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Affective Disorders Flashcards

1
Q

Depression Ix

A 
Collateral hx
Physical exam
Bloods: FBC, TFT, U+E
Rating scales: PHQ9, HAD, CDI (children)
Risk assessment
Assess severity (no, Sx + severity, duration)
Explore possibility of previous episodes of depression and mood elevation (BPAD)
ALWAYS assess suicide risk
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2
Q

Stepped care model depression

A

Step 1: All known and suspected depression
- Assessment, support, psychoeducation, active monitoring
Step 2: Persistent subthreshold, mild-mod depression
- Low intensity psychological intervention, medication
Step 3: Persistent subthreshold, mild-mod not responding or severe
- medication, high intensity pyschcological intervention
Step 4: severe and complex
- medication and high intensity psychological intervention (ECT, crisis service)
Explain Sx may get worse after starting treatment and give advise about seeking help

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3
Q

Mild-mod depression Mx

A

Sleep hygiene
FU in 2w
Low intensity psych intervention
Group CBT (if decline low intensity) 12-16wks
NOT routinely meds unless long term Sx, or Hx of mod/severe

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4
Q

Low intensity psychcological intervention

A

Individual guided self help based on principles of CBT
Computerised CBT (both over 9-12wks)
Structured group physical activity programme

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5
Q

Moderate-Severe Depression Mx

A

Combination of antidepressant and High intensity psychological intervention (CBT/IPT)

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6
Q

Antidepressant meds

A

First line: SSRI (sertraline)
Caution bleeding: give NSAIDs w/PPI
R/v at 2wks (if low risk suicide) and then monthly
Patients <30y or an increased risk of suicide FU at 1w

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7
Q

Antidepressant w/drug interactions

A

fluoxetine, fluvoxamine, paroxetine

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8
Q

Discontinuation syndrome antidepressant

A

paroxetine

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9
Q

Death from overdose antidepressant

A

venlflaxine

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10
Q

Overdose antidepressants

A

TCAs except lofepramine

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11
Q

Stopping treatment due to side effects antidepressants

A

venlaflaxine, duloxetine, TCAs

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12
Q

Blood pressure monitoring required antidepressant

A

Venlaflaxine

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13
Q

Worsening hypertension antidepressant

A

venlaflaxine, duloxetine

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14
Q

Postural hypotension and arrhythmia antidepressant

A

TCA

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15
Q

High intensity psychological interventions

A

Individual CBT:
16-20 sessions over 3-4m
Consider 2 sessions/wk in the first 2 weeks
Consider FU sessions over the following 3-6m
Interpersonal Therapy:
16-20 sessions over 3-4m
consider 2 sessions/wk in first 2 weeks
helps identify how interactions are affecting mood and finding ways to improve this

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16
Q

Caution when swtiching antidepressants

A

fluoxetine to others (has long half life)
From fluoxetine or paroxetine to a TCA (both inhibit TCA metabolism)
To new serotoninergic antiderpressant of MAOI (risk serotonin syndrome)
From non-reversible MAOI: 2 week wash out period required, w/ no other antidepressants

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17
Q

Complex and severe depression

A

Crisis resolution and home treatment teams for crises
Develop crisis plan to avoid triggers
Consider inpatient treatment if risk of harm or self neglect
Consider ECT as acute treatment if rapid response required

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18
Q

Summary of depression Mx

A

Mild or subthreshold: active monitoring, 2w FU
Persistent subthreshold, or mid-mod: consider low intensity pysch intervention, avoid routine antidepressant use
Mod-sev: antidepressant and high intensity
First episode: SSRI (citalopram, sertaline)
Recurrent: consider antidepressant that had good response in the past
If co-existing physical health condition - sertraline (low drug interaction)

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19
Q

Depression Dr Nayrouz Mx

A

Mod-sev needs Mx
if develop psychosis at any point add antidepressant
Stopping antidepressants should be done over 4weeks

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20
Q

Dr Nayrouz Depression first line

A

SSRI (sertraline best)
Increase from 50mg-200mg in steps of 50 every 2wks
sertraline is nonsedative
Other SSRI: citalopram (CI in any QTc prolongation)

