What percentage of women experience recurrent depressive disorder?
What percentage of men experience recurrent depressive disorder?
What is the usual age of onset of recurrent depressive disorder?
What is the F:M ratio for depression?
What % of the population has bipolar disorder at any one time?
What is the average age of onset of bipolar disorder?
What is the male to female ratio for bipolar disorder?
Roughly the same
What % of the population have cyclothymia?
Which age groups does cyclothymia usually begin in?
same as for bipolar, around the 20's
What is the incidence difference between M and F in cyclothymia?
What % of the population does dysthymia occur in?
What is the average age of onset for dysthymia?
Childhood, adolescence or early adulthood
What is the F:M ratio for dysthymia?
2:1 / 3:1
What does the monoamine theory for depression suggest?
That depression is due to a shortage of noradrenaline, serotonin and possibly dopamine?
Other than monoamines what is likely involved in depression?
GABA and various other peptides (this has not yet been proven)
Is depression thought to have a genetic element?
Yes (a 1st degree relative is thought to be a significant factor)
What two traits can families have that increase the relapse of depression?
1) High expressed emotion 2) Highly critical
What psychiatric condition can increase the risk of depression?
Name 4 vulnerability factors for depression.
1) 3 or more children at home under the age of 14
2) Not working outside the home
3) Lack of a confiding relationship
4) Loss of mother before the age of 11
With no treatment how long will a persons 1st depressive episode last?
What % of people will have another depressive episode?
How many times higher is the risk of suicide in a depressed pt?
How does the monoamine theory for depression apply to bipolar disorder?
Manic episodes are thought to be due to an increased central noradrenaline or serotonin level.
What is the concordance rate for bipolar disorder in monozygotic twins?
What is the concordance rate for bipolar disorder in dizygotic twins?
What % of pt will have another manic episode after their 1st one?
What is the average number of manic episodes in 10 years for a bipolar pt?
What is the average length of a manic episode?
What is defined as rapid cycling dipolar disorder?
4 or more episodes in 1 year. It has a poor prognosis.
What % of bipolar pts have rapid cycling dipolar disorder?
What % of bipolar pts successfully complete suicide?
What is the nature of the course of cyclothymia and dysthymia?
Insidious onset and chronic course.
Which other psychiatric conditions is cyclothymia associated with?
Severe affective disorders, most likely bipolar affective disorder
Which other psychiatric conditions is dysthymia associated with?
1) Depression (double depression) 2) Anxiety disorders 3) Borderline personality disorders
What is the treatment for cyclothymia and dysthymia?
The same as for bipolar and depression
What medications should be used with caution in cyclothymia?
Antidepressants due to the risk of turning mild depressive symptoms into hypomania.
Define a feeling.
A short-lived emotional state
A patients sustained, subjectively experienced state of emotion over a period of time.
Which three (core) symptoms are particularly important in depression?
1) Anhedonia --> A markedly reduced interest in almost all activities and a lack of ability to derive pleasure from these activities that were formerly enjoyed
2) Anergia --> Lack of energy or increased fatigability on minimal exertion leading to diminished activity
3) Low mood
How can depressive symptoms be divided when noting them down?
3) Psychotic and severe motor symptoms
What are the classic psychotic symptoms in depression?
Often mood congruent
1) Criticizing voices (2nd person auditory hallucination)
2) Smell rotting flesh (Olfactory hallucination)
Give an example of a motor symptom that occurs in depression.
Stupor (extreme unresponsiveness)
What is required for a diagnosis of depression?
4 symptoms including at least 1 core symptom
What are the "other" depressive symptoms?
1) Diurnal variation
2) Disturbed sleep
3) Diminished appetite
4) Loss of libido
5) Reduced concentration
6) Reduced self-esteem
7) Ideas of guilt and unworthiness
9) Ideas or acts of self-harm or suicide
10) Delusions or hallucinations
11) Psychomotor abnormalities
What are the groups of physical conditions that can cause low mood?
1) Neurological 2) Endocrine 3) Infections 4) Drugs 5) Others
What are the neurological conditions that can cause low mood?
1) MS 2) Parkinson’s disease 3) Huntington’s disease 4) Stroke
What are the endocrine conditions that can cause low mood?
