18% Depressive Disorders; Bipolar and Related Disorders Flashcards
(PPP 576)
define Bipolar II
hx of AT LEAST 1 MAJOR DEPRESSIVE EPISODE +
AT LEAST 1 HYPOMANIC EPISODE
**any current or prior manic episode make the dx Bipolar I
(Aquifer)
Pt w/ four weeks of psychotherapy and 20 mg of citalopram for treatment of depression presents c/o decreased libido and inability to orgasm. He notes his depressive symptoms are greatly improved. Which is best course of med mgmt?
D/c citalopram and start bupropion ~or~
D/c citalopram and start fluoxetine ~or ~
D/c citalopram and continue with only psychotherapy
d/c citalopram and start bupropion
“As fluoxetine is also an SSRI with similar side effects, substituting fluoxetine for citalopram is not an appropriate option.”
“it would not be appropriate to discontinue all medication therapy, as he is expressing improvement in symptoms, which is likely due to a combination of pharmacotherapy and psychotherapy.”
(PPP 576)
three things recommended for long term maintenance of Bipolar II
psychotherapy: cognitive, behavioral & interpersonal
good sleep hygiene
valproic acid or carbamazepine useful for rapid cycling
(PPP 576)
first line treatment for Bipolar II
lithium or 2nd gen antipsychotics
(PPP 576)
what’s an added benefit of using Lithium for treatment of Bipolar II?
it decreases suicide risk
(PPP 576)
name some 2nd gen (atypical) antipsychotics for management of Bipolar II
quetiapine
olanzapine
risperidone
ziprasidone
(PPP 575)
what is the strongest risk factor for Bipolar I?
FAMILY HISTORY
1st degree relatives, strongest risk factor - 10 x more likely
(PPP 575)
Bipolar I - the earlier the onset, the greater_____
…likelihood of psychotic features and the poorer the prognosis
men = women
(PPP 575)
what is the only requirement for Bipolar I dx?
at least 1 manic or mixed episode
**major depressive episodes are not required for the dx
(PPP 575)
describe mania in terms of defining it for Bipolar I diagnosis
abnormal and persistently ELEVATED, EXPANSIVE OR IRRITABLE MOOD at least ONE WEEK with MARKED IMPAIRMENT OF SOCIAL/OCCUPATIONAL FUNCTION in one of three areas: 1 - mood 2 - thinking 3 - behavior
(PPP 575)
three specific areas of social/occupational function affected by Bipolar I mania
MOOD: euphoria, irritable, labile or dysphoric
THINKING: racing, flight of ideas, disorganized, easily distracted, expansive, grandiose thoughts (highly inflated self-esteem), judgement impaired (spending sprees)
BEHAVIOR: phys hyperactivity, pressure speech, decreased need for sleep, increased impulsivity, excessive involvement in pleasurable activities
(PPP 575)
what should you rule out for Bipolar I diagnosis?
that s/s are not due to med conditions or substance use
(PPP 575)
first line treatment for Bipolar I, for acute mania as well as long term management
LITHIUM
also decreases suicide risk
(PPP 575)
what caution should be taken with mood stabilizer-adjunct antidepressant therapy for Bipolar I?
ANTIDEPRESSANT MONOTHERAPY MAY PRECIPITATE MANIA OR HYPOMANIA
so only use antidepressants as adjunct to mood stabilizers
(PPP 575)
what 2 meds can be used for rapid cycling or mixed feature Bipolar I?
valproic acid or carbamazepine
(PPP 575)
what are effective monotherapy or adjunctive therapy to mood stabilizers for Bipolar I?
2nd gen antipsychotics (atypicals): quetiapine olanzapine risperidone ziprasidone
(PPP 575)
how do we treat bipolar depression (list 4)?
lithium
lurasidone
lamotrigine
quetiapine
(PPP 575)
what is most effective in treating acute mania for Bipolar I?
