Treatment of Affective Disorder

Question 1

Why do Ps not always tell you the they are depressed?

Answer 1

Still lots of stigma surrounding mental health

Question 2

When should you screen for depression?

Answer 2

Past Hx of depression
Significant physical illness
Risk of depression is significant - childbirth, postnatal, elderly, social isolation
Unexplained physical symptoms

Question 3

What do we do for all Ps with depression?

Answer 3

Psychoeducation
Sleep hygiene advice
Actively monitor them

Question 4

How do we treat mild-moderate depression?

Answer 4

Psychosocial and psychological interventions

Question 5

How do we treat mild-moderate depression that does not respond to Rx?

Answer 5

Antidepressants + high intensity psychology

Question 6

How do we treat severe or v severe depression?

Answer 6

Antidepressants
High intensity psychology
Specialist referral - crisis team - admission

Question 7

What do we do for Ps in severe depression with high suicidal risk?

Answer 7

Urgent specialist referral + admission (detain if necessary)

Consider ECT

Antipsychotic medication if needed

Question 8

What is psychoeducation?

Answer 8

Talking to P about their difficulties and trying to find ways to improve day-to-day things which will help - inc. relationships, exercise, die, and sleep

Question 9

What are low intensity psychological interventions for depression?

Answer 9

Computerised CBT
Self help books
Group CBT

Question 10

What are high intensity psychological interventions for depression?

Answer 10

Individual CBT
Other individual therapies

Question 11

How does CBT work’?

Answer 11

Explores cognition behind the behaviour - collaborates with the P and gets P to complete tasks in order to better understand their behaviour and beliefs and change them

Question 12

What do most antidepressants work on?

Answer 12

Monoamine neurotransmission - act to increase the amount of NT at the synapse

Question 13

What are the monoamines involved in mood?

Answer 13

Serotonin
Noradrenaline
Dopamine

Question 14

Why is it thought that antidepressants take so long to work?

Answer 14

Believed to be due to alterations in gene expression (down-regulation of receptors) and promotion of neurogenesis (in which monoamines may play a role)

Question 15

Which parts of the brain are thought to have improved neurogenesis by increased monoamines?

Answer 15

Hippocampus
Prefrontal cortex

Question 16

What is the response rate for Ps on antidepressants?

Answer 16

50% (compared to 30% on placebo)

Question 17

How long do you have to continue antidepressants for? Why?

Answer 17

6 months
High rate of relapse if stopped before then

Question 18

What do response rates for antidepressants tells us?

Answer 18

That we need to also have psychosocial and psychological treatments in connection with antidepressants

Question 19

Name 5 antidepressant drug classes

Answer 19

SSRIs
SNRIs
TCAs
MAOIs
Monoamine receptor antagonists

Question 20

Which is the first line antidepressant drug that we use?

Answer 20

SSRIs

Question 21

How do SSRIs work?

Answer 21

Increase the amount of serotonin in the synapse by blocking its reuptake

Question 22

What are the common side effects of SSRIs?

Answer 22

Nausea
Loss of appetite
Sexual dysfunction
Insomnia
Agitation
Anxiety
Headaches

Question 23

What do you need to be careful about with SSRIs?

Answer 23

Can cause hyponatremia - be careful in older Ps or those with low Na.

Use with NSAIDs can increase chances of GI bleeds - need to prescribe PPI as well

Question 24

What side effects to SNRIs have?

Answer 24

Similar to SSRIs

Question 25

What do you need to be careful about with prescribing SNRIs?

Answer 25

Hypertension - SNRIs can cause an increase in BP Are toxic in overdose

Question 26

How do TCAs work?

Answer 26

Block monoamine reuptake - inc levels of serotonin and Nor in the cleft (and slightly more dopamine)

Question 27

What are the problems with TCAs?

Answer 27

Adverse effects - are toxic in overdose - have interactions with there medications Can have cardiotoxic effects

Question 28

What are TCAs sometimes used for?

Answer 28

Neuropathic pain

Question 29

What are the side effects of TCAs?

Answer 29

Sedation Confusion Loss of motor coordination Anticholinergic effects Cardiotoxicity

Question 30

What are anticholinergic effects?

Answer 30

Dry mouth Blurred vision Constipation Urinary retention

Question 31

How do MAOIs work?

Answer 31

Inhibit monoamine oxidase from breaking down MAs in the cleft - thus increasing levels of 5HT, NOR & Dopa

Question 32

What is the cheese reaction?

