Psychiatry SC073: I Am Depressed: Mood Disorders Flashcards

1
Q

Depression always pathological?

A

Mood fluctuations in responses to disappointment, frustration, losses in everyday life
- Usually short-lived
- Natural despondency can have important **survival function, resulting in **reorientation + ***maturation

Major depressive disorder:
1. **Severe symptoms
2. **
Impair adaptations, often disabling
- when enduring, depression can result in impaired function at work, school, in family

Epidemiology:
- >300 million worldwide
- Increase by >18% from 2005-15
- **F:M ~ 2:1
- Average lifetime and 12 month prevalence estimates of MDD: **
14.6% and 5.5% in the ten high income and 11.1% and 5.9% in the eight low to middle income countries
- One of leading causes of total DALYs for 1990, 2006, 2016
- One of major causes of **suicide —> 20x↑ in suicide risk
- Increases **
non-suicidal mortality (RR 1.2-4) —> Possible mediators:
1. Behavioural risk factors (e.g. poor adherence to treatment, inactivity, ↑ alcohol consumption)
2. Biological risk factors (e.g. altered thrombogenesis)
3. ↑ Subclinical disease / Prevalent disease (e.g. CVS disease)

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2
Q

Clinical presentations of Depression

A

***Can vary!!!

First obvious sign in Younger people may be:
1. **Loss of interest in friends
2. **
Decline in school performance
3. **Self-injury / **Bulimia / Drug use in a previously stable adolescent

Some older people, symptoms may mimic ***dementia
1. Deterioration of cognitive functioning + self-care

Some case may not have symptoms / masked until found dead by suicide

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3
Q

ICD-10 criteria of Depression

A

ICD-10:
Cardinal symptoms:
1. Depressed mood
2. Loss of interest (Anhedonia)
3. Loss of energy (Anergia)

Additional symptoms:
4. Reduced concentration
5. Reduced self esteem (present)
6. Guilty feelings (past)
7. Hopelessness and pessimism (future)
8. Self harm / suicidal ideas
9. Sleep disturbance
10. Decreased appetite
11. Loss of libido
12. Psychomotor changes

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4
Q

***DSM-5 criteria of Depression

A

Major depressive disorders:
1. **>=2 weeks
2. Symptoms cause clinically **
significant distress / impairment in social, occupational or other important areas of functioning
3. Episode **not attributable to physiological effects of a substance / another medical condition
4. Not better explained by **
schizoaffective disorder, schizophrenia, schizophreniform disorder, delusional disorder, other specified and unspecified schizophrenia spectrum and other psychotic disorders
5. Absence of previous **manic / hypomanic episode
6. **
Clear-cut changes in affect, cognition, neurovegetative functions

  1. **>=5 following symptoms, >=1 is either (1) / (2)
    —> (1) **
    Depressed mood (most of the day, nearly every day) (indicated by subjective report / observation by others / irritable mood in children or adolescents)
    —> (2) **Markedly diminished interest / pleasure in all / almost all, activities (most of the day, nearly every day) (either subjective account / observation)
    —> (3) **
    Significant weight loss / weight gain (>5% BW in a month) / appetite increase / decrease (nearly every day) (failure to make expected weight gain in children)
    —> (4) **Insomnia / Hypersomnia (nearly every day)
    —> (5) **
    Psychomotor retardation / agitation (nearly every day) (observable by others, not merely subjective feelings of restlessness or being slowed down)
    —> (6) **Fatigue / Loss of energy (nearly every day) (沒精打彩)
    —> (7) **
    Feelings of worthlessness / excessive / inappropriate guilt (which may be delusional) (nearly every day) (not merely self-reproach / guilt about being sick) (記: Uselessness, Hopelessness, Helplessness, Guilt)
    —> (8) **Diminished ability to think / concentrate / indecisiveness (nearly every day) (either subjective account / observation)
    —> (9) **
    Recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation without a specific plan / a suicide attempt or a specific plan for committing suicide

