Affective Disorders Flashcards

Question

In what cases should you be cautious about switching antidepressants?

Answer 1

From fluoxetine **to** other antidepressants (as fluoxetine has a 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 serotoninergic antidepressant or MAOI (because of risk of serotonin syndrome) From non-reversible MAOI: a 2-week washout period is required (other antidepressants should not be prescribed during this period)

Answer 2

At least a third of people don’t recover with a ﬁrst antidepressant. Medication concordance and the diagnosis are reviewed, before considering a higher dose, different medication, or different class of antidepressant. Specialists can use augmentation strategies (adding something to the antidepressant), e.g.: * Lithium. * Second- generation antipsychotics (SGAs); lower doses than for psychosis. * Tri- iodothyronine (T3). * Combining two antidepressants.

Answer 3

o Views psychological problems are as result of the patient’s distorted perceptions of themselves, the world or the future o Therapist helps patient to notice negative automatic thoughts (NATs), triggered by day to day situations and resulting in unhelpful moods and behaviours o Mood, thought and behaviour are mutually reinforcing o Patient learns how distorted core beliefs and dysfunctional assumptions, often set up in childhood, feed into a vicious circle o CBT targets thoughts and behaviours with the aim of making changes that have a knock-on effect on mood o Depressed people often believe they are worthless and life is hopeless Activity scheduling helps patient to engage in behaviours that will enhance energy levels, develop interests and provide sense of achievement o Common thinking errors include Generalisation (I *always* mess *everything* up) Minimisation (I only passed that by chance) Distorted beliefs are tested through discussion during sessions and behavioural experiments

Answer 4

The developing relationship between the person and their therapist is the focus. The patient’s past experiences of relationships cause them to behave (unconsciously)in certain ways, e.g. expecting the therapist to let them down. This distorted transference is picked up by the therapist, who can draw it to the person’s conscious awareness through interpretations and comments, e.g.‘You’re afraid I’ll humiliate you’, ‘You expect me to dislike you’ o Putting words to patient’s feelings can allow them to recognise hidden beliefs and re-evaluate them with current reality Srticulating these feelings allows the person to recognize and re- evaluate them, changing the way they see themselves and others, inﬂuencing their behaviour outside therapy. Although classical psychodynamic psychotherapy is provided over a year or more, a focused course can be delivered over 16– 20 weeks

Answer 5

Focuses on themes of unresolved loss, psychosocial transitions, relationship conflict and social skills therapy

Answer 6

o Use **crisis resolution** and **home treatment teams** to manage crises o Develop a **crisis plan** that identifies potential triggers and strategies to manage triggers (share with the GP and any other people involved in the patient’s care) o Consider inpatient treatment if significant risk of suicide, self-harm or neglect o Consider **ECT** for acute treatment of severe depression that is life-threatening and when a rapid response is required, or when other treatments have failed

Answer 7

• ECT (electroconvulsive therapy) o Fast and life-saving in severe or psychotic depression e.g. if stopped eating and drinking o Use of electrodes to induce tonic-clonic seizure while the patient is anaesthetised o Main concern is degree of memory loss after the procedure It’s usually given twice- weekly for 6– 12 sessions, but the continuation is reviewed after each session

Answer 8

Seasonal depressive disorder (formally seasonal affectivedisorder, SAD) occurs in autumn/ winter, often with reversed biological symptoms of hypersomnia and hyperphagia. A light box or dawn simulator can compensate for reduced daylight which is thought to be causative

Answer 9

Add an anti-psychotic earlier

Answer 10

Dose should be tapered down over a period of 4 wks

Answer 11

* Psychoeducation is essential and may include self- help books, websites, or apps. * Support groups may help by providing further information, peer support, and social inclusion activities. * People should be supported to tell family and friends, rather than feeling ashamed of their struggles; this can mobilize their social network to offer practical and emotional support * Exercise, sleep hygiene, healthy diet - good strategy * Problem solving for social stressors: e.g. brief sick leave if work is over- whelming, respite for carers, referral for debt or beneﬁts advice, housing assistance, and signposting to support groups for substance misuse and other chronic problems

