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Mood disorders Flashcards

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1
Q

What is the lifetime prevalence of depressive symptoms?

+ Prevalence of major depression (+ how many referred to outpts/hosp)

A

Lifetime prevalence = 10-20%

5% prevalence of major depression → 10% these to outpatients + 0.1% these hosp

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2
Q

What are some of the biological (4), psychological (3) + social (5) causes of depression?

A 
Bio:
Genetics
Hormonal changes
Substance misuse
Serious illness

Psycho:
-ve thoughts
Learned helplessness
Psychodynamic defence mechanisms

Social:
Loss / Bereavement
Life events
Childhood abuse
Social isolation
Social adversity
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3
Q

What is the prognosis like for depression?

What are the chances of relapse?

A

<2/3rd recover within a year
<1/3rd chronic depression (>2yr)
Rest % die by suicide

25% relapse within 1yr
75% relapse within 10yrs

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4
Q

What are the core (3) + additional (7) symptoms of depression?

A

CORE:
Low mood
Anhedonia
Anergia

ADDITIONAL:
Reduced concentration
Reduced appetite
Disturbed sleep
Self-harm/suicidal thoughts/acts
Psychomotor symptoms
Pessimism about future
Feelings of guilt/worthlessness
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5
Q

How long should depressive symptoms technically have been lasting for to be official ‘depressive symptoms’?

A

Symps >2wks

Can be shorter if rapid onset / severe symptoms

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6
Q

What are the biological symptoms (somatic syndrome) of depression? (5)

A 
Early morning awakening
Loss of appetite/ wt loss
Diurnal variation in mood
Psychomotor retardation/agitation
Loss of libido
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7
Q

Describe the delusions that may be experienced in severe depression (3)

A

Mood congruent
Nihilistic (self/others/world ceased to exist)
Persecutory

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8
Q

Describe the hallucinations that may be experienced in severe depression (2)

A

2nd person auditory - derogatory/accusatory

Olfactory - filth/rotting flesh

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9
Q

List the psychiatric DDx for depression (4)

A

Schizophrenia
Anxiety
Eating disorder
Dementia

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10
Q

List the organic DDx for depression (22) (surgical sieve)

A

Infection: HIV / Typhoid / EBV / Syphilis / Herpes
Iatrogenic: Opiates / Steroids / LDOPA
Immune: SLE / RA

Tumour: cerebral tumour / other malignancies (esp panc)
Trauma: head injury / SC injury

Endocrine: Thyroid/Para / Cushing / Addisons

Neuro: CVA / MS / Parkinsons/Huntingtons

Systemic: Renal failure / Porphyria

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11
Q

What drugs may precipitate Depression? (10)

A

Antihypertensives: B-blockers / methyldopa
Steroids: corticosteroids / oral contraceptive
Neuro: BZDs / LDOPA / anticonvulsants (pheny+carba)
Analgesics: opiates / certain NSAIDs (ibu/indo)
Psychiatric: antipsychotics

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12
Q

What physical Ix can be done into depression? (3)

A

Neuro + Endocrine examination
TFTs + Ca levels
LFTs, U+Es, FBC, ESR

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13
Q

What does Step 1 of NICE management of depression consist of? (5)

A

For all known/suspected presentations of Depression:

Assessment/active monitoring
Psychoeducation
Computerised CBT
Self-help guides
Sleep hygiene
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14
Q

What does Step 2 of NICE management of depression consist of? (3)

A

Mild/moderate:

Low intensity psychosocial interventions
Psychological interventions
Medication if moderate

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15
Q

What does Step 3 of NICE management of depression consist of? (3)

A

Moderate/severe unresponsive to Step 2:

Medication
High intensity psychological interventions
Consider secondary referral

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16
Q

What does Step 4 of NICE management of depression consist of? (5)

A

Severe complex / life threatening:

High intensity psychological interventions
MDT
Crisis team
ECT
Inpatient care
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17
Q

List some possible indications for antidepressants (10) (ACID NIMBI)

A 
Anxiety
Chronic fatigue syndrome
IBS
Depression (moderate/severe)
Narcolepsy (TCAs)
Insomnia
Migraines
Bulimia
Impulsivity
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18
Q

What are the SEs of SSRIs? (9) (SAD AND SIC)

A

Sexual Dysfunc (++++)
Apathy/fatigue
Diarrhoea

Akathesia
Nausea
Dizziness

Sweaty
Insomnia
Cardiac teratogenic (paroxetine)

(No weight gain)

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19
Q

When are SNRIs used?

