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Hi, everyone. Sorry. It's, um, starting a little late. Um, I'm just trying to upload my, um, slides just one second. I just get a bit of time for people to join. There we go. That's great. That's good. So, yeah, I'll give it another few minutes just waiting for people to join. Um, but welcome to everyone who's come so far. My name is Chloe. I'm a final year medical student at Southampton University. This is a revision session that the Psychiatry Society are hosting. We're doing a bunch of them. We've had a few gone just before Christmas. There was a slight pause due to, we had our final exams, but we're starting back up again now and they're taught by normally the higher years for the lower years and designed to help you at whatever stage of your journey in medicine. So, whether you've not done any psychiatry, that's absolutely fine. This will help you in your future teaching or if you know, some people are still about to do their final year exams. So that's helpful. But a lot of people have fourth year exams and that's when you get a lot of psychiatry teaching. So we're hoping to help you with those. Um, and yeah, we're just here to try and cover all the things that could potentially come up. I try and put in a few good suggestions of things that come up in exams that I've seen come up at least. And good stuff to remember and just to make psychiatry. Yeah, like really interesting and, um, informative and hopefully give you a good start or support wherever you are in your learning. So yeah, we'll get a minute or so and then we will start. Amazing. So as I said, everyone who's just recently joined. Welcome. My name is Chloe. I'm the psych, so president in Southampton University and we'll be doing a bit of a revision session covering mood disorders today. So if you have any questions throughout popping in the chart, I might not be able to see them whilst I'm presenting, but I'll come back to them at the end just because I've got a few tabs open to make sure I can see everything. Um So yeah, please do any questions you have. I'll do my best to answer. As I say, I like, I'm not going to be perfect, but I do hope to help as much as I can and I hope this is helpful and so hopefully you guys can all see the slides. Yeah, if not just put it in the chat, but I'm assuming you guys can. So just a little schedule just say we're doing introductions. Now we'll go through the different types of mood disorders and their sort of background. Why people think they've come into existence and then we'll cover the big films, which is the clinical features of both depression and bipolar and then their subsequent differentials, some basic investigations. This isn't, there's not as much to cover with mood disorders as there was last time for schizophrenia, for example, but good to know a few good ones. And then the Baker section which is on management will cover that as there's quite a lot and finish up with prognosis. And then I've got a few questions. Um, we can go through and just, I can go answer any questions and any exam suggestions I might have as well. So, first of all, we want to talk about definitions. So we talk about mood disorders. It's a broad title to cover a lot of things that cover mood. So one of them is depression and that's the most common mood disorder and it's just characterized by low mood and HD Donia, which is a lack of pleasure in things and sort of lots of other features that we'll go through later. Um, and then bipolar disorder is the other one. It's not very as common, but it's quite, has quite significant effects on people and has a larger prognosis. So we cover that mostly in exams and in medicine in general. Um, and there are a few others. So hypothymic disorder, persistent depressive as premenstrual dysphoric disorder, which is a recent slightly controversial addition to I think the DSM. But we'll go through what that means and everything later if you don't know. Um So yeah, a few sort of different things. So mainly just worth remembering that depression is a really common disorder. It affects 264 million people around the world and it's the leading cause of disability and is a big contributor to just the general global burden of disease including in the UK, whereas bipolar disorder is a cyclical mood disorder, so it's cyclical rather than depression, which is pretty constant. And that fluctuates between episodes of mania and depression. As I say, we'll go through the characteristics more further on, but it's just worth remembering and the lifetime prevalence of bipolar is much less than depression. It's about 0.1 to 2.4% but it is very disabling and detrimental to the person. So that's why it's important to know. Um So yeah, as I say, these are the other conditions you can that included in mood disorders. I wouldn't really worry too much about what they are. But if you want, you can look them up or I can explain them later in questions. So, the etiology which is sort of the understanding of the contributions or causes of depression, these fall into four distinct categories. So the first one is genetics as is true for most things. And it's a very broad genetics, lots of different things, no specific, defined genetic change, but it has quite high heritability, depression with about 35 to 50% heritability, but bipolar it's extremely high heritability. So just remembering that it's about 80 to 90% according to twin studies. So, um it's very significant if you have a family member with depression. So just remember if you're doing a OS the screen for that, when you're asking about a history, for example, and additionally relatives of people with depression obviously have a high risk of depression. Whilst relatives of people with bipolar have a greater risk of both bipolar and depression, it's both. So it is quite significant basically. And then you have childhood and life experiences. This is quite bored, but it's quite a strong factor what we call adverse life events normally in early childhood. So things like neglect or abuse, they are big contributors to any type of mental health disorder. So just if you don't know that already, just remember that, but it's particularly a risk factor for recurrent and persistent depressive episodes, you're more likely to get those and for treatment resistance. So