1
Q
what physical health conditions are associated with depression
A
- stroke
- MI
- MS
- PD
2
Q
what are the core symptoms of depression
A
- Low mood
- Anhedonia (a lack of pleasure or interest in activities)
3
Q
what are cognitive symptoms of depression
A
- poor concentration
- slow thoughts
- poor memory
4
Q
what are essential factors to explore when taking a history of depression
A
- Caring responsibilities (e.g., children or vulnerable adults)
- Social support
- Drug use
- Alcohol use
- Forensic history (e.g., violence or abuse)
5
Q
what 4 things should a depression history taking risk assess for
A
- Self-neglect
- Self-harm
- Harm to others (including neglect)
- Suicide
6
Q
what is the PHQ-9 questionnaire used for
A
assess severity of depression
- nine questions about how often the patient is experiencing symptoms in the past two weeks
- higher score = more severe depression
7
Q
how can the PHQ-9 questionnaire results be interpreted
A
- 5-9 indicates mild depression
- 10-14 indicates moderate depression
- 15-19 indicates moderately severe depression
- 20-27 indicates severe depression
8
Q
what are the NICE recommendations for offering anti-depressants
A
not recommended for patients with less severe depression (less than 16 on the PHQ-9) unless they have a preference for taking them
9
Q
when might admission be required in depression
A
where there is a high risk of self-harm, suicide or self-neglect or immediate safeguarding issue
10
Q
what are additional specialist treatments for unresponsive or severe depression
A
- Antipsychotic medications (e.g., olanzapine or quetiapine)
- Lithium
- Electroconvulsive therapy
11
Q
how does ECT work
A
- under GA
- electrodes are placed on the patient’s head, and a brief electrical current is administered
- triggers a short generalised seizure lasting around 30 seconds
12
Q
what are side effects of ECT
A
headache
muscle aches
short-term memory loss (retrograde more common than anterograde)
13
Q
what 2 questions can be used to screen for depression
A
- ‘During the last month, have you often been bothered by feeling down, depressed or hopeless?’
- ‘During the last month, have you often been bothered by having little interest or pleasure in doing things?’
14
Q
how do NICE guidelines categorise depression
A
- a score < 16 on the PHQ-9: less severe depression
- a score of ≥ 16 on the PHQ-9: severe depression
15
Q
give the top 5 treatment options recommended by NICE for more severe depression
A
- a combination of individual cognitive behavioural therapy (CBT) and an antidepressant
- individual CBT
- individual behavioural activation (BA)
- antidepressant medication: SSRI, SNRI
- counselling
16
Q
give the top 5 treatment options recommended by NICE for less severe depression
A
- guided self-help
- group cognitive behavioural therapy (CBT)
- group behavioural activation (BA)
- individual CBT
- individual BA
- group exercise
17
Q
give 2 examples of SNRIs
A
duloxetine
venlafaxine
18
Q
what should be offered in GAD if a person cannot tolerate SSRIs/SNRIs
A
pregabalin
19
Q
what is the 1st line management of panic disorder
A
SSRIs
20
Q
if SSRIs are contraindicated or there is no response after 12 weeks, what should be offered in panic disorder
A
imipramine or clomipramine
21
Q
what is the mode of action of SSRIs
A
blocking the reuptake of serotonin by the presynaptic membrane on the axon terminal
- results in more serotonin in the synapses throughout the central nervous system, boosting the communication between neurones
22
Q
what are key side effects of SSRIs
A
- GI upset
- headaches
- sexual dysfunction
- hyponatremia
- anxiety/agitation
23
Q
what increases the risk of bleeding when SSRIs are used
A
when they are taken alongside anticoagulats or NSAIDs
24
Q
what is a contraindication of SNRIs
A
uncontrolled HTN
25
what is another use of duloxetine
diabetic neuropathy
26
give 2 examples of TCAs
amitriptyline
nortryptyline
27
what are TCAs generally used to treat
commonly used at low dose to treat neuropathic pain
28
in which patients should TCAs be avoided and why
heart disease or those that have risk factors for suicide
- cause arrhythmias (tachycardia, prolonged QT, BBB
29
what is the main side effect of TCAs
anticholinergic side effects
- dry mouth, constipation, urinary retention
30
when are TCAs normally taken and why
at night as they cause sedation
31
after starting antidpressants, when should patients be followed up
NICE recommend arranging a review **within two weeks** of starting an antidepressant (**one week in patients aged 18-25** due to the increased risk of suicide)
32
how long does it take for antidepressants to respond
usually a noticeable response **within 2-4 weeks** of treatment
- where there is an inadequate response, the next step is to consider increasing the dose or switching to an alternative treatment
33
what are the guidelines for swapping from citalopram, escitalopram, sertraline, or paroxetine to another SSRI
direct switch is possible
34
what are the guidelines for swapping from fluoxetine to another SSRI
**withdraw** then **leave a gap of 4-7 day**s (as it has a long half-life) before starting a **low dose** of the alternative SSRI
35
what are the guidelines for swapping from SSRI to TCA
**cross-tapering** is recommended (the current drug dose is reduced slowly, whilst the dose of the new drug is increased slowly)
36
what are the guidelines from switching from citalopram, escitalopram, sertraline, or paroxetine to venlafaxine
direct switch is possible (caution if paroxetine used)
37
how long should antidepressants be continued for before stopping
for at least six month
- withdrawing them too early can lead to the depression returning.
