07: Course & Treatment of Depressive & Bipolar Disorders

Question 1

What are the risk factors for Major Depressive Disorder?

Answer 1

• Genetic:
  
  • 2-4x risk if 1st degree relative w/ major depression
  • Common genetic variation accounts for 21% of depression
  • Total heritability = 37%
• Environment: particularly early childhood loss and stress
• Adverse life events may precede an episode, but do not impact the course and prognosis

Question 2

What is the course of a Major Depressive Episode?

Answer 2

• Persists 6-9 months w/o treatment
• 1/3 of untx patients develop chronic depression (i.e., persistent depressive disorder/dysthymic disorder)
• One episode increases risk for recurrent episodes, but many patients have only a single lifetime episode
• If > 1 episode, likely 4-5 over lifetime

Question 3

What is Persistent Depressive Disorder?

Answer 3

• Depressed mood for at least two years and never without symptoms for more than two months
• Accompanied by at least 2 symptoms:
  
  1. Change in appetite
  2. Change in sleep
  3. Fatigue
  4. Low self-esteem (milder form of guilt/worthlessness)
  5. Poor concentration/indecisive
  6. Hopeless (milder form of suicidal ideation)

Question 4

Describe morbidity and mortality for major depressive disorder.

Answer 4

• Functional impairment including
  
  • Parenting
  • Time away from work
• Suicide
• Increased incidence of cardiovascular disease
• Increased rates of death after MI
• Greatest health burden for individuals under the age of 45

Question 5

What are the mood disorder specifiers, and why are they important?

Answer 5

Specifiers affect prognosis and treatment choices.

1. Psychotic features: higher suicide risk, more common in bipolar disorder
2. Melancholic features: more severe form of depression, often associated with psychosis
3. Anxious distress: higher suicide risk
4. Seasonal pattern: recurrent fall/winter depressions
5. Atypical: increased appetite & sleep
6. Peripartum onset: more common in bipolar disorder
7. Catatonia

Question 6

What is the treatment for major depressive episode?

Answer 6

• Antidepressants
  
  • SSRIs first line (e.g., Prozac, Zoloft)
  • Also dual uptake inhibitors (SNRIs; e.g., Cymbalta), tricyclics
  • Duration of 6 months for first episode
  • Long-term prophylactic use if recurrent
• Antipsychotics if psychotic features
• ECT (particularly for psychotic and melancholic subtypes)
• Bright lights (for seasonal pattern)
• Psychotherapy alone and in combination with medication is very effective

Question 7

What are the risk factors for Bipolar Disorder?

Answer 7

• Greater genetic contribution to etiology than depression
  
  • Common genetic variation accounts for 25% of bipolar disorder
  • Total heritability = 75%
• Less role for environmental and psychosocial factors

Question 8

Describe the course of Bipolar Disorder.

Answer 8

• Lifelong, episodic
• Euthymic between episodes
• Decreasing cycle length with age
• Rapid cycling (at least 4 distinct episodes within 12 months)

Question 9

What is Cyclothymic Disorder?

Answer 9

• Milder form of Bipolar Disorder
• Symptoms of hypomania and dysthymia

Question 10

Describe Mood Disorder with Mixed Features.

Answer 10

• Simultaneous depressive and manic symptoms
• “Dysphoric mania”
  
  • Racing, not needing sleep, but feeling miserable with suicidal ideation
• Psychosis common
• High suicide risk
• Less responsive to standard treatment

Question 11

Describe the treatment of Manic Episodes.

Answer 11

• Mood stabilizers
  
  • Lithium
  • Anticonvulsants (valproic acid, carbamazepine)
• Antipsychotics (also used in acute manic episode: more rapid response than mood stabilizers)
• ECT

Question 12

Describe the treatment of Bipolar Disorder.

Answer 12

• Mood stabilizers
• Antipsychotics
• Avoid antidepressants
• Adjunctive psychotherapy (no role in treatment of acute mania)
• Interpersonal and social rhythm therapy:
  
  • Help pts take care of sleep, regular routine (e.g., exercise)
  • Sleep deprivation can trigger manic episode, therefore self-care important
• Ongoing medication often necessary

Question 13

What is Schizoaffective Disorder?

Answer 13

• Major depressive or manic episode present concurrently with active-phase symptoms of schizophrenia
• Delusion/hallucinations present without mood symptoms for at least 2 weeks
• Episodes of depression or mania present for the majority of the illness’s total duration
• Must specify whether depressive or bipolar type

Question 14

What is the prevalance and course of schizoaffective disorder?

Answer 14

• 0.3% overall, F>M (particularly depressive type)
• Social and occupational dysfunction associated but not required (in contrast to schizophrenia)
• Often chronic course but overall prognosis generally better than for schizophrenia