Mood disorders, suicide & self-harm Flashcards
(164 cards)
1
Q
What percentage of women experience recurrent depressive disorder?
A
20%
2
Q
What percentage of men experience recurrent depressive disorder?
A
8%
3
Q
What is the usual age of onset of recurrent depressive disorder?
A
late 20s
4
Q
What is the F:M ratio for depression?
A
2:1
5
Q
What % of the population has bipolar disorder at any one time?
A
1%
6
Q
What is the average age of onset of bipolar disorder?
A
20
7
Q
What is the male to female ratio for bipolar disorder?
A
Roughly the same
8
Q
What % of the population have cyclothymia?
A
0.5-1%
9
Q
Which age groups does cyclothymia usually begin in?
A
same as for bipolar, around the 20’s
10
Q
What is the incidence difference between M and F in cyclothymia?
A
No difference
11
Q
What % of the population does dysthymia occur in?
A
3-6%
12
Q
What is the average age of onset for dysthymia?
A
Childhood, adolescence or early adulthood
13
Q
What is the F:M ratio for dysthymia?
A
2:1 / 3:1
14
Q
What does the monoamine theory for depression suggest?
A
That depression is due to a shortage of noradrenaline, serotonin and possibly dopamine?
15
Q
Other than monoamines what is likely involved in depression?
A
GABA and various other peptides (this has not yet been proven)
16
Q
Is depression thought to have a genetic element?
A
Yes (a 1st degree relative is thought to be a significant factor)
17
Q
What two traits can families have that increase the relapse of depression?
A
1) High expressed emotion 2) Highly critical
18
Q
What psychiatric condition can increase the risk of depression?
A
Personality disorder
19
Q
Name 4 vulnerability factors for depression.
A
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
20
Q
With no treatment how long will a persons 1st depressive episode last?
A
8-9 months
21
Q
What % of people will have another depressive episode?
A
80%
22
Q
How many times higher is the risk of suicide in a depressed pt?
A
20x
23
Q
How does the monoamine theory for depression apply to bipolar disorder?
A
Manic episodes are thought to be due to an increased central noradrenaline or serotonin level.
24
Q
What is the concordance rate for bipolar disorder in monozygotic twins?
A
65-75%
25
What is the concordance rate for bipolar disorder in dizygotic twins?
14%
26
What % of pt will have another manic episode after their 1st one?
90%
27
What is the average number of manic episodes in 10 years for a bipolar pt?
4
28
What is the average length of a manic episode?
3 months
29
What is defined as rapid cycling dipolar disorder?
4 or more episodes in 1 year. It has a poor prognosis.
30
What % of bipolar pts have rapid cycling dipolar disorder?
5-15%
31
What % of bipolar pts successfully complete suicide?
10-15%
32
What is the nature of the course of cyclothymia and dysthymia?
Insidious onset and chronic course.
33
Which other psychiatric conditions is cyclothymia associated with?
Severe affective disorders, most likely bipolar affective disorder
34
Which other psychiatric conditions is dysthymia associated with?
1) Depression (double depression) 2) Anxiety disorders 3) Borderline personality disorders
35
What is the treatment for cyclothymia and dysthymia?
The same as for bipolar and depression
36
What medications should be used with caution in cyclothymia?
Antidepressants due to the risk of turning mild depressive symptoms into hypomania.
37
Define a feeling.
A short-lived emotional state
38
Define mood
A patients sustained, subjectively experienced state of emotion over a period of time.
39
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
40
How can depressive symptoms be divided when noting them down?
1) Cognitive
2) Biological
3) Psychotic and severe motor symptoms
4) Mood
41
What are the classic psychotic symptoms in depression?
Often mood congruent
1) Criticizing voices (2nd person auditory hallucination)
2) Smell rotting flesh (Olfactory hallucination)
42
Give an example of a motor symptom that occurs in depression.
Stupor (extreme unresponsiveness)
43
What is required for a diagnosis of depression?
4 symptoms including at least 1 core symptom
44
What are the "other" depressive symptoms?