## Footnote
two years in recurrent depression
38
why should antidepressants not be stopped suddenly
dose should be **reduced slowly over at least four weeks** to minimise discontinuation symptoms
- usually mild but occasionally are more severe
- typically start within 2-3 days of stopping treatment and resolve within 1-2 weeks
39
what are examples of discontinuation symptoms
* Flu-like symptoms
* Electric shock-like sensations
* Irritability
* Insomnia
* Vivid dreams
40
what is a serious side effect of high doses of antidepressants or when multiple antidepressants are used
serotonin syndrome
41
how is serotonin syndrome treated
supportive care e.g. **sedation with benzos** and withdrawal of causative meds
42
what are key side effects of mirtazapine
sedation
inc appetite
weight gain
43
what is the cycle of self harm
* Emotional suffering
* Emotional overload
* Panic
* Self-harming
* Temporary relief
* Shame and guilt
44
what are factors that are associated with an increased risk of suicide
- male
- hx of deliberate self harm
- alcohol or drug misuse
- hx of mental illness
- unemplyment
45
if a patient has attempted suicide, what factors might increase risk of completed suicide in future
* efforts to avoid discovery
* planning
* leaving a written note
* final acts such as sorting out finances
* violent method
46
what are protective factors that may help reduce risk of suicide
* Social support and community
* Sense of responsibility to others (e.g., children or family)
* Resilience, coping and problem-solving skills
* Access to mental health support
47
what are management consideration for self-harm
* **Empathy, supportive communication and building rappor**t
* **Identifying triggers** for episodes
* **Separating the means of self-harm** (e.g., removing blades or medications from the environment)
* **Discussing strategies for avoiding further episodes** (e.g., distractions, alternative coping strategies and getting help)
* Providing details for **support services** in a crisis (e.g., mental health services, Samaritans and Shout)
* Treating underlying mental health conditions (e.g., depression and anxiety)
* Cognitive behavioural therapy
48
how is benzodiazepine overdose treated
flumenazil
49
how is cocaine overdose treated
diazepam
50
what is self harm
hurting or harming yourself on purpose e.g:
* taking too many tablets – an overdose
* cutting yourself
* burning yourself
* banging your head or throwing yourself against something hard
* punching yourself
* sticking things in your body
51
in which demographics are self harm more common
* young people
* prisoners, asylum seekers, and veterans of the armed forces
* gay, lesbian, bisexual and transgender people - this may be due to the stress of prejudice and discrimination
* a group of young people who self-harm together - having a friend who self-harms may increase your chances of doing it as well
* people who have been neglected or experienced physical, emotional or sexual abuse during childhood
52
what is the short term management of adult self-harm in primary care
1. establish rapport and ensure safety
2. treat any physical injuries
3. safety plan ad psychosocial assessment
4. risk assessment
4. referral to mental health
5. follow up in few days and consider regular reviews
53
give 3 similarities betwen self harm and suicide
1. both often stem from intense emotional pain, psychological distress or trauma
2. commonly associated with depression, anxiety, BPD
3. require sensitive, thorough psychosocial assessment
54
give 3 differences between self-harm and suicide
1. self harm usually not intended to cause death
2. self harm can be repetitive or habitual but suicide is often single, planned act
3. self harm is a strong risk factor for suicide but suicide is the end point of severe distress ± history
55
how is bipolar disorder defined by ICD-10
2 or more episodes of mood disorder, at least one which must have been low mood and the other of elevated mood (hypomania, mania or mixed)
56
whehn does bipolar disorder typically develop
late teens
57
what are potential features of mania
* Abnormally elevated mood
* Significant irritability
* Increased energy
* Decreased sleep (sometimes going days without sleeping)
* Grandiosity, ambitious plans, excessive spending and risk-taking behaviours