again, ask about that and your osc history taking obviously sensitively, but it's good to remember um in adults, though there are still factors that can increase your likelihood of developing mood disorders. So factors like unemployment, a lack of a confiding relationship, low socioeconomic status, as well as social isolation are all associated with a high risk of depression and for bipolar. Um despite the high heritability that I noted earlier childhood maltreatment is actually associated with greater bipolar severity as well as greater comorbidity and more frequent relapses and suicide attempts than in people without childhood abuse. So, although heritability is important, childhood abuse is probably the biggest contributing factor to developing bipolar. And then you sort of addition to that you also have stressful life events and those kind of overlap. But these are particular triggers that they might already be predisposed. So they might already have had those childhood life experiences. But then they have a stressful life event, which is the sort of trigger. So sort of like the gun is already cocked back, but that's you pulling the trigger. So these can be lost events. So things for depression. So things you know, like a bereavement but actually lost events can be any kind of loss. So it can be a loss of autonomy. So for example, someone suddenly becomes disabled and not needing a lot of help or a loss of job, a loss of sense of purpose. So retirement or loss of job or that's why I think suddenly becoming a mother and taking time off work can be quite a trigger because there's a loss of sort of function and purpose to life um for things for something like mania, though both negative and positive life events can trigger it. So you often go through with a patient, what potential triggers there might be because these can be both good and bad. Um So for example, there's childbirth can be a trigger for mania as well as sleep deprivation. But at the same time, something like flying across time zones is known to be a trigger for mania. So it can be quite odd and it's worth talking about those with your patient. And then finally, there's organic causes, there's lots of things to learn about. So I definitely worth look it up more thoroughly on keys, whatever fici sites you use. But mania can be caused by physical disorders like Cushing's or head injury. And a big one is steroids. They often ask about that in exams, they might present with manic like features, but they will be on a long term steroid and it's worth and you need to decide whether that's a true bipolar disorder or steroid induced mania. And yeah, and then physical illnesses that can mimic depression include things like Cushing's disease as well. Hypothyroidism is a big one. Do you remember that? It's a very good mimic of depression and people often forget about it and don't test, people do a blood test just to make sure they've not got hyperthyroidism before you start the medication. So yeah, as well as strokes. Um Parkinson's disease can also mimic depression and hyperparathyroidism as well. Then we move on to theories. These are much more broader ideas for trying to understand why someone would develop a mood disorder in terms of the way their sort of brain is processed and, and how that triggers them basically. So there's lots of different theories. The first one is sort of behavioral and cognitive theories and these are used often to explain anxiety disorders. So um they're, they're applied in a slightly different way here. But basically argue that negative thinking can depress mood, which in turn generates negative thoughts and it creates this sort of downward spiral where people become more and more depressed. So they have a sort of triad of negative views of the self, the world and then the future in depression. And then there's also psychoanalytical theories. These stem from sort of Freud, old fashioned Freud, but they do sometimes apply. Um And these hold that sort of early experiences, particularly the sort of quality of our early relationships predispose people to depression, for example. So, um you know, basically depression can be understood as a harsh internal judge or a super ego and it's bullying the helpless self, which is the ego into despair. Um But yeah, it sort of implies that it's an unconscious thing. Meanwhile, mania is considered to be an unconscious self-defense against the depression by denying vulnerability and you're so much better than anything. So that sort of counteracts the depression you're feeling. And then finally, there's the classic neurochemical theories and the main one is the monoamine hypothesis of depression. It's worth knowing a little bit about this. It gets tested a lot and there's also been a lot of controversy about it lately. I could go on. It's a big topic to cover. Um, but basically it's this idea that when the antidepressants were first developed, they, they were created serendipitously in the 19 fifties. And what they found is it improved people's mood when they gave them to patients. It was initially for tuberculosis. And what they found is that it inhibits monoamine oxidase and basically increases the amount of serotonin in you in your brain. And therefore, they associated depression not having that with um not having um the monoamine um dysregulation. So actually, that's basically the hypothesis is that if you restore normal function in depressed patients by increasing the level of monoamines in the synaptic level. So, um but there has been a lot of recent stuff that's come out that suggested that's not the case. We don't quite know there's lots of things that don't quite fit with that model. So that's just a brief introduction. I know it's very brief, but it's hard to cover it all in such a short space of time. So yes, we'll go on to the typical features. So as I said, this can't be an extensive breakdown. We just don't have time to cover it all. And obviously, it's good to do your own revision. So um do check out ki medics, it's really, really good for their depression, it covers everything and particularly what I didn't have time to cover in this, which is sort of depression with psychotic features or other features that it can have. So worth checking that out. Um But mainly it's worth thinking about the general features which are persistent sadness