Specifiers for major depressive disorder:
1. Course: Single / Recurrent episode
2. Severity: Mild / Moderate / Severe, with **psychotic features, in partial remission, in full remission, unspecified
3. Other specifiers without codes:
- Anxious distress
- Mixed features
- Melancholic features
- Atypical features
- **
Mood-congruent psychotic features (與情緒吻合的症狀)
- ***Mood-incongruent psychotic features
- Catatonia
- Peripartum onset
- Seasonal pattern (recurrent episode only)

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5
Q

With melancholic features (憂鬱型抑鬱)

A

“Distinct quality” of mood

1 of following present during the most severe period of the current episode:
1. Loss of pleasure in all, or almost all, activities
2. Lack of reactivity to usually pleasurable stimuli (does not feel much better, even temporarily, when something good happens)

> =3 of following:
3. A distinct quality of depressed mood characterised by profound despondency, despair, and/or moroseness or by so-called empty mood
4. Depression that is regularly worse in the **morning (normal human should feel good in morning since refreshed)
5. **
Early-morning awakening (i.e. >=2 hours before usual awakening)
6. Marked psychomotor agitation / retardation
7. Significant anorexia / weight loss
8. Excessive / inappropriate guilt

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6
Q

With anxious distress

A
  1. High levels of anxiety have been associated with higher suicide risk, longer duration of illness, and greater likelihood of treatment non-response
  2. > =2 ***Anxiety symptoms
    - Feeling keyed up / tense
    - Feeling unusually restless
    - Difficulty concentrating because of worry
    - Fear that something awful may happen
    - Feeling that the individual might lose control of himself or herself
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7
Q

With mixed features

A
  1. A significant risk factor for the development of ***Bipolar I / Bipolar II disorder
  2. Coexistence of >=3 manic symptoms (insufficient for a manic episode)
    - Elevated, expansive mood
    - Inflated self esteem / grandiosity
    - More talkative than usual or pressure to keep talking
    - Flight of ideas or subjective experience that thoughts are racing
    - Increase in energy or goal directed activity (either socially, at work or school, or sexually)
    - Increased or excessive involvement in activities that have a high potential for painful consequences (e.g. engaging in unrestrained buying sprees, sexual indiscretions, foolish business investments)
    - Decreased need for sleep (feeling rested despite sleeping less than usual; to be contrasted with insomnia)
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8
Q

With atypical features

A

Does not connote an uncommon / unusual clinical presentation as the term implies

  1. Mood reactivity (i.e. mood brightens in response to actual or potential positive events)
  2. > =2 of following symptoms:
    - Significant weight gain / Increase in appetite
    - Hypersomnia
    - Leaden paralysis (i.e. heavy, leaden feelings in arms or legs)
    - A long standing pattern of interpersonal rejection sensitivity (not limited to episodes of mood disturbance) that results in significant social / occupational impairment
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9
Q

With psychotic features

A
  1. Delusions / Hallucinations are present
  2. Mood-congruent psychotic features
    - Personal inadequacy, **guilt, disease, death, **nihilism (Cotard’s syndrome (delusion of non-existence 幻想自己無左一d部位) / deserved punishment
    - Delusion of **persecution
    - Delusion of **
    poverty
    - ***Hypochondriacal delusion
  3. Mood-incongruent psychotic features
    - Does not involve typical depressive themes
    - Or a mixture of mood-incongruent and mood-congruent themes
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10
Q

With catatonia

A

Catatonic features are present during most of the episode

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11
Q

With peripartum onset (產前/後抑鬱)

A

Peripartum:
- 50% of “postpartum” major depressive episodes actually begin prior to delivery

  1. Onset of symptoms occurs **during pregnancy / within **4 weeks following delivery
  2. With or without psychotic features
    - Infanticide is most often associated with command hallucinations to kill the infant / delusions that the infant is possessed
    - Postpartum mood (major depressive or manic) episodes with psychotic features occur in from 1 in 500 to 1 in 1,000 deliveries
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12
Q

