Depression, Bipolar and anxiety Flashcards
Describe the criteria for mild, moderate and severe depression
mild: 2 core and 2 other symptoms
moderate: 2 core symptoms and 3+ other symptoms
severe: 3 core symptoms and 4 other symptoms
- functional deficit and severity of individual symptoms should also be taken into account
Describe the diagnostic criteria for depression
- at least 1 core symptom
- plus at least 3 or 4 of the following to a minimum of 5 depressive symptoms in total
- Symptoms should persist for at least 2 weeks and have caused significant distress and impairment
- organic causes should have been excluded
What are the 3 core symptoms of dperession
- Persistent sadness or low mood nearly every day for at least 2 weeks
- Anhedonia: Loss of interest or pleasure in most activities
- Fatigue: a lack of energy which goes beyond poor sleep
Give 7 additional symptoms of depression (non core)
Physical symptoms: - poor appetite and weight loss (>5% BW in a month) - disturbed sleep-- insomnia or EMW - psychomotor agitation (restlessness) or retardation (reduced movement) - reduced libido - constipation, aches and pains Cognitive: - decreased concentration - increased indecision - feelings of guilt, worthlessness, low self esteem, tearful, irritable - recurrent thoughts about death, suicide, suicide attempts Social: - not doing well at work - avoiding contact with friends - neglecting hobbies or interests - difficulties in home life
What is thought to cause depression?
Multi factoral:
- biological: genetic, monoamine function decreased
- psychological: personality traits such as neuroticism, low self esteem and childhood events
- social: distruption to life events (births, jobs, divorce, illness), stress associated with poor social environment and social isolation, social drift to lower class, alcohol and drug use
Give 5 physical/ organic causes of depression?
- hypothyroidism
- diabetes
- anaemia
- hormonal inbalance eg addisons
- substance use
- pregnancy
- nutritional deficiencies eg vit B12 and D
- drugs: L dopa, B blockers, steroids, opioids, digoxin
What bloods should be done for depression
- FBC, glucose and HbA1c, calcium, TFTs, U&Es, LFTs, haematinics
name 5 psychiatric disorders involving depression
- persistent depressive disorder
- mixed anxiety/ depressive disorder
- postnatal depression
- bipolar disorder
- seasonal affective disorder
give 4 RFs for depression
- female
- significant physical illness
- fhx, pmh
- other mental health problems
- psychosocial problems: divorce, homelessness, abuse
What are the 5 stages of bereavement
- Denial: shutting out reality to cope
- Anger: angry at themselves or others
- Bargaining: hoping to avoid or undo grief
- Depression: disconnect to avoid trauma
- Acceptance: coming to terms with the inevitable
Describe the non pharmacological management of depression
- manage co- morbitidy
- lifestyle: increase exercise, encourage social interaction and going to work, reding clubs etc
- meditation and mindfullness
- psychotherapy eg CBT
- manage safeguarding
- assess risk and manage accordingly
- advise on sleep hygiene: exercise, meditate, no smoking, no screens, good blinds, comfortable mattress, room temp etc
What factors contribute to a high risk of suicide?
- made a plan
- self harm
- previous attempt
- male gender
- unemployment
- living alone, not married
- alcohol or drug use
- religion, children, familly, sense of responsibility are protective
What antidepressants should be used in depression?
SSRI (fluoxetine, citalopram, sertraline) 1st line
Then try swapping to a different SSRI. If no effect switch to SNRI then TCAs (amitryptline) or MAOIs
Mirtazapine is often used at night to help with sleep symptoms
Mood stabilisers eg lithium, valproate, lamotrigine and carbemazepine are sometimes used
What are the two types of bipolar and what is the ICD 10 definition
- Bipolar I: 1 or more manic episodes and 1 or more depressive episodes
- Bipolar II: 1 or more depressive episodes with at least 1 hypomanic episodes
ICD10: requires at least 2 episodes, one of which must be a hypomanic, manic or mixed episode
What are the clinical features of mania?
- mood: irritable, eurphia,
- cognition: distractability, poor concentration, flight of ideas, racing thoughts, confusion, lack of insight
- behaviour: rapid speech, hyperactivity, reduced sleep, hypersexuality, extravagance
- psychotic symptoms: deulsions or hallucinations
Must be present for at least a week to be considered mania and must be severe enough to limit function
Describe the clinical features of hypomania?
- no psychotic symptoms
- no impairment in function or need for inpt admission
- mildly elevated, expansive mood
- increased energy or activity
- increased self esteem
- socialability, talkativeness and over familliarity
- increased sex drive
- reduced need for sleep
- difficulty in focusing on one task
Give 4 differentials for bipolar
• Medication: steroids, illicit substances (amphetamines, cocaine), antidepressants • dementia hyperthyroidism delerium frontal lobe disease (disinhibited) cerbeal HIV schizophrenia (if delsions prominent) cyclothymia
What investigations should be done for bipolar disoder?
- CT head
- EEG
- screen for drugs
- TFT
- anti psychotic drug baseline investigtaions (ecg, bmi, BP, lipids, Hba1c, FBC, U&E, LFT)
What is the non pharmacological management of bipolar disorder?
