Treatment of affective disorders Flashcards
The 2 questions below are useful for what?
- During the last month have you often been feeling down, depressed or hopeless?
- During the last month have you often been bothered by having little interest or pleasure in doing things?
- screening depression
- needed as people wont tell you they are depressed
In all patients with depression, what are the 3 things they should be offered straight away?
1 - advice about sleep hygiene, active monitoring of symptoms, medication
2 - psychoeducation, CBT, active monitoring of symptoms
3 - psychoeducation, advice about sleep hygiene, CBT
4 - psychoeducation, advice about sleep hygiene, active monitoring of symptoms
4 - psychoeducation, advice about sleep hygiene, active monitoring of symptoms
In patients with mild to moderate depression, what would be the treatment strategy?
1 - low intensity psychosocial and high intensity psychological interventions
2 - CBT and low intensity psychosocial interventions
3 - low intensity psychosocial and psychological interventions
4 - low psychological interventions and CBT
3 - low intensity psychosocial and psychological interventions
- if no improvement from 1 and 2 then need to consider medication
In all patients with mild-mod depression and not responding to low intensity psychosocial and psychological interventions, what should these patients be offered?
1 - high intensity psychosocial and/or antidepressant medication
2 - CBT and antidepressant medication
3 - low intensity psychosocial and antidepressant medication
4 - low psychological interventions and CBT
1 - high intensity psychosocial and/or antidepressant medication
In all patients with severe and complex depression, what should these patients be offered?
1 - high intensity psychosocial and/or antidepressant medication
2 - high intensity psychosocial intervention, antidepressants, specialist referral and crisis team
3 - low intensity psychosocial and antidepressant medication
4 - low psychological interventions and CBT
2 - high intensity psychosocial intervention, antidepressants, specialist referral and crisis team
- specialist referral is MDTs
- consider crisis team is admission to hospitals
In patients with severe depression who are a high risk with threat to life (self neglect, suicidal) what are other treatment alternatives?
- urgent specialist referral
- hospital admission
- detained under mental health act 2 for 28 days of assessment
- consider electroconvulsive therapy (ECT)
- antipsychotic medication for psychotic symptoms
What is psychoeducation?
- evidence-based therapeutic intervention
- patients with depression and their loved ones are provided with information and support to better understand and cope with depression
Psychoeducation is an evidence-based therapeutic intervention where patients with depression and their loved ones are provided with information and support to better understand and cope with depression. What sort of things might be spoken about?
1 - Day to day things that can impact on mental health (+ and -)
- Work
- Family life
- Sleep
- Level of exercise
- What we eat (i.e. diet)
- Drugs and alcohol, smoking
2 - Sleep hygiene
When a patient has been actively monitored, provided with psychosocial and given advice about their sleep hygiene, but none of this works, they could be offered a low intensity psychosocial intervention. What are 4 examples this form can this low intensity psychosocial intervention take?
1 - regular exercise or group activity programmes
2 - befriending services
3 - local support groups and social groups
4 - social prescribing (identify and access groups and activities)
When a patient has been actively monitored, provided with psychoeducation and given advice about their sleep hygiene, but none of this works, they could be offered a low intensity psychological intervention. What are low and high psychological interventions?
1 - low
- computerised CBT - guided self help (e.g. book) based on CBT - group CBT
2 - high
- individual CBT - other individual therapies
What are the 3 things that are focussed on in cognitive behavioural therapy?
1 - feelings
2 - thoughts
3 - behaviour
The majority of anti-depressant medications act on monoamines neurotransmitters. What are the 3 key monoamines that anti-depressant medications act on?