With seasonal patterns

A
  1. Regular ***temporal relationship between onset of major depressive episodes and a particular time of year (e.g. fall / winter)
  2. ***Full remissions (or a change from major depression to mania or hypomania) also occur at a characteristic time of year (e.g. depression disappears in the spring)
  3. In the last ***2 years, 2 major depressive episodes have occurred that demonstrate temporal seasonal relationships + no non-seasonal major depressive episodes have occurred during that same period
  4. Seasonal major depressive episodes substantially outnumber non-seasonal major depressive episodes that may have occurred over the individual’s lifetime
  5. Often characterised by prominent energy, hypersomnia, overeating, weight gain + craving for carbohydrates
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13
Q

Key changes from DSM-4

A
  1. **Removal of “Bereavement exclusion”
    - Depressive symptoms may be understandable / considered appropriate to significant loss (e.g. bereavement, financial ruin, losses from a natural
    disaster, a serious medical illness or disability)
    - Exercise of clinical judgment based on individual’s history + cultural norms
    - Now considered a **
    precipitating factor
  2. Dysthymia now changed to ***Persistent depressive disorder (include both chronic major depressive disorder + previous dysthymic disorder)
  3. Introduction of 2 new disorders
    - **Disruptive mood dysregulation disorder: persistent irritability + frequent episodes of extreme, out-of-control behaviour in children up to age 18
    - **
    Premenstrual dysphoric disorder: mood symptoms occur during the final week before onset of menses + improve within a few days of menses
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14
Q

Causes of Depression

A
  • Pathophysiology largely unknown
  • Several mechanisms have been proposed
  • Depressive disorder is caused a combination of biological + social + psychological factors, which disturb the brain’s capacity for stress management
  1. Biological hypothesis
    - Classical “serotonin hypothesis”
    - Genetic factors (3x risk among 1st degree relatives)
    - Structural brain changes: volume reduction + decreased quantity of glial cells in subgenual cortex, reduced hippocampal size
    - Hormonal changes: dysregulation of HPA axis, ↓ estradiol (in women) / testosterone (in men), ↓ triiodothyronine + TSH, ↓ BDNF level
  2. Psychosocial hypothesis
    - Early environment: parental separation, physical / sexual abuse, non-caring / overprotective parenting styles
    - Lack of supportive networks, poorly functioning relationships, poor social integration
    - Stress + trauma: long term difficulties, recent life events (in particular events that lead to feelings of entrapment and humiliation)
    - Personality: sociotropy (a strong need for approval), neuroticism (情緒不穩定性)
    - Cognitive theory: **Cognitive distortions, e.g.
    **
    SOAP
    —> **Selective abstraction (斷章取義): focusing on a detail and ignoring more important features of a situation
    —> **
    Overgeneralisation (以偏概全): drawing a general conclusion on the basis of a single incident
    —> **Arbitrary inference (妄下判斷): drawing a conclusion when there is no evidence for it and even some evidence against it
    —> **
    Personalisation (過度自責): relating external events to oneself in an unwarranted way
    —> **Magnification: blowing things out of proportion (web)
    —> **
    Minimisation: downplaying importance of positive thought, emotion, event (SpC Psychi PP)
    - Psychoanalytical theory: loss of an “object”, insecure attachments
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15
Q

Classical “serotonin hypothesis”

A
  • Diminished activity of serotonin pathways
  • Antihypertensive drug reserpine (deplete monoamine) produced a depressive state
  • Diminished monoaminergic activity was detected in brains of decedents of suicide + bodily fluids of people with depression
  • Evidence suggests that cause of depression is far more complicated than reduced level of serotonin
  • Monoamines: Serotonin + Norepinephrine + Dopamine are relevant to mood regulation, and play an essential role in regulation of other bodily function

Serotonin:
- Affects body temperature
- Regulates sleep and wakefulness
- Mood and impulse control
- Low level of serotonin metabolites in brains of suicide decedents + spinal fluids of depressed patients
- Serotonin functioning also reduces in depressed patients

Norepinephrine:
- Regulates mood + anxiety levels.
- Mood symptoms emerged among patients who took propranolol

Dopamine:
- Regulates motor + mental activity, attention and motivation
- Dopaminergic neurons in ***mesolimbic reward pathway play an important role in motivation, reinforcement + pleasure response
- Diminished in brains of suicidal decedents with depression

