Affective disorders Flashcards
depression: core symptoms, other symptoms and criteria
Need symptoms for at least two weeks
And NOT secondary to the effects of drug / alcohol misuse, organic illness, or bereavement
Core symptoms:
Low mood – may be worse in the morning (diurnal variation)
Anhedonia - inability to derive pleasure
Anergia – reduced energy levels
Other symptoms:
- poor concentration
- poor sleep
- worthelss/guilt
- suicidal ideations
- reduced libido
- chage in appetite
- psychomotor retardation
Severe depression
* Psychotic Features: Delusions (e.g. nihilistic delusions, Cotard’s syndrome) and hallucinations.
* Depressive Stupor: Profound immobility, mutism, and refusal to eat or drink, sometimes necessitating electroconvulsive therapy (ECT).
Severity of depression rating
differentials to depression
Investigations in depression
- a score < 16 on the PHQ-9: less severe depression
- a score of ≥ 16 on the PHQ-9: severe depression
depression management
Depression is usually managed in primary care. GPs can refer to secondary care (Psychiatry) if there is a high-suicide risk, symptoms of bipolar disorder, symptoms of psychosis, or if there is evidence of severe depression unresponsive to initial treatment.
Persistent subthreshold depressive symptoms or mild-to-moderate depression:
- 1st line = Low-intensity psychological interventions (individual self-help, computerised CBT).
- 2nd line = High-intensity psychological interventions (individual CBT, interpersonal therapy)
- 3rd line = Consider antidepressants
Mild depression unresponsive to treatment and moderate-to-severe depression:
- 1st line = High-intensity psychological interventions + antidepressants (1st line = SSRI)
- 2nd line (Treatment-resistant depression) – switch antidepressants and then use adjuncts
Severe depression and poor oral intake/psychosis/stupor:
1st line = ECT
Although the exact mechanism remains elusive, it is thought that the induced seizure, rather than the ECT procedure itself, has therapeutic benefits.
Short-term side effects of ECT include headache, muscle aches, nausea, temporary memory loss, and confusion, while long-term side effects can include persistent memory loss. Due to the induced seizure, there is a risk of oral damage, and due to the general anaesthetic, a small risk of death.
Recurrent depression:
Treated with antidepressant + lithium
Medical management of depression - additional notes:
First-line pharmacological treatment typically involves a Selective Serotonin Reuptake Inhibitor (SSRI) such as sertraline. SNRIs such as venlafaxine can also be used first-line, but are less preferable due to the risk of damage from overdose, which is less likely with SSRIs.
In people aged 18-25 there is an increased risk of impulsivity and suicidal risk upon commencing antidepressant medication and so they should have a follow-up appointment arranged after **one week **to monitor progress. Initial reviews can otherwise be arranged 2-4 weeks after starting medication in patients >25.
Continuation of antidepressants for at least six months post-remission is recommended to mitigate relapse risk. Tapering should be done gradually over a four-week period when discontinuing antidepressants.
Definition of bipolar disorder
Bipolar disorder is a chronic mental health disorder characterised by periods of mania/hypomania alongside episodes of depression.
Epidemiology bipolar disorder
typically develops in the late teen years
lifetime prevalence: 2%
- Two types of bipolar disorder are recognised:
Two types of bipolar disorder are recognised:
* type I disorder: mania and depression (most common)
* type II disorder: hypomania and depression
What is mania/hypomania
- both terms relate to abnormally elevated mood or irritability
- with mania, there is severe functional impairment or psychotic symptoms for 7 days or more
- hypomania describes decreased or increased function for 4 days or more
- from an exam point of view the key differentiation is psychotic symptoms (e.g.delusions of grandeur or auditory hallucinations) which suggest mania
Symptoms of mania and hypomania
Differences between mania and hypomania
Clinical features of bipolar disorder
- Differential diagnoses to bipolar
investigations in bipolar
- Especially if a first presentation, or in those without any previous psychiatric history, it is important to rule out organic causes.
- This includes ruling out substance misuse (e.g. urine toxicology, amphetamine levels).
- Delirium also needs to be ruled out, which can be secondary to infection, thyroid dysfunction (TFTs,), vitamin deficiencies (B12/folate)
Management of bipolar: acute presentation including hypomania/mania and long term management
common indications for admission in depression
- serious risk of suicide or harm to others
- significant self-neglect (e.g. weightloss)
- severe psychotic symptoms
- treatment resistant
- initiation of ECT
Lithium toxicity management
lithium levels are affected by:
other mood stabilisers other than lithium