1 - neuroadrenaline, serotonin, acetylcholine
2 - neuroadrenaline, acetylcholine, dopamine
3 - neuroadrenaline, serotonin, dopamine
4 - acetylcholine, serotonin, dopamine
3 - neuroadrenaline, serotonin, dopamine
The majority of anti-depressant medications act on monoamines neurotransmitters. The 3 key monoamines that anti-depressant medications act on are neuroadrenaline, serotonin and dopamine. They are able to have a rapid effect within the synapse, but can then take time to have a therapeutic effect. How long can some anti-depressants take before the begin to have a therapeutic effect?
1 - 1 week
2 - 2 weeks
3 - 3-4 weeks
4 - >4 weeks
3 - 3-4 weeks
Although not exactly known the reason there is a delayed response in anti-depressant medication is thought to be due to alterations in gene expression. One of the things altered gene expression may be involved in is down-regulation of receptors, what happens here?
- medication will result in an increase in the levels of neurotransmitter
- gene expression down regulates receptors, called desensitisation
- cell is no longer as responsive to neurotransmitter
Although not exactly known the reason there is a delayed response in anti-depressant medication is thought to be due to alterations in gene expression. One of the things altered gene expression may be involved in is neurogenesis/synaptic plasticity, what happens here?
- create new synapses
- increase hippocampal and prefrontal cortex neurogenesis
In clinical trials what % of patients with depression respond to active anti-depressant medication and placebo?
- active anti-depressant medication = 50%
- placebo = 30%
What are the first line choice in anti-depressant medication?
1 - benzodiazepines
2 - gabapentinoids
3 - selective serotonin reuptake inhibitors (SSRIs)
4 - ion channel blockers
3 - selective serotonin reuptake inhibitors (SSRIs)
- Citalopram is the core drug
Selective serotonin reuptake inhibitors (SSRIs) are the first line choice in anti-depressant medication. If the patient is responding and there are no issues how long should these drugs be taken for and if stopped earlier what can happen?
1 - >1 month and relapse of depression
2 - >3 months and relapse of depression
3 - >6 months and relapse of depression
4 - >12 months and relapse of depression
3 - >6 months and relapse of depression
Citalopram is a key drug that we need to be aware of. What class of drug is this and what is it generally used to treat?
- selective serotonin reuptake inhibitors (SSRI)
- anti-depressant medication
Citalopram is a key drug that we need to be aware of. It is a selective serotonin reuptake inhibitors (SSRI) used commonly to treat anti-depressant medication. What is its mechanism of action?
1 - inhibits Monoamine oxidase B
2 - inhibits enzymes degrading serotonin in synaptic cleft
3 - blocks serotonin reuptake transporters (SERTs) on pre-synapse
4 - bind to post-synaptic receptor and acts as an agonist
3 - blocks serotonin reuptake transporters (SERTs) on pre-synapse
- blocks the breakdown and re-absorption of serotonin at the pre-synapse
- means serotonin levels are increased for longer in synaptic cleft
Citalopram is a key drug that we need to be aware of. It is a selective serotonin reuptake inhibitors (SSRI) used commonly to treat depressant. Why is it important to warn patients about the side effects of SSRI, such as nausea and loss of appetite, diarrhoea, sexual dysfunction, insomnia, agitation, anxiety and headaches?
- patients can initially feel worse and stop taking the medication
- therapeutic effects may not begin for 3-4 weeks
Citalopram is a key drug that we need to be aware of. It is a selective serotonin reuptake inhibitors (SSRI) used commonly to treat depressant. Although not commonly identified as common side effects, what are 2 side effects that can be dangerous in some patients?
- hyponatraemia (low Na+)
- interaction with NSAIDs (GIT dysfunction)
Amitriptyline is a tricyclic antidepressants (TCAs) medication. What is its mechanism of action?