Answer 12

Approx. 50% patients will have at least one more episode Each episode lasts 8-9 months Treatment can reduce this to 2-3 months Psychotic depression has poorer prognosis, but shows response to ECT 15% of patients with major depression eventually commit suicide

Answer 13

Antidepressants are not addictive, but should not be suddenly stopped Include flu-like symptoms, electric shock sensations, headaches, vertigo or irritability Withdraw drugs over a few weeks to avoid Different classes of antidepressants can interact dangerously – check before changing o Serotonin syndrome is caused by excess serotonin (giving 2 antidepressants at once) o Potentially life-threatening o Sx include restlessness, sweating, myoclonus, confusion and fit

Answer 14

A manic episode is an extreme mood state lasting at least a week (unless shortened by treatment)

Answer 15

A hypomanic episode is a persistent mood state lasting at least several days, whose symptoms are less severe (than manic episode), and don’t cause marked impairment in the person’s work or social functioning.

Answer 16

A mixed episode is a mixture or rapid alteration between manic and depressive symptoms on most days for at least 2 weeks

Answer 17

BPAD is diagnosed when someone has experienced at least one manic/ mixed episode (type I) or a hypomanic episode and at least one depressive episode (type II). Episodes may alternate. BPAD may be ‘rapid cycling’ if he person experiences four or more episodes within 1 year; this is commoner in women

Answer 18

Mood, energy, and enjoyment, lowered in depression, are elevated in mania. The person is elated, excited, irritable, with rapidly changing (labile) mood, including brief tearfulness and distress. They’re energetic, overactive, restless, and talkative, with rapid or pressured speech. They may take up new activities and make many acquaintances

Answer 19

* Inflated self esteem and confidence * Believe they are gifted, attractive, creative, intelligent and extremely special * Optimism * Pressure of speech and flight of ideas

Answer 20

Reduced sleep Increased appetite for food and sex Reckless and disinhibited behaviour Inappropriate behaviour with raised libido Excessive spending, reckless driving and gambling Increased consumption of drugs and alcohol

Answer 21

Optimism develops into grandiose delusions Examples include an important mission, fame or special manners Persecutory delusions may arise if patient believes others are jealous of them Auditory hallucinations reflect elevated mood e.g. prime ministers or saints talking to them

Answer 22

**Organic** Drug-induced states e.g. amphetamines, cocaine Dementia Frontal lobe disease Delirium Cerebral HIV Myxoedema madness (paradoxically, a state of frenzied activity in extreme hyp**o**thyroidism) **Schizophrenia/Schizoaffective Disorder** • Psychotic symptoms precede and outweigh affective sx. **EUPD** labile mood and impulsivity can mimic mania, but will be persistent traits, not episodic symptom **Cyclothymia** Persistent mood instability with many episodes of mild low mood and mild elation None of the episodes are sufficiently severe or prolonged to meet criteria for even mild depression or hypomania **ADHD** can be hard to distinguish from emerging BPAD in young people, but ADHD is more persistent and develops earlier (by the age of 6) **Puerperal disease**

Answer 23

Collateral Hx Physical Examination Blood tests o FBC o TFTs o CRP (infection) ESR for infection/autoimmune/ thyroid problems; other tests as indicated by history, e.g. HIV Urine drug screen CT/MRI brain to exclude organic causes Consider Lumbar puncture

Answer 24

Priorities for acute mania/ hypomania are containing risk and initiating mood stabilizing management. Longer- term treatment is required after even a single manic episode, since likely future episodes are potentially devastating.