and low mood. Often it's very highly associated with anxiety. Most people would argue they're practically the same illness because most people get one or the other at the same time. And then you have anon, which is a lot of pleasure in things. So all the stuff that normally brings you pleasure like food, if you like making nice food, watching TV, seeing friends no longer brings you any joy, you often feel very worthless and very guilty. That's a common feeling. They feel like they shouldn't feel this way that it's such pathetic and not right. And then um often you have changes to sort of biological changes. So they might lose appetite, you might not sleep very well, but you can also have atypical depression, which sort of goes in the opposite way where you overeat and you oversleep. So remember, it can go both ways, but typically it will be a lack of energy regardless. And they can also have kind of slowed cognition. So they can really struggle with basic tasks, be very slow to understand things. Um And then remember, there's also often sexual dysfunction. So a loss of libido, erectile dysfunction and orgasm. So remember to ask for those. I know it can be a bit uncomfortable sometimes to ask those questions. But it's really important. It's quite a good feature to think about. And then we also can separate depression into different types. And that's really important when we're thinking about treatment so often, this is done with a screening questionnaire. So there's lots of different types. In this case, I'm giving you an example of the PHQ nine, which is the, is it patient hospital questionnaire? I think I can't remember what it stands for, but um it's just one of them. There are many scales you can use but defining whether it's mild, moderate or really severe is very important. I think the severer one that you just want to differentiate is a really severe and that's normally it's pretty much all the time. It's very significant functional impairment. They can't leave the house, they can't leave their bed really bad. So that's why it's just useful to have that classification as I explained later on. So yeah, then the different diagnoses for depression um there's organic causes. So I mentioned before, hypothyroidism is a big one. Don't forget that one can also have an hyperactive delirium or Addison's disease or dementia. Those are the main organic causes. I remember sadness, bereavement that is quite common has someone had a loss. It's typical for them to be sad for at least a year after a loss and have the depression for at least a year after a loss. So, um, don't over medicate and over medicalize just because someone's breathing adjustment disorder is a sort of mild, effective sort of disorder after a stressful event in life. But it's not severe enough to diagnose depression. And then dysthymia is a sort of chronic low mood and it's for more days than not and it lasts years, but it's not enough again to be diagnosed with depression. It's a bit of an odd one. It's sort of like, is it depression? And in reality, would they just be diagnosed with depression and treated anyway? That's a good question. I don't know. And then finally, bipolar disorder is an obvious differential which we'll discuss. And the main difference there is you have those episodes of depression, but you also have episodes of mania or hypomania. We'll discuss the differences between those two in a minute. So moving on to bipolar. Um so there's lots of actually, you can classify into different types of bipolar disorders. We won't go into that too much. But I think the main thing that characterizes it is you've got those episodes of depression. People will have episodes of depression with bipolar, but you have in between those episodes, you will have episodes of mania or hypomania and that's how someone gets diagnosed with bipolar disorder. So you're probably thinking, what's the difference between mania and hypomania? It's a very common exams of questions. So we're thinking about and remembering, just remember, mania is just more extreme and hypo is, it always means little or less, less mania. That's how I remember. At least hypothyroidism, less, less thyroid. So, um, mania is more severe, it's more debilitating. It often needs to result in an inpatient admission. They are much more disinhibited and um, it really affects their life. They probably won't work. People can become very sexually disinhibited which has big problems. It can also almost present like a psychosis. It's very rapid speech, very high mood, almost a very grand was delusion. So this idea that you're much bigger person than you are, that's what we mean by that. Um Very racing thoughts and very distractible, very poor concentration, constantly moving on to different ideas. So it's very extreme. Whereas um hypermania has those features of mania, but it's not as severe and it doesn't lead to as many um sort of social or occupational impairments. So you can still go about your daily business sometimes. But normally your people who know you will say there is something odd about you. You are actually much more joyful and happy. So people will mention that, but it's often a bit more manageable, it can be managed in the community rather than in patient. And the main difference I'd say is mania lasts for at least a week, whereas hypomania might last at least four days, it lasts for less time. So that's just worth remembering. So I briefly mentioned before the DSM criteria and the fact that there are different types of bipolar disorder. So I just wanted to cover that in case that was a bit confusing. Um So there are two diagnostic manuals and we in this country use the ICD. It's now 11 I put 10 there, but it's now the 11 I realize, but in America they use the DSM and um they just have slightly different classifications for how you classify disease. And DSM is a bit more controversial because it often can medicalize and sort of create diagnoses for things. And that's what people don't like about it. People like that. So pros and cons ICD is a bit more blanket. So it just has a diagnosis of bipolar. Very simple. You have to have at least two mood episodes, one of which must be mania or hypomania. So typically someone has an episode of depression and then an episode of mania, that's the diagnosis. Whereas DSM, it categorizes it a bit