1 - inhibits Monoamine oxidase B
2 - inhibits enzymes degrading serotonin in synaptic cleft
3 - blocks SERTs and NETs on pre-synapse
4 - bind to post-synaptic receptor and acts as an agonist
SERT = serotonin reuptake transporter NET = noradrenaline reuptake transporter
3 - blocks SERTs and NETs on pre-synapse
- means increased serotonin and noradrenaline remains in synaptic cleft
- increases action potentials at the post synapse
Amitriptyline is a tricyclic antidepressants (TCAs) medication. Its mechanism of action is to block the serotonin (SERT) and noradrenaline (NET) receptors on the pre-synapse, thus increasing serotonin and noradrenaline in the synaptic cleft and increasing action potentials at the post synapse. What are the most common side effects of this drug?
- toxicity in overdose and cardiotoxicity
- anticholinergic effects
- sedation
- confusion
- loss of motor coordination (NB falls in elderly)
Monoamine oxidase is an enzyme located in the pre-synapses of neurons. What is the role of this enzyme?
1 - degrades monoamines (dopamine, serotonin and norephedrine) to control levels
2 - degrades monoamine dopamine to modulate levels
3 - synthesise monoamines (dopamine, serotonin and norephedrine)
4 - synthesise monoamines dopamine
1 - degrades monoamines (dopamine, serotonin and norephedrine) to control levels
- stops monamines being re-packages into vesicles
Monoamine oxidase inhibitors (MAOIs) are a group of drugs used as an anti-depressant. What is the mechanism of action of this class of drugs?
1 - inhibits MAO and increases monoamines (dopamine, serotonin and norephedrine) levels
2 - inhibits MAO and increases monoamine dopamine levels
3 - agonist of MAO and increases monoamine degradation
4 - synthesise monoamines dopamine
MAO = Monoamine oxidase
1 - inhibits MAO and increases monoamines (dopamine, serotonin and norephedrine) levels
- monoamines can therefore be repackaged into vesicles for release
Monoamine oxidase inhibitors (MAOIs) are a group of drugs used as an anti-depressant. They are able to inhibit monoamine oxidase (MAO) which breaks down monoamines. Why can this be bad in cheese consumption?
- cheeses can contain a lot of Tyramine, which is metabolised by MAO in the GIT
- if not metabolised it can be absorbed causing sympathomimetic effects
- can cause hypertensive crisis and intracranial haemorrhage
Although anti-depressants can be effective in treating depression they do have adverse events. However, there is one very serious thing that that these drugs have been shown to increase the risk of?
1 - CVD
2 - stroke
3 - suicidal thoughts, plans and actions
4 - dementia
3 - suicidal thoughts, plans and actions
- more prevalent in children, adolescents and young adults
All anti-depressants have the risk of causing what physiological adverse event that can be very dangerous?
1 - hyponatraemia
2 - hypokalemia
3 - hypocalcemia
4 - hypophosphatemia
1 - hyponatraemia
All anti-depressants have the risk of causing hyponatraemia. This can be very dangerous and cause seizures, delirium, and is potentially fatal. How does hyponatraemia cause these dangerous effects?
- low Na+ outside a cell causes hypotonic osmosis
- increased solutes concentration inside cell means H2O flows into the cell
- cells swell, causing oedema in the brain
- can impair cognitive function, causing seizures, delirium and can be fatal
When people stop taking anti-depressants, why do they suffer from withdrawal effects?
- the body still has increased levels of monoamines
- these monoamines can cause physiological affects
When people stop taking anti-depressants, they suffer from withdrawal effects which is likely to be due to excessive levels of monoamines that can elicit physiological affects and/or a temporary deficiency of synaptic serotonin and time needed for down-regulated receptors to adjust. When stopping a patients anti-depressant medication, what duration should they be stopped over?
1 - 50% reduction every week
2 - 25% reduction every week
3 - 25% reduction every 8 weeks
4 - 25% reduction every 2-4 weeks
4 - 25% reduction every 2-4 weeks
Lithium is a monovalent cation (Li+) and is a drug used to augment anti-depressant drugs. Why is this good in
- makes the effects of the anti-depressant drugs more effective
- good if people have not responded to a drug
Lithium is a monovalent cation (Li+) and is a drug used to augment anti-depressant drugs, essentially making the effects of the anti-depressant drugs more effective. It has also been shown to improve the efficacy of drugs that patients had not previously responded to. Why do we need to be cautious with lithium though?
