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what is it called when manic and depressive symptoms COEXIST?
mixed affective episode
what is the lifetime risk of BPAD?
what is average age of onset of BPAD?
what is sex ration of BPAD?
which socioeconomic groups is BPAD assoc with and urban/rural?
what 3 categories can you split symptoms of mania into and give eg
- 1. biological:
- less need for sleep (not assoc with fatigue)
- increased energy (spending, risky business)
- increased interest in sex (disinhibition)
- general: psychomotor excitation
- 2. cognitive:
- self esteem, grandiose
- poor concentration, easily distractible
- accelerated thinking: flight of ideas, pressured speech
- impaired judgement and insight
- 3. psychotic
- thought form disorder: circumstantiality (lots of detail eventually to the point), tangentiality (never to the point),
- thought content disorder: secondary delusions (grandiose and persecutory) - mood congruent,
- abnormal perceptions: auditory hallucinations (2nd person) and sensory distortions (hyperacusis or visual hyperaesthesia)
what is the main difference between hypomania and mania?
- in mania there has to be 1 week duration of symptoms
- COMPLETE DISRUPTION OF WORK AND SOCIAL LIFE (whereas in hypomania it is not complete)
what is the differential diagnosis of elevated or irritable mood?
- MOOD DISORDERS: hypomania, mania, depression (after AD or ECT) or agitated depression
- SECONDARY TO GENERAL MEDICAL CONDITIONS: brain tumour, infarct, infection, cushiness disease, huntington's disease, hyperthyroid, MS, temporal lobe epilepsy
- PSYCHOACTIVE SUBSTANCE USE: amphetamines, antidep, cocaine, steroids, hallucinogens
- PSYCHOTIC DISORDERS: schizoaffective disorder (may be similar to mania with psychosis, but delusions are mood INCONGRUENT), schizophrenia
- PERSONALITY DISORDERS
- DELIRIUM OR DEMENTIA
what is the immediate biological treatment of bipolar / mania? (4marks)
- RISK ASSESSMENT: where what who treat (OP, CC, IP)
- 1. mood stabilisers: lithium, anti-convulsants (sodium valproate, carbamazapine, lamotrigine)
- 2. anti psychotic: olanzapine
- 3. prophylaxis: if had 2 episodes
- 4. depression: anti-depressants (but may cause secondary mania) use SSRI with mood stabiliser
how is lithium administered?
as a chemical salt - carbonate or citrate, sulphate
what is the distribution and MOA of lithium?
- small so cross BBB into CNS
- interacts with receptors to decrease noradrenaline release and increase serotonin synthesis
what needs to be done before starting lithium?
- 1. establish diagnosis
- 2. discuss need for prolonged treatment
- 3. renal and thyroid function, weight
- 4. pregnancy test (Ebsteins heart defect)
- 5. tell patient must use contraception if on Lithium as don't want to accidentally have baby then its got defect
what is the starting dose of lithium and at what time of day?
- 600-800mg nocte
- then can gradually increase dose
when do levels of lithium need to be checked again?
after 5-7 days from first starting
what is the level of lithium that is aimed for in the blood?
what are the benefits of lithium in mania?
- 1. reduce the risk of manic episodes by 30-40%
- 2. reduce the length and severity of manic episodes
how is lithium treatment monitored?
- 1. monitor mood - mood diary?
- 2. adherence or concordance with treatment?
- 3. any SE from lithium
- 4. Li level every 3 months (note every time change dose of Li, check after a week)
- 4. Renal function every 6 months
- 5. Thyroid function every 12 months
- 6. Discontinue Li slowly - otherwise risk of manic relapse
what are the SE of lithium?
- thirst- polydipsia
- metallic taste
- GI disturbance
- mild tremor
at what levels of lithium do signs of Li toxicity appear?
what are the early signs of lithium toxicity?
what are the late signs of lithium toxicity?
- severe bloody diarrhoea
what are the causes of death in Li toxicity?
- cardiac effect
- pulmonary complications
who is susceptible to Li toxicity at therapeutic levels?
- also as many on diuretics which dehydrates
what is the MOA of anticonvulsant drugs?
- enhances the actions of GABA
- may have effects on membrane excitability
give 4 indications of carbamazepine in psychiatry
- 1. treatment resistant mania or depression
- 2. treatment resistant schizophrenia
- 3. adjunct to lithium in prophylaxis of BPAD
- 4. rapid-cycling BPAD: multiple episodes >4/year
what are the adverse effects of carbamazepine? think systems…
- CNS: headache, drowsiness, diplopia
- Liver: elevation of GGT, hepatitis, cholestatic jaundice
- Other GI: N&V
- Blood dyscrasias
- Skin rashes
- Teratogenic effects - folate deficiency (spina bifida, anencephalcy)
how does carbamazepine affect other drugs?
- hepatic enzyme inducer
- so induces metabolism of:
- anticoagulants, AD, AP, OCCP, Steroids
what are the 5 MOA of sodium valproate?