**Mood:**
1) Diurnal variation
**Biological:**
2) Disturbed sleep
3) Diminished appetite
4) Loss of libido
**Cognitive:**
5) Reduced concentration
6) Reduced self-esteem
7) Ideas of guilt and unworthiness
8) Hopelessness
**Dont forget:**
9) Ideas or acts of self-harm or suicide
10) Delusions or hallucinations
11) Psychomotor abnormalities
45
What are the groups of physical conditions that can cause low mood?
1) Neurological 2) Endocrine 3) Infections 4) Drugs 5) Others
46
What are the neurological conditions that can cause low mood?
1) MS 2) Parkinson’s disease 3) Huntington’s disease 4) Stroke
47
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
48
What are the infectious conditions that can cause low mood?
1) Hepatitis 2) Infectious mononucleosis (aka glandular fever) 3) STI's
49
What are the drugs that can cause low mood?
1) Beta-blockers
2) steroids
3) Neurological drugs: carbamazepine, phenytoin, benzodiazepines
4) Analgesics: opiates, ibuprofen
5) Psychiatric: antipsychotics
50
Are men or women more likely to commit suicide?
Men
51
Are women or men more likely to self-harm?
Women
52
Which group have the highest rate of suicide?
Men 15-44
53
What is the leading cause of death in young adults?
Suicide
54
What are the leading methods of suicide in men and women respectively?
Hanging in men and poisoning in women.
55
What three things increase the national suicide rate?
1) springtime 2) economic depression 3) famous suicide (copycat suicide)
56
Is suicide more common in lower or higher social class?
Lower social class
57
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
58
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
59
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?
60
Most antidepressants have been shown to have similar efficacy, except one which is slightly better, which is?
Venlafaxine -\> serotonin-norepinephrine reuptake inhibitor (SNRI)
61
What should you choose an antidepressant based on?
side-effect profile?
62
How long generally does it take for a response to anti-depressants (ADs) to show? (in 60-70% of pts)
4-6 weeks
63
After remission, how long should ADs be continued for?
6 months, before being tapered off.
64
Which conditions are TCAs used for?
1) Depression
2) Anxiety disorders
3) OCD
4) Chronic pain
5) Eating disorders
65
Which conditions are SSRIs used for?
1) Depression
2) Anxiety disorders
3) OCD
4) Bulimia nervosa
66
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)
67
How do tricyclic antidepressants (TCAs) work in depression?
Presynaptically blockade both noradrenaline and serotonin reuptake pumps (and dopamine to a lesser extent).
68
What causes TCAs significant side-effect profile?
Blockade muscarinic, alpha-adrenergic and histaminergic receptors
69
How do selective serotonin re-uptake inhibitors (SSRIs) work?
Selective presynaptic blockade of serotonin re-uptake pumps.
70
Name the common TCAs.
ACID
amitriptyline
clomipramine
imipramine
dosulepin + doxepin
(others include: lofepramine + nortriptyline)
71
Name the common SSRIs.
citalopram, paroxetine, sertraline, fluoxetine
72
Name the common SNRIs.
venlafaxine, duloxetine
73
How do serotonin-noradrenaline reuptake inhibitors (SNRIs) work?
Presynaptic blockade of both the noradrenaline and serotonin reuptake pumps (also dopamine if using high doses)
74
To what extent do SNRIs act on muscarinic, histaminergic and alpha-adrenergic receptors.
A negligible amount
75
How to monoamine oxidase inhibitors (MOAIs) work?
non-selective and irreversible inhibition of monoamine oxidase A and B.
76
Name an MOAI.
isocarboxazid
77
Name a noradrenergic and specific serotonergic antidepressant (NaSSA).
mirtazapine
78
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)
79
Name a noradrenaline reuptake inhibitor (NRI)
reboxetine
80
How do noradrenaline reuptake inhibitors (NRIs) work?
Selective presynaptic blockade of noradrenaline reuptake pumps
81
What side-effects of TCAs can be useful?
The sedative effects.
82
Why are TCAs dangerous in overdose?
as they are cardiotoxic
83
Which TCA is especially cardiotoxic?
amitriptyline
84
Name 3 contraindications for TCAs.