differently into bipolar one and bipolar two. I wouldn't be too worried about that. I don't think it would come up in an exam and we will use the ICD in this country anyway. So as long as you remember, bipolar, they have one, normally an episode of depression and then an episode of mania hypomania, I think you'll be absolutely fine. I just pop that in just in case you hear it or see it and they're confused because it can be a bit confusing. So yeah, then the differential diagnoses for bipolar disorder slightly different. We've still got organic causes. Always remember those. So those can include delirium intoxication. So particularly with things like cocaine or amphetamines can mimic a mania make you really excitable and very high dementia. Frontal lobe damage is a common one for a bipolar disorder. It can be quite similar to mania because you have change of personality, you're quite sexually disinhibited with frontal lobe damage. So, do remember that obviously, the main difference is with frontal lobe damage is probably permanent and it will stay that way mania does end. Um cerebral infection with HIV can mimic mania as well as well as myxedema madness as it's called, which is when you have an extremely low thyroid and it can cause a sort of madness like symptoms and then people often fall into coma as well. So if you have a really low thyroid and schizoaffective disorder, um is a sort of psychotic disorder and it has both psychotic but also affective symptoms. So sort of depressive symptoms as well. But the main thing to remember with schizoaffective disorder is that both the low mood, for example, and the psychotic symptoms, they happen at the same time simultaneously. And that's how you differentiate it from bipolar disorder or even just depression with psychotic features because they happen at the same time, then you have emotionally unstable personality disorder or borderline again, they can be given different names according to the DSM or the ICD. Um BPD as it's known, is often causes quite a low mood, very impulsive and that can mimic mania. But again, remember these traits are persistent to their personality and you normally will ask about, have you always been like this or is it a change? And normally they will say they've always been like this than perinatal disorders. So think about postpartum psychosis. That's a very classic one. There's a few others a bit more niche but just ask, uh have you recently given birth or anything like that? Just to exclude that? And then finally, ADHD and that can again be quite hard to distinguish from a sort of emerging bipolar disorder if they're quite young. But ADHD again, is more persistent and it also develops earlier. Normally you can, I think people diagnose now at age of seven. So you're not going to be diagnosed somewhere by Polar disorder at that age. I tends to present later. Typically it's like late teens, early twenties, I think is the most common presentation. So, yeah, those are the differentials, the investigations, these aren't too long, but we've got a just a bit of a list I put together for all the various things you need to do and cover if you're approaching a patient. Um So obviously you want to take a good history. I'm going to, if I can attach to this presentation, I've made some notes on how to take a good depression history that I think is quite useful and I'm happy to share. So check that out after the event, I'll add it in as soon as we finish and then do a physical exam again, you might want to check their thyroid. For example, you know, check other things that if they've come with other ailments, just double check and then what we talked about before like a rating scale. So the PHQ, so it was patient health questionnaire, but there's also the beck depression inventory. There are loads often, it depends on the trust which one they recommend using. So um just ask your colleague and it will come up there. So normally we want to do one of those, see how severe it is that can guide our management. Good to do a cognitive assessment. As I said, depression particularly can affect cognition. So worth assessing that and making a score of it. And if you can seeing whether that's changed from previously, again, you could do a CT and MRI, but that's not really routine unless you've got a reason to think. So. Otherwise, good to do a urinary drug screen, particularly for bipolar, as I said, amphetamine, cocaine can mimic mania. So if you are suspicious of that, just use that to screen it out. It's an easy test. And then I think this list is the one that you should remember and note down for your vision. These are probably the most important and these are done to exclude other differentials and then they're also done to help with um management choices. So for things like lithium, we'll talk about that later. But you really need to monitor thyroid function and renal function for lithium. So if you want to do that first before, um you do it. So things like that, it's just worth a long list. So management in general, um this is more sort of everything that you want to think about. Obviously, it's quite bored with psychiatry. So think about MDT support, you get the mental health nurses involved, get the psychologists involved. And that's where the community mental health team comes in. If you are going to go on a placement as part of your course, you will hopefully have some chance to meet those teams, they're really great, they're really supportive and they do work very well as a collaborative team. And I think the nice thing about psychiatry is it's a bit more egalitarian. People aren't too worried about hierarchy. It's not like surgery where often it can be very much the surgeon as the consultant is at the top and everyone sort of just falls in line with them. I think with psychiatry, they're much more open to exploring everyone has different perspectives and wants to make sure that the overall goal is a good health outcome and that could be quite nice. So hopefully you get a chance to do that. If you haven't already, I would recommend it. I really liked my time in community mentality. So just a little plug for that, then there's also a crisis resolution team. Again, if you are going on placement, you might have an opportunity to join them. They're there for when patients are in a really bad way and patients