Psychiatry Flashcards
Depressive disorder
Affective mood disorder characterised by persistent:
* Low mood
* Loss of pleasure (anhedonia)
* Lack of energy
Accompanied by emotional, cognitive and biological symptoms
Cause of depression
Multifactorial
Use bio-psychosocial model
* Genetic predisposition
* Early adverse life experiences
* Biological vulnerability
* Personality/temperament
* Biological alterations in brain functioning
* Traumatic or adverse life events
* Social circumstances
* Alcohol/substance misuse
* Physical illness
What is the monoamine theory
Deficiency of functioning monoamines (noradrenaline, serotonin and dopamine) causes depression
Biological risk factors for depression
- Older
- Female
- Family history
- Postnatal period
- Physical comorbidities - dementia, brain injury, hypothyroidism, congestive cardiac failure, chronic pain syndromes
- Medications - corticosteroids
Psychological risk factors for depression
- Beck’s triad - negative thoughts about self, world and future
- PMH of depression
- Other mental health diagnoses, e.g. dementia
- Alcohol and substance misuse
- Anxious, impulsive and obsessive personality
- Stressful life events
- Poor coping strategies
Social risk factors for depression
- Divorce or separation
- Lack of social support
- Childhood abuse
- Unemployment
- Poverty
- Homelessness
- Lack of parental care
- Parental alcoholism
3 core symptoms of depression
- Anhedonia
- Low mood for at least 2 weeks, present most of the day, nearly every day
- Lack of energy
Biological symptoms of depression
- Diurnal mood variation (mood worse in morning)
- Early morning wakening
- Insomnia or hypersomnia
- Loss of libido
- Psychomotor retardation (slow speech and movement) or agitation
- Weight loss and loss of appetite
Cognitive symptoms of depression
- Lack of concentration
- Feelings of worthlessness
- Excessive guilt
- Suicidal ideation
Common hallucinations in those with depression with psychosis
- Auditory - defamatory or accusatory voices, cries for help or screaming
- Olfactory - bad smells (rotting food, faeces, decomposing flesh)
- Visual - tormentors, demons, the devil, dead bodies, torture
Common delusions in those with depression with psychosis
- Hypochondriacal
- Guilt over presumed misdeeds
- Poverty
- Personal inadequacy
- Responsibility for world events (accidents, natural disasters, war), deserving of punishment, nihilistic
Symptoms of atypical depression
- Depressed mood but reactive
- Hypersomnia (sleeping > 10 hours / day, at least 3 days / week for at least 3 months)
- Hyperphagia (weight gain > 3kg in 3 months)
- Leaden paralysis (heaviness in limbs, 1 hour / day, 3 days / week for at least 3 months)
- Oversensitivity of perceived rejection
How is depression diagnosed?
Clinically
* Mild depression: 2 core symptoms + 2 other symptoms
* Moderate depression: 2 core symptoms + 3-4 other symptoms
* Severe depression: core symptoms + 4 or more other symptoms
* Severe depression with psychosis: core symptoms + 4 or more other symptoms + psychosis
Diagnostic questionnaires for depression
Patient health questionnaire 9 (PHQ9)
HADS
Beck’s depression inventory
Investigations to rule out differential diagnoses of depression
- FBC (anaemia)
- TFT (hypothyroidism)
- U&E
- LFT
- Calcium
- Glucose (DM)
- Cortisol
- B12 and folate
- Syphilis serology
- MRI/CT head
Differential diagnoses of depression
- Psychiatric - bereavement, PTSD, bipolar affective disorder, anxiety disorders, eating disorders, schizophrenia, personality disorders
- Neurological - dementia, Parkinson’s, stroke, head injury
- Endocrine - hypothyroidism, menopause, Cushing’s
- Metabolic - hypoglycaemia, hypercalcaemia
- Anaemia
- Infections - syphilis, HIV encephalopathy
- SLE
- Sleep apnoea
- Medications - antihypertensivse, corticosteroids, sedatives
- Substance misuse - alcohol, benzodiazepines, opioids
Management of mild depression
- Assess suicide risk
- Watchful waiting and reassess in 2 weeks time
- Consider antidepressants
- Psychoeducation, self-help based on CBT principles, computerised CBT and structured group physical activity programmes
When are antidepressants given for mild depression?
- Depression has lasted a long time (over 2 years)
- Past history of moderate-severe depression
- Failure of other interventions
- Depression complicated care of other physical health problems
Management of moderate/severe depression
- Assess suicide risk
- Antidepressant - SSRI, tricylic, SNRI, MAOI
- If severe: psychiatric referral +/- hospital admission
- Consider ECT
- CBT, interpersonal therapy, behavioural activation, counselling and psychodynamic therapy
- Social support groups
When is ECT indicated for depression?