1) Recent MI
2) Arrhythmias
3) Severe liver disease
85
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)
86
What is the minimum length of time a symptoms should be present for before it can be considered depression?
2 weeks
87
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
88
Define mania.
An elevated or irritable mood where the patient may often feel ‘high’.
89
What categories can the symptoms of mania be split into?
Biological, cognitive and psychotic.
90
What are the biological symptoms of mania?
1) Decreased need for sleep 2) Increased energy
91
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
92
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
93
Give 3 examples of disorders of thought form that occur in mania.
Circumstantiality, tangentiality, flight of ideas.
94
How long must symptoms be present for before mania can be diagnosed?
1 week
95
On what is the severity of mania decided in ICD-10?
The degree of psychosocial impairment.
96
Name 4 antimuscarinic side-effects of TCAs.
1) Dry mouth 2) Constipation 3) Urinary retention 4) Blurred vision
97
Name 4 categories of side-effects of TCAs.
1) muscarinic 2) alpha-adrenergic 3) histaminergic 4) cardio toxic effects
98
Name an alpha-adrenergic side effect (s/e)
Postural hypotension
99
Name two histaminergic s/e's of TCAs
1) Weight gain 2) Sedation
100
Name 4 cardiotoxic s/e's of TCAs
1) QT interval prolongation
2) ST segment elevation
3) Heart block
4) Arrhythmias
101
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
102
Which patient groups should SSRIs be used in?
1) Those with cardiac problems
2) Those at risk of overdose (both due to cardiotoxicity)
103
What mental state should SSRIs not be used in?
Mania
104
What are the side effects of SSRIs?
1) GI disturbance (early only): nausea, vomiting, diarrhoea, pain
2) Anxiety and agitation (early only)
3) Sweating
4) Sexual dysfunction (anorgasmia, delayed ejaculation)
5) RElinquish of appetite and weight loss (occasionally weight gain)
6) Insomnia
105
What can a "Cheese" reaction lead to?
A life threatening hypertensive crisis.
106
What is an early sign of a "Cheese" reaction?
A headache
107
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)
108
Chemically what is "serotonin syndrome"?
When medication (mainly AD) cause too much serotonin to be released in the CNS.
109
Other than ADs what can cause serotonin syndrome when combined with an MAOI?
Opiates
110
What are the side effects of MAOIs?
Similar to TCAs including postural hypotension and anticholinergic effects.
111
What is a discontinuation syndrome?
When you stop ADs quickly it leads to s/e. (Note: this is not a dependance syndrome or addiction)
112
What side effects occur with a discontinuation syndrome?
FINISH:
**F**lu-like symptoms
**I**nsomnia
**N**ausea
**I**mbalance
**S**ensory disturbances
**H**yperarousal (anxiety/agitation)
113
Which medications are particularly likely to cause a discontinuation syndrome?
SSRIs with short half lives (e.g. paroxetine) and venlafaxine (SNRI) are particular culprits
114
How can discontinuation syndrome be avoided?
Gradually tapering down ADs before stopping.
115
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)
116
How do mood stabilisers work?
It is not actually known
117
What is the theory of how lithium works?
It modulates the neurotransmitter induced activation of second messenger systems
118
What are the theorys of how valproate and carbamazepine work respectively?
1) carbamazepine is a GABA receptor agonist
2) valporate inhibits GABA transaminase
119
What are the main indications for lithium?
1) acute mania
2) prophylaxis of bipolar affective disorder
3) treatment resistant depression (lithium augmentation)
120
What are the main indications for valproate?
1) epilepsy
2) acute mania
3) prophylaxis of bipolar affective disorder
121
What are the main indications for carbamazepine?
1) epilepsy 2) prophylaxis of bipolar affective disorder (if unresponsive to lithium) 3) rapid cycling bipolar disorder
122
What is the therapeutic range for lithium?
0.5-1.2mmol/L
123
Via which route is lithium excreted?
Via the kidneys
124
What causes a decrease in lithium excretion?
1) Renal insufficiency
2) Sodium depletion
3) Diuretics
4) NSAIDs
5) ACEIs
125
What is the effect of taking APs with lithium?
