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Mood Disorders Flashcards

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1
Q

Image showing possible symptoms of major depressive disorder

A
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2
Q

What are the 2 most common mood disorders?

A

The two most common mood disorders are major depressive disorder and bipolar affective disorder (manic depressive illness).

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3
Q

Definition of major depressive disorder

A

Period of low mood lasting over 2 weeks that is characterised by a mixture of core, biological and cognitive symptoms. Core symptoms: low mood, anhedonia and fatigue.

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4
Q

Core symptoms of depression

A

Anhedonia
Anergia
Apathy

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5
Q

Biological symptoms of depression

A

Sleep disturbance; Appetite/weight disturbance; Low libido; Disturbed sleep (particularly early morning waking); Psychomotor agitation or retardation

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6
Q

Cognitive symptoms of depression

A

Impaired memory; Reduced concentration and attention; Guilt and worthlessness; Low self-esteem and confidence; Bleak view of the future; Ideas or acts of self-harm or suicide

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7
Q

What symptoms may patients develop in severe depression?

A

patients may develop delusions and hallucinations (psychotic depression). These are congruent to their mood e.g. nihilistic delusions.

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8
Q

Investigations for depression

A

Collateral history
Physical examination
Bloods: FBC, TFT, U&E
Rating Scale: PHQ9, HAD, CDI (children)
Risk Assessment

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9
Q

What must you always do in depression?

A

RISK ASSESS

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10
Q

PACES: What rating scales can be used for depression?

A

PHQ9, HAD, CDI (children)

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11
Q

What subtypes of depression exist?

A

Seasonal – worse in winter
Psychotic – with psychotic features
Atypical – mood reactivity is core feature, hyperphagia, hypersomnia, leaden feeling in limbs, hypersensitivity to rejection

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12
Q

Management of mild to moderate depression

A

Sleep hygiene
Arrange further assessment within 2 weeks
Low-Intensity Psychosocial Intervention (ALWAYS CBT)

NOTE: Do NOT routinely consider MEDICATION unless:
Past history of moderate or severe depression
Symptoms have been present for a long time (> 2 years)
Symptoms persist despite other interventions
NOTE: Do NOT recommend St. John’s wort but warn patients about uncertainty in dosing and drug interactions

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13
Q

Should you consider medication in mild to moderate depression?

A

Do NOT routinely consider MEDICATION unless:
Past history of moderate or severe depression
Symptoms have been present for a long time (> 2 years)
Symptoms persist despite other interventions
NOTE: Do NOT recommend St. John’s wort but warn patients about uncertainty in dosing and drug interactions

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14
Q

What does management of moderate to severe depression involve?

A

Provide a combination of:
Antidepressant medication
High-intensity psychological intervention (CBT or interpersonal therapy (IPT))

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15
Q

1st line medication for moderate to severe depression

A

SSRI (e.g. sertraline)

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16
Q

Best antidepressant for young people

A

Fluoxetine

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17
Q

Which drug class pose a risk of bleeding?

A

SSRIs, need to give PPI if they need NSAIDs

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18
Q

What drugs are at high risk of interactions?

A

Fluoxetine, parocetine

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19
Q

What drug is at high risk of discontinuation symptoms?

A

Paroxetine

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20
Q

What drug causes death from overdose?

A

Venlafaxine

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21
Q

What drug class often causes overdoses?

A

TCAs

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22
Q

What drugs are often stopped due to side effecgts?

A

Venlafaxine, duloxetine, TCAs

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23
Q

Which drug needs BP to be monitored?

A

Venlafaxine

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24
Q

Which drugs cause worsening hypertension?