Other neurotransmitter:
Abnormal Glutamate, GABA, Substance P have been detected in patients with depression

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16
Q

Assessment of Depression

A
  1. History
  2. Mental state examination
  3. Use of standardised instruments
  4. P/E + Investigation to rule out medical conditions that may cause depressive symptoms
    - Basic: CBP, R/LFT, **TFT
    - Others:
    —> Blood alcohol level
    —> Blood and urine toxicology screen
    —> HIV test
    —> **
    Cosyntropin (ACTH) stimulation test (for Addison disease)
    —> EEG (for epilepsy) / CT / MRI (for organic brain syndrome or hypopituitarism) should be considered if indicated by history / P/E

Objective measures of severity of depression:
1. ***Hamilton Rating Scale for Depression (HAM-D)
2. Montgomery Asberg Depression Rating Scale (MADRS)
3. Patient Health Questionnaire 9 (PHQ 9)
4. Beck Depression Inventory (BDI)
5. Center for Epidemiologic Studies Depression Scale (CES-D)
6. Special patient groups (e.g. Geriatric Depression Scale, Cornell Scale for Depression in Dementia, Edinburgh Postnatal Depression Scale)
- Useful in clinical practice and research but not diagnostic
- Should not be used as a substitute for a clinical diagnosis made from a thorough interview

17
Q

***DDx of Depression

A
  1. **Psychiatric conditions
    - **
    Adjustment disorder with depressed mood
    - **Manic episode with irritable mood / mixed episodes
    - **
    Persistent depressive disorder (formerly Dysthymic disorder)
    - ***Anxiety disorder
    - Substance / Medication-induced depressive disorder
    - Mood disorder due to another medical condition
  2. Medical conditions
    - Neurological disorders (e.g. epilepsy, Parkinson’s disease, dementia, multiple sclerosis, Huntington disease, cerebrovascular disease, migraine)
    - Endocrine disorders (e.g. hypothyroidism, hyperthyroidism, Cushing’s syndrome, Addison disease, prolactinomas, hyperparathyroidism)
    - Drug-related conditions (e.g. antihypertensive esp. reserpine, methyldopa, smoking cessation aids, steroids, sex hormones, medications that affect sex hormones, H2 blockers, sedatives, muscle relaxants, appetite suppressants, chemotherapy agents, alcohol / cocaine / amphetamines / cannabinoids / sedatives / hypnotics / narcotics abuse)
    - Infectious disease (e.g. mononucleosis, HIV infection, hep C infection, Lyme disease, syphilis)
    - Neoplasia / Paraneoplastic syndromes (e.g. pancreatic cancer)
    - Chronic diseases (e.g. coronary artery disease, type II DM)
    - Chronic pain + psychosomatic conditions
    - Sleep-related disorders, in particular OSA
18
Q

Management of Depression

A
  1. Pharmacological
    - Non-selective monoamine reuptake inhibitors
    - Selective serotonin reuptake inhibitors (SSRI)
    - Serotonin and norepinephrine reuptake inhibitors (SNRI)
    - Norepinephrine + Dopamine reuptake inhibitors
    - Monoamine oxidase inhibitors + Reversible inhibitors of MAO-A
    - Melatonergic antidepressants
    - Others (Trazodone, Mirtazapine)
  2. Psychosocial
    - Interpersonal therapy
    - CBT
    - Problem solving therapy
    - Supportive therapy
  3. Physical activity
    - Aerobic / Nonaerobic execise
    - Home-based
  4. Physical treatment
    - Electroconvulsive therapy (ECT)
    - Deep brain stimulation
    - Transcranial magnetic stimulation (TMS)
    - Transcranial direct current stimulation (TDCS)
  5. Diet
19
Q
  1. Pharmacological treatment
A
  1. Non-selective monoamine reuptake inhibitors
    - TCA (Amitriptyline, Imipramine, Nortriptyline, Clomipramine, Dothiepin, Trimipramine, Desipramine)
    - Tetracyclic antidepressants (Mianserin)
  2. Selective serotonin reuptake inhibitors (SSRI)
    - Fluoxetine, Paroxetine, Sertraline, Citalopram, Escitalopram, Vortioxetine
  3. Serotonin and norepinephrine reuptake inhibitors (SNRI)
    - Duloxetine, Venlafaxine, Desvenlafaxine
  4. Norepinephrine + Dopamine reuptake inhibitors
    - Bupropion
  5. Monoamine oxidase inhibitors + Reversible inhibitors of MAO-A
    - Tranylcypromine, Phenelzine, Isocarboxazid, Selegiline, Moclobemide
  6. Melatonergic antidepressants
    - Agomelatine (SpC Psychi: Need to monitor ***LFT)
  7. Others (Trazodone, Mirtazapine)

