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Year 5: Conditions > Psychiatry- Affective Disorders > Flashcards

Psychiatry- Affective Disorders Flashcards

1
Q

What is depression

A

Characterised by the absence of positive affect

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2
Q

What is seasonal affective disorder

A

◦ Episodes of depression that recur annually at around the same time (remission in-between)

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3
Q

What is atypical depression

A

◦ Increased appetite/eating causing weight gain and increased sleep (hypersomnia)

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4
Q

What is agitated depression

A

◦ Psychomotor agitation instead of retardation

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5
Q

What is depressive stupor/catatonic depression

A

◦ Psychomotor retardation causing inability to move, patient phased out not speaking

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6
Q

Organic causes of depression

A

• Hypothyroidism
• Hypercalcaemia
• Cushing’s Disease
• Vitamin B12 deficiency
• Vitamin D deficiency
• Alzheimer’s dementia
• Space occupying lesion
• Chronic condition
• Peri/Post-partum
• Genetics
• Medication:
◦ Beta-blockers
◦ Steroids
◦ COCP

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7
Q

Psychosocial causes of depression

A

◦ Bipolar Affective Disorder
◦ Adjustment disorder: Mild affective symptoms following large/stressful life event
◦ Personality disorder
◦ Bereavement
◦ Substance misuse
◦ Childhood trauma
◦ Unemployment/isolation

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8
Q

Core symptoms of depression

A

Core Symptoms (present for most days, most of the time for 2 weeks):
• Low mood: Diurnal- worse in mornings and at night
• Loss of enjoyment (anhedonia)
• Low energy (anergia)

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9
Q

Adjunct symptoms of depression

A

Biological:
• Sleep:
‣ Either reduced or increased (atypical)
‣ Early morning waking is characteristic
• Appetite:
‣ Decreased or increased (atypical)
• Low libido
• Psychomotor retardation/agitation

Psychological:
• Hopelessness
• Guilt
• Lack of concentration
• Suicidal thoughts/acts/self-harm

Psychotic:
• Delusions:
• Nihilistic (my organs are rotting) (Cotards syndrome)
• Hallucinations

• Pseudodementia: Cognitive impairment due to severe depression (global memory loss)

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10
Q

Diagnostic criteria for mild depression

A

◦ 2 core symptoms
◦ 2 non-core symptoms

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11
Q

Moderate depression criteria

A

◦ 2 core symptoms
◦ 3-4 non-core symptoms

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12
Q

Severe depression diagnostic criteria

A

◦ 3 core symptoms
◦ 5 non-core symptoms
◦ ±Psychotic symptoms

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13
Q

Mental state examination of depression

A

• A: Appearance and Behaviour:
◦ Neglect, dehydration, posture, poor eye contact, psychomotor retardation
• S: Speech (quantity, quality, rate, rhythm, tone, appropriateness):
◦ Slow, quiet, mute
• E: Emotion (mood and affect):
◦ Flat or blunted affect, low mood
• P: Perception (hallucinations and delusions):
◦ If severe- hallucinations, delusions (nihilistic), guilt
• T: Thought (form, content, possession):
◦ Beck’s triad- worthlessness, hopelessness, helplessness. Poverty of thought
• I: Insight:
◦ Usually intact
• C: Cognition:
◦ Pseudodementia from severe depression

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14
Q

What rating scale used for depression

A

• PHQ-9

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15
Q

What bloods done for depression

A

• FBC
• TFT
• Glucose/HbA1c
• Vitamin D + B12
• Cortisol
• Folic acid

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16
Q

Mild depression in children management

A

◦ 1) Active monitoring + Supportive care:
◦ For 6 weeks (2 week follow-ups)
◦ Self-help (Mind)
◦ Lifestyle advice: sleep hygiene, diet, exercise)
◦ 2) CBT
◦ 3) CAMHS referral (after 2-3 months)

(Stepped care approach)

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17
Q

Moderate-to-severe depression management in children

A

◦ Managed by CAMHS
◦ Psychological intervention (Family-based interpersonal therapy (<12 yo) or individual CBT (>11 yo)
◦ Consider SSRI for >11 yo:
◦ Fluoxetine

(Stepped care approach)

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18
Q

Mild depression management in adults

A

Active monitoring
‣ Follow-up in 2 weeks
‣ Lifestyle advice: sleep hygiene, exercise, self-help, info

(Stepped care approach)

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19
Q

Mild-to-moderate depression management in adults

A

◦ Low-intensity psychological interventions ± medication
◦ Individual CBT, computerised CBT or structured group activities (CBT around 9-12 weeks)
◦ Medications ONLY if:
◦ Moderate to severe depression history
◦ Concurrent chronic condition
◦ Depressive symptoms >2 years

(Stepped care approach)