- inhibit GABA transaminase
- inhibit calcium channel current
- increase GABA binding in hippocampus
- reduce action of NA at alpha2 receptors
- inhibit formation of protein kinase C
what are the indications of sodium valproate? (6)
- 1. refractory mania
- 2. rapid cycling BPAD
- 3. may have benefit in prophylaxis
- 4. epilepsy
- NB: most effective in non-psychotic patients
- may have benefit in prophylaxis
what are the SE of sodium valproate?
- weight gain
- tremor, teratogenic
what is MOA of lamotrigine?
- stabilise sodium channels
- inhibits glutamate release
what is the use of lamotrigine in bipolar?
- it is an anti-depressant in bipolar depression
- (mood stabiliser)
what are the SE of lamotrigine?
- GI problems
- CNS problems
what are the 2 major SE to be worried about in anti-psychotics?
- tardive dyskinesia
- neuroleptic malignant syndrome (medical emergency)
what are extra-pyramidal SE?
- acute dystonia: torticollis
- spasm of any muscle group esp head and neck
- akathesia: inner disccomfort and restlessness
- signs of parkinsons disease
- tardive dyskinesia: repetitive, involuntary, purposeless actions eg lip smacking, grimacing, tongue protrusion. tardive=slow onset
what are the psychosocial treatments of bipolar disorder?
- 1. bipolar prodromes: recognise early signs and symptoms
- 2. life events monitoring, diary
- 3. regulate social and sleep routines (disruption of circadian rhythms)
- 4. structured short term problem-focused therapies eg cognitive to develop new coping skills
- teach to reject negative thoughts
what are the SE of risperidone?
sexual dysfunction especially in men
what are the SE of olanzapine?
whats the median duration of a manic episode?
what is the median duration of a depressive episode?
what % of pts get chronic mania with deteriorating course?
how does mania change with age?
- remissions are shorter
- episodes more severe
which is more common mania or depression in middle aged?
depression more common and longer
who experiences more mixed affective and depressive episodes?
what is rapid cycling mania? who gets it more
- 4 or more episodes per year
- women more
what are 5 poor prognostic factors of mania/bipolar?
- young age onset
- more severe symptoms
- co-morbid: Personality disorder
- Co-morbid substance misuse
- treatment avoidance
what are the type of delusions found in depression with psychotic symptoms?
- ill health
- nihilistic delusions: pt believe something important has ceased to exist eg family no longer exists, bowel disintegrated
what is depressive stupor?
- severe depression
- slowing of movement
- poverty of speech
what are the cognitive features of depression?
negative patterns of thinking about the present, future, past and the world.
which physical medical conditions can present as depression?
- medications eg antiHTN or steroids
what are the at risk groups for depression?
- low socioeconomic class
- certain occupational groups eg doctors
- single men
- women with children
- chronically physically ill or disabled
- people with other psychiatric disorders or substance misuse
what is the risk of depression for a 1st degree relative if a person has major depression?
what are the etiological factors for depression?
- early environment eg childhood trauma, separation
- divorced parents
- poor relationship with parents
- childhood sexual abuse
- any loss events
what are the 3 psychological theories for depression?
- 1. psychodynamic theory: repressed sense of loss and anger turned inwards, excessive dependence on others
- 2. learning theory: seligman - learned helplessness: cannot control the stresses that presented to you - learned passive acceptance
- 3. cognitive theory: negative feelings follow from illogical negative beliefs about self.
- Becks triad: self, future, world. negative interpretation of events
which endocrine abnormality is found in depression?
- stress response
- hypothalamic pituitary adrenal axis
which areas of the brain are found to have underactivity and overactivity in PET scans of depressed people?
- underactivity: frontal and temporal cortices
- overactivity: limbic
what % of people hospitalised for depression will commit suicide?
15%, highest in first 7 days of leaving hospital
give the immediate social intervention for depression?
- RISK assessment
- 1. suicide
- 2. self neglect
- 3. self harm
- 4. insight and compliance
- 5. psychotic symptoms
- 6. ongoing stressors
- decide - need inpatient/outpatient or crisis team care??
what is the intermediate social intervention for depression?
- minimise adverse life events: finance, house, relationship, work
- contact with key worker - CPN or SW
- admit to day hospital
what is the long term social intervention for depression?
- social network
- access to help: debt, jobs, relationships
- structured activities
- regular exercise
what are the 2 main types of IMMEDIATE biological interventions for depression?
- antidepressant drugs
- ECT - in an emergency
what are the 5 main classes of AD drugs? give examples
- 1. TCA: amitriptyline, imipramine
- 2. SSRI: fluoxetine, sertraline, citalopram, paroxetine
- 3. MAOI: phenelzine, moclobemide
- 4. SNRI: venlafaxine
- 5. NASSA: mirtazapine
what are the actions of 5HT1A receptors?
- anti anxiety
- anti obsessive
what are the actions of 5HT2 receptors?