Systematic review:
- Agomelatine, amitriptyline, escitalopram, mirtazapine, paroxetine, venlafaxine, and vortioxetine are more effective than other antidepressants
- Agomelatine, citalopram, escitalopram, fluoxetine, sertraline, and vortioxetine are more tolerable than other antidepressants
- Older antidepressants (e.g. tricyclics, MAOIs) associated with significant adverse events + drug-drug interactions
- Marked inter-individual variation in antidepressant tolerability
- Choice of medication determined by clinical circumstances, patient’s physical comorbidity + concomitant medications

20
Q
  1. Psychosocial treatment
A
  • Systematic psychological treatment with well-defined objectives
  • CBT, Interpersonal therapy highly effective in remedying mild and moderate depression
  • As many as 85 % of patients receiving both antidepressants + psychotherapy achieve remission
  1. Interpersonal therapy
    - Problems are understood in interpersonal context
    - e.g. facilitate grieving process, encourage ***role transition, explore interpersonal disputes, improve interpersonal skills
  2. CBT
    - Monitor, evaluate + modify negative dysfunctional thoughts + distorted perceptions and beliefs
    - Use cognitive techniques (e.g. list pros & cons, examine evidence)
    - Increase activity scheduling
  3. Problem solving therapy
    - Improve ability to deal with specific everyday problems + life crisis
    - Identify problems, brainstorm ways to solve problems + evaluate effectiveness —> best possible solution
  4. Supportive therapy
    - Facilitate expression of affect, highlight positive and successful experiences, offer empathy, impart therapeutic optimism
    - Empathic listening, reflection, emotional processing, encouragement
21
Q
  1. Physical activity
A
  • Aerobic exercise (e.g. running, walking)
  • Nonaerobic exercise (e.g. strength training, progressive resistance training)
  • Inverse association between duration of intervention + magnitude of the association of exercise with depression

Mechanisms:
- Normalise BDNF level
- Change neurotransmitter functioning, especially serotonin and endorphin
- Improve psychological health + social sense of wellbeing

22
Q
  1. Physical treatment
A
  1. **Electroconvulsive therapy (ECT)
    - Where **
    prompt action is needed e.g. strongly suicidal
    - SE: headache, **confusion, **memory impairment, **seizure induction
    - Need for **
    anaesthesia, costs
    - Inconvenience to the patient, stigma
  2. Deep brain stimulation
    - Require ***craniotomy
  3. Transcranial magnetic stimulation (TMS)
    - **Non-invasive
    - Hand-held, plastic-coated coil placed close to the scalp
    - Creates a potent (near 1.5T) but brief (µs) **
    magnetic field that stimulates electrical activity in the nerve tissue below the coil
    - Carried out while the person ***awake and alert
    - Limited SE
    - Suitable for use in medically unwell people who cannot tolerate antidepressants or ECT
    - Monotherapy / Adjunct
  4. Transcranial direct current stimulation (TDCS)
    - ***Non-invasive
    - Anode: ↑ cortical activity and excitability
    - Cathode: ↓ cortical activity and excitability
    - Modulates spontaneous neuronal network activity
    - Modifies responsivity of the targeted brain regions to afferent input or efferent demand
    - Limited SE
23
Q
  1. Diet
A
  • Healthy diet may help as part of the overall depression treatment though **NO specific diet has been proven to relieve depression
    1. **
    Food rich in antioxidants (e.g. blueberries, oranges, carrots, nuts)
    2. **Complex carbohydrates (e.g. whole grains) can have a calming effect
    3. **
    Protein-rich foods (e.g. turkey, tuna, and chicken) boost alertness
    4. **Mediterranean diet as a source for B vitamins
    5. **
    Omega-3 fatty acids
  • Essential polyunsaturated lipids that influence cellular metabolism and function
  • Earlier studies linked low seafood intake (a major source of omega-3 FAs) and mood disorders, and positive results with fish oil intervention —> subsequent results more diversified
  • EPA rather than DHA as the effective component
  • Monotherapy / Adjunct therapy
24
Q