can self report to them and go when they're really struggling and are really either suicidal or maybe if they're really manic things like that. Um Sometimes you might need admission into acute care. This can be through a hospital, any or it can be directly sometimes to a inpatient facility. Obviously, we are struggling because there are so few available beds, but typically someone with mania will often be admitted unfortunately, because it's quite hard to manage. It takes a few weeks to manage and they can do a lot of damage to themselves in the meantime. So it's often they might be brought under the Mental Health Act, not always, but sometimes and then you're really vital. Never forget the risk assessment. People often forget about it. It's really vital. Think about their risk yourself, risk to others, risk from others. Nice and easy. And then, yeah, just remember any comorbidities that they might have as well, there's lots of funds that can be going on. So as worth revising those. So more specifically the management, um I I've separated it into less severe depression and more severe as we discussed before. You would do that by asking to some rating scales. And then obviously you can make that clinical judgment from your history as well to determine the severity. But nice recently changed the guidelines, I think last year. And it's now first line is always psychological therapy over pharmacological therapy. So bear that in mind for exams that can come up and they might sort of trick you to thinking, oh, I have to give them a antidepressant. And what they might sometimes look for is your understanding of the severity of the condition. So they'll give you a bit of history and they might even give you like a PHQ score and be like what should be the management? And those are quite tricky questions because I remember doing one, I was thinking, oh, which one would it be? So just bear that in mind. Nowadays, first line is always going to be a psychological therapy. And in this case, it's typically a cognitive behavioral therapy. If you don't know what that is. Cognitive behavioral therapy is based around understanding a patient's thoughts of their cognitions and how their thoughts act on their behavior and thinking about how that happens. And therefore then using strategies to change their cognitions and change their behavior subsequently. So it's about thinking about it and then introducing interventions to change it. So in this case, I think I'm worthless. You address, why do you think that you're worthless. Where does that come from? How does that feeling of worthlessness affect what you do and how can we change that? What interventions can we do to challenge it? For example, if I think I'm worthless, how come my family and friends? Very supportive with me, that challenges that perception and therefore thinking your behavior is, I therefore don't want to see my friends because they think I'm worthless. I think I'm worthless. Or what happens when you do go and see your friends. Do you feel worthless when you're with them? Do they make you feel that way? Probably not. That's a brief introduction to CPT. Anyway. So, yeah, for less severe, definitely first line is just CBT or even as simple as guided self help, you can just be given a bit of psycho education about depression, how you're feeling, sort of general tips about sleep hygiene about self care. And that can be surprisingly effective because depression is very common. So if you catch it early, you might not need something as strong as an antidepressant. Um, but if not, you can move on to sort of often it's a group CBT. We now prefer group. I don't know. I think in that case with nice, it's much more about cost than it is about efficacy, but I could be wrong. Whereas if it's more severe, you want to think about, um, probably starting with both individual CBT and an antidepressant, but it can be individual CBT on its own. It again would depend on patient preference. So when it's more severe, just remember it's more individual and you're probably allowed them to introduce an antidepressant. So there's a long list of preference there. But I just remember those two things. Um, if it's not severe, start with psychological therapies. If it's the psychological therapies and an antidepressant, this is just a brief thing I found from my notes and thought it was quite good. I don't know whether it would come up in an exam, but it's just worth thinking about, about just the limitations to each approach in terms of like sort of pharmacological interventions versus psychological and social. So what's the benefits? What's the sort of down side? So remember, I think particularly with pharmacological things, we always think a pill sorts everything. It's the best thing you can do. But actually, we often have adherence issues, compliance issues. There's also a lot of side effects with, you know, antidepressants and people can also develop tolerances and there's lots of things. So just remember that and, and to be fair, some similarly, there can be things with psychological stuff that people have to be willing to engage in a program to work. They have to go home and they have to do the homework, they have to practice. It's not an easy thing to do. Um So yeah, that was just a brief slide just to cover that and just think about things. So antidepressants. Um I'm sorry, this picture is not great. I just had to screenshot it from, I think there's this really good book. If you haven't got it already, I would recommend it from the library. It's called Psychiatry P RN. Um It's really excellent. A lot of my notes come from that. It covers everything and it does it in a lot of detail. So it even has sort of mock um history takings in it to sort of help you think about it from people's perspective. It's even got the little snippets of recommended TV, viewing for extra bonus points. So I really recommend it's a good book to revise. I'll pop it in the chat at the end. But yeah, it's from there and it just gives you a quick sum of the three main types of antidepressants. Although let's be honest, we only use the top one pretty much the most common one we use is selective serotonin reuptake inhibitors. I think you can go into a lot of detail about these and that's important. But I think my notes on the side are the main things you need to