Answer 25

* **Biological Treatments** * Use of mood stabilisers * Acute treatment of mania/hypomania * Long-term treatment * **Psychological Treatment** * **Social Interventions** *

Answer 26

o Stop all medications that may induce symptoms (e.g. anti-depressants, recreational drugs, steroids and dopamine agonists) o Monitor food and fluid intake to prevent dehydration o If not currently on treatment Give an **antipsychotic and a short course of benzodiazepines** o If already on treatment o Optimise the medication o Check compliance o Adjust doses o Consider adding another medication (e.g. antipsychotic added to mood stabiliser) Short-term benzodiazepines may help o **ECT** may be used if patients are unresponsive to medication

Answer 27

Mood stabilizers ‘even out’ the extreme highs of mania and, to a lesser extent, the profound lows of depression Mechanisms of action aren’t fully understood but the anticonvulsants may work through sodium channels and the inhibitory neurotransmitter, GABA. Antipsychotics, e.g. olanzapine, can stabilize mood. They’re initiated during a manic episode and may be continued for long- term prophylaxis. SGAs are preferred because of fewer side effects

Answer 28

* Lithium * Valproate * Carbamazepine * Lamotrigine *

Answer 29

* Anticonvulsant * Treats acute mania * Prophylaxis in BPAD * Given as sodium valproate because of reduced side effects Plasma levels do not need monitoring * No widely accepted therapeutic range * Dose-related toxicity is not usually an issue * Check BMI, FBC and LFTs before starting

Answer 30

• Carbamazipine o Anticonvulsant which causes toxicity at high doses (unlike valproate) o Liver enzyme inducer – need to monitor liver enzymes and check for interactions before prescribing drugs o Less effective than lithium, second line in BPAD prophylaxis

Answer 31

Mood stabilisers are **teratogenic** Risk of harm to fetus should be weighed against harm of manic relapse Lithium - **Ebstein's anomaly** Valproate and carbamazepine - **spina bifida** Women of childbearing age should be given contraceptive advice and prescribed a **folate supplement** if using valproate Closely monitor the fetus if mood stabilisers are used in pregnancy

Answer 32

* Antipsychotics * Anticonvulsants

Answer 33

**Antipsychotics** (e.g. olanzapine) Usually atypical (e.g. olanzapine, risperidone, quetiapine) because of fewer side-effects Before starting, check BMI, pulse, BP, fasting blood glucose or HbA1c, lipid profile **Anticonvulsants** Lamotrigine is 2nd line for prophylaxis in BPAD type II Check FBC, U&Es and LFTs before starting

Answer 34

o Mood stabilisers are the main stay o Other medications may be added when new symptoms arise or when facing stress that could precipitate relapse (e.g. antipsychotics or benzodiazepines) o **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 Monitor closely for signs of mania and immediately stop antidepressants if signs are present Medication can be cautiously withdrawn if the patient is symptom-free for a sustained period

Answer 35

* Psychoeducation * CBT

Answer 36

The clinician (e.g. care coordinator, psychologist, psychiatrist) works with the person to identify relapse indicators (early warning signs), such as insomnia or increased energy. This helps to establish relapse prevention strategies, e.g.: * Daily routine. * Sleep hygiene * Healthy lifestyle. * Limiting excessive stimulation/ stress. * Addressing substance misuse. * Medication changes

Answer 37

CBT reduces relapse frequency and the duration and number of inpatient admissions. It combines psychoeducation with opportunities to test and challenge grandiose thoughts, to regain perspective. CBT can inform a Wellness Recovery Action Plan (WRAP), which helps the person identify triggers and relapse indicators, agreeing a management plan for future episodes.

Answer 38

* Family therapy * Interpersonal and social rhythm therapy - incorporates aspects of IPT for depression, with attention to circadian rhythms. Stabilizing sleeping, waking, eating, and exercise times support the biological rhythms which regulate mood * Support groups - Bipolar UK * Aid when returning to work

Answer 39

o Psychological interventions designed for BPAD may be helpful o **Lithium** is the mood stabiliser of choice Alternative: sodium valproate o During an acute manic episode, may need to stop antidepressant o Consider antipsychotic therapy (e.g.olanzapine) o **Management of Depression**: talking therapies, fluoxetine (given with olanzapine or quetiapine) o Address co-morbidities: diabetes mellitus, cardiovascular disease and COPD o **Primary Care Referral** Symptoms of hypomania → routine referral to CMHT Symptoms of mania or severe depression → urgent referral to CMHT

Answer 40

Manic episodes often begin abruptly and are normally shorter than depressive episodes (2 weeks – 5 months) Remissions become shorter with age and depressions become more frequent 15% of people with BPAD kill themselves Long term tx with lithium reduces this risk

Answer 41

* 7-13% * 10%

Answer 42

* Adolescent and young adults * Women are more likely than men to be treated for self- harm but male prevalence may be similar. * People in social classes IV and V are at highest risk

Answer 43

Up to 2% of all deaths are suicides, representing nearly a million worldwide each year.

