Psychiatry Flashcards
What is Depression?
Can be a symptom - form of sadness, not just absence of happiness.
Syndrome - constellation of symptoms and signs.
Recurrent illness - recurrent depressive disorder.
When is depression abnormal?
Persistence of symptoms.
Pervasiveness of symptoms.
Degree of impairment.
Presence of specific symptoms or signs.
What are the 3 main categories of symptoms?
Psychological - change in mood, change in thought content.
Physical - Change in bodily function.
Social - Loss of interest, withdrawal, Irritability.
When can depression be diagnosed?
Last at least 2 weeks.
No hypomanic or manic episodes in lifetime.
Not attributable to psychoactive substance use or organic mental disorder.
Need to exclude other psychotic illnesses first like schizophrenia.
Depression - somatic syndrome diagnosis
Lack of emotional reactions to events or activities that would normally produce an emotional response.
Waking 2 hours before normal time.
Depression worse in the morning.
Objective evidence of psychomotor agitation.
Loss of appetite, weight loss.
What would be diagnostic of 1.mild, 2.moderate and 3.severe depression
At least two of:
1,2,3: Depressed mood that is abnormal for most of the day almost everyday for 2 weeks.
Loss of interest or pleasure.
Decreased energy or increased fatigability.
- At least 2 additional.
- At least 4 additional.
- At least 6 additional.
e. g. loss of confidence, suicidal behaviour, agitation, sleep disturbance.
What is post-natal depression?
Increased risk of psychiatric admission in the 30 days following childbirth.
75% of women experience “blues” within 2 weeks.
What are some of the differential diagnosis of depression?
Normal reaction to life event. SAD Dysthymia Bipolar Stroke, tumour, dementia Hypothyroidism, Addison's Infections Drugs
Treatment for Depression
Antidepressants:
- Selective Serotonin Reuptake Inhibitors.
- Tricyclic antidepressants (TCAs)
- Monamine Oxidase Inhibitors
Psychological Treatments
- CBT, IPT, Individual dynamic psychotherapy, family therapy.
Physical treatments
- ECT, Psychosurgery, DBS.
What measurement tools can be used for depression?
SCID SCAN HDRS BDI-II HADS PHQ-9
What is Mania?
State of feeling, or mood, that can range from near-normal experience to severe, life-threatening illness.
Rarely a symptom - associated with grandiose ideas, disinhibition, mental effects of stimulant drugs (AMPH, cocaine)
Pathological, inappropriate elevated mood.
How is mania classified
Hypomania - Lesser degree, mild elevation of mood, increased energy, Increased sociability, concentration reduced.
Mania - 1 week severe enough t disrupt ordinary work and activities, disinhibition, alteration of senses.
What are some mania differentials?
Mixed affective state
Schizophernia
ADHD
Drugs and Alcohol
Stroke, MS, Tumour, epilepsy, AIDS, Hyperthyroid.
How are symptoms measured?
SCID
SCAN
Young mania rating scale.
How is mania treated?
Antipsychotics - Olazapine, Risperidone.
Mood stabilisers - sodium valporate.
Lithium
ECT
What is Bipolar?
Consists of repeated (2+) episodes of depression and mania or hypomania.
(ICD-10)
Onset about 21.
What are the outcomes of major depression?
Typical episode lasts 4-6months 54% recover at 26 weeks 12% fail to recover 15% die by suicide 80% have further episodes. 2nd commonest cause of morbidity globally.
What are the outcomes of bipolar / mania?
Typical manic episode lasts 1-3 months. 60% recovered at 10 weeks 5% fail to recover 90% haver further episodes 1/3 have poor outcome 1/3 have good outcome 10% die by suicide.
What are the 3 most common mental health disorders?
Affective anxiety.
Substance misuse.
Reaction of psychological stress. (PTSD)
What are some of the affective / anxiety disorders?
Major Depressive Disorder (MDD)
Generalised Anxiety Disorder (GAD)
Panic disorder and phobic anxiety disorders
Obsessive-compulsive disorder.
What is Cognitive Behavioural therapy and what is it used for?
How our thoughts are related to our feelings and behaviour.
Particularly good for depression, anxiety, phobias, OCD, PTSD.
Short term, problem focussed, goal oriented, individual or self-help book.
What happens during CBT?