1) Cushing’s disease 2) Addison’s disease 3) Thyroid disorders 4) Parathyroid disorders 5) Menstrual cycle-related
What are the infectious conditions that can cause low mood?
1) Hepatitis 2) Infectious mononucleosis (aka glandular fever) 3) STI's
What are the drugs that can cause low mood?
3) Neurological drugs: carbamazepine, phenytoin, benzodiazepines
4) Analgesics: opiates, ibuprofen
5) Psychiatric: antipsychotics
Are men or women more likely to commit suicide?
Are women or men more likely to self-harm?
Which group have the highest rate of suicide?
What is the leading cause of death in young adults?
What are the leading methods of suicide in men and women respectively?
Hanging in men and poisoning in women.
What three things increase the national suicide rate?
1) springtime 2) economic depression 3) famous suicide (copycat suicide)
Is suicide more common in lower or higher social class?
Lower social class
What are the aspects of a suicide attempt that suggest a person actually wished to end their life?
1) The attempt was planned in advance
2) Precautions were taken to avoid discovery or rescue
3) A dangerous method was used e.g. firearms
4) No help was sought after the act
Describe the management of a suicide attempt.
1) Perform a MSE (ensure patient isnt drunk or drugged)
2) Perform a risk asessment
3) Decide if the pt needs to be admitted to psych hospital or released into the community with/without a CPN
What should you ask in a post-suicide risk assessment?
1) Current mood state – is there any regret or ongoing suicidal ideation. Features of hopelessness or worthlessness are associated with higher risk of suicide
2) Ascertain protective factors – anything to stop the patient doing it again i.e. not wanting to leave their kids alone
3) Check for an undiagnosed mental illness – especially depression, schizophrenia, alcohol dependence and personality disorders
4) Social support – what do they have available to them if discharged, do they have the ability to cope?
Most antidepressants have been shown to have similar efficacy, except one which is slightly better, which is?
Venlafaxine -> serotonin-norepinephrine reuptake inhibitor (SNRI)
What should you choose an antidepressant based on?
How long generally does it take for a response to anti-depressants (ADs) to show? (in 60-70% of pts)
After remission, how long should ADs be continued for?
6 months, before being tapered off.
Which conditions are TCAs used for?
2) Anxiety disorders
4) Chronic pain
5) Eating disorders
Which conditions are SSRIs used for?
2) Anxiety disorders
4) Bulimia nervosa
What is the general mechanism of action of ADs?
To increase neurotransmitters in the brain (this can be done through the dopamine, serotonin or noradrenaline pathway)
How do tricyclic antidepressants (TCAs) work in depression?
Presynaptically blockade both noradrenaline and serotonin reuptake pumps (and dopamine to a lesser extent).
What causes TCAs significant side-effect profile?
Blockade muscarinic, alpha-adrenergic and histaminergic receptors
How do selective serotonin re-uptake inhibitors (SSRIs) work?
Selective presynaptic blockade of serotonin re-uptake pumps.
Name the common TCAs.
dosulepin + doxepin
(others include: lofepramine + nortriptyline)
Name the common SSRIs.
citalopram, paroxetine, sertraline, fluoxetine
Name the common SNRIs.
How do serotonin-noradrenaline reuptake inhibitors (SNRIs) work?
Presynaptic blockade of both the noradrenaline and serotonin reuptake pumps (also dopamine if using high doses)
To what extent do SNRIs act on muscarinic, histaminergic and alpha-adrenergic receptors.
A negligible amount
How to monoamine oxidase inhibitors (MOAIs) work?
non-selective and irreversible inhibition of monoamine oxidase A and B.
Name an MOAI.
Name a noradrenergic and specific serotonergic antidepressant (NaSSA).
How do noradrenergic and specific serotonergic antidepressant (NaSSA) work?
Presynaptic blockage of:
α2-adrenoceptor autoreceptors (I think it blocks all α2-adrenoceptors but to have its effect it is the autoreceptors that matter)
certian serotonin receptors
(results in increased noradrenaline and serotonin from presynaptic neurons)
Name a noradrenaline reuptake inhibitor (NRI)
How do noradrenaline reuptake inhibitors (NRIs) work?
