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M2 Psych > 10/12 Mood Disorders: Depression - Palmeri > Flashcards

10/12 Mood Disorders: Depression - Palmeri Flashcards

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1
Q

mood disorders

A
  • illnesses marked primarily by disturbances in mood (persistent emotional state)
    • elevated (manic) or depressed
  • always see impairment in occupational/social/other areas of fx
  • not attributable to effects of a substance, another med/psych condition

primary symptom : mood change

addtl symptoms almost always occur in sleep/appetite/cognition/behavior

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2
Q

depressive disorders

A
  1. disruptive mood dysregulation disorder
  2. major depressive disorder
  3. persistent depressive disorder
  4. premenstrual dysphoric disorder
  5. substance/medication-induced depressive disorder
  6. depressive disorder due to other med cond
  7. other specified or unspecified depressive disorder
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3
Q

disruptive mood dysregulation disorder

features

duration, specifications

onset/dx/ddx

comorbidity

A

severe, recurrent temper outbursts (verbal and behavioral) that are grossly out of proportion in intensity and duration

  • inconsistent with developmental level
  • occur 3+ times weekly
  • between outbursts: irritable or anger most of the day on most days
  • 12+ months
  • in at least 2/3 settings (home, school, with peers)
  • severe in at least one setting

often severe disruption in family/peer/school activities

onset before age 10, diagnosis between 7-18

ddx: bipolar, major depression, substance induced, others

comorbidity high esp with oppositional/defiant disorder

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4
Q

major depressive disorder

A

5 or more symptoms for at least 2 weeks, nearly every day

  • ONE SX MUST BE either depressed mood or anhedonia (loss of interest/pleasure) for almost every day in that period

other sx can be:

  • at least 5% change in body weight with wt loss, wt gain, change in app
  • insomnia/hypersomnia
  • psychomotor agitation/retardation
  • fatigue/loss of energy
  • feelings of worthlessness/guilt
  • cognitive symptoms
  • recurrent thoughts of death/SI
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5
Q

depression acronym

A

SIG E CAPS

S - sleep disturbance

I - loss of interest in usual activities

G - guilt/worthlessness

E - loss of energy

C - changes in concentration

A - changes in appetite/weight

P - psychomotor changes

S - suicidal thoughts

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6
Q

major depression clinical features

A

NOT sadness

  • 66% contemplate suicide, 10-15% follow through
  • anxiety is common
  • many physical sx
  • kids: more behavioral difficulty
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7
Q

depression epidemiology

course of illness

A

lifetime prevalence 13-20%

  • 18-29 rate 3x as high as 60+ rate
  • 2-3x more common in women than men

course: remitting vs chronic

  • recovery within 1yr for 4/5 patients
  • chronic MDD for 1/5
    • risk of chronicity increases wit anx, personality disorders, psychosis, and substances
    • also incr with severity of first episode, younger populations, prev multiple episodes

may be present as first episode of eventual bipolar or schizophrenic disorders

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8
Q

major depression risk and prognosis

A

negative affectivity

adverse childhood experiences

substance abuse, anxiety, borderline personality, chronic medical conditions incr risk

heritability 40%

  • 1st degree family members? 2-4x higher risk than genpop
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9
Q

major depression ddx

A

medical disorders

  • drug intoxication/withdrawal
  • tumors
  • infections
  • cerebrovascular, CV events
  • metabolic, endocrinological, nutritional disturbances
  • neurological illnesses

psych illnesses

  • substance abuse
  • anx disorders

NOT SADNESS

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10
Q

MDD

course and prognosis

A

first episode occurs before 40 in half of patients

untreated? 6-13 months

5-10% of initial MDD diagnoses → manic episodes

recurring illness

  • 25% in 6mo
  • 30-50% in 2yr
  • 5–75% in 5yr
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11
Q

MDD etiology

neurobiological correlates

A

multifactorial interplay of physiologic, psychological, social factors

neurobio correlates

  • genetic features
  • monoamine dysfx
  • HPA axis
  • alteration in sleep
  • link between brain/emotions
  • nt dysfx
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12
Q