How do SEs compare to SSRIs?

A

2nd/3rd line

Same SEs as SSRIs but more discontinuation symptoms + more sedation

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20
Q

What receptors do TCAs work on? (5)

Why are they less used now?

A 
Serotonin
Dopamine (lesser extent)
Noradrenaline
Alpha-adrenoceptors
Histaminergic

Less SEs + toxic in overdose
However TCAs 1st line in pregnancy as not teratogenic

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21
Q

What are the SEs of TCAs? (SW ADHD) (6)

A 
Sedation
Weight gain (++)

Antimuscarinic (dry mouth, blurred vision, urinary retention, constipation)
Diarrhoea
Hypotension
Delirium

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22
Q

Give some egs of MAOIs (3)
When are MAOIs used?
Why are they rarely used now?

A

Phenylazine, moclobemide (reversible), tranylcypromide

Used in treatment-resistant/ atypical
Rarely used due to tyramide (cheese) interaction

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23
Q

What are the SEs of MAOIs (6)

Study These Flashcards
A 
Dry mouth
Nausea/Diarrhoea/Constipation
Postural hypotension
Sleep disturbances
Headaches
Cheese reaction
24
Q

What is the main NaSSA used? (Noradrenaline + Selective Serotonin Antidepressant)
What are the advantages over SSRIs
Why still used less than SSRIs?

Study These Flashcards
A

Mirtazapine

Poss more effective in depression + anxiety
Can use in combo w. other antidepressants

