PSYCH CASE 1 – BPAD

i) History

Brief

Gemma Parker, a 27 y.o. female, has been referred to the psychiatry outpatient clinic.
Take a brief hx about her dx (8 minutes), discuss it with the examiner and then counsel
the patient on a management plan.

Actor Brief
After seeing the GP for your depressive sx (tiredness, lack of motivation and energy),
you have been referred to psych OP.

Case

HPC
• Sx started a year ago but have been worse over last 2 months.
• Low mood, tiredness, decreased confidence, didn’t want to go out with partner to
work party last month as felt overwhelmed
• Sometimes stay in bed and don’t wash for days
• No psychotic sx:
o No visual / auditory hallucinations
o No thought insertion / withdrawal / broadcasting

• (only say if prompted) Last summer on holiday:

o Experienced 1 week of high mood, energy, and enjoyment
o Reduced sleep
o Increased appetite
o Increased sex - cheated on partner
o Thought you were the ‘best person in the business’, gambled company
money and got fired.
• Risk assessment: no suicidal thoughts, no thoughts of self-harm, no harm to/from others

• FLAWS: no weight loss, change in appetite, night sweats, or fever

PMH
 • N/A

FH
• Only child. Dad has T1DM. Mum has depression. You are worried that you
will be like her (suicidal attempts).

DH&A
• N/A

SH
Around 3 bottles of wine/wk.
Non-smoker.
You are currently unemployed and living at home with your partner.
Quit new job because too tired to come into work.

ICE

I – I am depressed
C – I may end up like my mother who was depressed and had suicide
attempts
E – To be given treatment to make feel better

ii) Investigations

“At this stage, What are your differentials?

o BPAD, depression, substance misuse, organic illness (e.g. Cushing’s,
thyroid)

“What Investigations would you like to request?”

Bedside

● Urine
● Physical examination
● PHQ-9

Blood
 ● TFT
● FBC
● U&Es

STI swabs & urine

“These are the results of the Investigations you requested”

• PHQ-9 Score: 19; moderately-severe

• Urine drug screen clear
• Physical examination no findings
• TFT normal
• FBC normal
• U&Es normal
• STI Screen normal

“What is the most likely diagnosis?”

· Diagnosis: BPAD

III) Management

“Please explain to the patient the likely diagnosis and next steps in
Management”

•We think you are experiencing a depressive episode caused by chemical

imbalances in the brain, as part of a condition called bipolar affective disorder

•Mood can be represented on a spectrum, and everyone goes through periods of

happiness and sadness. Bipolar disorder is when your mood is at the very extremes
of the spectrum, and it can cause you to drastically change the way that you
behave and interact with the world and others around you.

• During the depressive phase symptoms may include:

o Feeling sad, hopeless or irritable most of the time
o Lacking energy
 o Difficulty concentrating and remembering things
o Loss of interest in everyday activities
o Feelings of emptiness or worthlessness
o Suicidal thoughts
• During the manic phase symptoms may include:

o Feeling very happy, elated or overjoyed

o Talking very quickly
o Feeling full of energy
o Being easily irritated or agitated
o Being delusional, hallucinating and disturbed or illogical thinking
o Not feeling like sleeping
o Doing things that often have disastrous consequences – such as
spending large sums of money on expensive and sometimes
unaffordable items
o Self-harm or harming others

• If you have bipolar disorder, you may have episodes of depression more
regularly than episodes of mania, or vice versa. Between episodes of
depression and mania, you may sometimes have periods where you
have a "normal" mood.
• You’ll typically need ‘mood-stabilizing’ and antidepressant medication to control

your episodes and therapy may also be beneficial

IV) VIVA
1. What are the two types of bipolar affective disorder?
a. Type 1: characterised by episodes of mania interspersed with depressive
episodes
b. Type 2: mainly recurrent depressive episodes with less prominent
hypomanic episodes
2. What are some features of lithium toxicity?
a. GI disturbance (diarrhoea and vomiting)
b. Sluggishness
c. Giddiness
d. Ataxia
e. Gross tremor
f. Fits
g. Renal failure
3. What are some long-term consequences of lithium use?
a. Hypothyroidism
b. Renal impairment
4. What are the teratogenic effects of mood stabilisers in pregnancy?
a. Lithium – Ebstein’s anomaly
 b. Valproate and Carbamazepine – spina bifida
5. This patient is in the depressive phase of BPAD, how would you manage
him?
a. Antidepressant (e.g. SSRI) with an atypical antipsychotic (e.g.
aripiprazole, quetiapine) to prevent triggering mania