MDD sleep abnormalities

A
  • delayed sleep onset
  • shortened REM latency
  • longer initial REM period
  • abnormal delta sleep (long wave sleep)
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13
Q

MDD psychological etiologies

A

life events and environmental stressors can alter fx state of neurotransmitters and structure of brain

  • personality factors (perfectionism) and temperamental factors (sensitivity) → predisposed to sense of loss
  • interal conflicts re: aggression/love/sense of self → predisposing
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14
Q

MDD psychological factors

A

dysfunctional thought patters and beliefs about oneself, environment, future → painful affects, dysfxnl behavior, expectation of failure

  • can predispose to depression

loss of interpersonal connections and efficacy → perpetuate depression

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15
Q

MDD social etiologies

A
  • occupational and financial stressors
  • lack of social supports
  • physical health status
  • role of spirituality/organized religion
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16
Q

selected specifiers for MDD

subsets of depression:

with anxious distress

A
  • feeling keyed up/tense
  • feeling restless
  • difficulty concentration (due to worry)
  • fear that something awful will happen
  • feeling that pt might lose control of self
17
Q
A
18
Q

selected specifiers for MDD

subsets of depression:

with melancholic features

A

either:

  • loss of pleasure in all/almost all activities
  • lack of reactivity to pleasurable activities

AND

3 or more of the following:

  • profound despondency
  • depression worse in morning
  • EMA (early morning awakening)
  • psychomotor agitation/retardation
  • anorexia and wt loss
  • excessive/inapprop guilt
19
Q

selected specifiers for MDD

subsets of depression:

with melancholic features

A

either:

  • loss of pleasure in all/almost all activities
  • lack of reactivity to pleasurable activities

AND

3 or more of the following:

  • profound despondency
  • depression worse in morning
  • EMA (early morning awakening)
  • psychomotor agitation/retardation
  • anorexia and wt loss
  • excessive/inapprop guilt
20
Q

selected specifiers for MDD

subsets of depression:

with atypical features

A
  • mood reactivity

AND

2 or more of the following:

  • significant weight gain or increase in appetite
  • hypersomnia
  • leaden paralysis
  • interpersonal rejection sensitivity
21
Q

selected specifiers for MDD

subsets of depression:

with psychotic features

A
  • delusions and hallucinations
  • mood congruent (punishment, guilt)
  • mood incongruent (atypical)
22
Q

selected specifiers for MDD

subsets of depression:

with peri partum onset

A

sx occur during pregnancy or in 4 weeks following delivery WITH OR WITHOUT PSYCHOSIS

may be more common in first pregnancy

pt presenting with psychotic ft more likely with second episode or history of MDD or bipolar

23
Q

selected specifiers for MDD

subsets of depression:

with seasonal pattern

A

regular relationship with onset of dep and time of year (fall/winter)

  • full remission or switch to hypomania/mania occurs at characteristic time

over lifetime, should display more seasonal than non-seasonal depressions

24
Q

persistent depressive disorder

A

depressed mood most of the day for more days than not for at least 2 years

two or more of the following while dep:

  • appetite change
  • sleep change
  • low energy
  • low self esteem
  • poor concentration
  • feelings of hopelessness

never without symptoms during those two years for more than two months

5-6% of genpop, more common in women

lots of comorbidity

onset: early

risk/prognostic factors:

  • negative affectivity
  • substance abuse
  • conduct disorder
  • parental loss or separation
25
Q

persistent depressive disorder

etiology

A

biological

  • decreased REM latency

psychosocial factors

  • vulnerability of patients with certain personaly traits
  • abnormal thoughts → sense of helplessness, poor interpersonal relationships → depressed mood
26
Q

persistent depressive disorder

course and prognosis

A

ddx: “double depression” (PDD + MDD event on top of it), substance abuse/dependence, personality disorders

about 50% of pt have sx before 25

  • 20% progress to MDD
  • 15% progress to bipolar II
  • 5% progress to bipolar I

treatment helps, but 25% never attain remission

27
Q

premenstrual dysphoric depressive disorder

A

five sx must be present in final week before onset of menses and IMPROVE within a few days after onset of menses and BECOME MINIMAL in week after menses

