Mood disorders Flashcards
Bipolar depression
Worse or wired when taking ADT (agitated/restless) - agitation if SE should improve over time
Hypomania, hyperthymic temperament or mood swings in history
Irritable, hostile or mixed features
Psychomotor retardation
Loaded fhx: BPAD, affectivity, mood swings
Abrupt onset and or termination of depressive episodes in <3mths
Seasonal or postpartum depression
Hyperphagia and hypersomnia
Early age of onset - early 20s
Delusions Hallucinations and Psychotic features
Bipolar depression mx
lamotrigine - 25mg increased 25mg every 2 weeks
quetiapine 300-600
olanzapine + fluoxetine
2nd line add mood stabiliser
then add antidepressant
Mixed features in depression
Inner tension/agitation
Racing or crowded thoughts
Irritability
No psychomotor retardation
Talkativeness
Dramatic description of suffering or frequent spells of weeping
Mood lability and marked emotional reactivity
Early insomnia
Ix AND Treatment of depression with mixed features
Rule out organic e.g. hyperthyroid, TBI
Rule out substance use or meds- L dopa, steroids
Assess for hypomania, fhx of BPAD
1st line: lurasidone, quetiapine, aripiprazole
2nd line: lamotrigine, valproate, lithium, olanzapine
ADT mono generally not recommended
Sx of melancholic depression
anhedonia
retardation
neurocognitive - concentration
guilt worthlessness
suicidality
neurovegetative
Chronic pain and depression pathophys
pain - cognitive distortions e.g. dependence on meds - increased feelings of helplessness - withdrawal from physical and social activities - intensification of depression - influence on perception and reactions to pain - more pain
behavioural activation, cognitive restructuring
Rapid cycling presentation
- four or more episodes of mood disorder fulfilling criteria for mania or depression
over a 12-month period - It is also used to describe mood disorder that rapidly changes from one mood state to
other without periods of remission
Rapid cycling mx
Exclude non compliance
Stop antidepressant
Thyroid disorder (subclinical hypothyroidism)
Substance use
Lithium + valproate
Atypical depression dx and mx
Mood reactivity
hypersomnia hyperphagia
leaden paralysis
interpersonal sensitivity
phenelzine
Chronic adjustment disorder
Significant adjustment issues such as loss of role, family, untreated grief
Post migration stresses
Loss of identity
Unemployment
Family conflict
Loss of cultural identity
Stereotyping
Racism
Profession and ethical issues in involuntary patient
- Autonomy - may or may not be able to consent to ECT due to lack of capacity. This may be related to severity of illness, therefore ax of decision making capacity and explore pt wishes
- Privacy and confidentiality. Respect confidentiality of pt and obtain consent to speak to family members
- Benefience - The patient has symptoms of ___ that is associated with high risk of ___.
___ is an evidence based treatment for ___ and has a high response rate
Therefore the treatment may be in the best interest of the pt - Non malefience - withholding ___ may increase the risk of suicide
- Advanced directives - look at advanced directives and previous wishes. Second opinion. MHA legislation if fulfils criteria for significant risk and pt lacks capacity
Factors contributing to depression failing to improve
-Treatment resistant depressive nature associated with nihilistic delusions and agitation, which indicates psychotic depression
-Which requires broad spectrum ADT e.g. SNRI/TCA at high doses (dopaminergic and noradrenergic antidepressants)
Venla 225 for 3 weeks is subtherapeutic dose and duration
-Needs antipsychotic
-Severe vasculopathy, psychotic depression may be associated with vascular features
-Organic factors: hyponatremia, thyroid, addison’s disease, brain tumour, neurocognitive impairment contributing to tx resistance
-Non compliance
-Psychological factors - however psychotic has more biological weighting
Factors contributing family opposition to ECT
- Stigma against ECT due to media perception
- Negative attitude due to negative past experiences
- Lack of knowledge about modern techniques of ECT. Psychoeducation not provided about the benefits and risks in a detailed manner
- Concerns about side effects of ECT. Explanation not provided about different electrode placements and techniques to minimise cognitive deficits
- Family may be respecting pt wishes
- Poor engagement with treating team or psychiatrist, transference and countertransference issues
- Cultural factors or beliefs in alternate models of care
Mx of ECT induced hypomania
- Stop ECT, wait and watch
- Space out the ECT and monitor for worsening hypomania
- Reduce dose of ADT with aim of ceasing, gradual cessation due to anticholinergic rebound
- Optimise mood stabiliser for tx of mania
- Lithium augmentation for tx resistant depression and mania
Differences in mood stabiliser properties
- Lithium has more antimanic properties
- Lamotrigine has greater effect for depression
- Valproate is more effective for mixed episodes
lamotrigine + valproate - need to reduce lamotrigine