Selective presynaptic blockade of noradrenaline reuptake pumps
What side-effects of TCAs can be useful?
The sedative effects.
Why are TCAs dangerous in overdose?
as they are cardiotoxic
Which TCA is especially cardiotoxic?
Name 3 contraindications for TCAs.
1) Recent MI
3) Severe liver disease
Describe the 4 groups of side-effects from TCAs. (I have included specific symptoms in the answer, however these make up a separate question)
1) Muscarinic (dry mouth, constipation, urinary retention and blurred vision)
2) Alpha-adrenergic (postural hypotension)
3) Histaminergic (weight gain, sedation)
4) Cardio toxic effects (QT interval prolongation, ST segment elevation, heart block, arrhythmias)
What is the minimum length of time a symptoms should be present for before it can be considered depression?
What is diagnosed when a patient has a mixture of manic and depressive symptoms at the same time (or in very short succession)?
Mixed affective disorder
An elevated or irritable mood where the patient may often feel ‘high’.
What categories can the symptoms of mania be split into?
Biological, cognitive and psychotic.
What are the biological symptoms of mania?
1) Decreased need for sleep 2) Increased energy
What are the cognitive symptoms of mania? (note some overlay into psychotic psychopathology)
1) Elevated self-esteem (can lead to grandiosity but would ∴ be a psychotic symptom)
2) Accelerated thinking
3) Poor concentration
4) Impaired judgement
5) Poor insight
What are the psychotic symptoms of mania?
1) Disorders of thought form
2) Perceptual disturbances (altered intensity of perceptions) such as hallucinations, pseudohallucination and illusions
3) Abnormal beliefs --> mainly 2ry delusions
Give 3 examples of disorders of thought form that occur in mania.
Circumstantiality, tangentiality, flight of ideas.
How long must symptoms be present for before mania can be diagnosed?
On what is the severity of mania decided in ICD-10?
The degree of psychosocial impairment.
Name 4 antimuscarinic side-effects of TCAs.
1) Dry mouth 2) Constipation 3) Urinary retention 4) Blurred vision
Name 4 categories of side-effects of TCAs.
1) muscarinic 2) alpha-adrenergic 3) histaminergic 4) cardio toxic effects
Name an alpha-adrenergic side effect (s/e)
Name two histaminergic s/e's of TCAs
1) Weight gain 2) Sedation
Name 4 cardiotoxic s/e's of TCAs
1) QT interval prolongation
2) ST segment elevation
3) Heart block
Generally how do the side effects of TCAs differ from SSRIs?
1) SSRIs have fewer anticholingergic (aka antimuscarinic) side effects than TCAs
2) SSRIs are less sedating than TCAs
3) SSRIs are less cardiotoxic
Which patient groups should SSRIs be used in?
1) Those with cardiac problems
2) Those at risk of overdose (both due to cardiotoxicity)
What mental state should SSRIs not be used in?
What are the side effects of SSRIs?
1) GI disturbance (early only): nausea, vomiting, diarrhoea, pain
2) Anxiety and agitation (early only)
4) Sexual dysfunction (anorgasmia, delayed ejaculation)
5) RElinquish of appetite and weight loss (occasionally weight gain)
What can a "Cheese" reaction lead to?
A life threatening hypertensive crisis.
What is an early sign of a "Cheese" reaction?
Why should one be careful of prescribing a MAOI when the patient is on another AD? (How can any complications be avoided)
As being on an MAOI and another AD can lead to a serotonin syndrome which can be potentially lethal. (Have a 2-3 week break of no AD between being on an MAOI and starting anther AD)
Chemically what is "serotonin syndrome"?
When medication (mainly AD) cause too much serotonin to be released in the CNS.
Other than ADs what can cause serotonin syndrome when combined with an MAOI?
What are the side effects of MAOIs?
Similar to TCAs including postural hypotension and anticholinergic effects.
What is a discontinuation syndrome?
When you stop ADs quickly it leads to s/e. (Note: this is not a dependance syndrome or addiction)
What side effects occur with a discontinuation syndrome?