Suicide risk assessment (Ryan Ho)

A

Stage of suicide:
Depressed mood
—> Hopelessness
—> Pointlessness of life (I can’t see any future)
—> Passive rejection of life (I’d be better off dead)
—> Active rejection of life (I wish I were dead)
—> Passive thoughts of self-harm (I could take an overdose)
—> Active thoughts of self-harm (I will take an overdose)
—> Act

Past:
1. Demographic factors
2. Psychiatric + Medical history
3. Recent stressors

Present:
1. Current mental state
2. Suicidal attempts / intent / thoughts
- Depressed mood
- Negative thoughts (Guilt, Worthlessness, Hopelessness)
- Suicidal acts
—> Purpose (expectation of dying, perceived lethality of means)
—> Plans
—> Preparations (will, suicide note, putting affairs in order)
—> Concealment (avoid discovery, delayed being rescued)
—> Communication (not telling others, no help sought after act)
—> Attempts

Future:
1. Amenable risk factors
2. Protective factors

25
Q

***Assessment of suicidal attempts (Ryan Ho)

A
  1. Background
    - Establish suicidal attempt / ideation
    - Reason for suicide (life stressors, mood disorder, delusion, hallucination, substance abuse)
  2. Before
    - **Suicidal ideation (duration, frequency, intensity)
    - **
    Belief of intent (true intention vs attention seeking, perceived lethality)
    - ***Suicidal plan + preparation + communication
    —> Purpose (expectation of dying, perceived lethality of means)
    —> Plans
    —> Preparations (will, suicide note 遺書, putting affairs in order 身後事)
    —> Communication (not telling others)
    —> Concealment (avoid discovery, delayed being rescued)
  3. During
    - **When, Where, Who, How
    - Lethality of means
    - **
    Concealment (avoid discovery, delayed being rescued)
    - ***How patient was saved
  4. After
    - **Communication (sought help / informing others after act)
    - **
    Remorse / Reaction
    - Future attempts / plans
  5. Risk factors
    - **Previous attempts
    - Friend / Relative completing suicide
    - Psychiatric disease
    - Medical disease
    - **
    Substance abuse
    - Impulsivity
  6. ***Protective factors (有咩留戀)
    - Good social + family support
    - Good coping skills (e.g. positive problem-solving)
    - Engagement in responsibilities (e.g. children, pregnancy, pets)
26
Q

(Electroconvulsive therapy (ECT) (Ryan Ho))

A

MOA:
- Induction of seizure to treatment psychiatric disorders
- Underlying MOA unknown

Indications (ECT: Emergency, Catatonia, Treatment-resistant):
1. **Severe depression
- Rapid definitive response required
- Life-threatening situations e.g. persistent suicidal intent
- Refractory to treatment
- Previous good response to ECT
2. Mania
3. **
Catatonia
4. Puerperal psychosis with prominent mood symptoms (rapid treatment to allow reuniting with baby)
5. ***Schizophrenia (Treatment-resistant)

Course:
- 6-12 treatment
- 2-3 per week

Process:
- 5 mins **GA
- 2 electrodes deliver electric pulse —> induce **
>=15s of generalised tonic-clonic seizure
- Unilateral vs Bilateral: Bilateral more effective but more cognitive impairment

SE:
- **Confusion
- **
Amnesia (Anterograde / Retrograde)

CI (Relative):
- Heart disease
- ↑ ICP
- ICH risk
- Poor anaesthetic risk