1
Q
What are the ICD-10 core features of depression?
A
- Low mood
- Anhedonia (inability to enjoy oneself)
- Anergia (lack of energy)
2
Q
What are the adjunct symptoms of depression?
A
- Insomnia/early waking
- Poor concentration
- Increased OR descreased appetite/weight
- Suicidal thoughts/acts
- Agitation OR Slowing of movements
- Guilt/Self blame
- Low libido
3
Q
Name medication known to cause depression.
A
- Steroids
- COCP
- Beta-blockers (propranolol)
- Statins
- Ranitidine
- Retinoids (isotretinoin)
- Chemo
- HIV medications
4
Q
What is seasonal affective disorder?
A
Episodes of depression, recurring annually at the same time in the year with remission in between
5
Q
What is atypical depression?
A
Somatic symptoms (weight gain, hypersomnia)
- Symptoms are opposite of expected/classical depression
6
Q
What is anxiety-induced insomnia?
A
- Lack of sleep/ability to fall to sleep due to anxiety
- An increase in sleep + eating = increased mood
7
Q
What is agitated depression?
A
Psychomotor agitation instead of retardation
8
Q
What is depressive stupor?
A
Psychomotor retardation so bad that they grind to halt
9
Q
What are some causes of depression, split into biological or psychosocial factors?
A
- Biological
- Endocrine - chronic stress (increased cortisol causes decreased neurotrophin expression and damaged hippocampal neurones)
- Illness - direct (Cushing’s) or indirect (cancer)
- Medication - steroids, anti-HTN, COCP
- Psychosocial
- Childhood - adverse events/abuse/criticism etc
- Vulnerability - reduced resilience due to unemployment, isolation
- Life events - death, divorce, jail
- Substance abuse
10
Q
What investigations should be done for suspected depression?
A
- Full history/collateral history
- Physical exam
- Bloods
- FBC (anaemia), TFT (hypothyroid), glucose/HbA1c (diabetes), U&Es, calcium
- HIV, Syhillis, drug screening
- Imaging – rule out intracranial physical pathology
- Screening Scale
- PHQ9, HADS, BDI-II (adults) or CDI (children) – EPDS (pregnancy)
- MSE
11
Q
What might be expected in a depressed patients MSE?
A
- Apearance and Behaviour - signs of neglect, dehydration, miserable, disinterested, anxious movements, poor eye contact, tearful, posture
- Speech - slow, quiet, mute
- Emotion - restricted range of affect, Nihilism (exsistence is meaningless and useless)
- Perception - if severe: hallucinations, nilihistic or persectutory delusions, evil images, guilt
- Thought - Beck’s triad
- Insight - Nil
- Cognition - psychomotor retardation can mimic cognitive impairment
12
Q
What differential diagnoses should be considered in depression?
A
- Physical – hypothyroid, head injury, ‘quiet’ delirium, low Vit D, drug-induced, Parkinson’s, Chronic diseases/pain, anaemia
- Adjustment disorder – mild affective symptoms following life events à do not reach the severity of depression
- Bereavement – normal grief for <6m
- BPAD, schizoaffective disorder, schizophrenia – previous mania or psychotic features
- Substance withdrawal/misuse
- Postnatal – depression/puerperal illness
- Dementia
- Pseudodementia is global memory loss in severe depression
13
Q
What is Pseudodementia?
A
Global memory loss in severe depression
14
Q
What is the management of mild depression in children/young people?
A
- 1st line: Watchful waiting (for 2 weeks, and follow-up)
- Self-help (mind.org, youngminds.org)
- Lifestyle advice (i.e. sleep hygiene, diet, exercise)
- 2nd line: CBT (digital, group)
- Not successful/sufficient improvement in 2-3m = referral to CAMHS
- Treated in primary care
15
Q
What is the management of moderate to severe depression in children/young people?
A
- 5-11yo – psychological intervention:
- Family-based IPT (Interpersonal Therapy); OR
- Family therapy; OR
- Individual CBT
- 12-18yo – psychological intervention:
- Individual CBT
- If needs arent met then family therapy, IPT-A (“Adolescents”), psychodynamic psychotherapy
- SSRI (fluoxetine) can be added but is rare and avoided in must cases
- Treated in CAMHS
16
Q
Which anti-depressant is specifically licenced for it use in children?
A
Fluoxetine
17
Q
What is the management of depression which is unresponsive to treatement in children/young people?
A
- Intensive psychological therapy
- Treated by CAMHS
18
Q
What is the management of depression in adults?
A
- CHECK SUICIDE RISK: suicidal acts or intent? Have they made plans? P**rotective factors/risk factors?