Which medications are particularly likely to cause a discontinuation syndrome?
SSRIs with short half lives (e.g. paroxetine) and venlafaxine (SNRI) are particular culprits
How can discontinuation syndrome be avoided?
Gradually tapering down ADs before stopping.
What are the common mood stabilisers?
1) Lithium 2) Valproate (anticonvulsant) 3) Carbamazepine (anticonvulsant) (There are some other anticonvulsants being investigated for mood stabilisation properties)
How do mood stabilisers work?
It is not actually known
What is the theory of how lithium works?
It modulates the neurotransmitter induced activation of second messenger systems
What are the theorys of how valproate and carbamazepine work respectively?
1) carbamazepine is a GABA receptor agonist
2) valporate inhibits GABA transaminase
What are the main indications for lithium?
1) acute mania
2) prophylaxis of bipolar affective disorder
3) treatment resistant depression (lithium augmentation)
What are the main indications for valproate?
2) acute mania
3) prophylaxis of bipolar affective disorder
What are the main indications for carbamazepine?
1) epilepsy 2) prophylaxis of bipolar affective disorder (if unresponsive to lithium) 3) rapid cycling bipolar disorder
What is the therapeutic range for lithium?
Via which route is lithium excreted?
Via the kidneys
What causes a decrease in lithium excretion?
1) Renal insufficiency
2) Sodium depletion
What is the effect of taking APs with lithium?
Increases lithium neurotoxicity
What is the effect of lithium on the thyroid?
It leads to hypothyroidism and goitre
What tests should be done before starting lithium?
1) FBC (can cause leukocytosis)
2) eGFR/U+E's (as its renally excreted + can be renotoxic)
3) TFT (as thyrotoxic)
4) ECG (as somewhat cardiotoxic)
5) Pregancy test (as teratogenic)
Describe the monitoring of lithium.
Kidney + thyroid function 6 monthly
1) Monitor weekly until stable (for 4 weeks)
2) 3 monthly for the following year
3) Then 6 monthly monitoring
What are the contraindications to lithium?
2) renal insufficiency
3) thyroid disease
4) cardiac conditions
5) neurological conditions (e.g. Parkinson’s or Huntington’s)
What tests should be done before starting Carbamazepine and Sodium Valporate?
2) Haematological function prior and soon after starting these drugs (i.e. FBC, blood film, etc)
(due to the risk of serious blood and hepatic disorders)
When should ECT be used for depression?
Its not 1st line. Used when there is:
1) life-threatening poor fluid intake
2) strong suicidal intent
3) psychotic features or stupor
4) antidepressants are ineffective or not tolerated
5) A mother who has just given birth to reunite with baby
When is ECT used in mania? (what is the paradoxical nature of this)
Used in established mania. (but can precipitate a manic episode in bipolar disorder)
What can ECT be used in?
2) Established mania
4) Puerperal psychosis (new mothers) to rapidly reunite her with her baby
What specific types of schizophrenia is ECT generally used in?
1) catatonic states
2) positive psychotic symptoms
3) schizoaffective disorder
What is the general course for ECT?
2-3 times per week and most patients need 4-12 treatments
Explain the procedural process of ECT.
1) An anaesthetist gives a short acting inducing agent and muscle relaxant that ensures about 5 minutes of general anaesthesia.
2) Electrodes are then placed bilaterally or unilaterally on the patients head and an electric current of sufficient charge is delivered to affect a generalized seizure lasting for 15 seconds or greater in duration.
Explain how ECT works.
It is not clear how ECT works. It causes a release of neurotransmitters in the brain as well as hypothalamic and pituitary hormones whilst also affecting neurotransmitter receptors and second-messenger systems thereby resulting in a transient increase in blood-brain barrier permeability.
What are the potential s/e's of ECT?
1) Loss of memory (particularly for events surrounding the ECT process).
2) Impairment of autobiographical memory.
3) Minor complains such as nausea, confusion, headache and muscle pains in 80% of pts.
(4) In patients on antidepressants and antipsychotics a prolonged seizure may occur due to a lowered seizure threshold.)
How can memory loss be reduced in ECT?
Using unilateral ECT.
What are the contraindications for ECT?
