1
Q
what is depression
A
Depression is a condition composing of a number of clinical symptoms
The sufferer usually displays
- > Depressed Mood
- > Loss of Interest and enjoyment
- > Reduced energy leading to increased fatigue and lack of activity
-> A duration of two weeks is required.
There are some other common symptoms
2
Q
what is recurrent depressive disorder
A
- Repeated episodes of depression
- With complete recovery in-between
(“several months”) - No evidence of severe elation of mood or hyperactivity
(because that would make the diagnosis Bipolar Affective Disorder)
3
Q
first line med for depression
A
SSRI
At least Moderate Severity (comment about drug effectiveness based on severity)
NNT - 3
4
Q
which pts should have ECT
A
- CATATONIA
- LIFE THREATENING DEPRESSION/DEPRESSIVE STUPOR
- TREATMENT RESISTANCE
- PREGNANCY
5
Q
What is cotard
ass w
A
believes that they (or in some cases just a part of their body) is either dead or non-existent. This delusion is often difficult to treat and can result in significant problems due to patients stopping eating or drinking as they deem it not necessary.
severe depression and psychotic disorders
6
Q
physical disorders that can cause secondary mood disorders
A
anaemia hypothyroidism malignancy cushing's syndrome addison's disease MS parkinsonism
7
Q
psychiatric disorder that cause secondary mood disorders
A
schIzophrenia
alcoholism
dementia
personality disorder
8
Q
drugs that can cause secondary mood disorder
A
beta-blockers interferon-alpha corticosteroids digoxin antiepileptic drugs anitdepressants
9
Q
RFs of depression
A
female Family history Alcohol Adverse events Past depression Physical co-morbidities LOW Social support Socioeconomic status
10
Q
core Sx
cognitive Sx
Biological Sx
Psychotic Sx
DEPRESSION
A
CORE
- anhedonia - lack of interest
- low mood - present for at least two weeks
- lack of energy - anergia
COGNITIVE Sx
- lack of concentration/attention
- negative thoughts
- excessive guilt
- suicidal ideation
- low self-esteem
BIOLOGICAL Sx
- Changes in sleep pattern - diurnal variation in the mood
- early morning wakening
- loss of libido - reduced sexual drive
- psychomotor retardation
- weight loss and loss of appetitie
PSYCHOTIC Sx
- hallucinations auditory > visual (
- delusions nihilistic - where they think part of them is not working, persecutory)
11
Q
ICD-10 classification of depression
A
mild depression = 2 core Sx + 2 other Sx
moderate depression = 2 core Sx + 3-4 other Sx - pt is distressed and cant continue
Severe depression = 3 core Sx +>= >4 other Sx - sig deficits in self-esteem and feelings of worthlessness and/or suicide. CANT FUNCTION
Severe depression w psychosis = 3 core Sx + >= other Sx + psychosis
12
Q
Ix for depression
Diagnostic questionnaires
Imaging
A
Diagnostic questionnaires - PHQ-9, HADS and Beck’s depression inventory
MRI/CT scan
13
Q
Blood tests for depression
A
- FBC - exclude anaemia
- TFTs exclude hypothyroidism
- U&Es
- GLUCOSE
- VIT B12
FOLATE - calcium levels (biochemical abnormalities may cause physical Sx which can mimic some depressive inventory
- glucose (diabetes - anergia)
14
Q
Mx of mild to moderate depression
A
1) watchful waiting - reassess in 2 weeks
2) low intensity psychosocial interventions - sleep hygiene, regular exercise, befriending services
low intensity psychological intervention -> IAPT
-> antidepressants - ONLY FOR 1. long time 2. PMH of moderate-severe depression 3. failure of other interventions
or
- > High intensity psychological intervention
- CBT
- IPT
- behavioural activation
- behavioural couples therapy for ppl who have a regular partner
15
Q
Mx of moderate sever depression
A
suicide risk assessment - high risk AVOID citalopram, TCAs
1) 1st line SSRIs
OR
- anxiety may worsen initially
Tx for a t least 6 months following remission - consider toxicity in overdosex
16
Q
define bipolar affective disorder
A
chronic episodic mood disorder
- last one episode of mania (or hypomania) and a further episode of mania or depression
17
Q
genetic
neurochemical
endocrine
environmental
causes of bipolar
A
monozygotic twin studies
strong FH
neurochemical - increased dopamine, increased serotonin
endocrine - increased cortisol, aldestrone, thyroid
environmental - adverse life events, exams, post-partum period, loss of loved one
18
