Affective disorders

Question 1

what are the important questions to ask about suicide?

Answer 1

have you thought about giving up, life is not worth living, committing suicide?
how often?
have you tried?
have you made any plans?
do you have access to any of these?
is there anything stopping you?
is there anyone around you that have committed suicide?

Question 2

what are the important questions to ask about self harm?

Answer 2

are you thinking about self harm?
how often do you think about it?
have you tried? when was the most recent?
how do you do it? do you have access to that?
do you know anyone who harm themselves?
does anyone tell you to do it (command hallucinations)
do you feel safe at the moment?

Question 3

what are the principles of treatment for the big D?

Answer 3

mild depression = psychotherapy
moderate dep = psychotherapy + adjunct pharmacological therapy
moderate to severe dep = pharmacotherapy is more effective than psychotherapy

Question 4

how long does anti-depressants take to act?

Answer 4

takes at least 1 -2 weeks usually, and full benefit may not occur for 4 - 6 weeks in some cases

Question 5

what are the initial first line treatment of depression?

Answer 5

SSRI (citalopram/escitalopram, fluoxetine/paroxetine)
SNRI (duloxetine, venlafaxine, desvenlafaxine)
Mirtazapine

Question 6

what anti-depressants should not be used w/ children under the age of 8

Answer 6

SSRI - increased suicidal ideation esp amongst adolescence

TCA - due to adverse effect profile

Question 7

diagnostic criterion for MDD

Answer 7

duration of more than 2 weeks of:
(2 cardinal symptoms) anhedonia, depressed mood
(3 themes of thought) worthlessness, guilt, suicidal/hopelessness
(4 basic function changes) sleep, appetite, concenctration/attention, sex

Question 8

what are some psychotherapy techniques that can be used for depression?

Answer 8

psychoeducation about their condition 
mantaining therapeutic relationship between patient and doctor 
activity scheduling 
CBT 
anger and assertion training 
problem solving skills 
mindfulness

Question 9

what are some risk factors for suicide risk/

Answer 9

age 45 and older
white males 
prior history of poor physical health 
poor social supports 
prior suicide attempt
comorbid use of drugs or alcohol
recent severe loss 
detailed plan for suicide, pattern of chronic self-destructiveness, psychotic symptomology

Question 10

what is the acute treatment of bipolar depression?

Answer 10

cannot give anti-depressants alone, have to use mood stabilizer and withdraw anti-depressants upon remission (within 1 - 2 months)

antidepressants + mood stabilizer
quetiapine
if refractory: change anti-dep, psychotherapy, ECT

Question 11

what is the acute treatment for mania?

Answer 11

olanzapine 5mg oral, nocte, increasing to 10mg at night
OR
risperidone

Question 12

what are the prophylactic treatment for mania?

Answer 12

lithium 125 - 500 mg oral, twice daily, two weeks. dose adjust to serum concentration
2nd gen antipsychotics: olanzapine, risperidone, paliiperidone, quetiapine, amipriprazole
lamotrigine
carbamazepine
valproate

Question 13

main side effects of lithium

Answer 13

nephrogenic diabetes insipidus
lithium toxicity - old, dehydrated, renal impairment, polypharmacy
cognitive slowing
hypothyroidism

Question 14

common non significant side effect of lithium

Answer 14

fine tremor
metallic taste
gi effect: diarrhoea, n/v, reduced appetite

Question 15

what are the effects of lithium toxicity according to the doses?

Answer 15

mild (1.5 -2): nystagmus, ataxia, diarrhoea, n/v, dizziness, slurred speech
moderate (2-2.5): n/v, anorexia, blurred vision, clonic limb movements, convulsions, delirium
severe (>2.5) generalized convulsions, oliguria, renal failure

Question 16

tests to do before starting lithium

Answer 16

UEC, TFT, BHCG, ECG, PTH

Question 17

what is the monitoring regime of lithium

Answer 17

8 - 12h after last dose for first 5 days,

when steady dose is reached: 3 monthly lithium serum, 6 monthly thyroid and Cr, CMP/PTH 12 monthly

Question 18

compare factors that predict +ve response in lithium vs valproate?

Answer 18

lithium: pure mania, preivous good response, fhx of good response, mania followed by depression
valproate; rapid cycling patient, mixed patients, comorbid substance abuse, comorbid anxiety disorders

Question 19

what are the side effects of valproate?

Answer 19

thrombocytopenia and platelet dysfunction 
n/v, weight gain 
transaminitis 
sedation, tremor 
increased risk of NTD defect 
hair loss

Question 20

what are the tests required before starting valproate, and what are the monitoring required for valproate?

Answer 20

before starting: FBE, b-HCG, folate levels, LFT, start folate
monitoring: check FBE, LFT 8 - 12 after last dose in the first 5 days till steady state is reached.

Question 21

what are some of the features of severe depression?

Answer 21

thoughts/plans for suicide 
psychotic symptoms 
catatonia 
judgement impairment 
normal functioning is impaired

Question 22

features of grief?

Answer 22

getting better over time 
sadness that comes in waves 
some sources of pleasure 
somatic symptoms that are mild 
usually no suicidal ideations/themes of hopelessness, helplessness, guilt

Question 23

features of adjustment disorder w/ depressed mood?

Answer 23

depressed/low mood in response to stressor within 3 months
that is not normal of the expected reaction to that stressor
does not meet criterion for MDD
resolves within 6 months after the stressor and consequences have ended

Question 24

features of depression associated w/ BPAD?

Answer 24

presence of psychotic features 
subthreshold mania/hypomania 
earlier onset of depression 
poorer interval functioning 
atypical depression w/ polyphagia and hypersomnia 
family history of bipolar disorder 
multiple recurrence of major depression 
poor response to anti depressants 
comorbid anxiety disorder