Answer 32

Tyramine in cheese is normally metabolised by MAO in gut - MAOIs block this - can cause sympathomimetic effects, hypertensive crisis & intercranial haemorrhage

Question 33

What is it important to remember about MAOIs?

Answer 33

They cannot be prescribed with other antidepressants - is potential for interactions with them

Question 34

Why is it important to engage with active monitoring when first prescribing SSRIs and SNRIs?

Answer 34

Is evidence for increased suicidal thoughts and acts - esp in children, adolescents and young adults.

Question 35

What do you need to beware of when prescribing antidepressants, especially to older Ps?

Answer 35

Hyponatremia

Question 36

What can hyponatremia cause?

Answer 36

Delirium, seizures & death

Question 37

What are the withdrawal symptoms of antidepressants?

Answer 37

Diziness Anxiety Insomina & vivid reams General malaise Irritability Headache Electric shocks in arms and legs Low mood, suicidal thoughts Agitation

Question 38

Does the fact that antidepressants have withdrawal symptoms mean they are addictive?

Answer 38

No - is the act there is a temporary deficiency of synaptic serotonin due to down-regulated receptors which need time to adjust.

Question 39

How do you reduce antidepressants?

Answer 39

25% every 2-4 weeks

Question 40

What is lithium used for?

Answer 40

As an add on to antidepressants when they dont work.

Question 41

What do you need to be aware of with lithium?

Answer 41

Has a narrow therapeutic window - monitoring required. Can also have drug interactions

Question 42

What are the early side effects of lithium?

Answer 42

Polyuria, tremor, dry mouth, metallic taste, weakness & fatigue

Question 43

What are the late side effects of lithium?

Answer 43

Tremor, nephrogenic diabetes insipidus, goitre, hypothyroidism, weight gain, GI symptoms, sedation, ECG changes, CKD

Question 44

How often should you monitor lithium?

Answer 44

Frequently whilst establishing correct dose - then 6 monthly.

Question 45

What should you check when P is on lithium?

Answer 45

Lithium level, renal function (U&E, eGFR), thyroid function tests

Question 46

When is ECT used?

Answer 46

Severe depression when life is threatened AND there is a lack of response to the treatments

Question 47

What is the general approach to managing bipolar disorder?

Answer 47

Treat acute mood episodes (e.g. depression or mania) Maintain treatment to promote mood stability Aim to prevent relapse

Question 48

Why is it important to treat acute mania?

Answer 48

High death rate in mania

Question 49

What do we do for manic Ps?

Answer 49

Stop antidepressants. If not on treatment - use antipsychotic. If on treatment - check compliance and considering adding/changing antipsychotic.

Question 50

Which drug can be used as an adjunctive treatment for bipolar disorder? Why?

Answer 50

Benzodiazepines Reduce overactivity, restore sleep

Question 51

Which treatment is first line for maintenance treatment of bipolar disorder?

Answer 51

Lithium

Question 52

Which drug is most commonly used as an anticonvulsant in bipolar disorder?

Answer 52

Sodium valporate

Question 53

What is the downside of using lithium and anticonvulsants in treating mania in bipolar disorder?

Answer 53

They are slower acting than antipsychotics

Question 54

What pharmacological treatments are used in bipolar disorder?

Answer 54

Lithium Anticonvulsants (sodium valproate) Antipsychotics

Question 55

How is depression managed in bipolar disorder?

Answer 55

In a similar way to unipolar depression - - Psychological & Psychosocial - Antidepressants - often combined with mood stabiliser (lithium, valproate, antipsychotics)

Question 56

When treating depression in bipolar depression, what do you need to be aware of?

Answer 56

Risk of manic switch - can tip P into hypomania / manic state

Question 57

Which drug is first line for treating the MANIA of bipolar disorder?

Answer 57

Antipsychotics Manic Ps need urgent treatment

Question 58

How do we treat depressive episodes of bipolar?

Answer 58

Same as unipolar Careful not to tip into mania Antidepressant + mood stabiliser (lithium/valporate/antipsychotic)

Question 59

What is the MAINTENANCE treatment for bipolar to prevent further episodes?

Answer 59

Lithium first line Sodium valproate second line Antipsychotics Prevent relapse - needs multidisciplinary support

Question 60

Name 2 drugs which are being consider for future treatment of depressive disorders.

Answer 60

Ketamine (NMDA blocker - rapid antidepressant) Psilocybin (5HT agonist)