remember. So remember the side effects generally for them, they will change between each one and that's very niche. And that's more for an actual psychiatrist as a trainee, you need to know that. But just remember normally it's, it's the anticholinergic or it's antimuscarinic side effects trying to remember now. But yeah, um I think it's antimuscarinic. But yeah. Um so things like nausea, vomiting, um you can get sort of sweating the big one sexual dysfunction. Most people, men particularly will say I'm struggling to maintain an erection. It's really affecting my relationship. So do bear that in mind. That can be a significant distress for people. So don't ignore that and make sure you ask about it as well. If you are reviewing a patient, for example, it's a good thing to think about. The big one comes up a lot in MCQ S is that Citalopram increases, the QT interval comes up all the time. They'll be like, what's the cause of the prolongation on this ECG? And they'll give you a list of the medications and that's a common one. It comes up in um, the PSA if you're doing that um in the UK, then remember as well for under 20 fives. If you're starting them on an antidepressant for the first few weeks, there is a much greater risk of them having increased suicidality. So you have to check in with them a week after starting and give them a phone call or whatever it is. Um So do you remember it's a week on get a phone call or something just to review and make sure check their suicidal state, basically. Um And then there's a few other things in terms of interactions. This is more specifically to prescribing examinations. Um But I think one of the big ones that they come up a lot in the PSA I haven't put on the screen that someone might already be on an antidepressant and an SSRI and then they've given traMADol as pain relief and because they both work in the same way it can cause a serotonin syndrome. So you might get a question where they present, you know, sweating really unwell, really hot. Um And they'll ask you what's going on, what's the cause? What's the drug cause? So just remember that it will probably be the traMADol. That's a common question. Um So yeah, there's also SNRI S and those are often used more when SSRI S don't work. And um, yeah, they're less common but the ones remember as it says on the little box, they avoid Ven the vaccine because it does, if there's a risk of arrhythmias, if they have any heart problems, you're not allowed to use ven the vaccine, often it will come up on the NF so that sort of thing. And as I say, with all of them, you just have to remember to gradually stop them over four weeks or it can cause withdrawal symptoms. And again, that can come up as a question. So in your revision, I couldn't have time to put it all in, but look up the withdrawal symptoms for antidepressants. Great. Again, if there's any questions like pop them in the chart, I know I'm going quite fast. So it can cover a lot. So, yeah. Do you have any questions you have? Finally, I just wanted to cover electroconvulsive therapy. I thought I'd throw in that picture because it is seen as quite a sort of archaic thing. But it can be very good. It's not used routinely, obviously, but it is shown to be very useful for people who have really severe depression that hasn't responded, that's very treatment resistant and is very recurrent and disabilitating, disabilitating. I can't speak. But yeah, um it can be really beneficial and people have lots of misconceptions about it. And I think if you do ever get a chance to see it, if you're on placement, people can do it. It's not at all like in the movies they don't spasm about often. I think you can actually find videos on youtube of people getting it. They are often sedated, they have muscle relaxants, they don't hurt themselves in any way. They are very severely, strongly monitored. So it it can be beneficial, but it should be used precaution like anything, it's still a severe thing. And as you see there, there are side effects. So the short term ones that normally don't last very long and that can include like memory loss a little bit. And then the big one they worry about is obviously a cardiac arrhythmia. So they monitor you with an ECG monitor and they do it and they monitor afterwards. Um And then the main long term side effect is impaired memory and that's what people mostly report. So as I put in the little star there do check out Gig Medics, they do an ECT T counseling, a guide and that's really helpful because it would be a weird station, but I don't think it would be a terrible station to give to. You're counseling, a patient who is about to have it and you have to inform them of the pros and cons. So just worth checking out really. But yeah, I like to frame it in the sense that it's not as ok as people think it does have its benefits. So, moving on to management of bipolar disorder. Um so you have, I've split it up into sort of three sections. Bipolar disorder is much more um treated medically and and pharmacologically than depression is. So the main thing with bipolar disorder, we treat with mood stabilizers or mood stabilizing antipsychotics. And this helps to sort of even out the extremes of the mania or hypomania. And also sometimes it can also help with the lows a little bit and it's just to help balance the mood and it is shown to be quite effective. And the main way we do that as I'll talk about later is the main mood stabilizer we use is lithium. There are other mood stabilizers. So um we sometimes use the anti epileptic drug, sodium valproate, which seems a bit unusual, but um that also can work quite well. Again, that has a lot of side effects though. And you have to be very careful with that. I think there's also, is it lamoTRIgine? No. Yes. Motrin and carBAMazepine. That's the other one. Um, so yeah, um, worth looking those up as well. But the main one we'll talk about is lithium. That's the big one that comes up in the exam. So I haven't covered the others, but you can look them up in your own time. Also worth remembering that in acute mania, it's important to stop any exacerbating medications. And this again is a common question. Someone presents with acute mania and they are on an antidepressant. You need to stop the antidepressant because it will exacerbate the mania. One of those weird things, I don't