Answer 44

Globally, suicide prevalence increased from 10 to 16 per 100,000 in the past 50 years but declined in the UK

Answer 45

* Males - 3 to 4 times more likely to die from suicide - partly due to more violent means of suicide * Social classes I and V * Middle aged (40-54yrs) * Over 80 yr olds

Answer 46

* Genetics * Childhood and Life experiences * Social Isolation * Occupation * Physical illness * Hx of self-harm * Psychiatric illness

Answer 47

* A family history of self- harm is common in people who self- harm, while a family history of suicide is common in people who self- harm with suicidal intent. * The risk of completed suicide is elevated in people with a family history of mental illness or suicide. * Suggested heritability of suicide is 43%.

Answer 48

* Many people who self- harm have a history of **childhood abuse** (including sexual abuse), neglect, or bullying; these may also predispose to suicide, years later. * Self-harm is commoner among certain adolescent subcultures, e.g. LGBTQ (lesbian, gay, bisexual, transgender, queer) and ‘goth’ young people. * Self- harm is associated with stressful life events in adulthood, including current domestic violence. * Completed suicide is particularly associated with loss events, especially **bereavement.**

Answer 49

People who die from suicide are more likely to be isolated, divorced, widowed, single, unemployed or living alone

Answer 50

Stressful jobs with access to lethal means e.g. doctors, vets, farmers, pharmacists and dentists - reduced recently The highest risk occupations are now manual, male- dominated trades, e.g. building, metalwork, construction.

Answer 51

* Chronic illness * Painful illness * Terminal illness * Risks are particularly high in neurological (e.g. epilepsy) and stigmatized conditions (e.g. HIV)

Answer 52

Any history of self- harm increases the risk of future self-harm. Up to 60% of people who die by suicide have previously self- harmed. The lifetime risk of suicide in people who have self- harmed is 3– 5%, increasing to 10– 15% if there was clear suicidal ideation. **Self- harm with suicidal intent** is the **strongest predictor** of eventual suicide

Answer 53

**Depression:** lifetime risk 15% o Depressed patients at highest risk of suicide tend to High- risk symptoms include: * recurrent suicidal thoughts * insomnia * weight change * extreme hopelessness * worthlessness * guilt. o 80% of people who die by suicide are depressed **Bipolar affective disorder**: 15% die by suicide and 30% attempt suicide. **Schizophrenia:** lifetime risk 10% People experiencing command hallucinations to self- harm; and young, high- functioning, recently diagnosed people, with insight into the severity of their illness, are at highest risk. **Substance misuse** o Alcohol dependence * increased risk of suicide, as intoxication can exacerbate distress and impulsivity. * Fifty per cent of suicide attempts are associated with alcohol use within 6 hours. Alcohol dependence carries a lifetime suicide risk of 7% **• Personality disorder** o Up to 50% of people who commit suicide have a PD

Answer 54

* **Mentalization** * Normal: In childhood, parents take emotions seriously which allow children to reflect and mentalize emotions, this does not happen in traumatic, abusive childhoods * Rather than learning how to process emotions, these children learn how to ventilate these emotions → sometimes self- harm may be used to deal with difﬁcult emotions like anger, sadness, or anxiety. * **Self-preservation** * Self-harm can be a coping strategy → only hurt part of the body to preserve the whole body * For some people, painful, non- lethal self- harm protects them from suicide.

Answer 55

* Scratching, punching, head- banging. * Cutting, burning, interfering with wounds. * Self- poisoning, e.g. overdoses, ingesting bleach, pesticides. - **most commonly treated in hospital** * Inhaling toxic fumes (e.g. car exhausts) or inert gases (e.g. helium). * Swallowing or inserting items, e.g. razor blades. * Self- stabbing. * Jumping from a height (e.g. bridges, car parks) or in front of trains/ vehicles. * Hanging, asphyxiation. * Shooting. * Drowning. * Self- immolation (setting yourself on ﬁre).

