What is bipolar
characterised by recurrent episodes of depression and mania (T1) or hypomania (T2)
Give 5 features of mania
completely impaired functioning +/- psychosis
* abnormally elevated mood, euphoric
* irritability
* grandiosity, excessive spending, ambitious plans
* decreased sleep, increased energy
* pressured speech and flight of ideas
* disinhibition/ impulsive
lasting at least 1 week
What is hypomania
milder symptoms of mania without having a significant impact on their function
What is required to make a diagnosis of bipolar disorder
BP 1: at least 1 manic (>=1w) episode or mixed episode
BP 2: at least 1 episode of major depression and one episode of hypomania (>=4d)
Patients with bipolar can sometimes experience auditory hallucinations. What type is most common
second person - talking to patient
What is cyclothymia
- characterised by episodes consisting of hypomanic and depressive symptoms that do not meet the full criteria for bipolar or major depressive disorder
- persistent instability of mood >2 years
Give 2 RFS for bipolar disorders
- FHx
- substance misuse
How is an acute manic episode managed pharmacologically
- if patient not taking antipsychotics/ mood stabiliser: offer antipsychotic - haloperidol, olanzapine, quetiapine or risperidone
- if tried 2 antipsychotics and they are ineffective or poorly tolerated, consider adding Lithium
- If adding lithium is ineffective or not suitable, consider semisodium valproate
- consider stopping antidepressant if on one
- urgent referral to CMHT
How is an acute episode of depression managed in bipolar disorder
- psychological intervention: CBT etc
if not on any meds: - olanzapine + fluoxetine or
- quetiapine monotherapy
- lamotrigine monotherapy if above ineffective
What is the long term management for bipolar disorder
- psychoeducation - triggers, coping strategies
- psychotherapy - CBT, interpersonal therapy
- peer/ carer support
- maintenance: 1st - lithium, 2nd - valproate
What is unipolar depression
when the person only has episodes of depression, without hypomania or mania.
What are the core symptoms of depression
- persistently low mood
- anhedonia - loss of enjoyment
Give 4 physical symptoms of depression
- Low energy (fatigue)
- Abnormal sleep (particularly early morning waking)
- Poor appetite or overeating (weight change)
- Slow movements
Give 3 cognitive symptoms of depression
- Poor concentration
- Slow thoughts
- Poor memory
Give 5 emotional/ behavioural symptoms of depression
- Irritability
- suicidality
- Low self-esteem
- Guilt
- Hopelessness about the future
What questionnaire is used to assess the severity of depression
PHQ-9 Questionnaire
Describe the PHQ-9 questionnaire
- 9 questions about how often the patient is experiencing symptoms in the past two weeks
- higher score = more severe the depression
On the PHQ-9 questionnaire, what range would indicate less severe depression
< 16
On the PHQ-9 questionnaire, what range would indicate more severe depression
≥ 16
Give 5 differentials of depression
- hypothyroidism
- neuro: MS, Parkinson’s, dementia
- bipolar disorder
- grief reaction
- anxiety disorders
How is depression investigated
- psych Hx, MSE, risk assessment
- PHQ-9
- Bloods: FBC, TFT, LFT, B12/folate
How is less severe depression managed
- 1st line: guided self help and active monitoring
- individual or group CBT or behavioural activation
- couples therapy
- group exercise, group mindfulness and meditation
- antidepressants (SSRIs) - not routinely prescribed first line. follow up 2-4w
What can occur in severe depression
psychosis
How is more severe depression managed
- combination of individual CBT and an antidepressant (SSRIs or SNRIs)
- couples therapy
- guided self help and group therapy
- antipsychotics (if experiencing psychosis)
- treatment resistant: lithium
