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Summary Final year MD notes - mood & anxiety conditions £6.42   Add to cart

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Summary Final year MD notes - mood & anxiety conditions

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A collection suite of final psychiatric and mental health MD notes to ace your penultimate and final year exams! Look no further and save the stress of accessing multiple resources as this PDF collates and summarises information from several resources including but not limited to: -Talley and...

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  • December 4, 2023
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  • 2023/2024
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THE PERSON WITH MOOD OR ANXIETY SYMPTOMS
Depression GAD Bipolar Disorder
5 or more symptoms in same 2-week period with At least one (1) Group of disorders “mania and melancholy”
Ø Low mood (pervasive sadness) OR anhedonia (GAD, panic disorder, social anxiety, separation “difficult to dx as need manic episode”
PLUS (diurnal pattern of – e.g. worse AM/better PM) anxiety, specific phobia, PTSD, agorophobia) Mania = feeling amazing!! NO sleep needed!
Ø Suicidal ideation
Uncontrolled XS worry/anxiety on most days
Define Ø
Ø
Interest loss
XS Guilt / worthlessness
for 6/12 months with ≥ 3 out of 6 symptoms
Bipolar I = Major depression + mania
Criteria for mania
/Sx Ø Energy loss
BELOW causing significant impairments to
ADLs, social and occupational life Ø > 1 week of elevated mood plus 3 Sx
Ø Poor concentration Ø > 1 week of irritable plus 4 Sx
Ø Loss of appetite + >5% wt loss D istractability
I rritability
Ø Psychomotor retardation I ndiscretion / impulsive / irritable –, XS spend, sex,
C oncentration impaired – circumstantial
Ø Sleep disturbance (insomnia, hypersomnia) thoughts substance (impaired function)
Function impaired during episode BUT not b/w episodes G randiosity – ?special powers or talents, ?new
A nxiety, nervousness, worry on most days
hobbies, interest, hobbies
(1) Unipolar depression (NO mania or hypomania) N o control over worry
F light of ideas (distractibility) – pressured speech
• Melancholic depression (early AM waking, psychomotor T ime > 6/12 (rapid speech), clanging, word salad, alogia
agitation, diurnal mood variation) R estlesness
A ctivity increased energy (goal-directed)
• Atypical depression (sleep a lot and eat a lot) E nergy decrease S leep deficit – no sleep
• Depression due to general medical condition or substance S leep impaired
T alkativeness (racing thoughts)
Types. misuse (CS, cannabis, Roaccutane, SSRI) T ension in muscles
• Dysthmia = (> 2 years) persistent depressive disorder (longer-
lasting, less depressive symptoms with minimal fxn impairment) Bipolar II = milder hypomania
AND
• Catatonic depression è ECT needed Ø Depressed mood for 2 weeks
• NOT due to drugs or substance absue Ø Hypomania Sx (elation) > at least 4 days
• Normal bereavement è low mood <6/12 post trauma event
• NOT due to other mental health illness
(2) Bipolar depression Ø NO impaired function
Ø mania and/or hypomania Sx present in life Ø Lower Lows – higher suicide risk
Biological cause Biological cause 1% of population
• Early childhood (pre-term, dev. trauma, TBI) • NO specific biological markers • FHx
• CO-morbidities (e.g. low Vit D, CVD, hypothyroidism, chronic • HPA axis abnormalities [CRH release • Childhood traumatic events
pain, inflammation) è higher relapse risk increased by amygdala] • Acquired brain injury (3x more likely to
• Meds (steroids, chemotherapy, anti-psychotics) • Anxiety inherited (possible epigenetic, develop)
Cause. Psychological cause intergeneration effects) • Hypermania causes = steroids (anabolic, CS,
• Recent childhood (stressors, loss job) • Biology of arousal –resting tachycardia, isoniazid)
• Past trauma and losses (previous abuse) hyperventilation
Social cause • Personality (?OCPD, OCD)
• Poverty , homelessness and rural vs urban