really know why that happens. Um but it can come up in MCQ S again, it can come up in prescribing exams. So just remember, stop the antidepressants if you can try and remember to stop steroids and take me like this. But I think that's quite a big ask. I think just mainly remember about antidepressants because I've seen that question a lot. So that's the medical side. Then we have the psychological side. And this is more based around psychoeducation rather than that much psychotherapy. So it involves supporting the person as we talked about a bit earlier, it's really important to identify relapse indicators. So when they're starting to edge into mania or hypermania, there might be small things that people do and they might even be able to notice themselves. Um But it's also really important for people's families because as we go on to a bit and the second it was social management. Um but yeah, it can also help create good prevention strategies and making sure they get good sleep because sleep deprivation is often a trigger for mania. Um making sure, you know, you've got a good daily routine and a good structure and support um with like sort of how to manage stimulation and things like that. And that can all be really important. So you can also do CBT and it does show to reduce the relapse frequency. It doesn't necessarily help with um symptoms, but it overall helps the outcome. And I think it can be really helpful for people again to identify their triggers and help them get to better know themselves and their mental health condition. And therefore the earlier treatment you get, the more support you get that's obviously going to have better outcomes. So I think that's, that's how that sort of fits in. And then finally, the social management, I think this is really important and often overlooked is support for family members. Because with mania, the insight is quite lacking, often people won't realize that they are edging into mania because they feel so great, they feel so related that they won't realize so often family therapy is used to help the patient and help their family member identify when they're going into those episodes and really support them as to how best to manage it because it's really, it's very debilitating to have someone like that around you and know what to do. It can be quite frightening. They're behaving completely out of character so that can really help. And there's this thing called interpersonal and social rhythm therapy. And um it's quite a new thing but it's used to sort of support biological rhythms. So the circadian rhythms with sleep and making sure they're regulated to help reduce the likelihood of them developing a mania or hypomania. So that's the management of bipolar and we'll talk about the can. Um So the main thing to remember again is the adverse effects. Um I think this is a long list. I know it's quite hard to remember all of the long list for them. So I like to, the main thing I remember is um starting off typically is like a fine tremor and that's in terms of toxicity and it getting worse, it starts off with a fine tremor and then it normally gets worse and becomes tiredness and really, really fatigued. And then when they're definitely taking too much lithium, they might fall into having seizures, cardiac problems, things like that. But the main things to warn them about is nausea, vomiting, diarrhea, those are the big ones and then potentially the tremor. And um and then, you know, counsel them on signs of toxicity. So potentially the tremor, nephrotoxicity problems, thyroid problems, um you know, heart problems as well is worth counseling at the moment. The second part to knowing about lithium, that's really important is monitoring lithium. This is a very common question that comes out. It's a good question they can ask for MCQ S. Um And it's particularly as I put in the little star it because there's been a lot of reviews about them with doctors and GPS and saying that there hasn't been adequate monitoring. And so now N has introduced new guidelines. So it's a very hot topic for exams now. So worth noting, I don't think you'd need to know this off by heart and they normally give it to you but never say never. Um The therapeutic plasma range is 0.6 to one per liter for lithium and it can, people can start experiencing toxicity at just 1.2. So it's a very small difference before it edges into toxicity. So that's quite significant. Um So when checking lithium levels, a common question that comes up, make sure you do it 12 hours post dose. But if you're starting lithium, you should check the levels weekly and after each dose change until the concentrations are stable and then once they're stable, then you normally measure lithium levels every three months. That's a very common question. How often do you measure lithium levels once they're stable? Obviously, if there's a change, it goes back to weekly before it becomes stable again and then every three months and then again, the big one to, to remember for monitoring, this is more common with prescribing um exams is that thyroid and renal function should be checked every six months. Um because that's the most adverse effect, that's most common. So um yeah, that's lithium. Those are the big things to remember. Um Do make sure you reply those they are common questions. So we're sort of wrapping up now. Um So I just want to go over prognosis for both. It's worth remembering because more just to remind yourself of the significance of mental health conditions and also just people might want to ask you again in an osk situation, you know, what's the prognosis for this patient? For example, that can be a question. So the bipolar disorder, it's just worth remembering manic episodes are can go on for quite some time, but they are, they normally urge on shorter but two weeks to five months. And then in between those people can be completely fine. They won't have any episodes of depression, they won't have any methods of mania. So it's not like depression where people can sort of remain somewhat depressed, they typically go back into complete remission. But I think the big thing to remember, remission becomes shorter with age and depressive episodes become more frequent as people get older. They will tell you, I don't really get any mania or hypomania. I am just increasingly have