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20
Q

Moderate-to-severe depression psychological management in adults

A

◦ High intensity psychological interventions + Medication
◦ Individual CBT (16-20 sessions) or
◦ Interpersonal Therapy (IPT): better if depression due to death

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21
Q

Moderate-to-severe depression pharmacological management in adults

A

• 1) SSRI (sertraline, fluoxetine, citalopram, paroxetine)
◦ Increase dose every 2 weeks for 6 weeks
◦ Follow-up every 2 weeks for first 3 months (every 1 week if suicidal or <25yo)
◦ Continue at least 6 months after remission of symptoms

					• 2) Switch to another SSRI

					• 3) SNRI:
						◦ Taper down SSRI and start SNRI (e.g. venlafaxine, duloxetine)
						◦ OR
						◦ TCA (Mirtazapine)- good for rescued appetite and insomnia 


					• 4) Add SSRI or augment with Lithium or Antipsychotic
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22
Q

Very severe + complex depression management in adults

A

‣ Electroconvulsive Therapy (ECT):
◦ Electrodes placed on head to induce controlled seizure
◦ Done under GA with muscle relaxant
◦ 12 sessions
◦ Absolute contraindication= Raised ICP

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23
Q

What to ask to check suicide risk

A

◦ Suicidal acts or intents?
◦ Plans in place?
◦ Previous attempts
◦ Protective factors?
◦ If significant risk: Refer to Crisis Resolution and Home Treatment Team

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24
Q

Which anti-depressant has smallest side-effects of atypical profile + good post-MI

