscle rigidity, fever, altered mental status, elevated white cell count
What are three examples of extrapyramidal side effects?
Acute dystonia
Parkinsons syndrome
Akathisia
What agents may be prescribed to treat extrapyramidal side effects?
Amantadine (dopamine facilitators)
Propranolol (beta-blocker)
What are anxiolytics and what are they used to treat?
Drugs used, often in conjunction with SSRIs/SNRIs to treat many diagnoses including panic disorder, generalised anxiety, substance-related disorders and their withdrawal etc.
Give two examples of anxiolytics
Buspirone
Benzodiazepines