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21
Q

Dr NayrouzDepression second line

A 
taper down SSRI switch to SNRI
eg venlaflaxine, duloxetine
V: 37.5mg BD to 75mg BD, to 75mg in morning and 150mg in evening
SNRI pharmacology does not switch from its SSRI effect to SNRI until you reach max dose
At this point check:
adherence
Dx - ?BPAD
drug interactions
perpetuating factors
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22
Q

Dr Nayrouz Depression third line

A

treatment resistence
add augmentation (atypical e.g. quetiapine 150-300mg or Li (aim for blood level 0.4-0.8
or another antidepressant eg mirtazipine or mianserin

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23
Q

Dr Nayrouz Depression fouth line

A

ECT

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24
Q

Catch up phenomena

A

if pt recovers from depression due to Rx when it is stopped the depression will be worse

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25
Q

Serotonin syndrome

A 
Clin fx.: fever, agitation, confusion, hypertension, hyperreflexia, clonus, tremor, diarrhoea, dilated pupils
Withdraw offending drug
supportive care
1-3d duration
benzos for agitation
?cyproheptadine (antihistamine)
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26
Q

Mania and biplar affective disorder Ix

A 
Collateral hx
physical exam
Blood: FBC TFT U+E LFT ECG
urine drug screen
rating scale: Young
Risk assessment
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27
Q

Mood stabilisers Mania and biplar affective disorder

A 
Even extreme highs and lows
More effective against mania
3 main drugs:
Lithium
Na valproate
Carbamezapine
MOA ?Na/GABA channel intearction
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28
Q

Lithium Mania and biplar affective disorder

A 
Therapeutic range: 0.6-1mmol/L
Toxicity >1.2mmol/L
Check levels weeks until steady level achieved
Then monitor 3monthly
U+E + TFTs every 6m (hypothyroid)
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29
Q

Li toxicity

A 
>1.2mmol/:
Life threatening
Presentation:
GI disturbance
polyuria/polydipsia
sluggishness
giddiness
ataxia
tremor
fits
renal failure
Trigger: Salt balance change, diuretics, overdose
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30
Q

Li toxicity Mx

A

check level
stop dose (risk precipitating mania/depression)
Transfer for medical care
?gastric lavage/dialysis

31
Q

Valproate Mania and biplar affective disorder

A 
Treats acute mania
Prophylaxis in BPAD
No plasma monitoring
No accepted therapeutic range
Dose related toxicity not an issue
32
Q

Carbamazepine Mania and biplar affective disorder

A

Toxicity at high dose
induces liver enzymes
close monitoring essential
check interactions before prescribing

33
Q

Pregnancy Mania and biplar affective disorder

A

Mood stabilisers teratogenic
Harm vs risk of manic episode
Li - Ebsteins anomaly
Valproate and carbamazepine - spina bifida
Give contraceptive advise and folate supplement if valproate

34
Q

non mood stabilisers in Mania and biplar affective disorder

A

antipsychotics (olanzapine)

anticonvulsants (lamotrigine) is second line prophylaxis for BPAD type II

35
Q

Acute treatment of mania or hypomania

A

Stop all meds that may induce Sx (antidep, drugs of abuse, steroids, dopamine agonists)
Monitor food and fluids to prevent dehydration
If treatment free: antipyschotic or mood stabiliser, short course benzos
If on Rx:
optimise, check compliance, consider adding agent (antipsychotic), ?short term benzos
ECT if unresponsive to medication

36
Q

Long term treatment of Mania and biplar affective disorder

A

Mood stabilisers mainstay
other drugs symptomatically
Depression in BPAD: hard bc antideps can cause mania, so need to be given w/mood stabiliser/antipsych.
1st line: fluoxetine + olanzapine/quetiapine
2nd: lamotrigine
Monitor for sx of mania
Cautiously withdraw meds if sx free for a while

37
Q

Psychological treatment Mania and biplar affective disorder

A

CBT: identify relapse indicators and strategies

Psychodynamic psychotherapy: useful if mood stabilised

38
Q

Social intervention Mania and biplar affective disorder

A

family support and therapy

aiding return to work

39
Q

Prognosis of Mania and biplar affective disorder

A

manic episodes begin abruptly and are usually shorter than depressive (2wks-5m)
Recovery usually complete between episodes
Remissions shorter w/age and depression more common
15% will commit suicide
Li reduces this level to same as population