ANTIPSYCHOTICS: risperidone or olanzapine > haloperidol
or
MOOD STABILIZERS: lithium or valproic acid
(PPP 575)
two distinct differences between Bipolar I and Bipolar II
Bipolar I: major depression is typical, but NOT REQUIRED and presence of mania/mixed s/s
Bipolar II: major depression and presence of HYPOmania ONLY (no mania)
(PPP 576)
three indications for LITHIUM
bipolar disorder (both manic & depressive episodes) acute mania (mood stabilizer) schizoaffective disorder
(PPP 576)
seven adverse effects of lithium:
HypOthyroidism
Hyperparathyroidism
Hypercalcemia
Hypermagnesemia
Nephrogenic DI
Na depletion
Thirst (increased thirst, drink 8-10 glasses of water/day)
(PPP 576)
three contraindications for Li
PREGNANCY (may be associated with Ebstein’s anomaly if taken in 1st trimester)
severe renal disease
cardiac disease
(PPP 576)
buzzwords:
EBSTEIN’S ANOMALY
may occur if lithium is taken during first trimester of pregnancy
(PPP 570)
two main components of management of MDD
psychotherapy (INTERPERSONAL THERAPY, CBT, & supportive therapy)
SSRIs (first line med mgmt)
(PPP 570)
second line treatment for MDD
SnRIs (duloxetine, venlafaxine)
bupropion
(PPP 570)
diagnostic criteria for MDD
at least 2 distinct episodes of AT LEAST 5 ASSOCIATED SYMPTOMS (MUST INCLUDE EITHER DEPRESSIVE MOOD OR ANHEDONIA)
almost every day for most of the days for AT LEAST 2 WEEKS
**these s/s must cause SIGNIFICANT DISTRESS OR IMPAIRMENT (SOCIAL OR OCCUPATIONAL)
(PPP 570)
3 risk factors for Major Depressive Disorder
FH
female: male = 2:1
peak onset of age in the 20’s
(OnlineMedEd)
what meds are NEVER the right answer to questions about MDD?
TCAs
(-triptylines, imipramine, doxepin)
MAOIs
(selegeline, phenylzine)
(OnlineMedEd)
four SSRIs for treatment of MDD
(es)citalopram
fluoxetine
paroxetine
sertraline
(OnlineMedEd)
two SnRI’s for treatment of MDD
(des)venlafaxine
duloxetine
(OnlineMedEd)
two features of SnRIs that influence decision to use
“cleaner” - fewer SEs
$$ more expensive than SSRIs $$
(OnlineMedEd)
what is the primary side effect profile of SSRIs?
sexual dysfunction -
- decreased libido
- prolonged ejaculation
(PPP 570)
what distinguishes “atypical depression” from “major depressive disorder”?
pts experience MOOD REACTIVITY (IMPROVED MOOD IN RESPONSE TO POSITIVE EVENTS)
(RoshReview)
Which treatment option for Bipolar II should be avoided in a patient who is hospitalized for mania but would be an appropriate choice for an outpatient with one episode of major depression and currently experiencing 6-7 days of hypomania?
LAMOTRIGINE
“Lamotrigine works well to stabilize mood fluctuations in patients with bipolar II disorder but is NOT an antimanic drug and is not useful when treating acute mania.”
(RoshReview)
MOA of lamotrigine
INACTIVATES VOLTAGE-GATED SODIUM CHANNELS –> decreasing neuronal synaptic firing
“Lamotrigine is an antiepileptic drug that works by inactivating voltage-gated sodium channels in the brain, thus decreasing neuronal synaptic firing.”
(RoshReview)
“Why must the dose of lamotrigine be slowly titrated upward?”
“To lessen the chance of developing a fatal rash.”
(RoshReview)
s/s of serotonin syndrome
a prodrome involving n/v/d
hyperreflexia,
myoclonus,
ataxia
“most commonly occurs with the combined use of serotonergic agents (e.g., citalopram, fluoxetine, tramadol, mirtazapine)”
(RoshReview)
s/s of NMS
neuroleptic malignant syndrome, and it’s clinically identified:
mental status changes
fever,
rigidity, and
autonomic instability
“most commonly results from the use of high-potency first-generation antipsychotic agents (e.g., haloperidol, fluphenazine). “
(RoshReview)
“What are the two most common side effects of mirtazapine?”