Identify thoughts, feelings and behaviours.
Assess whether thoughts are unrealistic / unhelpful.
Identify what can change.
The client then engages in the task which challenges the unrealistic or unhelpful thoughts.
What does Behavioural Activation do?
Focus on avoided activities.
- guide for activity scheduling, functional analysis of cognitive processes that involve avoidance.
Focus on what predicts and maintains an unhelpful response by various reinforces.
Client taught to analyse unintended consequences of their way of responding.
What are the different types of avoidance that can be seen in depression?
Social withdrawal - avoiding friends.
Non-social avoidance - excessive time in bed.
Cognitive avoidance - not making decisions or being serious about work.
Avoidance by distraction - comfort-eating, gambling.
Emotional avoidance - Use of alcohol or other substances.
What are the benefits of behavioural activation?
Collaborative / empathic / non judgmental.
Structured agenda- review progress.
Small changes - build to long term goals.
What is interpersonal Psychotherapy?
Treatment for depression / anxiety.
Time limited (12-16 weeks)
Focused on the present.
What events can lead to depression?
Disturbing change in or contingent with significant I-P event:
Complicated bereavement.
Dispute
Role transition
Interpersonal deficit
How does IT work in practice?
Identify the interpersonal context.
Focus on a specific area - depressive symptoms linked to interpersonal events (weekly)
Reduce depressive symptoms
Improve interpersonal functioning.
What are the 1. pros and 2. cons to IT?
- A grade evidence for treating depression.
No formal homework
Client can continue to practice skills beyond the sessions ending. - Requires a degree of ability to reflect - may be difficult for some.
Poor social networks - limited interpersonal support.
What do motivational interviews aim to do?
Express empathy - understand person’s predicament.
Avoid argument.
Support self - efficacy - patient sets agenda, generates what they might consider changing.
What are the stages of change?
Pre - contemplation Contemplation Planning Action Maintenance. Prochaska and DiClemente (1982)
What are the stages of alcohol intervention?
- Raise issue
- Screen and feedback.
- Listen for readiness to change.
- Choose a suitable approach.
Where can extra help on mental health syndromes be found?
NICE
SIGN
THE MATRIX
What creates a stigma?
Attitudes develop early in childhood.
Stable over many years.
Influenced by personal experience.
Older males, less education.
Tolerance depends on closeness of interaction.
Little change in attitude over last 50 years.
Why is there stigma around mental illness?
Media reports.
Portrayal of uncontrollable killers.
Mental illness in movies.
What is being done to combat such stigmas?
Individuals. Good medication management. CBT approach. Consider own attitudes and awareness. "Us and Them" attitude Influence of celebrities
What are some of the issues around mental health diseases?
Diagnosis. Social control. Treatment without consent. Rising rates of antidepressant prescription. Security. Detention.
What are the 1. pros and 2. cons of using peoples stories?
1. Shows real treatment Real effects and side effects. ECT effective when used. Issue debated openly. Cutting edge research described.
- Dramatic music and run down asylum. (exaggerated)
Balance
Talks about loss of basic skills
What is important to consider when prescribing drugs for mental illness?
Establish diagnosis and identify target symptom.
Select agent and lowest effective dose.
Remember delayed response and drug-drug interactions.
Always strive for the simplest regime.
When would the use of antidepressants be indicated?
Unipolar and bipolar depression. Organic mood disorders, schizoaffective disorder, anxiety, OCD, panic, social phobia, PTSD.
What are the classifications of antidepressants?
Tricyclics (TCAs)
Monoamine Oxidase Inhibitors (MAOIs)
Selective Serotonin Reuptake Inhibitors (SSRIs)
Serotonin/noradrenaline reuptake inhibitors (SNRIs)
Novel antidepressants.
Delay of 3-6 weeks before symptoms improve.
What are the worries about TCAs?
e.g. amitriptyline
Unacceptable side effects.
Lethal in overdose (even a one week supply)
Can cause QT lengthening.
What are side effects of Secondary and Tertiary TCAs?
Antihistaminic - sedation and weight gain.
Anticholinergic (dry mouth, dry eyes, constipation, memory deficits.
Antiadrenergic (sexual dysfunction and orthostatic hypotension)
How do MAOIs work?
Bind irreversibly to monoamine oxidase and thereby prevent inactivation of amines such as serotonin leading to increased synaptic levels.