40
Q

Mania Dr Nayrouz Mx

A

2 antimanic classes:
Mood stabilisers (eg Li)
- not as effective in manic phase, if you start it during mania add atypical antipsych
Atypical antipsychotics
- more freq. used, work quickly, if fails add a mood stabiliser

41
Q

atypical antipychotics

A

aripiprazole
quetiapine
olanzapine
risperidone

42
Q

Dr Nayrouz stabilising bipolar

A

use mood stabiliser or atypical antipsychotic

either will work equally well

43
Q

Bipolar depression Dr Nayrouz

A

SSRI (fluoxetine first line) w/atypical antipsychotic (olanzapine, quetiapine)
always check Li levels if it appears ineffective

44
Q

Self harm and suicide Physical treatment

A

OD: activated charcoal for some substances ingested (antidepressants) must be <1hr after ingestion, antidotes eg NAC for paracetamol
Laceration: suture/steristrip, plastic surg for deep cuts, analgesia

45
Q

Self harm and suicide risk assessment

A 
Thoughts of hurting themselves again
Thoughts of hurting others
Thoughts of being hurt by others
Specific features:
careful planning
acts preparing for death
precaution to prevent discovery
suicide note
definite intent
belief of legality
Violent method
ASSESS CAPACITY BIG MAN
46
Q

Immediate intervention Self harm and suicide

A

at risk of suicide and lacking capacity: admit to psych ward
pts at lower risk Mx at home
Crisis plan (who they will tell, how they’ll get help)

47
Q

Followup intervention Self harm and suicide

A

FU within 1wk of self-harm d/c
Treat underlying dx
Psychological therapy (CBT/DBT, mentilisation based Mx)

48
Q

Coping strategies Self harm and suicide

A 
Distraction
mood raising technique
Supportive environment
Avoiding substances
bite into strong flavoured thing eg lemon
49
Q

Schizophrenia Ix for first line psych

A 
Collateral history
physical exam
bloods: FBC, U+E, lipids, LFT
Urine drug screen
rating scale: brief psychiatric rating scale
ADL assessment and housing/finance
50
Q

Early intervention in psychosis service

A

Psychosis is toxic, the longer it happens the more it will affect cognitive abilities, insight, social situation
Sooner treatment means better prognosis
This service engages w/very early sx pts
offered antipsych and psychosocial intervention to keep DUP under 3mo
Can be used by children >14

51
Q

Schizophrenia psychological Mx

A

Antipsychotics: block D2R
Extrapyramidal side effects can occur at high conc. of ALL antipsych. but less common w/atypicals
Avoid using more than 1 antipsych

52
Q

typical antipsychs

A 
older drugs
Chlorpromazine
Haloperidol
Flupentixol decanoate
Cause EPSE at normal dose
Effective, cheap, depot options
53
Q

atypical antipsychs

A 
in addition to dopamine R also block Serotonin 5-HT2 R
Eg. Olanzapine
risperidone (depot available)
Quetiapine
Apiprazole
Clozapine
Amisulpride
54
Q

Consider starting atypical antipsych

A

1st line newly dx schiz.
SE from typicals
relapse on typucal

55
Q

Extrapyramidal side effects - dystonia

A

Onset: early
Sx: involuntary painful sustained muscle spasms e.g. torticollis (neck twists to one side) oculogyric crisis
Rx: anticholinergic (procyclidine)

56
Q

Extrapyramidal side effects - Akathsia

A

Onset: hours-weeks
Unpleasant subjective feeling of restlessness (pacing, jiggling)
Rx: decrease dose/change antipsychotic, add propranolol/benzo

57
Q

Extrapyramidal side effects - parkinsonism

A 
Onset: days-weeks
Triad:
-resting tremor
- rigidity
- bradykinesia
Mask like face
Shuffling gait
Rx: decrease dose/change antipsych, try anticholinergic (procyclidine) but r/v frequently and do not use as proph.
58
Q

Extrapyramidal side effects - tardive dyskinesia

A

Onset: months-yrs
Sx: Rhythmic involuntary movements of mouth, face, trunk which are v distressing
Pts may grimace, make chewing/sucking movements
Rx: stop antipsych. or reduce dose if poss. (may worsen sx initially) Avoid anticholinergics (often worsen problem), swtich to atypical or clozapine
Often irreversible

