Management of mood disorders

Question 1

What scales are used to assess depression?

Answer 1

IDS-30-SR (30 question patient related scale)
QIDS (shorter version of ADS-30-SR which assesses biological symptoms)
HADS
MADRS

Question 2

Which is the best all round SSRI?

Answer 2

Escitalopram

Question 3

Why is sertraline used in the older population?

Answer 3

Good cardiac safety profile

Easy dose titration

Question 4

What are the benefits of mirtazapine?

Answer 4

Promotes sleep and appetite/weight gain

Question 5

What should you think about if antidepressants aren’t working?

Answer 5

Medication concordance
Right diagnosis?
Substance misuse
Physical illness
Any other predisposing, precipitating and prolonging factors

Question 6

What should be tried medication wise if antidepressants aren’t working?

Answer 6

Dose increase; there is a dose response relationship with ADs
Swap
Combine; SSRI/SNRI plus mirtazapine
Augment; antipsychotic or lithium

Question 7

What should be assessed before ADs are started?

Answer 7

Ratings of depressive symptoms using clinical scales
Warn pts about side effects but the probability that they will be transient
Review after 1-2 weeks

Question 8

What constitutes a trial of ADs?

Answer 8

6 weeks in adults

8 weeks in elderly

Question 9

What is treatment resistant depression?

Answer 9

2 adequate trials of 2 different antidepressants

Question 10

What treatment should be given to prevent relapse in the 1st episode of depression?

Answer 10

Continue AD fo at least 6 months after full recovery without reducing the dose

Question 11

What should be done for relapse prevention after 2 or more depressive episodes?

Answer 11

Continue AD for at least 1-2 years after full recovery without reducing dose

Question 12

What are the principles of managing acute mania/hypomania?

Answer 12

Maximise antimanic dose if already on maintenance
ADs should be discontinued
Combo therapy may be required
Hospital admission likely to be required if mania

Question 13

What is 1st line in management of acute mania?

Answer 13

Antipsychotic; olanzapine, quetiapine or risperidone

Question 14

What are 2nd line options in the management of acute mania?

Answer 14

Lithium
Valproate
Carbamazepine
ECT

Question 15

When will benzodiazepines be used in acute mania?

Answer 15

Symptom control; agitation and insomnia

Question 16

What are the principles of management of acute bipolar depression?

Answer 16

ADs should NOT be prescribed without an antimanic drug
Avoid ADs in those with a recent manic/hypomanic episode or history of rapid cycling
SSRIs (particular fluoxetine) preferable to other classes

Question 17

What is the 1st line treatment for bipolar depression?

Answer 17

Antipsychotic; quitipanie, olanzapine or lurasidone

Question 18

Can you prescribe an AD by itself in bipolar disorder?

Answer 18

No; can be used alongside an antipsychotic, lithium or valproate, lamotrigine, ECT (to prevent mania)

Question 19

What is the gold standard for long term maintenance of bipolar disorder?

Answer 19

Lithium

Question 20

When should you prescribe lamotrigine in bipolar maintenance?

Answer 20

If primarily depression

Question 21

When should you prescribe valproate in bipolar maintenance?

Answer 21

If primarily manic

Question 22

What needs to be done when patients are on lithium?

Answer 22

Monitor levels; very narrow therapeutic range
U+Es
ECG
TFTs
Calcium 
NEED to stay hydrated

Question 23

What are common side effects of SSRIs?

Answer 23

Postural hypotension

Falls common

Question 24

Which drugs are an absolute CI to the prescription of lithium?

Answer 24

NSAID

ACEi

Question 25

What is the basis of ECT?

Answer 25

Under GA Induces seizures for 20-30 seconds If prolonged give midazolam

Question 26

For what conditions is ECT indicated?

Answer 26

Bipolar depression Bipolar mania Resistant catatonia

Question 27

How is ECT given?

Answer 27

Twice weekly | Bitemporal

Question 28

Absolute CI to ECT?

Answer 28

Recent MI (within 3 months) Recent cerebrovascular accident Intracranial mass lesion Pheochromocytoma

Question 29

Relative CI to ECT?

Answer 29

``` Angina pectoris Congestive heart failure Severe pulmonary disease Severe osteoporosis Pregnancy ```

Question 30

Physical side effect of ECT?

Answer 30

``` Headache Memory problems Cognitive problems Muscle aches Confusion Nausea Acute confusion Cardiovascular Manic mood swings Anaesthetic complication Prolonged seizure Cerebrovascular ```

Question 31

How does ECT work?

Answer 31

Not sure Turns down an overactive connection between the limbic system and the prefrontal cortex Bolsters neuronal survival Promotes a production of new neuronal processes in areas involving cognitive and emotional function

Question 32

What are the different types of psycho behavioural therapy

Answer 32

``` CBT Cognitive Behavioural Analysis System of Psychotherapy Interpersonal therapy Acceptance and commitment therapy Psychoeducation ```

Question 33

What are the risks associated with mood disorders?

Answer 33

``` Self harm and suicidal ideation Financial difficulties; erratic overspending; time off work Neglect Driving; can't drive if manic Aggression Sexual disinhibition if manic Child protection Criminal justice system Assaulted ```

Question 34

What are predisposing factors to mood disorders?

Answer 34

``` Genetics Attachment problems as a child Sources of negative schema Childhood trauma TBI Intellectual disability ```

Question 35

What are precipitating factors for mood disorders?

Answer 35

``` Recent trauma Positive change Stress Childbirth Hormonal imbalance New medications (never prescribe tramadol in elderly) Sleep disturbance Change of social rhythms ```

Question 36

What are prolonging factors to mood disorders?

Answer 36

Illness related Distressed as being held under MHA Worried about job security Substance misuse

Question 37

What are protective factors to mood disorders?

Answer 37

Friends Family Religion Meaningful activities