Q
clinical features of depressive bipolar disorder
A
Depressive Sx Depressed mood Energy loss (anergia) Anhedonia Death thoughts Sleep disturbance Worthlessness or guilt Appetite Mentation (concentration) reduced Psychomotor retardation
19
Q
ICD-10 criteria for bipolar disorder
A
requires at least two episodes - one of which MUST BE MANIA OR HYPOMANIA
REQUIRES 3/9 Sx to be present
(1) Grandiosity/inflated self esteem
2. decreased sleep
3. pressure of speech
4. flight of ideas
5. distractibility
6. psychomotor agitation
7. reckless behaviour
8. loss of social inhibitions
9. marked sexual energy
20
Q
Ix for bipolar disorder
A
blood tests - FBC TFTs - hypo/hyperthyroidism U&Es - baseline renal function with view to starting lithium LFTs - baseline hepatic function glucose calcium - biochemical distrubances
CT head to rule out SOLs, tumour, infarction, haemorrhage, MS
may show hyperintense subcortical structures (esp. temporal lobes), ventricular enlargement, and sulcal prominence
21
Q
general Mx of bipolar disorder
A
full risk assessment - suicidal ideation and risk to self
DVLA
medical
22
Q
DVLA rules if they have stable hypomania or mania
A
DO NOT DRIVE
NOTIFY DVLA
- may be considered if well fro at least 3 MONTHS
- adheres to Mx
23
Q
DVLA rules if they have Unstable hypomania or mania
A
DO NOT DRIVE
NOTIFY DVLA
- may be considered if well fro at least g MONTHS
- adheres to Mx
24
Q
Mx of bipolar depression
A
psychological intervention
- CBT
- INTERPERSONAL THERAPY
- BEHAVIOURAL COUPLES THERAPY
pharm fluoxetine + olanzapine OR Quetiapine OR lamotrigine
if already on Li
- ^ dose
- fluoxetine and olanzapine
25
medical mx for acute manic epsiode
FIRST LINE - offer an antipsychotic - olanzapine, risperiodne, quetiapine, haloperidol
SECOND LINE - mood stabilisers - lithium
sodium valporate
26
MSE of a bipolar patient
Appearance and behaviour – Perhaps flamboyant or revealing clothing, irritability,
psychomotor agitation, over-familiar behaviour.
Speech – pressured speech which is difficult to interrupt, loud speech, copious/excessive
speech.
Mood – May be excessively happy or excitable, or may be irritable and easily angered.
Thoughts – Thought disorder in the form of flight of ideas. May describe racing thoughts,
grandiose thoughts, persecutory beliefs most often related to their own perceived special
status/abilities (e.g. others jealous of them or after their ideas). Thoughts of harm to self or
others may occur secondary to delusional beliefs. Delusional beliefs are usually mood
congruent.
Perceptions – Perceptual abnormalities are less common than in schizophrenic type illnesses
(if psychosis is a predominant feature, the diagnosis of schizoaffective disorder may be
considered).
Insight likely to be diminished
27
caution for prescribing sodium valporate
avoided in women of child-bearing age
-> teratogenic
-> birth defects
- spina bifida
- cleft lip/palate,
abnormalities of the limbs/heart/urinary tract and developmental delays
- Higher incidence of Polycystic Ovarian Syndrome (PCOS) which can
affect future fertility
28
what monitoring is required when initiating lithium and continuing lithium
1. U&Es to check eGFR – monitored 3-6 monthly.
Can lead to reduced
-> eGFR
-> CKD
ass w nephrogenic diabetes insipidus which can lead to thirst and polydipsia.
2. TFTs – risk of hypothyroidism - monitored 6 monthly.
3. Weight
4. ECG – particularly important in those with risk factors for, or pre-existing cardiovascular
disease – to monitor for ECG changes or arrhythmias.
5. Lithium levels - When initially started monitoring should be done weekly until concentrations are stable. 12 hours after first dose then weekly therapeutic level (0.8-1.0mmol/L) has been stable for 4 weeks. Once stable every 3 months for a year.
thyroid, renal, CA, weight/BMI - 6 monthly
29
common side effects of Lithium
```
Lethargy.
Insipidus (diabetes)
Tremor. fine
Hypothyroidism.
Insides (GI upset)
Urine (increased)
Metallic taste.
```
```
long term
nephrotoxic - nephrogenic DI
hyper/hypothyroid
hyperpara
renal tumor
rhabdomyolysis
```
30
minimum effective serum Li level for maintenance
ideal range
0. 4mmol/L
0. 6-0.8mmol/L
narrow therapeutic range
31
Li toxicity level and the Sx seen
```
> 1.5mmol/L
EARLY
tremor
anorexia
nausea/vomiting/diarrhoea, dehydration
lethargy.