- sexual dysfunction
what are the actions of 5HT3 receptors?
- GI symptoms
what is the effect of alpha 1 receptors on 5HT release?
increase 5HT release
what is the effect of alpha 2 receptors on 5HT release?
decrease 5HT release
what are the anticholinergic SE of most AD?
- dry mouth
- blurred vision
what are the alpha 1 adrenergic SE of AD?
what are the anti histamine SE of AD? and give eg of a drug that especially causes that
- weight gain
- sedative - drowsy
- eg mirtazepine (NaSSA)
what are the SE of SSRI?
- 5HT2 actions:
- anxiety (early - will resolve with time)
- agitation (early - will resolve with time)
- sexual dysfunction
- 5HT3 actions:
- GI irritation: N&V (early - will resolve with time)
- discontinuation effects: body becomes used to having a drug on a receptor, if stop abruptly - body isn't used to not having it, get flu like effects for a week
what are the SE of TCAs?
- dry mouth
- urinary retention
- blurred vision
- alpha adrenergic block:
- postural hypotension - dizzi, syncope
- histamine block: wt gain, sedation
- cardiotoxic: long QT, ST elevation, heart block, arrhythmias
what are the 2 main SE of mirtazapine?
- weight gain
- so good if skinny and tired!
what are the NICE guidelines for using AD?
use ONE antidepressant if possible as they can interact, more SE, harder to remember to take them, £££
what things need to be explained to a patient when initiating an AD?
- 1. AD are effective on basis of evidence
- 2. NICE: 1st line SSRI (fewer SE, safer than TCA, esp if heart probes)
- 3. warn there are many SE, many are temporary SE eg GI, anxiety will resolve
- 4. not addictive
- 5. delayed therapeutic onset,
- 6. treatment for 6-8 months after recovery
- 7. risk of discontinuation syndrome in some
- ***DOCUMENT THE DISCUSSION***
if there is no response after 4-6 weeks of starting an AD, what needs to be checked and done?
- 1. dosage
- 2. duration
- 3. adherence
- 4. SE
- consider SWAPPING
- 2nd line: SSRI (citalopram, fluoxetine), mirtazapine, reboxetine or TCA
- 3rd line: venlafaxine
- if still no response:
- lithium augmentation
name 3 main indications for ECT according to NICE?
- 1. severe depressive illness including psychotic depression
- 2. catatonia (schizophrenia): immobile, mute
- 3. prolonged or severe manic episode
when is ECT used as an emergency?
where rapid symptom relief is required eg not eating or drinking, suicide risk
what % of depressed pts improve on ECT?
what is the mechanism of ECT?
- electric current passed briefly across brain via electrodes
- to produce GENERALISED seizure
what risk of ECT must be monitored?
what may the effect of ECT be mediated by?
increased turnover of NA, DA, 5HT
what are the SE of ECT?
- feel muzzy for short period
- short term memory loss both anterograde and retrograde
- possible loss of long term episodic memory
what is the mortality of ECT?
same as GA for minor surgery
what is the definition of treatment resistant depression?
severe depression that has failed to repined to treatment trials with 2 or more anti depressant for an adequate time and dose
what are the CI for ECT?
- 1. any significant medical condition where there is a very high anaesthetic risk
- 2. if had an MI: within 3 months there is an increased risk of arrhythmias
- 3. if had stroke within 3 months - risk of rebelled
- 4. pre-existing brain pathology eg tumour.
- always have to balance these with the patient not eating or drinking due to the depression, so ECT may really be needed.
after a first episode of depression, what % of patients will go on to have a second?
what % of those who have a second depressive episode go on to have a 3rd?
what are NICE recommendations for continuing Rx if people have had 2+ episodes?
continue Rx for 2 years
what is the most important part of the IMMEDIATE psychological intervention
- for depression?
- psychoeducation (after secured a confiding relationship)
- 1. explain that it is common
- 2. can be treated, will improve
- 3. lifestyle changes help: no alc or drug, more social support, exercise
- 4. clear info about Rx
- 5. sleep hygiene (keep work apart from bedroom, sleep early, horlicks)
what are the INTERMEDIATE psychological interventions for depression treatment?
- 1. counselling
- 2. problem solving therapy: identify and resolve current life difficulties, good for major depression in primary care and self harm
- 3. supportive psychotherapy: mild depression
- 4. CBT
- 5. interpersonal thearpy (IPT)
- 6. short term psychodynamic psychotherapy
what is the principle of CBT?
- examines connections between THOUGHTS, EMOTIONS and BEHAVIOURS
- structured approach: homework
- addresses cognitive distortions -eg arbitrary inference (everything focussed on self - all bad things)
what is the principle of interpersonal therapy?
- explores ORIGINS of depression in terms of interpersonal lOSSES, role disputes
- deficits in social skills
what are the long term psychological interventions for Rx of depression?
- patient themselves using CBT approaches
- supportive relationship with GP or keyworker