A

Sertraline

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25
Which anti-depressant use in children
Fluoxetine
26
Which anti-depressant good for insomnia and reduced appetite
Mirtazapine
27
Which anti-depressant safe to use in pregnancy
• SSRIs have most safety information, therefore are 1st line (sertraline or paroxetine) • Lowest effective dose should be used
28
What are side-effects of anti-depressant use in pregnancy
◦ Small risk of congenital heart defects in 1st trimester (particularly paroxetine) ◦ Risk of Persistent Pulmonary Hypertension in 3rd trimester
29
Side effects of SSRIs
• Citalopram: prolonged QTc, therefore ECG • HYPONATRAEMIA • SNRIs: can increase BP • Sexual dysfunction • Anxiety • GI dysfunction
30
Complications of depression
• Psychotic Depression: ◦ Severe depression + delusions or hallucinations ◦ Cotard syndrome: Nihilistic delusions where the patient believes they are dead ◦ Psychotic depression delusion: ‘Person wants to kill me because world is better off without me’ • Serotonin syndrome: Caused by SSRI and/or SNRI
31
What is serotonin syndrome
Excessive serotonergic stimulation of 5-HT and 5-HT2a receptors
32
Serotonin syndrome causes
‣ Monoamine oxidase inhibitors (when taken with SSRIs) ‣ Triptans ‣ St John’s wort ‣ Ecstasy
33
Presentation of serotonin syndrome
• Abrupt TRIAD of: • Neuromuscular Excitation: ◦ Hyperreflexia ◦ Myoclonus: brief involuntary muscle jerks ◦ Rigidity • Autonomic symptoms: ◦ Hyperthermia ◦ Sweating ◦ Hypertension ◦ Tachycardia ◦ Dilated pupils ◦ Flushed skin • Altered mental status: ◦ Confusion ◦ Agitation ◦ Coma
34
Onset of serotonin syndrome
‣ Within minutes to hours of: ◦ Starting new antidepressant ◦ Increasing dose ◦ Adding second drug
35
Investigations for serotonin syndrome
• Exclude sepsis • FBC, U&Es, LFTs, coagulation, ECG
36
Management of serotonin syndrome
• Cessation of offending medication • Benzodiazepines (Diazepam): reduce neurological excitability • Supportive fluids • Activated charcoal if overdose
37
SSRI interactions:
• NSAIDs: Try to avoid, but if given then co-prescribe PPI to reduce risk of gastric bleeding • Warfarin/Heparin/Aspirin: Avoid SSRIs and prescribe Mirtazapine instead • Triptans: Avoid SSRIs • Monoamine Oxidase Inhibitors: Avoid, can result in Serotonin Syndrome
38
What is BPAD
At least 2 episodes of mood disturbance with one being manic/hypomanic, other can be depressive
39
Subtypes of BPAD
BPAD 1 BPAD 2 Rapid Cycling BPAD
40
What is BPAD 1
◦ Mania + Depression ◦ Most common
41
What is BPAD 2
◦ Hypomania + Depression
42
What is rapid cycling BPAD
◦ 4 or more episodes per year ◦ Responds well to sodium valproate
43
Risk factors for BPAD
• FAMILY HISTORY • Substance misuse disorders • Early age of onset • Use of SSRIs: SSRI can cause manic episodes due to improvement in mood
44
What is mania
‣ Symptoms last >7 days + must impair social functioning/daily life ‣ Core symptoms= Irritability, elevated mood and/or increased energy
45
What is hypomania
• Symptoms last >4 days + do NOT impair social functioning (or NO psychotic symptoms) • Slightly less exaggerated symptoms of mania
46
Symptoms of mania
◦ Elevated mood, extreme irritability + aggression: Typically irritability ◦ Increased energy or activity ◦ Decreased need for sleep ◦ Pressure of speech ◦ Flight of idea ◦ Grandiosity ◦ Poor judgment ◦ Risk activities: e.g. gambling ◦ Distractibility, poor concentration ◦ Increased libido, sexual disinhibition ◦ Psychotic symptoms: • Grandiose delusions or hallucinations (usually voices)
47
Mental state examination of mania
‣ Appearance and Behaviour: ◦ Irritable, excitable, distracted, inappropriate clothing ‣ Speech: ◦ Pressure of speech, loud tone, can be inappropriate ‣ Emotion: ◦ Increased self-esteem, grandiosity, irritable, loss of inhibition ‣ Perception: ◦ Grandiose delusions, hallucinations, paranoia ‣ Thought: ◦ Flight of ideas ‣ Insight: ◦ Minimal, causing reckless behaviour ‣ Cognition: ◦ Intact
48
What investigations for mania to screen organic causes
‣ Urine drug screen, TFTs, FBC, CRP, U&Es
49
Diagnosis: what to do in primary care with hypomania
Routine referral to Community Mental Health Team (CMHT)
50
Diagnosis: What to do in primary care with mania
Urgent referral to CMHT
51
Diagnosis: what to do in primary care if risk to self/others/lack of insight
Psychiatric admission
52
General acute management of mania/hypomania
• FOR EVERYONE: ◦ Stop all medications that may cause symptoms (e.g. SSRIs or steroids) ◦ Short course of benzodiazepines may be required for sedation (e.g. lorazepam)
53
Acute management of mani/hypomania in treatment free patients
◦ 1) Antipsychotic: ◦ Olanzapine ◦ To stabilise before starting mood stabiliser ◦ Can cause weight gain, sedation, metabolic disorders ◦ 2) Different antipsychotic: ◦ Haloperidol, risperidone, quetiapine ◦ 3) Add sodium valproate
54
Acute management of mania/hypomania in patients already on treatment
• 1) Optimise medications ◦ Check compliance, stop anti-depressants, check lithium levels • 1) Add atypical antipsychotic (e.g. Olanzapine)
55
Long-term management of mania/hypomania
Long-Term Management of Mania/Hypomania (4 weeks after acute episode): 1) Mood Stabilisers: ◦ 1) Lithium alone: ◦ Monitor for lithium toxicity ◦ Takes 5 weeks to titrate to right level ◦ 2) Lithium + Sodium Valproate
56
Pregnancy/breast-feeding with BPAD
• Switch Lithium gradually to Atypical Antipsychotic
57
How to manage depression in BPAD
• Cannot add antidepressant individually due to risk of manic symptoms recurring • Add mood stabiliser or antipsychotic • 1) Fluoxetine + Olanzapine
58
Psychological therapy for BPAD
• CBT • Family Support • Sleep hygiene • Substance misuse prevention
59
What monitoring is needed for Lithium use
‣ Do FBC, TFTs, ECG before starting ‣ Monitor weekly when starting or when changing dose until steady dose reached (5 weeks) ‣ Then monitor every 3 months with sample taken 12 hours post-dose ‣ U&Es + TFTs every 6 months
60
Signs of lithium toxicity
‣ Purple book ‣ >1.2mmol/L ‣ Nausea & Vomiting ‣ Nephrotoxicity: • Polyuria, polydipsia • Nephrogenic diabetes insipidus ‣ Hypothyroidism ‣ Weight gain ‣ Constipation ‣ Dehydration ‣ Coarse tremor (toxic): Fine tremor (common, therapeutic level) ‣ Seizures ‣ Arrhythmias ‣ Confusion ‣ Teratogenic: ‣ Ebstein’s anomaly (mitral valve) ‣ Switch out for atypical antipsychotic during pregnancy and breastfeeding
61
Drug caution with lithium
• Caution with NSAIDs + ACEi • Ensure hydration
62
Management of lithium toxicity
• Haemodialysis (in severe cases) • Can give IV fluids beforehand
63
Sodium valproate side effects
• Teratogenic- not to be used in women of child-bearing age ◦ Risk of neural tube defect (spina bifida) • Hair loss, weight gain, tremor

Year 5: Conditions (17 decks)

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