```
sever > 2 seizures, syncope, hyperreflexia, dehydration death
Further CNS effects
include drowsiness, muscle weakness/twitching and ataxia. These can progress to marked
disorientation, seizures, coma and death.
32
Apart from pharm Mx other Mx that should be considered in bipolar
Psychoeducation programmes – to discuss medication, lifestyle, relapse warning signs. Group
psychoeducation may be considered.
Psychological management such as CBT or family therapy can be recommended if
appropriate.
Ongoing CPN support.
Support with benefits or occupational support if relevant.
33
common SEs of sertraline
- syncope
- lightheadedness
- diarrhoea
- nausea
- sweating
- dizziness
- xerostomia
- confusion
- hallucinations
- tremor
- somnolence
- impotence
34
if a pt refuses Mx and wants to commit suicide in a GP setting what do u do
Arrange a Mental Health Act assessment as she is refusing treatment. Crisis to work the pt needs to consent to engage in order to make the referral
35
class of venlafaxine
SNRI - selective noradrenaline reuptake inhibitor
36
Which section/form would the consultant complete to initiate emergency ECT?
Section 62 of the MHA – FORM IS C6. Allows two sessions of emergency ECT. A second opinion approved doctor (SOAD) should be applied for at this time in order to provde the required legal framework for ongoing ECT
37
Possible SEs of ECT
- short memory loss – memory tests should be performed throughout treatment to monitor for significant memory loss
- headache – analgesia
- confusion
- sore muscles – due to seizures, although muscle relaxants are given during the procedure
- Feeling sick
- increased heart rate and blood pressure
38
other components of Mx in depression apart from medication
Referral for a CPN.
Referral to the outpatient psychiatry clinic.
Referral to the Crisis Team for initial support on discharge – especially whilst awaiting
allocation of a CPN. The crisis team can provide initial more intensive support for the first
week or two after discharge.
Psychological therapies – this may differ from patient to patient. CBT is often recommended
for mood disorder.
Recommend support groups or psychoeducation courses.
Benefits and occupational advice.
Advice on lifestyle measures e.g. the importance of sleep and routine and the risks of
substance use, e.g. alcohol.
Mindfulness.
39
which SSRI is recommended in reduced doses in the elderly
citalopram as it is thought to prolong QT interval in which will lead to cardiac arrhythmias
40
what monitoring is done w pts on sodium valoprate
LFTs are recommended before and during the firs t 6 months of Mx DUE TO RISKS OF HEPATOTOXICITY
41
Which drugs should not be prescribed with lithium
NSAIDs
42
which Mx is NOT an option for treatment resistant depression
sodium valporate
43
DDx of depression
organic causes - hypothyroidism, delirium
grief reaction
- bipolar disorder
- adjustment
- seasonal affective disorder
- dementia
- schizophrenia
44
stopping antidepressants
reduce dose frequnecy gradually over 4 weeks
discontinuation Sx
restless, altered feelong, physical Sx
onset few days from treatment cessation
mild, self-limiting
increase risk: increase dose/Tx duration
shorter 1/2 life antidep ie paroxetine
45
serotonin syndrome
triggers
SSRI
MAOI
Drugs - stimualnts ie cocaine, ectasy, amphetamines
```
features
cognitive - headache, agitation, hypomania, confusion, hallucinations, coma
confusion
agitation
muscle twitching
sweating
shivering
diarrhoea
```
autonomic - increase temp, HR, BP
neurological - hyperreflex, dialted pupils, rigidity
sweating, tremor, myoclonus
Mx
stop offending agent
benzodiazepines (Agitation)
supportive Mx IV fluids
sever cases serotonin antagoni crytpohepatidine
46
Tx for refractory cases
augmentation strategies - Li
ECT
light therapy
47
manic episode criteria
elevated at least 3 manic Sx, at least 1 week
major impairment functioning
psychotic features
hypomanic - at least 4 days
mixed
1 week hypomania + 3 depression Sx
- 2 weeks depression + 3 (hypo)mania Sx during current/recent episode
48
DDx for bipolar
- thyroid disorders
- substance misuse
- ADHD
- depression
- cyclothymia
- iatrogenic causes
- personality disorders
anxiety disorders, OCD,
schizophrenia
49
primary care referral
hypomania -> routine referral CMHT
Mania - urgent referral
long term
lithium
sodium
olanzapine
50
adverse effects of Na valporate
```
GI irritation
weight gain
hair loss
blood disorders (thrombocytopeni, leucopenia)
hepatotoxicity, pancreatitis
```
NB
P450 inhibitor
51
difference between hypomania and mania
presence of psychotic symptoms
| hypomania being less than 7-10 days
52
what is dysthymia