Bipolar Disorder Summary

1. What is Bipolar?
- Bipolar disorder is a recurrent and sometimes chronic mental illness marked
by alternating periods of abnormal mood elevation and depression
associated with a change or impairment in functioning.
2. How does Bipolar occur?
- The exact cause of bipolar disorder is unknown, although the risk for disease is
thought to be influenced by several genes.
3. How common is Bipolar?
- The UK National Institute for Health and Care Excellence estimates the lifetime
prevalence of bipolar I disorder at 1% of the adult population, while bipolar II
disorder is believed to affect approximately 0.4% of adults.
4. What patient groups are at the greatest risk of Bipolar?
- Positive family history - 1st degree relative to 7x inc. risk
- Stressful life events (i.e. pregnancy)
5. How to Diagnose Bipolar?
- ICD-10 BPAD definition:
o ≥2 episodes, 1 must be manic associated (hypomania/mania/mixed;
the other can be depressive); AND
▪ Mania lasts ~4m

▪ Depression lasts ~6m

o Complete recovery between 2 episodes

Cannot be diagnosed in primary care → Refer to specialist

• Symptoms of hypomania → routine referral to CMHT
• Symptoms of mania or severe depression → urgent referral to CMHT /
admission to psychiatric ward
• If admission is required, persuade them to go voluntarily. Compulsory
admission may be used if person requires assessment/treatment in hospital
and needs to be admitted in interests of themselves or others. Advise not to
drive during acute illness

Acute mania or hypomania

 • Gradually taper off and stop inducing medications (i.e. SSRIs) •
Monitor fluid/food intake
• Sedation may be required (clonazepam, lorazepam)

• ECT only if mania is not responsive to treatments below

• If not on treatment… aim is to stabilise them before starting lithium o

1st line = Antipsychotic (olanzapine > haloperidol, quetiapine,
risperidone)
o 2nd line = Different antipsychotic (switch to different antipsychotic from list
above)

o 3rd line = add lithium or sodium valproate

▪ Lithium is not as effective acutely (you need higher doses →
risks toxicity)
• If on treatment…
o Optimise medication / stop antidepressants
o Check compliance
o Check lithium levels → add atypical
o Short-term sedatives (benzodiazepines)

Maintenance
• 1st line: Lithium alone
o Monitor for lithium toxicity
o Monitoring required – may take up to 5 weeks to titre correctly
• Lithium not effective → Lithium and valproate
o Valproate = no monitoring
o Valproate SEs = hair loss, weight gain, nausea
• Lithium poorly tolerated → Valproate alone; OR Olanzapine alone

Depression co-existence
• 1st line → Fluoxetine and olanzapine

• 2nd line → Quetiapine alone

• 3rd line → Olanzapine alone; OR Lamotrigine alone

• If presenting in a manic episode on any antidepressants → taper and stop them

Psychological therapy
• Indications and purpose:
o May improve compliance with medications long-term
o Offered after the acute manic event has resolved
• CBT – Test excessively positive thoughts and gain a sense of perspective… o
 Identify relapse indicators
o Create relapse prevention strategies
o Development of WRAP
• Psychodynamic Psychotherapy (useful if mood stabilised)
Social interventions
• Family support and therapy

Mood Stabilisers
source: Alistair’s
PSYCH CASE 2 – Depression
iii) History

Brief

You are an F2 in a GP surgery. Alison Smith, 34, comes in because she is having trouble
sleeping. Please take a history from the patient (7 minutes) and discuss with the examiner.
After discussion, please advise the patient on her management (4 minutes).

Case
HPC
• You are a 34-year-old accountant presenting with problems sleeping and you are

after sleeping tablets. You have been struggling with this issue for 5 months now
and it is affecting your work.

• You are both struggling to fall asleep and wake up early in the morning but are
extremely tired and lethargic during the day.

•You have an extremely low mood which you can clearly identify started around the
same time, but you can’t find a reason for this (nothing happened to trigger).

•You find yourself crying often, but don’t why and you are extremely frustrated by
this. You used to really enjoy outdoor activities and going to the theatre but have
lost all interest in these activities.

• This is causing a big strain on your relationship with your husband, but do not
offer this information unless asked.