- Step 1 – Indications: initial suspected depression or subthreshold symptoms
- Watchful waiting with follow-up in 2 weeks
- Education – sleep hygiene, exercise, self-help, information, support
- Step 2 – Indications: mild depression or persistent subthreshold symptoms
- Low-intensity psychosocial interventions:
- Group/Computerised CBT
- Guided self-help (based on the principles of CBT)
- Structured group physical activity programme
- Medications if:
- History of moderate-to-severe depression
- Subthreshold depressive symptoms lasting >2 years
- Mild depression complicating care of chronic physical health problems
- Low-intensity psychosocial interventions:
- Step 3 – Indications: moderate depression or refractory persistent subthreshold symptoms
- High-intensity psychosocial interventions
- Individual CBT
- Interpersonal Therapy (IPT)
- IPT > CBT if due to death
- Medications - regular review: every 2 weeks for 3 months; every week if suicidal
- High-intensity psychosocial interventions
- Step 4 – Indications: severe depression or risk to life or neglect
- If suicidal = urgent referral to crisis team
- High-intensity psychosocial interventions
- Medications
- ECT if necessary
- Section via 2, 3 or 4 if necessary
19
Q
What are the risk factors for suicide?
A
Risk factors = young male, occupation (doctor, vet), live alone, mental illness, unmarried
20
Q
In what order are anti-depressants prescribed in adults?
A
- 1st line = SSRI (sertraline, citalopram, fluoxetine, paroxetine):
- Sertraline: stepped increase from 50mg to 200mg (50mg increase every 2 weeks; over 6 weeks)
- 2 trials of SSRIs before moving to 2nd line
- 2nd line = Taper down SSRI and switch to SNRI (venlafaxine, duloxetine):
- Venlafaxine: stepped increase from 37.5mg BD to 75mg BD to 75mg morning + 150mg evening
- 3rd line/Treatment resistant = Augment treatment with:
- Antipsychotic (i.e. quetiapine 150-300mg)
- Lithium (blood level of 0.4-0.8)
- Other antidepressant (e.g. mirtazapine or mianserin)
- 4th line = ECT
21
Q
What should be checked at every review of a depressed individual?
A
- Any new suicidal indeation
- Compliance to medication
22
Q
What is “Catch-up” phenomena?
A
- Recovery from depression with treatment, which is subsequently stopped, and that person falls back into depression leads to a worse depression state than before
23
Q
How should anti-depressants be used in pregnancy?
A
- No antidepressant is specifically licenced for use in pregnancy
- No antidepressant has been found to cause significant negative effects to the foetus or mother during pregnancy
- However, the lowest-effective dose should be used if possible
- Paroxetine may have mild risks:
- 1st trimester = congenital heart defects
- 3rd trimester = persistent pulmonary hypertension
- Mild or moderate depression = encourage to taper down and switch (if possible)
- Mild - facilitated self-help
- Moderate - CBT (or switch to a drug with lower risk of adverse effects)
- Severe depression = continue antidepressant or switch to a drug with lower risk of adverse effects
24
Q
Define psychotic depression.
A
A severe depression with delusions and hallucinations
25
How can a schizophrenic delusion be distinguished from a depressed delusion?
* Ask why is that?
* "He wants to kill me with an axe"
* Psychotic depression = ‘the world is better off without me’
* Schizophrenia = ‘I have no idea, but I got the message’
26
Why does suicidal ideation increase in the first few weeks of SSRI use?
* Medication takes some time to make a patient feel better
* However, they do improve motivation
* Makes any ideas of suicide more likely to follow through on them
27
What are the risk factors for serotonin syndrome?
* Antidepressants – especially combination or overdose
* Lithium
* ECT
* Opiates
28
What are the complications of serotonin syndrome?
* DIC
* Rhabdomyolysis
* Renal failure
* Seizures
29
What is the ICD-10 defintion of BPAD?
* **≥2 episodes**
* ****1 must be manic associated (hypomania/mania/mixed; the other can be depressive); AND
* Mania lasts ~ 4m
* Depression lasts ~ 6m
* **Complete recovery** between 2 episodes
30
What percentage of BPAD patients will experience depression after mania?
\>90%
31
What might be expected in a BPAD patient with mania MSE?
* Apearance and Behaviour - excitable, irritable, distracted, inapprpriate/flashy clothing
* Speech - pressured, mutism (severe cases)
* Emotion - increased self-esteem, grandiose, labile mood, irritable, insomnia, loss of inhibition, increased appetite
* Perception - Grandiose delusions, paranoia, catatonia (stupor)
* Thought - flights of ideas, racing thought, over-optimism, suicidal ideas, Schneider's 1st rank symptoms (not present outside of manic episode)
* Insight - Minimal - reckless/risky behaviour - particularly sexual
* Cognition - Nil
32
Define mania.
A distinct period of abnormally and persistently elevated, expansive or irritable mood with ≥3 characteristics of mania, lasting at least 7 days (ICD-10)
* Impairs occupational/social functioning
* ± Psychosis
33
Define hypomania.
\>3 characteristic symptoms of mania lasting ≥4 days
* Does not impair occupational/social functioning / no psychosis or delusions
* Slightly less exaggerated mania symptoms
* Mildly elevated mood; feeling of well-being, mental, or physical efficiency
34
What is mixed bipolar?