chronic mildly low mood which lasts at least several years but does not meet criteria for a recurrent depressive disorder
53
what is cyclothymia
chronic instability of mood with periods of mild depressive and elation, none of which are sever enough to meet criteria for bipolar/depression
54
what is the classification of mood disorders ICD-10
```
hypomania
manic episode
bipolar
depressive - mild/moderate/sever
recurrent depressive disorder
recurrent depressive disorder
persisted mood (affective states) - cyclothymia/dysthymia
```
55
physical Sx of depression
other Sx which may occur as part of the depressive syndrome
headaches
- abdominal pain
- GI symptoms - constipation, nausea
- pain
- chest pains
- > depersonalisation
- > obsessions
- > phobias
- > conversion syndrome
56
types of typical depressive delusions
```
delusion of guilt
delusion of hypochondriasis
delusion of poverty
nilhilistic delusion - no future
delusion of persecution
```
57
what are the variants of depressive disorder
agitated depression - common in elderly
retarded depression - psychomotor retardation
depressive stupor - pt is motionless, mute, refuses to eat/drink
atypical depression - characterised by reversed biological Sx iw increased sleep, increased appetite
58
types of SSRI
common SEs
fluoxetine, paroxetine, sertraline
nausea
agitation
insomona
sexual dysfunction
59
components of CBT
behavioural activation - pts are encouraged to plan and engage in more activites that are enjoyable and satisfying
cognitive retraining - challenge negative thoughts
60
types of psychological Mx
CBT
supportive adn problem-solving treatments
interpersonal psychotherapy - improving pts interpersonal functioning
dynamic psychotherapy
61
clinical features of a mania/manic episode
-> Elevated mood increased energy
• Over-activity.
• Reduced need for sleep.
-> Formal thought disorder
• Pressured speech.
• Flight of ideas.
• Racing thoughts.
```
-> increased self-esteem, evident as:
• Over-optimistic ideation.
• Grandiosity.
• Reduced social inhibitions.
• Over-familiarity (which may be overly amorous)
- facetiousness
```
-> Tendency to engage in behaviour that may have serious
consequences:
• Preoccupation with extravagant, impracticable schemes. • Spending recklessly.
• Inappropriate sexual encounters.
- > Other behavioural manifestations, including excitement, irritability, aggressiveness, and suspiciousness.
- > Marked disruption of work, usual social activities, and family life.
mutism
suicidal ideation
62
psychotic Sx of mania
• Grandiose ideas may be delusional
• Suspiciousness -> persecutory
delusions.
• Pressured speech
• Flight of ideas, prolixity, and pressured thoughts can result in the
loss of clear associations.
• Irritability and aggression may lead to violent behaviour.
• Preoccupation with thoughts and schemes may lead to self-
neglect, to the point of not eating or drinking, and poor living
conditions.
* Catatonic features—also termed manic stupor.
* Total or partial loss of insight.
63
DDx for mania
* Schizophrenia, schizoaffective disorder, delusional disorder, other psychotic disorders.
* Anxiety disorders/PTSD.
* Circadian rhythm sleep–wake disorders
* ADHD/conduct disorder.
* Alcohol or drug misuse, e.g. stimulants, hallucinogens, opiates.
* Physical illness, e.g. hyper-/hypothyroidism, Cushing’s syndrome, SLE, MS, head injury, brain tumour, epilepsy, HIV, other encephalopathies, neurosyphilis, Fahr’s disease, WD, and pseudobulbar palsy.
* Other antidepressant treatment or drug-related causes
64
clinical features of hypomania/hypomanic episode
- > Mildly elevated, expansive, or irritable mood
- > increased energy and activity.
- > Marked feelings of well-being, physical, and mental efficiency
- > self-esteem.
- >Sociability.
- > Talkativeness.
- > Over-familiarity.
- > increased sex drive.
- > Reduced need for sleep.
- > difficulty in focusing on one task alone
65
stopping lithium treatment how are u supposed to do it
reduce the dose gradually over at least 4 weeks, and preferably up to 3 months
66
what needs to be measured when starting Na valporate, monitoring and stopping
weight
BMI
FBC
LFTs
monitoring -> weight/BMI, LFTs, FBC again after 6 months of Mx and then annually
stopping reduce dose over at least 4 weeks
67
What are the advantages and disadvantages of SSRIs as compared to tricyclic antidepressants (TCAs)?
reduced the risk of toxicity in overdose
fewer side effects better tolerated
more effective in treatment of depression with anxiety
disadvantages
in severe illness TCAs are supposed to be better
thoughts of suicide and self harm has increased
psychiatry
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