There are none (e.g. as it may prevent suicide in depressed pts) Relative contraindications include:
1) Heart disease
2) Raised intracranial pressure
3) Risk of cerebral bleeding
4) Poor anaesthetic risk
What are the mood disorders?
Disorders affecting the mood: 1) depression 2) mania (bipolar) 3) cyclothymia 4) dysthymia 5) hypomania
What are the main psychological interventions in mood disorder?
1) counselling and supportive psychotherapy
2) psychodynamic/psychoanalytic psychotherapy
3) cognitive behavioural therapy
Briefly describe supportive psychotherapy.
Emphasis relies on the client using their own strength with the therapist being reflective and empathetic.
Generally brief and for minor mental health issues. (least complex type of psychological intervention)
It is NOT time limited.
Briefly describe psychodynamic/psychoanalytic psychotherapy.
Essentially past-issues have led to the pts psychiatric disorder but they are unable to identify these past-issues due to defence mechanisms of their mind. The mind prevent the person recalling these issues as it causes anxiety when thought of by the patient. The issues are uncovered using:
1) Transference --> patient inappropriately transfers feelings or attitudes experienced in an earlier significant relationship onto the therapist.
2) Counter-transference --> therapist transfers feelings from the course of the therapy onto patient. The therapist can use these feelings to empathise with the patient.
Psychodynamic --> Therapist and patient are face to face. Once per week for 50 mins and can last longer than 6 months and is not time limited.
Psychoanalytic --> patient is on a couch with therapist out of view behind and the sessions are not time limited. It also can last longer than 6 months and is not time limited.
Briefly describe cognitive behavioural therapy.
Person has automatic negative thoughts (e.g. I am going to fail) which then produce dysfunctional assumptions (e.g. If i dont pass im completely useless), pt and therapist then test these assumptions using behavioural experiments. CBT main points:
1) CBT is time-limited (12 - 25 sessions)
2) goal-orientated (i.e. does look back at pts past)
3) pt + therapist jointly decide agenda of sessions
4) involves homework
Other than the three main types of psychological intervention name 4 other types.
1) Interpersonal therapy (IPT) – evaluating social interactions and skills
2) Group therapy – shows pt their not alone + supportive enviroment
3) Family therapy – focuses on improving communication and reducing conflict
4) Therapeutic communities – cohesive residential units that consist of about 30 patients for 9-18 months. The residents are encourage to take responsibility for themselves during this time and are particularly useful for personality disorders.
What are the main types of psychological intervention in depression?
2) psychodynamic therapy
4) group therapy
What are the main types of psychological intervention in Anxiety disorder, OCD and PTSD?
2) psychodynamic therapy
3) Systematic desensitization
What are the main types of psychological intervention in schizophrenia?
2) Family therapy
What are the main types of psychological intervention in eating disorder?
2) Family therapy
What are the main types of psychological intervention in borderline personality disorder?
1) Psychodynamic therapy
2) Therapeutic communities
What are the main types of psychological intervention in alcohol dependence?
2) Group therapy
What neurotransmitters does MAO-A degrade?
NA, adrenaline, serotonin and dopamine
What neurotransmitters does MAO-B degrade?
(Also: benzylamine and phenylethylamine)
Name some common antimuscarinic symptoms.
- Blurred vision
- Dry mouth
- Urinary retention
Name a common α-adrenergic side-effect due to TCAs.
Name some common histaminergic side-effects due to TCAs.
- Weight gain
What are the cardiotoxic side-effects that TCAs can cause?
- QT interval prolongation
- ST segment elevation
- Heart block
What are the abnormal beliefs that occur in mania?
What pathology can pushed a diagnosis of hypomania to being full blown mania?
Psychotic psychopathology specifically
What are the mood symptoms of depression?
1) Diurnal variation
What are the biological symptoms of depression?
1) Disturbed sleep
2) Diminished appetite
3) Loss of libido
What are the cognitive symptoms of depression?
6) Reduced concentration
7) Reduced self-esteem
8) Ideas of guilt and unworthiness
What are the 'Don't forget' symptoms of depression?
Ideas or acts of self-harm or suicide
Delusions or hallucinations