• Adjustment disorder (specific traumatic event with no physical • Performance anxiety • Substance induced bipolar (e.g. stimulant,
& emotional symptoms of clinical depression) • Trauma (PTSD) steroids, anti-depressant)
• anxiety, substance use disorder • Panic disorder (cannot leave house) - • Schizophrenia & its subtypes
• PTSD DISABLING IRRATIONAL FEAR • Personality disorder (e.g. cluster B types ®
DDx. • Personality disorder (e.g. borderline) • Panic attack è Abnormal intense fear of borderline, histrionic)
• negative affect of schizoaffective disorder losing control, losing your mind or dying • Organic causes (thyroid storm, pheo)
• Bereavement/grief = abnormal if after 4/12 post-event • Agoraphobia (fear of the market place,
• Organic causes (hypothyroid, T2DM, PD, post-stroke/MI) going out) ® avoid many situations
• Social phobia è Fear of criticism
• DASS21 (anxiety, stress, depression cause of low mood) Exclude ddx: • MSE, thyroid, CV, Resp exam
• Edinburgh Post-natal depression Ø FBC, EUC, CMP, CRP, Fe, B12, folate, TFT, • FBC, EUC, LFT, CRP, TFT, BSL
Ix Exclude ddx:
Ø
vitamin D
ECG:
• Urine drug screen and B-HCG
Ø FBC, EUC, CMP, CRP, Fe, B12, folate, TFT, vitamin D • Li concentration
Ø ECG ® CT/MRI brain • CT or MRI brain +/- EEG
Lifestyle (1st line = mild) Non-pharm Acute episodes
1. Involuntary Ax (scheduled under MH act 2007)
• Better diet, regular exercise • Cognitive behavioural therapy (e.g.
® call on-call psych reg for mania
graded exposure + minimise avoidance
• Improve sleep hygiene 2. Once-off Anti-psychotics (haloperidol,
behaviour)
• Avoid smoking, drugs, alcohol olanzapine or risperidone)
• Muscle relaxation (mindfulness, clench 3. Add Mood stabiliser (Li, Na val or lamotrigine)
• Address social issues – work, finances, housing and relax from bottom to top) acutely + prophylactically
• Address co-morbidities (DM, RA, OA, Chronic pain, cancer) • Abdominal breathing (box breathing) 4. Check blood/urine for illicit drugs
• AVOID
GPMP needed + safety planning (when to go to ED) • Breath counting
Ø Anti-depressant = may trigger mania
Ø BZDs – falls, sedation in elderly
Refer to: (2nd line = mod) Pharm Beware of Li Toxicity (esp. long-term use)
Mx • CBT or psychodynamic psychotherapy 1. SSRI – fluoxetine, paroxetine • Acute = fine tremor, urinary freq., polydipsia (DI),
ankle oedema, GI (N/D) è seizures
• Case worker, significant other, NGOs (black dog, lifeline) 2. SNRI - venlafaxine
• Long = CKD, hypo/hyperthyroidism, HPTH
3. MAOi / mirtazapine
• Cause = due to changing Na levels ®
Medication Acute agitation / risk of suicide dehydration, low salt diet, Addison’s
• SSRI (fluoxetine (child), sertraline (adult)) • BZD (GABA agonists) potent anxiolytics, Monitoring:
® beware of tolerance / Dependence • Check Li levels EUC/CMP, TFT weekly for 3/12
• SNRI > mirtazapine (if poor appetite), TCAs
• Avoid ACEi/ARB, NSAID, diuretics, SSRI,
metronidazole (increase Li toxicity)
If unresponsive / refractory CI for Li use: AKI ® Change to:
Invasive (If psychosis present)
• ?ECT (less effective than for MDD) • Lamotrigine (BD tablet) è inconvenient, SJS
• If Rx resistant è ECT, TMS
• Valproate (OD tablet) è check LFT.
1) Stigma
2) Lack of resources (E.G. remote communities)
Assessing suicide risk
Barriers 3) Lack of trained clinician’s • All patients are “high risk”, as suicide risk
fluctuates
4) Incorrect or missed diagnosis (incorrectly prescribed)
• We are NOT independent observers of
suicide risk (it is interaction between pt and
dr)
• Suicide risk assessment (is BAD) = can
never be a basis for clinical decisions,
because the base rate is too low + known
risk factors are too common, to identify a
person at risk of suicide
• Game theory (b/w dr and pt)=
Aim to provide a good standard of
patient-specific care NOT to predict what
will happen
• Address modifiable RF (untreated mental
illness, substance use etc)
• Mobilise support networks ® instill hope
• Avoid behaviour or service responses that
might trigger suicide