Weight gain and sedation
(PPP 577)
another name for persistent depressive disorder
dysthymia
(PPP 577)
another name for dysthymia
persistent depressive disorder
(PPP 577)
define PDD
PDD = dysthymia + chronic major depressive disorder
(DSM V combined them)
(PPP 577)
diagnostic criteria for PDD
chronic depressed mood for
at least 2 years
in adults
in that 2 yr period, pt is not symptom free for >2 months at a time
(PPP 577)
two components of management of PDD
pharmacotherapy: SSRIs, SnRIs, TCAs, MAOIs
psychotherapy: interpersonal, cognitive, insight-oriented psychotherapies
COMBINATION TX WITH PSYCHOTHERAPY & PHARMACOTHERAPY MORE EFFICACIOUS THAN EITHER ALONE
(PPP 577)
similar to Bipolar II but less severe
cyclothymic disorder
(PPP 577)
how is diagnosis made for cyclothymic disorder?
AT LEAST 2 YEARS of prolonged,
MILDER ELEVATIONS AND MILDER DEPRESSIONS IN MOOD that
DO NOT MEET THE CRITERIA FOR FULL HYPOMANIC EPISODES OR MAJOR DEPRESSIVE EPISODES (at least 1 yr in children)
(PPP 577)
what is the management of Cyclothymic Disorder?
similar to Bipolar I
MOOD STABILIZERS (lithium, valproic acid)
or
2ND GEN ANTIPSYCHOTICS (risperidone, olanzapine, quetiapine, ziprasidone)
(RoshReview)
“which medications are known to increase lithium levels?”
ACE-Is NSAIDs Thiazide Diuretics Tetracycline Metronidazole
(RoshReview)
how long should you treat PDD (dysthymia)?
6-12 months after symptom improvement or resolution
(RoshReview) depressed mood for at least 2 years accompanied by at least two of the following: low energy, poor self-esteem, decreased or increased appetite, insomnia, hypersomnia, hopelessness, or poor concentration
PDD/dysthymia
(RoshReview)
“what is the first-line therapy for treatment of bipolar major depression?”
quetiapine or
lurasidone
(RoshReview)
“Which antidepressant requires discontinuation for 5 weeks prior to initiating a MAOI??
fluoxetine
(RoshReview)
A pt w/ MDD is refractory to both first- and second-line therapies. You decide to prescribe selegiline. What pt education is appropriate regarding this agent?
foods that contain TYRAMINE should be strictly eliminated while taking this agent
(RoshReview)
when should pts be prescribed MAOIs?
due to an extensive and dangerous side effect profile, pts should be prescribed MAOIs only if they are refractory to first- and second-line antidepressant treatments (SSRIs, SnRIs, TCAs)
(RoshReview)
17 y/o woman presents w/ CC of sadness, loss of appetite, inability to sleep, unfocused at work, tired all the time. For past month she has been hearing voices telling her to harm herself. What is most appropriate 1st line therapy?
a) lithium
b) psychotherapy
c) sertraline
d) sertraline + olanzapine
D) SERTRALINE + OLANZAPINE
this is MDD with psychotic features: depressive symptoms w/ delusions or hallucinations (A or V)
1st line treatment = antidepressant plus an antipsychotic
studies show sertraline + olanzapine in combination works best
(RoshReview)
a 30 y/o woman with fatigue, excessive sleepiness, decreased appetite, depressed mood, increased guilt, thoughts of suicide says these
s/s started 1 wk after giving birth to her first child and have persisted for 7 weeks. What is the most likely diagnosis?
POSTPARTUM UNIPOLAR MAJOR DEPRESSION
(RoshReview)
what are “postpartum blues” and how do they differ from postpartum depression?
Postpartum blue = depressed mood, irritability, sleep disturbance, fatigue, decreased concentration that occurs naturally 2-3 days after delivery. self-limited, mild, disappear by 2 weeks postpartum
Postpartum depression = first few months postpartum
(RoshReview)
“T/F: women who begin antidepressants for postpartum depression should continue treatment for 6 to 9 months after symptom resolution”
True