What are the side effects of MAOIs?
Orthostatic hypotension, weight gain, dry mouth, sedation, sexual dysfunction, sleep disturbance.
Can develop serotonin syndrome if take MAOI with meds that increase serotonin. This causes abdo pain, diarrhoea, sweats, tachycardia, irritability.
How can Serotonin syndrome be avoided?
Wait 2 weeks before switching from an SSRI to an MAOI.
Exception is fluoxetine as 5 weeks needed due to long half life.
How do SSRIs work?
Block presynaptic serotonin reuptake.
What are the side effects of SSRIs?
GI upset, sexual dysfunction, anxiety, restlessness, nervousness, insomnia, fatigue, dizziness, sedation.
Can develop a discontinuation syndrome with agitation, nausea,dysphoria.
Pros of paroxetine
Short half life - no active metabolite.
Sedating properties - good iniital relief from anxiety and insomnia.
Cons of Paroxetine
Sedating, weight gain, likely to cause discontinuation syndrome.
Pros of sertraline
Very weak P450 interactions.
Short half life.
Less sedating compared to Paroxetine.
Cons of Sertraline
Max absorption requires a full stomach.
Increased number of GI adverse drug reactions.
Pros of Fluoxetine
Long half-life so decreased chance of discontinuation. Provide increased energy.
Can use to taper someone off SSRI to prevent Discontinuation.
Cons of Fluoxetine
Active metabolite may build up.
Initial activation may increase anxiety and insomnia.
More likely to induce mania than other SSRIs.
- Pros and 2. Cons of Citalopram?
- Fewer drug - drug interactions.
2. Dose-dependant QT interval prolongation with doses of 10-30mg. Can be sedating, GI side effects.
- Pros and 2. Cons of escitalopram
- More effective than citalopram in acute response and remission, Fewer drug-drug interactions.
- Dose dependant - QT prolongation. Nausea, headache.
Fluvoxamine cons
Shortest half life
GI distress, headaches, sedation, weakness.
Strong inhibitor of CYP1A.
What do SNRIs do?
Inhibit both serotonin and noradrenergic reuptake.
Pros of Venlafaxine
Minimal drug interactions.
Fast renal clearance.
Cons of Venlafaxine
Can cause increase 10-15 in diastolic BP. Nausea. Bad discontinuation syndrome. QT prolongation. Sexual side effect.
Cons of Duloxetine
Cannot break capsule, active ingredient not stable within the stomach.
Pros of Novel antidepressants - Mirtazapine
May provide goof augmentation strategy to SSRIs.
Cons of Mirtaapine
Increase serum cholesterol by 20%.
Very sedating at lower doses.
Weight gain.
Pros of Buproprion
No weight gain, sexual side effects, sedation or cardiac interactions.
Low induction of mania.
Cons of Buproprion
May increase seizure risk at high doses, avoid in patient with traumatic brain injury, anorexia or bulimia.
Doesn’t treat anxiety, can actually cause it.
What are some of the different mood stabilisers?
Lithium
Anticonvulsants
Antipsychotics
What is Dysthymia?
Below threshold depression, low mood with dips of further low mood.
What does Anhedonia mean?
No longer finds pleasure or interest from events that would normally cause pleasure or interest.
What are the pros of lithium?
Only medication to reduce suicide rate.
Effective in long-term prophylaxis of mania and depressive episodes.
What should be done before starting someone on Lithium?
Get baseline U&E and TSH. In women check pregnancy test.
Monitor - check after 5 days. Once stable check 3 months and then 6 months.
Side effects of Lithium?
GI distress. Thyroid abnormalities. Polyuria/polydypsia. Hair loss, acne. Intention tremor.
What are the different toxicity levels of lithium?
Mild - levels 1.5-2.0 - vomiting, diarrhoea, ataxia, dizziness, slurred speech.
Moderate - 2.0-2.5 - nausea, blurred vision, clonic limb movements, convulsions, delirium.
Severe - >2.5 - generalised convulsions, oliguria and renal failure.
- When is Valproic acid used?
2. What are side effects?
- Mania prophylaxis mainly.
- Nausea, vomiting, weight gain, sedation, tremor, hair loss.
DON’T GIVE TO WOMEN OF CHILD BEARING AGE.