Severe depression and:
* Life-threatening
* Rapid response required
* Psychotic features
* Severe psychomotor retardation or stupor
* Failure of other treatments
Psychological managements of depression
- Psychoeducation
- CBT (self-help, computerised)
- Group physical activity programmes
- Interpersonal therapy
- Behavioural activation
- Counselling
- Psychodynamic therapy
Management of depression with psychosis
- Antidepressant and antipsychotic
- ECT
Management of treatment resistant depression
- Review diagnosis
- Check their compliance
- Continue monotherapy at maximum tolerable dose
- Change antidepressant
- Augment antidepressant with an antipsychotic or mood stabiliser (lithium)
- Combine antidepressants from different classes
- ECT
- Possibility of psychosurgery
Reasons to admit someone with depression to hospital
- Serious risk of suicide
- Significant self-neglect
- Severe depressive symptoms
- Severe psychotic symptoms
- Lack or breakdown of social support
- Initiation of ECT
- Treatment-resistant depression
- A need to address comorbid conditions
When starting antidepressants
- First review within 2 weeks (or 1 week if aged 18-25 or particular concern for risk of suicide)
- Regular monitoring
Serotonin syndrome
Occurs within minutes of taking antidepressants
* Cognitive: headache, agitation, hypomania, confusion, hallucinations, coma
* Autonomic: shivering, sweating, hyperthermia, hypertension, tachycardia, diaphoresis, diarrhoea
* Somatic: myoclonus (muscle twitching), hyperreflexia, tremor, rigidity
Discontinuation syndrome
Antidepressant dose reduced too quickly
* GI symptoms
* Headache
* Anxiety
* Dizziness
* Paraesthesia
* Electric shock sensations in the head, neck and spine
* Tinnitus
* Insomnia
* Flu-like symptoms: fatigue, sweating, chills
* Hypomania
* Restlessness
Which antidepressants are most likely to cause discontinuation syndrome and why?
Venlafaxine and paroxetine
Short half-lives
6 SSRIs
- Sertraline
- Citalopram
- Escitalopram
- Paroxetine
- Fluoxetine
- Fluvoxamine
Main side effect of antidepressants
GI disturbance - nausea, diarrhoea, bloating
Why is SSRI first line for depression?
- Safer in overdose
- Less sedating and fewer antimuscarinic and cardiotoxic effects than TCAs
Which antidepressant is safesty post-MI?
Sertraline
Which is the preferred antidepressant for under 18s?
Fluoxetine
Cons of SSRIs
- Hyponatraemia
- GI bleeding (avoid in those on blood thinning medications)
2 SNRI
- Venlafaxine
- Duloxetine
4 tricylic and related antidepressants
- Lofepramide
- Clomipramine
- Imipramine hydrochloride
- Amitriptyline
Can’t pee, can’t see, can’t spit, can’t shit
Side effects of tricylic antidepressants
- Antimuscarinic: urinary retention, blurred vision, dry mouth, constipation
- CV: arrhythmias, postural hypotension, syncope
- Mania
Reasons to give amitriptyline for depression
Sedative compounds can help agitated and anxious patients
Safer in pregnancy (as are SSRIs)
Cons of tricyclic antidepressants
- Toxic in overdose
- Antimuscarinic side effects
Contraindications to tricyclic antidepressants
- CV: recent MI, arrhythmias
- Mania
- Severe liver disease
- Agranulocytosis
4 MAOIs
- Trancylcypromine
- Phenelzine
- Isocarboxazid
- Moclobemide
Interactions with MAOIs
- Tyramine-rich food (cheese, pickled herring, Bovril, marmite, red wine) > hypertensive crisis
- Drugs (insulin, opiates, SSRIs, TCAs, antiepileptics)
What reasons may mirtazapine be given for depression?
Help with insomnia and weight gain
What is cyclothymia?
Mood fluctuations over 2 years with episodes of elation and depression
What is dysthymia?
2 years of depressive symptoms that don’t meet the criteria for depressive disorder
Difference between mood and affect
Mood: sustained, experienced, emotional state over a period of time
Affect: transient flow of emotion in response to a particular stimulus
What are objective descriptions of mood?
Dysthymic (low)
Euthymic (normal)
Elated (elevated
What is an affective disorder?
Mood disorder
When a disturbance of mood is severe enough to cause impairment in ADLs
Any condition characterised by distorted, excessive or inappropraite moods or emotions for a sustained period of time
What is the difference between a primary and secondary mood disorder?
Primary: does not result from another medical or psychiatric condition
Secondary: results from aother medical or psychiatric condition
Name 2 unipolar primary mood disorders
- Depressive disorder
- Dysthymia
Name 2 bipolar mood disorders
- Bipolar affective disorder
- Cyclothymia
What physical disorders can cause a secondary mood disorder?
- Anaemia
- Hypothyroidism
- Malignancy
- Cushing’s
- Addison’s
- MS
- Parkinsonism