Some pts get signif sedation/weight gain even on low doses

25
What are the SEs of NaSSA/Mirtazapine (5)
Weight gain (+++) / Increased appetite Drowsiness Dizziness Headache
26
How long is needed when trialling antidepressants before deciding if failed?
3-4wks (continue even if partial improvement by then) upto 12wks in elderly 70% respond to first medication
27
Which antidepressants commonly experience withdrawal/discontinuation symptoms? (2) What are the possible Sx (8)
Paroxetine + Venlafaxine ``` Anxiety + sweating Nausea + vom Tingling + shaking Dizziness Headache Numbness Sleep disturbance/ strange dreams Electric-shock like sensations ```
28
What other biological treatments can be used in depression? (4)
Augmentation with treatment-resistant: Lithium Atypical antipsychotics T3 (triiodothyronine) ECT
29
What psychological interventions are used in Depression? (4)
Self-help materials Psychoeducation CBT Interpersonal Therapy (IPT)
30
What social interventions are used in Depression (5)
``` Work around social inclusion Housing/benefits support Employment/education support Carer support CPN + Outpt appts (for more severe) ```
31
What are the indications for ECT (4)
Treatment-resistant depression Life-threatening depression Treatment-resistant mania Catatonia
32
What are the possible MOAs of ECT
Modulation of NTs Modulation of neuronal connectivity Modulation of neuronal structure (inc hippocampal neurogenesis) Changes in regional blood/activity
33
List the contraindications to ECT (1 absolute + 9 relative)
Absolute: cochlear implant Relative: Raised ICP Intracranial aneurysm H/o cerebral haemorrhage ``` DVT Recent MI Aortic aneurysm Cardiac arrhythmias (uncontrolled) Cardiac failure (decompensated) Acute resp inf ```
34
What are the SEs of ECT? (4)
Headache Confusion Impaired cognitive function Temporary retrograde/anterograde amnesia (+poss long term but inconsistent evidence)
35
Where are the electrodes placed in ECT?
Mid-point b/wn lateral angle of eye + external auditory meatus
36
What are the organic DDx of bipolar disorder (5)
``` Hyperthyroidism (v severe) Metabolic disorders Epilepsy Space-occupying lesions (SOL) - esp frontal lobe Substance misuse (inc. steroids) ```
37
What is the lifetime risk of developing bipolar disorder? M:F ratio? Usual age of onset
1% lifetime risk Males+Females equal Usually late teens/early 20s
38
What are the 3 etiological factors of bipolar?
Genetics: relatives of bipolar have higher risk bipolar/unipolar dep/schizoaffective (but not other way round with unipolar dep) Life events: prolonged stresses/ vulnerability Substance misuse
39
What is the prognosis like in bipolar disorder?
≥90% have further episodes + req >25yr FU 20-30x more likely to die by suicide
40
What factors may contribute to relapse in bipolar disorder (6)
``` Natural/idiopathic Non-concordance with medication Substance misuse Life events/stressors Disruption of circadian rhythm Childbirth ```
41
List the ICD-10 Dx criteria for Hypomania (7)
``` Mild mood elevation Distractibility Mild overspending/risk-taking Sociability/overfamiliarity Increased energy Increased sexual energy Decreased need for sleep ```
42
List the ICD-10 Dx criteria for Mania (9)
``` Marked mood elevation/ agitation Marked distractibility Reckless behaviour Disinhibition Grandiose Flight of ideas Marked increase in sexual energy Increased activity Absent/severe probs with sleep ```
43
How many mood disturbance episodes defines Bipolar?
= at least 2 episodes severe mood disturbance | ≥1 of those being mania/hypomania
44
What are the 3 phases of bipolar disorder?
Acute mania Bipolar depressive phase Maintenance phase (remission/ req relapse prevention)
45
Describe the biopsychosocial management of acute mania (4:1:4)
1st line = Antipsychotic Consider lithium/val (or adjust) Stop any antidepressants BZDs in behav disturbance Psychoeducation (other interventions will be useless) Consider MHA/inpatient Consider calm/low-stim environment Advise not to make serious decisions whilst unwell Advise to maintain relationships with carers
46
Describe the biopsychosocial management of bipolar depressive phase (3:2:3)
Consider atypical Consider lithium/val (or adjust) Consider SSRI (only with mood stabiliser) CBT Psychoeducation Support re: social inclusion / employment / education Carer support Consider inpatient if at risk
47
Describe the biopsychosocial management of the maintenance phase of bipolar (relapse prevention) (3:3:3)
``` Lithium +/or valproate (+ if ineffective // or if intolerable) Antipsychotic 1st line in child-bearing Avoid antidepressant (NB never w/o stabiliser) ``` Family therapy CBT Psychoeducation Support re: social / employment / housing / benefits Carer support CPN/outpt appts to monitor
48
What physical health monitoring must be done in Bipolar? (5)
Healthy eating / physical exercise programme CV/Metabolic/Weight monitoring (annually) Mood stabiliser levels (e.g. lithium weekly then 3m) U&E + TFTs every 6m (with lithium) Contraception/folic acid for childbearing age
49
List the mood stabilisers available (7 - 3 of which antipsychotics)
Lithium Valproate Lamotrigine Carbamazepine Quietiapine Olanzapine Aripiprazole
50
What is another indication for mood stabilisers other than bipolar?
Augmentation for antidepressants in treatment-resistant
51
What is the lithium level range that is aimed for? | What level is assoc w. toxicity?
Aim for 0.4-1.2 mmol/L ``` >1.5 = toxicity >2.5 = serious toxicity medical emergency ```
52
List the common SEs of lithium (6) | G Will Make-sure Finances On PPoint
``` GI upset Wt gain Metallic taste in mouth Fine tremor Oedema Polyuria/dipsia ```
53
What congenital defects are assoc w. lithium in pregnancy? | What is incidence (% risk)
ASD/VSD Ebstein's anomaly (tricuspid abn) 6% risk major malformations
54
What congenital defects / effects are assoc w. valproate in pregnancy? (4) What is incidence (% risk)
Low verbal IQ 30% Autism 6% Congenital malformations 10% Neural tube defects 3%
55
What congenital defects may be seen with lamotrigine? | What is one of the rare/serious SEs with lamotrigine?
Least teratogenic but cleft lip/palate (if in 1st T) Steven-Johnson Syndrome
56
What factors must be considered/discussed when choosing a mood stabiliser (5)
Choose in conjunction w. pt Evaluate evidence / explain best option for pt as indiv Special consideration in childbearing Explain to childbearing women all are teratogens Adequate contraception essential

Psychiatry (11 decks)

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