- it has a narrow therapeutic window and needs close monitoring
What are some common early adverse events of lithium?
- polyuria
- tremor
- dry mouth
- metallic taste
- weakness and fatigue
What are some common late adverse events of lithium?
- tremor
- nephrogenic diabetes insipidus
- goitre (thyroid enlargement)
- hypothyroidism
- weight gain
- GI symptoms
- sedation
- ECG changes
- chronic kidney disease
How often must lithium be monitored?
- regularly and then move to every 6 months
- need to also check kidneys and thyroid function
Electroconvulsive therapy (ECT) can be used in severe depression. What is ECT?
- an electric current is applied to skull of anaesthetised patient
- a seizure is produced
- motor effects of seizure prevented using muscle relaxant (paralysis)
- altered internal stimulus that contributes to severe depression.
Why do we use the term unipolar depression?
- to separate it from depressive episodes in the context of bipolar disorders who may experience depression
When we are treating bipolar disorders, what are we trying to treat?
- the acute episode of depression or mania
- important to maintain therapy to maintain mood stability and prevent relapse
When we are treating bipolar disorders, are they treated in normal primary and secondary care centres?
- No
- often managed in specialist mental health services
When we are looking at treating bipolar disorders, specifically acute mania, it is essential that an urgent response is needed. What should be the first thing a clinician should do regarding anti-depressant medication and what to provide the patient with?
1 - increase depressant medication and prescribe an antipsychotic
2 - slowly reduce the antidepressants medication and prescribe an antipsychotic
3 - stop the antidepressants medication and prescribe an CBT
4 - stop antidepressants medication and prescribe an antipsychotic
4 - stop antidepressants medication and prescribe an antipsychotic
- antidepressants increase monoamines so may be exacerbating manic episode
What is the first line treatment class of drug for a patient with bipolar who is presenting with an acute episode of mania?
1 - GABA antagonists
2 - anti-psychotic
3 - SSRI
4 - benzodiazepines
2 - anti-psychotic
The first line treatment for a patient with bipolar who is presenting with an acute episode of mania is an anti-psychotic drug. In addition, why might a benzodiazepines be useful as adjunctive in treating the episode?
- benzodiazepines reduce brain activity through GABA
- the overall aim is to reduce neuronal activity and stimulation in the patient
The first line treatment for a patient with bipolar who is presenting with an acute episode of mania is an anti-psychotic drug. In addition, benzodiazepines be useful as adjunctive in treating the episode as it reduces brain activity through GABA, thus reducing neuronal activity and stimulation in the patient. However, once the patient is recovering, what is the maintenance treatment for bipolar disorder?
1 - diazepam
2 - zopiclone
3 - lithium
4 - aripiprazole
3 - lithium
- reduces risk of suicide
The first line treatment for a patient with bipolar who is presenting with an acute episode of mania is an anti-psychotic drug. In addition, benzodiazepines be useful as adjunctive in treating the episode as it reduces brain activity through GABA, thus reducing neuronal activity and stimulation in the patient. However, once the patient is recovering, the 1st line maintenance treatment for bipolar disorder is lithium (reduces risk of suicide). What other treatment options are available?
- anticonvulsants (valproate a GABA enhancing drug)
- antipsychotics
- lithium combined with anticonvulsants can be used in treatment of acute mania, but are slower acting than antipsychotics
When treating a patient with depression in a bipolar disorder we need to be careful of the ”manic switch”. What is this?
- drug treatment can cause patients to tip into hypomania or mania
What is the first line of treatment in a patient presenting with depression in a bipolar disorder?
- same treatment as unipolar depression
- low intensity psychosocial
- low intensity psychology
