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Affective Disorders Flashcards

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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
Serotonin syndrome
``` 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) ```
26
Mania and biplar affective disorder Ix
``` Collateral hx physical exam Blood: FBC TFT U+E LFT ECG urine drug screen rating scale: Young Risk assessment ```
27
Mood stabilisers Mania and biplar affective disorder
``` Even extreme highs and lows More effective against mania 3 main drugs: Lithium Na valproate Carbamezapine MOA ?Na/GABA channel intearction ```
28
Lithium Mania and biplar affective disorder
``` 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) ```
29
Li toxicity
``` >1.2mmol/: Life threatening Presentation: GI disturbance polyuria/polydipsia sluggishness giddiness ataxia tremor fits renal failure Trigger: Salt balance change, diuretics, overdose ```
30
Li toxicity Mx
check level stop dose (risk precipitating mania/depression) Transfer for medical care ?gastric lavage/dialysis
31
Valproate Mania and biplar affective disorder
``` Treats acute mania Prophylaxis in BPAD No plasma monitoring No accepted therapeutic range Dose related toxicity not an issue ```
32
Carbamazepine Mania and biplar affective disorder
Toxicity at high dose induces liver enzymes close monitoring essential check interactions before prescribing
33
Pregnancy Mania and biplar affective disorder
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
non mood stabilisers in Mania and biplar affective disorder
antipsychotics (olanzapine) | anticonvulsants (lamotrigine) is second line prophylaxis for BPAD type II
35
Acute treatment of mania or hypomania
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
Long term treatment of Mania and biplar affective disorder
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
Psychological treatment Mania and biplar affective disorder
CBT: identify relapse indicators and strategies | Psychodynamic psychotherapy: useful if mood stabilised
38
Social intervention Mania and biplar affective disorder
family support and therapy | aiding return to work
39
Prognosis of Mania and biplar affective disorder
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
Mania Dr Nayrouz Mx
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
atypical antipychotics
aripiprazole quetiapine olanzapine risperidone
42
Dr Nayrouz stabilising bipolar
use mood stabiliser or atypical antipsychotic | either will work equally well
43
Bipolar depression Dr Nayrouz
SSRI (fluoxetine first line) w/atypical antipsychotic (olanzapine, quetiapine) always check Li levels if it appears ineffective
44
Self harm and suicide Physical treatment
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
Self harm and suicide risk assessment
``` 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
Immediate intervention Self harm and suicide
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
Followup intervention Self harm and suicide
FU within 1wk of self-harm d/c Treat underlying dx Psychological therapy (CBT/DBT, mentilisation based Mx)
48
Coping strategies Self harm and suicide
``` Distraction mood raising technique Supportive environment Avoiding substances bite into strong flavoured thing eg lemon ```
49
Schizophrenia Ix for first line psych
``` 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
Early intervention in psychosis service
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
Schizophrenia psychological Mx
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
typical antipsychs
``` older drugs Chlorpromazine Haloperidol Flupentixol decanoate Cause EPSE at normal dose Effective, cheap, depot options ```
53
atypical antipsychs
``` in addition to dopamine R also block Serotonin 5-HT2 R Eg. Olanzapine risperidone (depot available) Quetiapine Apiprazole Clozapine Amisulpride ```
54
Consider starting atypical antipsych
1st line newly dx schiz. SE from typicals relapse on typucal
55
Extrapyramidal side effects - dystonia
Onset: early Sx: involuntary painful sustained muscle spasms e.g. torticollis (neck twists to one side) oculogyric crisis Rx: anticholinergic (procyclidine)
56
Extrapyramidal side effects - Akathsia
Onset: hours-weeks Unpleasant subjective feeling of restlessness (pacing, jiggling) Rx: decrease dose/change antipsychotic, add propranolol/benzo
57
Extrapyramidal side effects - parkinsonism
``` 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
Extrapyramidal side effects - tardive dyskinesia
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
Other side effects of antipsychotics (not extra pyramidal)
``` Hyperprolactinaemia (galactorrhoea, amenorrhoea, gyanaecomastia, hypogonadism, sexual dysfunction, osteoporrosis) Wt gain (olan/clozapine) Sedation Risk DM Dyslipidaemia Anticholinergic effects (proSNS) Arrythmia Seizure (reduces threshold) ```
60
Schizophrenia: psychological Mx CBT
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
Schizophrenia: psychological Mx Family therapy
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
Schizophrenia: psychological Mx Concordance therapy
collaborative approach where pt encouraged to consider pros and cons of Mx
63
Schizophrenia: social Mx
``` ?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
``` Schizophrenia other Mx Physical health ( ```
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
Schizophrenia other Mx: negative sx
arts therapy
66
Schizophrenia other Mx: carer support
Offer support (education and programmes) Right to carers assessment (free from social services) Consider peer support (someone who has recovered from psychosis)
67
Schizophrenia other Mx: monitoring: baseline
``` 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
Schizophrenia other Mx: monitoring ongoing
``` 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
Schizophrenia Treatment resistance
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
Summary of Schizophrenia
1st line; atypical antipsychotic (eg qeutiapine) CBT offered to all Close attenion paid to CV RF modification
71
Schizoprhrenia Dr nayrouz Mx
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
Neuroleptic maliganant syndrome MoA, Sx
Sympathetic hypersensitivity resulting from dopaminergic antagonism (onset 1-3d) Muscle rigidity, fever, sweating, confusion, autonomic dysfunction
73
Neuroleptic maliganant syndrome Ix
High CK high WCC Altered LFTs U+E(can cause AKI) and creatinine
74
Neuroleptic maliganant syndrome Mx
``` 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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