Answer 56

**Precautions against discovery** ✓ ✗ **Substance use involved** ✓ ✗ **Discovery** Found accidentally Sought help **Help- seeking** Refusing/ resisting Engaging **Hope** Hopeless \*Hopeful **Ongoing suicidal plans** ✓ ✗

Answer 57

* • **Physical Treatment** * **Risk Assessment** * **Immediate Interventions** * **Follow up interventions** * **Coping Strategies**

Answer 58

o Examine any physical injuries o Overdoses * Naloxone (for opioid overdoses) * Activated charcoal (decreases intestinal absorption of some substances (e.g. antidepressants)) * Must be used \<1 hour of ingestion * Antidotes * N-acetylcysteine for paracetamol overdose * Benzodiazepines: ﬂumazenil. * Insulin: glucagon. * Opiates: naloxone. * Digoxin: digoxin- speciﬁc antibody fragments - Digibind * Iron salts: desferrioxamine mesylate. * Active elimination * Gastric lavage o Lacerations Superficial cuts: sutures or Steristrips Plastic surgery for deep cuts Adequate analgesia should be given

Answer 59

**Risk Assessment** After stabilisation, a psychiatrist or psychiatric liaison nurse conducts a thorough **psychosocial assessment**. Assessment can be therapeutic, by validating distress and identifying the person’s support needs. It includes: * Details of current and previous self- harm. * Social circumstances and stressors, and triggers for self- harm. * Diagnosis of underlying mental illness and its relationship to self- harm. * Evaluation of hopelessness, suicidal intent, and persistent plans to self- harm. * Strengths and coping strategies ALSO: o Thoughts about hurting themselves again o Thoughts of hurting others o Concerns about being hurt by others o Specific features of increased risk: * Careful planning * Final acts in anticipation of death (e.g. writing wills) * Isolation at the time of the act * Precautions taken to prevent discovery (e.g. locking doors) Writing a suicide note * Definite intent to die * Believing the method to be lethal (even if it wasn't) * Violent method (e.g. shooting, hanging, jumping in front of a train) * Ongoing wish to die/regret that the attempt failed o If the patient is insistent on leaving you need to **assess their capacity**

Answer 60

o If at high risk of suicide and lacking capacity, they need to be **admitted to a psychiatric ward** for their own safety o Patients at lower risk may be managed at home (depending on home circumstance e.g. if they have a supportive family) o A **crisis plan** should be made to deal with future suicidal ideation or thoughts of self- harm * Who they will tell * How they will get help (e.g. coming straight to hospital)

Answer 61

o Follow-up **within 1 week** of the self-harm or discharge from the inpatient ward o This could be: * Community mental health team * Outpatient clinic * GP * Counsellor o Underlying disorders (e.g.**depression**) should be treated * SSRIs are safest for depression, but prescriptions should be short and reviewed regularly to prevent stockpiling for overdose o **Psychological therapies** CBT-based therapies (e.g. CBT, dialectical behaviour therapy) Mentalisation-based treatment Transference-focused psychotherapy o **Important**:30% of suicides occur within 3 months of discharge from psychiatric wards o Harm minimisation techniques (agreed with MDT) may be used if stopping self-harm is unrealistic in the short-term, e.g. using ice cubes, rubber bands

Answer 62

o Distraction techniques o Mood-raising activities(e.g.exercise, writing) o **Strategies to Decrease or Avoid Self-Harming** * Put tablets and sharp objects away Avoid triggers (e.g. photos online) Stay in public places or with supportive people when tempted to self-harm Call a friend or support line Avoid drugs and alcohol Squeeze ice cubes Snap a rubber band around their wrist Bite into something strongly flavoured (e.g. lemon) • Offer emotional support to relatives/carers if possible

Answer 63

1 in 6 people self harm again within one year of an episode Risk of completed suicide in 50x that of the general population

Affective Disorders Flashcards

(97 cards)