Increases lithium neurotoxicity
126
What is the effect of lithium on the thyroid?
It leads to hypothyroidism and goitre
127
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)
128
Describe the monitoring of lithium.
Kidney + thyroid function 6 monthly
Blood levels:
1) Monitor weekly until stable (for 4 weeks)
2) 3 monthly for the following year
3) Then 6 monthly monitoring
129
What are the contraindications to lithium?
1) pregnancy
2) renal insufficiency
3) thyroid disease
4) cardiac conditions
5) neurological conditions (e.g. Parkinson’s or Huntington’s)
130
What tests should be done before starting Carbamazepine and Sodium Valporate?
1) LFTs
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)
131
When should ECT be used for depression?
Its not 1st line. Used when there is:
Severe depression:
1) life-threatening poor fluid intake
2) strong suicidal intent
3) psychotic features or stupor
OR
4) antidepressants are ineffective or not tolerated
OR
5) A mother who has just given birth to reunite with baby
132
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)
133
What can ECT be used in?
1) Depression
2) Established mania
3) Schizophrenia
4) Puerperal psychosis (new mothers) to rapidly reunite her with her baby
134
What specific types of schizophrenia is ECT generally used in?
1) catatonic states
2) positive psychotic symptoms
3) schizoaffective disorder
135
What is the general course for ECT?
2-3 times per week and most patients need 4-12 treatments
136
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.
137
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.
138
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.)
139
How can memory loss be reduced in ECT?
Using unilateral ECT.
140
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
141
What are the mood disorders?
Disorders affecting the mood: 1) depression 2) mania (bipolar) 3) cyclothymia 4) dysthymia 5) hypomania
142
What are the main psychological interventions in mood disorder?
1) counselling and supportive psychotherapy
2) psychodynamic/psychoanalytic psychotherapy
3) cognitive behavioural therapy
143
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.
144
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.
145
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
146
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.
147
What are the main types of psychological intervention in depression?
1) CBT
2) psychodynamic therapy
Also:
3) IPT
4) group therapy
148
What are the main types of psychological intervention in Anxiety disorder, OCD and PTSD?
1) CBT
2) psychodynamic therapy
Also:
3) Systematic desensitization
4) hypnotherapy
149
What are the main types of psychological intervention in schizophrenia?
1) CBT
Also:
2) Family therapy
150
What are the main types of psychological intervention in eating disorder?
1) CBT
Also:
2) Family therapy
3) IPT
151
What are the main types of psychological intervention in borderline personality disorder?
1) Psychodynamic therapy
Also:
2) Therapeutic communities
152
What are the main types of psychological intervention in alcohol dependence?
1) CBT
Also:
2) Group therapy
153
What neurotransmitters does MAO-A degrade?
NA, adrenaline, serotonin and dopamine
154
What neurotransmitters does MAO-B degrade?
Dopamine
(Also: benzylamine and phenylethylamine)
155
Name some common antimuscarinic symptoms.
1. Blurred vision
2. Dry mouth
3. Constipation
4. Urinary retention
156
Name a common α-adrenergic side-effect due to TCAs.
Postural hypotension
157
Name some common histaminergic side-effects due to TCAs.
1. Weight gain
2. Sedation
158
What are the cardiotoxic side-effects that TCAs can cause?
1. QT interval prolongation
2. ST segment elevation
3. Heart block
4. Arrhythmias
159
What are the abnormal beliefs that occur in mania?
2ry delusions
160
What pathology can pushed a diagnosis of hypomania to being full blown mania?
Psychotic psychopathology specifically
delusions
and
hallucinations.
161
What are the mood symptoms of depression?
Mood:
1) Diurnal variation
162
What are the biological symptoms of depression?
Biological:
1) Disturbed sleep
2) Diminished appetite
3) Loss of libido
163
What are the cognitive symptoms of depression?
Cognitive:
6) Reduced concentration
7) Reduced self-esteem
8) Ideas of guilt and unworthiness
9) Hopelessness
164
What are the 'Don't forget' symptoms of depression?
Ideas or acts of self-harm or suicide
Delusions or hallucinations
psychomotor abnormalities