- education- relapse recognition and early warning signs
- dealing w/ consequences eg debt, returning goods, employer liasion
- good communication
- self help group
- support group
- self monitoring of symptoms
- coping strategies
- psychological therapy
- calming activities
- telephone support
How should acute mania be managed?
Anti psychotic eg haloperidol, olanzapine, risperidone. If ineffective try a different one, then try lithium then valproate. If taking anti depressant then stop this.
Assess suicide risk and cycling speed
How should acute depressive episodes be managed in bipolar disorder?
antidepressives are less effective and can cause mania/hypomania so use carefully. Mild depression may not require specific treatment. If previous mania then try anti manic drug. If mod- severe depression try fluoxetine and olanzapine
How should bipolar disorder be managed long term?
lithium 1st, then add valproate if ineffective. Valproate + olanzapine if lithium not tolerated or unprepared for lithium monitoring. Therapy lasts 2-5 years generally. CBT is effective. ECT is effective as last resort. When on treatment they need weekly reviews then annual when stable. Lipid levels, lithium levels, renal function, thyroid function, glucose, weight, tobacco and alcohol use and BP all need monitoring.
What monitoring is required for litium treatment?
check lithium levels weekly until dose has been constant for 4 weeks then monthly for 6 months then 3 monthly if stable.
U+E, TSH 6 monthly for hypothyroidism or nephrogenic diabetes insipidus side effects.
Very teratogenic so pregnancy tests and avoid if risk
How should lithium be discontinued?
gradual reduction over 2-4 weeks as up to 50% get mania
What is cyclothymia and dysthmyia?
Both mood disorders:
- cylcothymia: mild periods or elevation/ depression, common in relatives of BPD, similar management to BPD
- dysthymia: chronic low mood not fulfilling criteria for depression
Describe the pathophysiology of generalised anxiety disorder?
The amygdala is central to fear and anxiety so function may be distrupted in anxiety disorder.
It appears to be a genetically inherited neurochemical dysfunction that may involve autonomic imbalance; decreased GABA, COMT gene, increased cortisol and increased adenosine receptor function have all be implicated.
What are the diagnostic criteria for generalised anxiety disorder?
Excessive anxiety and worry occuring more days than not for at least 6 months about a wide range of activities or events.
They have difficulty controlling the worry. Often worry about how much they worry (type 2 worry). Also have positive worry beliefs (think the worrying helps them to some extent)
Anxiety is associated with 3 or more of: feeling on edge, fatigue, difficulty concentrating, irritability, muscle tension, sleep problems (1 for children).
Plus at least 4 secondary symptoms.
Other specific anxiety disorders exluded.
what anxiety disorder are there other than GAD
- panic disorder
- phobias including social phobia
- post traumatic stress disorder
- OCD
What are the secondary symptoms of generalised anxiety disoder?
- Autonomic arousal symptoms: palpitations, sweating, tachy, shaking, trembling, dry mouth
- Chest and abdo: difficulty breathing, feeling of choking, chest pain/ discomfort, nausea or abdo distress
- mental: dizzy, feeling faint, objects are unreal, fear of dying, loss of control
- general: flushings or chills, numbness or tingling, irritability, muscle tension or aches, difficulty getting to sleep
Give 3 RFs and 2 protective factors for anxiety
- age 35-54
- divorced or separated
- living alone
- lone parent
- age 16-24 and married or cohabiting are protective
How should GAD be managed?
- education and monitoring 1st
- low intensity psychological support, self help, psycho- educational groups
- CBT, applied relaxation, drug therapy
- crisis team if self harm/ suicide risk
What drug treatments are options for anxiety
- benzodiazepams or sedative antihistamines if need rapid response- but dont use for longer than 3 weeks
- SSRI (citalopram or paroxetine) or venlafaxine 1st choice
- betablockers (propanolol) used in panic disorder but not usually in GAD
What is neurosis
Maladaptive psychological symptoms not due to organic causes or psychosis and usually precipitated by stress. Symptoms inc fatigue, insomnia, irritability, worry, obsessions, compulsions and somatizations (physcial symptoms like trembling, tension, hyperventilation etc). Bit like a mild anxiety.
What is an obsession and a complusion?
Obsession: a thought that persists and predominates an individuals thinking despite their awareness the thought is without purpose. (thought that goes round in head even though they know its silly)
Complusion: motor acts of obsessions, may be an obsessional impluse directly leading to an action or may be mediated by an obsessional mental image/ fear- eg I need to turn light on and off 5 times of my family will die.
What is the diagnostic criteria for OCD?
- Obsessions, compulsions or both present on most days for at least 2 weeks.
- All obsessions and compulsions must: originate in the mind of the pt, be repetitive and unpleasant, be acknowledged by the pt as excessive or unreasonable (if not= psychosis), the pt tries to resist- unsuccessfully
- Carrying out the obsessive thought or act is not pleasurable
- Obessions/ compulsions must causes distress or interfere with the pts social or individual functioning