59
Q

Other side effects of antipsychotics (not extra pyramidal)

A 
Hyperprolactinaemia (galactorrhoea, amenorrhoea, gyanaecomastia, hypogonadism, sexual dysfunction, osteoporrosis)
Wt gain (olan/clozapine)
Sedation
Risk DM
Dyslipidaemia
Anticholinergic effects (proSNS)
Arrythmia
Seizure (reduces threshold)
60
Q

Schizophrenia: psychological Mx CBT

A

Offer to ALL
Emphasis on reality testing
Aim to gently challenge beliefs, aid awareness of illogical thinking
Encourage thinking about evidence and consider alternative explanations
Can also help with troublesome hallucinations/delusions
>15 sessions

61
Q

Schizophrenia: psychological Mx Family therapy

A

Can reduce relapse rate
Effects of high expressed emotion can be ameliorated through comms skills, education about dx, expanding social network
Offer respite for family
10+ sessions

62
Q

Schizophrenia: psychological Mx Concordance therapy

A

collaborative approach where pt encouraged to consider pros and cons of Mx

63
Q

Schizophrenia: social Mx

A 
?admission for observation, treatment, refuge
Help w/practical needs
Social skills training
Need to address:
- education
- skills
- housing
- accessing social activities
- developing personal skills
64
Q 
Schizophrenia other Mx 
Physical health (
A

Offer combined healthy eating and physical activity programme
Offer interventions for metabolic cx of antipsych (wt gain, cholesterol)
Help w/smoking cessation
Monitor physical parameters regularly

65
Q

Schizophrenia other Mx: negative sx

A

arts therapy

66
Q

Schizophrenia other Mx: carer support

A

Offer support (education and programmes)
Right to carers assessment (free from social services)
Consider peer support (someone who has recovered from psychosis)

67
Q

Schizophrenia other Mx: monitoring: baseline

A 
Baseline (pre-antipsych):
- wt
- waist circ.
- pulse and BP
- Fasting BM, HbA1c, lipid profile, prolactin
- assess for movement disorder
- assess nutritional status, diet, exercise
- ECG if CV RFs or req for meds
Children: height every 6m
68
Q

Schizophrenia other Mx: monitoring ongoing

A 
Response to rx and SE
Emergence of movement disorders
Waist circumference
Adherence
Overall phys. health
Weight:
- weekly for 6w
- at 12w
- at 1y
- annually after
Pulse and BP:
-12w
- 1yr
- annually
69
Q

Schizophrenia Treatment resistance

A

1st line: clozapine
Definition: failure to respond to 2+ antipsych. at least 1 of which was atypical each at therapeutic dose for 6w
Warning: small but sig risk agranulocytosis
Weekly blood tests
If poor response to clozapine consider adding another antipsych.

70
Q

Summary of Schizophrenia

A

1st line; atypical antipsychotic (eg qeutiapine)
CBT offered to all
Close attenion paid to CV RF modification

71
Q

Schizoprhrenia Dr nayrouz Mx

A
  1. Atypical:
    - apiprazole (10mg)/quetiapine (50->750mg)
    - olanzapine (10mg)/risperidone (3-6mg) (stronger but SE)
    Max quetiapine dose in mania:800
  2. If this doesn’t work after 2-4wks try new class
  3. If no response after 2 classes consider clozapine
    - Schizoaffective disorder: same meds but add mood stabiliser if you feel affective component, consider antidepressant
    Rapid tranq: lorazepam (1mg), haloperidol (5mg)
72
Q

Neuroleptic maliganant syndrome MoA, Sx

A

Sympathetic hypersensitivity resulting from dopaminergic antagonism (onset 1-3d)
Muscle rigidity, fever, sweating, confusion, autonomic dysfunction

73
Q

Neuroleptic maliganant syndrome Ix

A

High CK
high WCC
Altered LFTs
U+E(can cause AKI) and creatinine

74
Q

Neuroleptic maliganant syndrome Mx

A 
Stop antipsych
urgent medical treatment (ITU)
Treat hypothermia
?bromocriptine
Dantrolene for rigidity
benzo for agitation
?IV fluids/dialysis

Psych (13 decks)

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