Mixture, or rapid alternation (within a few hours) of manic/hypomanic and depressive symptoms
35
Define Type 1 BPAD.
Manic episodes interspersed with depressive episodes
36
Define Type 2 BPAD.
Recurrent depressive episodes, with less prominent hypomanic episodes
37
Define Rapid cycling BPAD.
≥4 episodes/year
38
What does Rapid cycling BPAD respond well to?
Sodium valporate
39
What are the risk factors for BPAD?
* Genetics - 1st degree relative = 7x increase
* Stressful life events are triggers - e.g. pregnancy
* More common in upper social classes
40
What biological changes occur in people with BPAD?
* Anatomical – decreased grey matter mass in emotional regulation areas; increased ventral limbic area activity
* Transmitters - increased NA, DA and serotonin trigger mania
41
What investigations should be done for suspected BPAD?
* Full psychiatric history/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*
42
How do most BPAD present?
* Most present in their **depressive episodes**
* Empathises the importance of always asking about manic symptoms
43
What differential diagnoses should be considered in BPAD?
* Organic
* *Drugs, dementia, frontal lobe disease, delirium, cerebral HIV, ‘Myxoedema Madness”*
* Schizophrenia/schizoaffective disorder
* Cyclothymia
* Puerperal disorders
44
What is cyclothymia?
Persistent mild mood instability
* Never sufficiently severe to be BPAD/depression
45
What is the management of acute mania or hypomania?
* Gradually taper off and stop inducing medications (i.e. SSRIs)
* If **NOT** on treatment = *aim is to stabilise before starting lithium*
* **1st line** = antipsychotic (olanzapine **\>** haloperidol, quetiapine, risperidone)
* **2nd line** = different antipsychotic (switch to different antipsychotic)
* **3rd line** = Add lithium or sodium valproate
* Lithium is not as effective acutely (needs higher doses so risks toxicity)
* If **ONn** treatment
* Optimise medication/stop antidepressants
* Check compliance
* Check lithium levels and possibly add atypical
* Short-term sedatives (benzodiazepines)
* Monitor fluid/food intake
* Sedation may be required (clonazepam, lorazepam)
* *_ECT only if mania is not responsive to treatments below_*
46
What is the long-term management of BPAD?
(4 weeks after an acute episode)
* **1st line =** **Lithium**
* Monitor for lithium toxicity
* Monitoring required – may take up to 5 weeks to titre correctly
* **2nd line =** **Lithium and Valproate**
* If Lithium poorly tolerated = Valproate alone or Olanzapine alone
47
What are some side effects of long-term sodium valporate use?
* Hair loss
* Weight gain
* Nausea
48
How is depression managed in BPAD?
* *Can’t use antidepressants by themselves as they may cause a switch to mania*
* *Only give antidepressants with a mood stabiliser or an antipsychotic*
* 1st line = **Fluoxetine** and **olanzapine**
* 2nd line = **Quetiapine**
* 3rd line = **Olanzapine** *or* **Lamotrigine**
49
What is the use of psychological therapy in BPAD?
* Indications and purpose
* May improve compliance with medications long-term
* Offered after the acute manic event has resolved
* CBT – T*est excessively positive thoughts and gain a sense of perspective*
* Identify relapse indicators
* Create relapse prevention strategies:
* Developing routine
* Ensuring good-quality sleep
* Promoting a healthy lifestyle
* Avoiding excessive stimulation/stress
* Addressing substance misuse
* Ensuring drug compliance
* Psychodynamic Psychotherapy (useful if mood stabilised)
50
What is the prognosis of BPAD?
* Remissions becomes shorter with age and depressions become more frequent
* 15% with BPAD will commit suicide - 15x higher than general population
* Lithium reduces this to same levels as general population
51
What social interventions can be used in the management of BPAD?
* Supported employment programmes
* Adaption in education systems
* Family support and therapy
52
What is the mean age of onset of BPAD?
* 30
* Before 25 is Early onset
* Very rare after 40
53
What are the risk factors for depression?
* Female (1 in 4 over 1 in 10 in men)
* Past history of depression
* Significant physical illness
* Other mental illness
* Afro-Caribbean, Asian, Refugee
* Social factors
* Abuse
54
What are the ICD-10 and DSM-V classification of depression?
**Symptoms**
**ICD-10**
**DSM-V**
1 core symptom and 1-3 other
Minor Depression
2 core symptom and 2+ other
Mild Depression
Mild
1-2 core symptom and 4+ other
Major Depression
2 core symptom and 4+ other
Moderate Depression
3 core symptom and 5+ other
Severe Depression
3 core symptom, 5+ other + Psychosis
Severe with Psychosis
55
What is the monoamine theory of depression?
57
What are some causes of secondary mania?
* Organic brain damage - especially in the right hemisphere
* Medication
* Levo-dopa
* Corticosteroids
* Illicit drugs
* Hyperthyroidism - can present as hypomanic or agitated