A

venlafaxine, duloxetine

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25
Which drugs cause postural hypertension and arrhythmia?
TCA
26
How often should medication be monitored in moderate to severe depression?
After starting antidepressant medication, review after 2 weeks for side-effects, then every 2-4 weeks thereafter for 3 months Patients < 30 years or at increased risk of suicide should be followed-up after 1 week Review response to treatment after 3-4 weeks
27
When should caution be exercised when switching antidepressants? Why?
From fluoxetine to other antidepressants (fluoxetine = long half-life) From fluoxetine or paroxetine to a TCA (both drugs inhibit TCA metabolism so a lower starting dose may be needed) To a new SSRI, SNRI or MAOI (risk of serotonin syndrome) From non-reversible MAOI: a 2-week washout period is required (other antidepressants should not be prescribed during this period)
28
Important note when swithcing fluoxetine to other antidepressants
Fluoxetine has a long half life
29
Important note when switching from fluoxetine or paroxetine to a TCA
both drugs inhibit TCA metabolism so need a lower starting dose
30
Important note when switching to a new SSRI, SNRI, or MAOI
RISK OF SERETONIN SYNDROME
31
Important note when switching from non-reversible MAOI
a 2-week washout period is required (other antidepressants should not be prescribed during this period)
32
Management of complex and severe depression
Use crisis resolution and home treatment teams to manage crises Develop a crisis plan that identified potential triggers and strategies to manage triggers (share with the GP and any other people involved in the patient’s care) Consider inpatient treatment if significant risk of suicide, self-harm or self-neglect Consider ECT for acute treatment of severe depression and when a rapid response is required
33
PACES: Who should be used to manage crises in complex and severe depression?
Crisis resolution and home treatment teams
34
When to consider inpatient treatment in depression?
if significant risk of suicide, self-harm or self-neglect
35
When is ECT used in depression?
If tretment regractory
36
What can ECT cause?
retrograde amnesia
37
Can ECT be used in depression?
Yes
38
Management of catatonic depression
Consider ECT for acute treatment of severe depression and when a rapid response is required
39
Definition of BPAD
A disorder characterised by 2 or more episodes in which the patient’s mood and activity levels are significantly disturbed, this disturbance consisting on some occasions of an elevation of mood and increased energy and activity (hypomania or mania) and on others of a lowering of mood and decreased energy and activity (depression).
40
How many episodes of mood disturbances are needed in order to diagnose BPAD?
2 or mroe
41
What are episodes of hypomania or mania without depression classified as?
bipolar
42
Types of BPAD
Bipolar I Disorder At least ONE manic episode Depressive episodes are common but are NOT necessary to make the diagnosis Bipolar II Disorder At least ONE hypomanic episode At least ONE major depressive episode Cyclothymia History of hypomanic episodes with periods of depression that do not meet the criteria for major depressive disorder
43
Requirements for diagnosis for type 1 BPAD
At least ONE manic episode Depressive episodes are common but are NOT necessary to make the diagnosis
44
Requirements for diagnosis of type 2 BPAD
At least ONE hypomanic episode At least ONE major depressive episode
45
Requirements for diagnosis of cyclothymia
History of hypomanic episodes with periods of depression that do not meet the criteria for major depressive disorder
46
What does BPAD typically manifest as?
a cyclical pattern of mania or hypomania and depression
47
Signs of a manic episode
THINK: DIG FAST Distractibility Irresponsibility Grandiosity Flight of ideas Agitation Less sleep Talking too much (pressured speech)
48
How long does a manic episode last?
Lasts at least a week
49
Classic features of a manic episode
disinhibition and irresponsibility - spends money, goes out naked, increased self-esteem and confidence, gambling life-savings
50
Typical case of a manic episode
a patient with a sudden change in mood to an elevated state, no sleeping, doesn’t go to work, altered behaviour
51
Is social functioning distrubed in mania?
Yes
52
Is social functioning distrubed in hypomania
Little or no impairment in social functioning
53
Difference ebtween manic and hypomanic episodes
Mania has delusions of grandeur Psychotic Symptoms in mania Impairment of social functioning
54
How long does a hypomanic episode need to last?
At least 4 days
55
Investigations for BPAD
Collateral history Physical examination (establish baseline state) Bloods: FBC, TSH, U&E, LFT, ECG Urine drug screen Rating scale: Young Mania Rating Scale Risk assessment
56
PACES: What rating scale is used in BPAD?
Young Mania Rating Scale
57
What is the mainstay of management in BPAD? What are the main drugs?
Mood stabilisers Main drugs: Lithium Sodium valproate Carbamazepine
58
What is the therapeutic range of Lithium? When does it become toxic?
Therapeutic range: 0.6-1.0 mmol/L, becomes toxic >1.2 mmol/L
59
How often should Lithium levels be monitored?
Lithium levels should be checked 1 week after starting or changing dose and monitored weekly until a steady therapeutic level is achieved It should be monitored every 3 months from then on
60
What blood test results should be monitored in Lithium use? How often? Why?
U&E and TFTs should be monitored every 6 months (can cause renal impairment and hypothyroidism)
61
When does lithium toxicity occur?
Level > 1.2 mmol/L
62
How does Lithium toxicity present?
GI disturbance; polyuria/ polydipsia; sluggishness; giddiness; ataxia; gross tremor; seizures; renal failure NOTE: It is life threatening