more depressive episodes and that can be very debilitating because bipolar, depression of bipolar can be much harder to treat than just depression. So just remember that um for both, I mean, up to 15% of people die by suicide. So worth noting that that's why we should always ask about risk and make sure you don't forget about this and monitor risk. Don't just do it at the start and then leave it once they start treatment, ask again about risk, ask in three months, check every year. That's really important. And then for bipolar disorder, as I mentioned before, it can cause manic episode can cause a lot of issues with the disinhibition. So they can have lots of sexual problems which can be really awful and have very serious sort of social relationship consequences and also financial stuff, particularly gambling is really common. People can gamble away their life savings in a manic episode and that would destroy you. So that's why it's worth thinking about. Um And then with depression, the most people, half of people have a subsequent depressive episode and the risk of having another one increases, the more recurrences you have the more likely to get it again if you have another recurrence. Um And yeah, they typically do last quite a long time, but with treatment it's much, much smaller. So I think that's a really good statistic because people can be really down about, you know, depression that has a really poor prognosis. But actually, you know, if it's properly treated, that's a really good thing. So, yeah, worth remembering. Um And yeah, and then um what I mentioned before about suicide, so that's fine. So what I want to do now in the last sort of five minutes or so is do a few M CQ practices for you. Hopefully they won't be too hard. They are taken from past me, but I think they're good practice. They're good classic questions. So we will hopefully start polling. So, are you guys, if you again, if you have any questions, start putting them in the chat or just? Yeah, contribute to the poll and mhm. So, I know it's a big, big chunk of a question. OK. Any more else is coming through? I'm going otherwise I'll give you another minute because there's a few questions I want to talk about. Well, if not, the one person who did it is completely correct is a nine hours that says because I said, you know, it's 12 hours after the dose that you need to check lithium. And typically what people do is they will um they'll check it, they'll, they'll do, they'll give the lithium dose at night and then check it with bloods in the morning. That's the easiest way I think people do it. Um But yeah, because it's so it's in nine hours because there's a you have to wait 12 hours from the last dose and the last dose was at 9 a.m. So, um and it's currently 12 p.m. So yeah, there we go and we'll do this one. Hopefully you guys will get this one right. I think, I don't think it's too hot. It just a bit of a bit of text, but I don't think it's too bad any questions you have at all. I know that was a bit of a, a run through, but it's all recorded. Um So if you want to watch again, you can, the slides are also uploaded so you can check out the slides just on their own. Um I'll also, as I say, upload the my sort of notes on how to take a good depression history because that can be quite a common Osk station. Um I'm not saying they're perfect, as I say, you know, but I think they're quite nice notes to have. Um And then while you're actually answering, I just, and I'll get you a link for the Psychiatry book. Um Yeah, there's a very long leg there if you would like it for the Psychiatry book. This one that I showed you before. It's Psychiatry PRN. It's a really great edition. If you can get it out of the library, I would really recommend it covers everything about psychiatry very much. So it's a bit, I think at some bits you don't need to know, but it's quite good. If you have an interest in psychiatry or just for revision, it has lots of really good in depth stuff. So I would recommend. But yeah, so for that question, you guys are completely correct. It is obviously a very clear manic episode. She's got features there of sort of grand delusions about herself. She's also had quite odd behavior, very fast paced speech, quite sexually inappropriate. These are all very classic, you know, identifier for mania. So just remember that we'll do one more question and then we will wrap up because I know you probably guys want to go, but I just want to give you a chance just to have a few questions. This is probably the hardest question. So don't worry if you're struggling. Um, it's a little bit harder. It's a bit a bit more niche. So don't worry, you need to do your revision and stuff, but give it a go, give you another minute and then we'll wrap up. But yeah, any questions, please put them in the chat. I'll do my best to answer them. Ok. Well, I know you guys probably want to go. So I don't want to waste too much time, but the person who answered, that's absolutely correct. Um So when you're changing the dose, you need to then restart and check again one week after and then do it weekly until the levels are stable. So that's just worth remembering. Um So yeah, well done. You guys did really great on those questions. Um So finally, just a little bit of a plug for Southampton Psych. So if of course you are a Southampton student, um you know, you can follow us if you're not, but it's probably more helpful if you are. But we have a whatsapp group which you can scan the QR code there, but we also have Facebook and Instagram and we post little updates about our events but also just interesting stuff that's going on in Psychiatry that is good for students. So check that out. Come to more of our events. We've got next week, we'll have, I think it's anxiety disorders revision session. So check in on that and yeah, if you have any questions, pop them in the chart. If not. Thank you so much for like joining. I really do appreciate and hope it was helpful. But yeah, I'll just go back to that in case anyone wants to scan and Yeah, thank you so much. Yeah, do give feedback if you can. Um That's really helpful. There's a bit of a feedback form that comes with it. So that's really helpful if you have any feedback. Yeah. Thank you guys so much. Hope you have a nice afternoon and good luck with all your studying of country.