* Disinhibition and sexually inappropriate behaviour
* Flight of ideas (rapidly generating and jumping between ideas)
* Pressured speech (rapid and unrelenting speech)
* Psychosis (delusions and hallucinations)
58
what are the 2 types of bipolar disorder
- **I:** at least one episode of mania ± episodes of depression
- **II**: one or more hypomanic episodes + at least one depressive episode
59
what is hypomania
a state in which manic symptoms are present and noticeable but do not cause serious degree of functional impairment
60
what might be the appearance and behaviour in mania
- inappropriately dressed, bright clothing/make-up but can become dishevelled as mood deteriorates
- overactivity
- socially inappropriate behaviour
- increased libido
- risky behaviours
61
what might speech be like in mania
fast (pressurised)
copious
loud
62
what might thought be like in mania
- racing thoughts
- loosening of consciousness
- flight of ideas
- grandiose or expansive ideas
- delusions
63
how is perception affected in mania
hallucinations - usually mood congurent
64
how is cognition and insight affected in mania
- poor concentration, distractability
- impaired insight
65
what are differential diagnoses for manic disorders
- **schizophrenia**: delusions are typically more static and are mood incongruent
- **dementia**: consider in middle-aged or older patients w no past history of affective disorder
- **endocrine**: hyperthyroidism
- **abuse of stimulant drugs**
66
what treatment should be stopped in patients suffering from a manic episode
antidepressants - they can aggravate manic episode
67
what is the 1st line treatment for mania in patients not on antimanic medication
atypical antipsychotic e.g. olanzapine, quetipaine or risperidone
## Footnote
if not tolerated, try different antipsychotic
68
what is the 1st line treatment for mania in patients already on antimanic medication
- check medication compliance
- increase dose
- if ineffective, change to different or add antipsychotic if on mood stabiliser
69
if 2 antipsychotics are partially or not effective in mania, what is the next step in treatment
- add lithium
- consider valproate if Li not tolerated/contraindicated
70
what should be considered in treatment resistant mania
ECT
71
what co-morbidities need to be considered when managing BPD
diabetes, CVD, COPD = x2/3 risk
72
who should a pt be referred to if symptoms suggest hypomania
**routine** referral to community mental health team
73
who should a pt be referred to if symptoms suggest mania or severe depression
**urgent** referral to the CMHT should be made
74
what are treatment options for an acute depressive episode
* Olanzapine plus fluoxetine
* Antipsychotic medications (e.g., olanzapine or quetiapine)
* Lamotrigine
75
what is the usual long term treatment for bipolar disorder
lithium
76
what monitoring is required for lithium treatment
serum lithium level (taken 12 hrs after most recent dose) closely monitored to ensure the dose is correct
77
what is the usual initial target range for serum lithium level
0.6-0.8 mmol/L
## Footnote
lithium toxicity if dose and levels are too high!!!
78
what are potential adverse effects of lithium
## Footnote
💡 LTHIUM
- **L**eukocytosis (benign)
- **T**remor/teratogen (Ebstein's anomaly)
- **H**ypothyroidism/hyperparathyroidism
- **I**ncreased urine output (nephrogenic DI)
- **U**nwanted GI: nausea, diarrhoea, metallic taste
- **M**iscellaneous: weight gain, skin issues
79
what is a contraindication of sodium valproate and why
females of childbearing age
- teratogenic casuing neural tube defects and developmental delay
80
which programme is responsible for monitoring sodium valproate use in women of childbearing age
Valproate Pregnancy Prevention Programme
- involves ensuring effective contraception and an annual risk acknowledgement form
81
which factors favour a diagnosis of depression over dementia
- short history, rapid onset
- biological symptoms e.g. weight loss and sleep disturbance
- pt worried about poor memory
- global memory loss (dementia = recent memory loss)
Patient will often answer “I don’t know” in depression but in dementia, they try to answer the question but incorrectly
PSYCHIATRY
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