• You have lost your appetite and lost significant weight as a result.

•You have cognitive symptoms of depression, if specifically asked about guilt you
admit you think you are a terrible person because when you were younger you
used to smoke weed and you feel PATHOLOGICALLY guilty for lying to your
parents about it. You feel like a worthless human being because you don’t have the
energy to play with your kids, you think you are a terrible mother.

•Risk: you sometimes think death would be a better alternative but would never
consider following through because of your children. No harm to/from others, no
thoughts of harming self

•This has happened to you twice previously when you were 28 and 29 but
have never seen a GP about it.

• No elated mood, anxiety.

PMH
• Had two elective caesareans.

FH
· Mother suffered with severe depression.
DH&A
· N/A

SH
• Live at home with husband and two kids, 3 and 4.
• You and your husband have been fighting a lot about your lack of energy and

lifelessness, you are majorly worried and get a bit tearful if asked about.
• You love your children but find it difficult to cope with taking care of them.

• You are struggling at work due to low energy levels, but not sure how to rectify
the situation.
• No smoking, insignificant alcohol, drugs when younger but haven’t for a long

time.

ICE

I – I don’t know, there wasn’t any trigger

C – Concerned about my thoughts of rather being dead
E – To be prescribed sleeping tablets to help with sleep problems

iv) Investigations

“At this stage, what are your differentials?

- Depression, BPAD, substance misuse, depressive personality disorder

“What investigations would you like to request?

Bedside
o PHQ9
o Physical examination (establish baseline and rule out organic causes)

Bloods
o TFT
o Calcium
o FBC
o Cortisol

“These are the results of the Investigations you requested”

• PHQ9 – 18; moderately severe

• Physical examination: no organic causes found

• TFT normal
 • Calcium normal

“Using the results of the investigations you had requested, what is the
most likely diagnosis?

· Diagnosis: Depression

III) Management and Counselling

“Explain the diagnosis and first management steps to the

patient” • What do you know about depression?

• Sadness is a natural response to stress. Depression is an illness where there is

persistent sadness due to an imbalance of chemicals in the brain. It affects 1 in 5
people.
• Common symptoms include those you’ve told me about today (recall symptoms).
There is no one cause of depression though (recall relevant risk factors) are
associated with it.
• We’d first suggest eating a healthy diet, exercising for at least 30 minutes daily
and practising sleep hygiene to help with symptoms.
• Nearly 80% of people with depression benefit from treatment. We’d first suggest
CBT- this is a type of therapy that looks at the way you think and behave. This
would be 8-16 sessions, once a week.
• If this isn’t helpful, we can discuss medication, but this has side effects
(diarrhoea/constipation, loss of appetite, dizziness, nausea, and vomiting)
and needs regular monitoring. It might also make symptoms worse for 2
weeks before it starts working.
• You can also find advice on the MIND website or the Depression Alliance.

• I’d like to catch up with you in 1 week to see if your symptoms have changed.

• Safety net: if your symptoms worsen or you believe yourself to be at risk of

harming yourself or others, contact the GP immediately.
IV) VIVA
• List some of the main symptoms of depression.
Anergia
Anhedonia
Low mood
Sleep change
Appetite change
Concentration deficits
Memory deficits
• List three classes of anti-depressants and give an example of each.
SSRI – sertraline, citalopram, escitalopram, fluoxetine
SNRI – duloxetine, venlafaxine
NaSSA – mirtazapine
TCA – imipramine, amitriptyline
• How might the treatment be different if the patient has psychotic
depression?
Start an anti-psychotic (e.g. quetiapine) alongside the anti-depressants
• How is psychosis in depression different from psychosis in schizophrenia?
Psychosis is mood congruent in psychotic depression
Psychosis tends not to be mood congruent in schizophrenia as patients have
blunted affect

Depression Summary
1. What is Depression?
- Depression is a mental state characterised by persistent low mood, loss of
interest and enjoyment in everyday activities, neurovegetative disturbance, and
reduced energy, causing varying levels of social and occupational dysfunction.