63
What triggers lithium toxicity?
Salt balance changes (e.g. dehydration, D&V) Drugs interfering with lithium excretion via the kidneys (e.g. diuretics) Accidental or deliberate overdose
64
How is lithium toxicity managed?
Check lithium level Stop lithium. WARNING: stopping lithium abruptly could precipitate symptoms of mania/depression) Transfer for medical care (rehydration, osmotic diuresis). If overdose is severe, the patient may need gastric lavage or dialysis.
65
What type of drug is Sodium Valproate? What does it treat in BPAD?
Anticonvulsant Treats acute mania Prophylaxis in BPAD NOTE: Plasma levels do not need monitoring. Dose-related toxicity is NOT usually an issue
66
What type of drug is carbamezapine? What issues can it cause in management of BPAD?
Anticonvulsant Can cause toxicity at high doses Induces liver enzymes (check for drug interactions before prescribing)
67
What must be checked before prescription of carabamazepine? Why?
Drug interactions, it induceds liver enzymes
68
Risks of mood stabilisers in pregnancy
Mood stabilisers are teratogenic Risk of harm should be weighed against harm of manic relapse Lithium - Ebstein's anomaly Valproate + carbamazepine - spina bifida
69
PACES: Advice to give women of childbearing age on mood stabilisers
Women of childbearing age should be given contraceptive advice and prescribed a folate supplement if using valproate
70
What does Lithium cause in pregnancy?
Ebstein's anomaly
71
What does Valproate and carbamazepine cause in pregnancy?
Spina bifida
72
Besides mood stabilisers, what other drugs can be used for management of BPAD?
Antipsychotics (e.g. olanzapine) Usually atypical (e.g. olanzapine, risperidone, quetiapine) because of fewer side-effects Anticonvulsants Lamotrigine is 2nd line for prophylaxis in BPAD type II
73
What is the acute treatment of mania or hypomania?
Stop medications that may induce symptoms (e.g. antidepressants, drugs of abuse, steroids and dopamine agonists) Monitor food and fluid intake to prevent dehydration If treatment free: Give an antipsychotic OR mood stabiliser (can be given together if not responding) A short course of benzodiazepines may be added for sedation (sleep deprivation can exacerbate mania) If already on treatment Optimise the medication; check compliance; adjust doses Consider adding another agent (e.g. antipsychotic as well as mood stabiliser) Short-term benzodiazepines may help
74
After stopping medications that may induce symptoms, what is the acute treatment of mania or hypomania if treatment free?
Give an antipsychotic OR mood stabiliser (can be given together if not responding) A short course of benzodiazepines may be added for sedation (sleep deprivation can exacerbate mania)
75
Why might a short course of benzodiazepines be added in the acute treatment of mania or hypomania?
A short course of benzodiazepines may be added for sedation (sleep deprivation can exacerbate mania)
76
After stopping medications that may induce symptoms, what is the acute treatment of mania or hypomania if already on treatment?
Optimise the medication; check compliance; adjust doses Consider adding another agent (e.g. antipsychotic as well as mood stabiliser) Short-term benzodiazepines may help
77
How to treat depression in BPAD?
DIFFICULT because antidepressants can cause a switch to mania To reduce this risk, antidepressants should only be given with a mood stabiliser or antipsychotic 1st line: fluoxetine + olanzapine/quetiapine 2nd line: lamotrigine
78
Why is it difficult to treat depression in BPAD?
antidepressants can cause a switch to mania
79
What must antidepressants be given with in the treatment of depression in BPAD? Why?
antidepressants should only be given with a mood stabiliser or antipsychotic 1st line: fluoxetine + olanzapine/quetiapine 2nd line: lamotrigine Because antidepressants can cause a switch to mania
80
What psychological therapy is used in BPAD?
CBT
81
What medication should you consider stopping during an acute manic episode?
During an acute manic episode, consider stopping antidepressant (if the patient is on one)
82
What is the antidepressant of choice in the management of depression in BPAD? What must it be given with?
fluoxetine is the antidepressant of choice (given with olanzapine or quetiapine)
83
How should primary care refer people with BPAD?
Symptoms of hypomania 🡪 routine referral to CMHT Symptoms of mania or severe depression 🡪 urgent referral to CMHT
84
PACES: Important questions to ask when risk assessing those with depression
Have you ever thought about/attempted to end your life? Have you ever purposefully hurt yourself or want to hurt yourself?
85
PACES: Important things to explore if patient has displayed thoughts or intent of harming themselves
Before – trigger, planned/impulsive, intoxication, preventing discovery During – Method (cutting, OD, burning, hitting oneself), thoughts during act, where were they After – who called for help, current mood, regret, would they do it again, will they accept treatment
86
Suicide risk factors
THINK: SAD PERSONS S - sex (male) A - age (young, elderly) D - depression P - previous attempt (highest risk factor) E - ethanol or drug use R - rational thinking loss (psychosis) S - sickness (medical illness) O - organised plan N - no social support S - states future intent
87
Protective factors against suicide
family support having children at home religious belief
88
What are some factors that suggest increased risk of completed suicide?
efforts to avoid discovery planning leaving a written note final acts such as sorting out finances (e.g. sorting a will) violent method
89
Beck's cognitive triad of depression

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