  • marked affective lability
  • irritability or interpersonal conflict
  • depressed mood
  • tension/anx
  • decr interest in usual activities
  • difficulty concentrating
  • lethargy
  • chagne in appetite
  • change in sleep
  • sense of being out of control/overwhelmed
  • physical sx

confirmed through two cycles of prospective daily rating, present through most of last year

onset after menarche, often worse near menopause

risk factors: stres, previous trauma, seasonal changes

potentially up to 50% heritability

OCP may lessen sx

28
Q

premenstrual dysphoric depressive disorder

treatment

A
  • mood charts
  • monitor caffeine, sugar, sodium
  • exercise
  • calcium, B6
  • light therapy
  • cognitive behavioral therapy
  • SSRIs
29
Q

substance/medication induced depressive disorder

A

prominent and persistent disturbance in mood which predominates clinical picture

AND

sx occur soon after intox/withdrawal/exposure to a sub/medication (within a month)

AND

substance/med is capable of producing mood changes

  • mood disturbance is not related to depressive disorder or delirium
30
Q

depressive disorder due to another medical condition

A

prominent and persistent depressed mod or decr interest that dominates clinical picture

  • direct pathophys effect of another medical condition
  • IS NOT DELIRIUM

associations with CVA (cerebrovasc accident), Huntington’s, Parkinson’s, TBI, Cushing’s, hypothyroidism

ddx: all other depressive disorders, medication-induced or adjustment disorders

31
Q

major depression

treatments

A
  • psychoparmacological
  • psychotherapeutic
  • electroconvulsive tx
  • phototherapy
  • transcranial magnetic stimulation

three phases of treatment

  1. acute: 4-8wk → induce remission
  2. continuation: 6-12mo → preserve remission
  3. maintenance: indicated for pt with at least 2 prev depression → avoid recurrence
32
Q

MDD treatment options

meds vs therapy

A

pharma

  • moderate-severe sx
  • sleep/appetite disturbances

psychotx

  • motivated pt with mild-mod sx and interpersonal psychosocial stressors

combined

  • for pt who incomplete responds to either pharma or psycho
33
Q

positive predictors for antidepressant response

A
  • vegetative sx
  • diurnal mood variation
  • psychomotor sx
  • acute onset
  • family history
  • lack of hypochondriacal sx
  • sensitivity to side effects
34
Q

guidelines for choosing medication to treat depression

A

basics: patient prefs, age, past hx, sx severity, side effect profile, cost

  • all antideps are similarly effective and safe, so comorbid conditions and side effect profiles important to consider
  • all antideps equally effective in preventing relapse and recurrence as well

PK: all antideps require a 4-8wk response time!

  • requires careful monitoring
  • elderly patient doses are titrated more slowly to lower overall dose level

only about 50% of patients response to first med trial

10% will be tx resistant

35
Q

types of psychotherapy

A

1. interpersonal therapy : relationships can either promote or protect form depression

  • issues with disputes, transitions, grief addressed

2. cognitive therapy (acute vs chronic illness) : how we think about ourselves and world dictates feelings and behavior

3. behavioral therapy : counteracts depression with behavioral changes → incr positive reinforcement

36
Q

electroconvulsive tx

features

indications

contraindications

side effects

A
  • efficacy superior to antidepressants
  • 8-12 treatments in a series
  • usually unilateral electrode
  • tx effect related to length of seizure

indicated when see resistance to other treatment

  • depression with psychotic ft
  • acute mania
  • catatonia
  • severe depression/mania in pregnancy
  • schizophrenia
  • neuroleptic malignant syndrome
  • infreq used as first line tx

contraindications: none absolute, BUT be careful with space occupying lesions!

side effects:

  • anterograde amnesia for variable pd of time
  • confusion
  • some retrograde amnesia
37
Q

transcranial magnetic stimulation

A

allowed by FDA since 2008

no evidence that it’s effective in patients who havent been tried on an antidep

no studies in patients with resistant depression

38
Q

deep brain stimulation

A

studied in Parkinson’s, major depression, Tourette’s

small studies → some efficacy in depression

lots of ongoing research

39
Q
A

M2 Psych (24 decks)

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