2. How does Depression occur / risk factors?

- Biological
o Genetics; Neurochemical; endocrine; illness; medication
 - Psychosocial
o Childhood trauma; life events; substance abuse; vulnerability
(unemployment, isolation)
3. How common is Depression?
- About 20% of adults will be affected by a mood disorder needing treatment at
some point in their life. Women are affected twice as often as men. In patients
with an affected first-degree relative, the lifetime risk of depression increases
two- to threefold. First onset occurs most frequently in patients aged 12 to 24
years or older than 65 years.
4. How to Diagnose Depression?
- Core symptoms: if ≥1 present for most days, most of the time, for at least 2
weeks
o Anhedonia
o Low mood
- Adjust symptoms
o Fatigue; Insomnia; Poor concentration; appetite change; suicidal
thoughts; agitation; guilt

Step 1 → All patients with low mood; sub-threshold symptoms

• Watchful waiting with follow-up in 2 weeks

• Education → Sleep hygiene, Exercise, Self-help (MIND UK, Depression UK)

Step 2 → Persistent sub-threshold symptoms; mild depression

• Psycho → Low intensity psychological therapy

o Group CBT
o Computerised CBT → Online materials supported by trained practitioner
to review progress (Over 9-12 weeks including follow-up)
o Guided self-help → Written materials supported by trained practitioner to
review progress (6-8 sessions (face-to-face or telephone) over 9-
12 weeks including follow-up)
o Structured group physical activities → Delivered in groups with
support from a trained practitioner (3 sessions per week (45-60
mins) over 10-14 weeks)

• Social → Encouragement to involve family and friends

• Bio → only if:

o History of moderate
o Sub-threshold depressive symptoms lasting >2 years
o Persistence despite intervention
Step 3 → Persistent sub-threshold symptoms [refractory to step 2]; moderate
depression

• Bio → Antidepressant (Regular review every 2 weeks for 3 months)

Review weekly if suicidal

o SSRI first line (Sertraline)
o MOAI may be first line for atypical
o Mirtazapine may be good if problem with falling asleep and appetite

• Psycho → High-intensity psychosocial interventions

o Individual CBT → Talking therapy based on idea that thoughts, mood and
behaviour are intertwined (16-20 sessions over 3-4 months)
o Interpersonal Therapy (IPT) → Identifies how interactions with others are
affecting the patient’s mood and ways of improving these interaction (16-
20 sessions over 3-4 months) → IPT is better for unresolved loses (Incl.
death)
• Social → Encouragement to involve family and friends

Step 4 → Severe depression; risk to life; neglect

• If imminently suicidal → urgent referral to crisis team

• Bio → ECT if necessary

• Psycho → High-intensity psychosocial interventions → Section via 2, 3 or 4 if
necessary
• Social → If not admitted visits from CMHT

What Medications do I use?

• 1st line = SSRI

o Sertraline: stepped increase from 50mg to 200mg (50mg increase
every 2 weeks; over 6 weeks)
o 2 trials of SSRIs before moving to 2nd line
• 2nd line = Taper down SSRI, switch to SNRI:
o Venlafaxine: stepped increase from 37.5mg BD → 75mg BD →
75mg morning / 150mg evening
o SNRI pharmacology does not switch from SSRI effect to SNRI effect until
reach maximum dose

• 3rd line = Treatment resistance → augment treatment with…

o Antipsychotic (i.e. quetiapine 150-300mg)
o Lithium (blood level of 0.4-0.8)
 o Other antidepressant (e.g. mirtazapine or mianserin)

• 4th line = ECT

In pregnancy:

• Mild or moderate depression → encourage to taper down and switch to… (if possible)
o Mild → facilitated self-help
o Moderate → CBT (or switch to a drug with lower risk of adverse effects)

• Severe depression → continue antidepressant or switch to a drug with lower

risk of adverse effects

Switching between antidepressants

1. Switching from citalopram, escitalopram, sertraline or paroxetine to another SSRI

o First should be withdrawn before the alternative is started

2. Switching from fluoxetine to another SSRI

o Withdraw then leave a gap of 4-7 days (fluoxetine has a long half-life)
before starting a low-dose of the new SSRI

3. Switching from SSRI to TCA

o Cross-tapering is recommended
o Exception: fluoxetine should be withdrawn before TCAs are started

4. Switching from citalopram, escitalopram, sertraline or paroxetine to venlafaxine

o Cross-taper cautiously (start venlafaxine 37.5 mg OD and increase
very slowly)

5. Switching from fluoxetine to venlafaxine

o Withdraw then start venlafaxine at 37.5 mg OD and increase very slowly

Take home message: fluoxetine takes longer to switch because it has a

long half-life