, MAJOR DEPRESSIVE DISORDER
• Major depression – clinical diagnosis
• Major depressive disorder – One of more episodes of major depression

Examples Investigations

Endocrine Hypo/hyperthyroid, Addison’s, Cushing’s, DM Ø MMSE, DASS21, MAS, GAD-7, PC-PTSD-5
Ø Bloods = FBC, EUC, LFT, BSL, Fe studies,
Chronic disease Cancer, CCF, COPD, chronic pain, post-partum, hearing loss
B12, folate
Medical Metabolic Hypercalcemia, anaemia Ø Hormone screen = LH/FSH, ACTH, TSH,
causes GH, PrL
Neuro • Parkinson’s, MS, TBI, dementia
Ø Viral serology (extended panel)
• CVA (STROKE), complex partial seizure
Ø Imaging = CT abdo, brain (CVA)
Viral Hepatitis, EBV, HIV Ø Deficiency – Fe, B12, Folate, B1, B3
Meds • Corticosteroids, oral COCP/POP, Ø Urine Tox screen

• Anti-HTN, statins, anti-psychotics,
• PD meds , maxolon
Iatrogenic
causes Euphoria Cannabis, opioids, stimulants, inhalants

Irritable/ Agitation Caffeine, cannabis, tobacco withdrawal

Environment Job loss, relationship breakdown, social isolation



Management options for mild, moderate and major depressive disorder
Mild Mod Severe
Alternatives:
Signs 2 core or main plus at 2 core or main plus at least 3/9 cognitive two core or main plus at least 4/9
(ICD-10 least 2/9 cognitive symptoms (> 2 wks) cognitive cognitive symptoms (> 2 wks) • Increasing dosage
symptoms(> 2 wks) More likely social and work affected
criteria) of anti-depressant
Somatic Sx Marked appetite loss, weight loss, loss of libido, diurnal variation of mood, psychomotor agitation
*Avoid TCA – risk of OD
• Psychoeducation about family commitments, chronic disease Mx and depression ® Relapse prevention plan
Education
• Risk outcomes assessment +assess social support • Adding 2nd line
• Lifestyle (Diet / exercise / sleep / reduce smoking and alcohol or medications that affect mood agent
Non-pharm • Psych Intervention e.g. CBT, family focused therapy, mindfulness • Switch to other
• Manage co-morbidities – hearing, vision, pain, constipation agent OR
None MUST TAKE FOR AT LEAST 3/12 for effect (LAG TIME) psychologist
*suggest SSRI if Check Na+ levels before commencing • ECT – needs patient
Pharm counselling ineffective • 1st line = SSRI ® sertraline/Zoloft, fluoxetine/Prozac, escitalopram (lexipro) consent
• 2nd line = SNRI (venlafaxine, duloxetine) ® more effective but more A/E
• 3rd line = mirtazapine (will cause wt gain, sedation)
• Primary care Mx • Specialist service referral . • ADMIT - (+++ self-harm, suicidal
• ECT (if meds fail) – risk of retrograde • Outreach or crisis team (e.g. Local
Referral amnesia MH support line -1800 011 511)
Ind. • CI = UA and CVA • Suicide ideation
• Ineffective meds
• Psychotic/manic episode

Major complications of depression:
1. Suicide: the risk of suicide in patients with depression is four times higher than in patients without depression
2. PMHx of substance abuse = BIGGEST RF for suicidal attempts
3. Chronic disease (e.g. DM, HIV, HD, CF) ® prolongs depression
4. Reduced QoL: patients may struggle with employment and relationships
5. Beware of psych referral mismatch
6. Antidepressant A/E: ↓sexual dysfunction, risk of self-harm, weight gain, hyponatraemia + agitation, insomnia


Rationale of creating a GP mental health treatment plan (GPMHP) inc. financial benefits for patient
• GP identifies what type of health care you will require to
improve/manage mental health condition
Purpose of GPMHP
• Details what you and your doctor have agreed you are
aiming to achieve. Identify RF for Protective factors
• claim up to 10 sessions each calendar year with a Medicare
registered mental health professional suicide for suicide
Rationale • (i.e. psychologist, psychiatrist, social worker or occupational • Access to • Married
therapist) for an initial 6 sessions, with the possibility of 4 weapons • Dependents
more after a review
Requirements GP appointment + Medicare card + ID (handguns) • Fear of social
Cost Free • Chronic disease disapproval
Savings
Medicare rebate may provide more then 50% off compared to • Substance abuse • Coping skills
out-of-pocket
Referral Patient’s choice
• Male • Fear of
• Mental Health Care Plan gives twenty sessions partially • Low SES suicide
Length of GPMHP
covered by Medicare until 30 June 2022. • FHx of suicide
• MHCP referral covers up to six mental health sessions at a
time – need to revisit GP for another referral
• Stigma (social and cultural)
Barriers to Rx
• Financial + logistical (seek counselling and paying for meds)
depression
• Misconception about psych meds (i.e. A/E, addiction)

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