387: Week 6 - Mood Disorders Flashcards
What is the DSM IV definition of “Major Depressive Disorder” (MDD)?
DSM IV – TR diagnostic criteria
- Depressed mood or a loss of interest or pleasure in nearly all activities - anhedonia
- Anhedonia must be present for at least 2 weeks
- Involves a change from previous functioning
- Impairs social/occupational functioning
Major symptoms of Major Depressive Disorders include… (how many must be present to make a diagnoses of MDD?)
At least 4 of the following symptoms must be present:
- Disruption in appetite (or weight) -> forgetting to, disinterest in or neglecting to eat
- Sleep disturbance
- Disruption in concentration
- Fatigue or loss of energy
- Psychomotor agitation or retardation
- Excessive guilt or feelings of worthlessness
- Recurrent thoughts of death or suicide-
What is “Dysthmia”? What is the diagnostic criteria for “Dysthmia”?
- Rather than discreet episodes of depression, individual feels depressed nearly all of the time – depression is more low grade compared to MDD
- Depressed mood for most of the day for more days than not for at least 2 years
OR
2 or more of the following symptoms:
-poor appetite or overeating
-insomnia or oversleeping
-low energy or fatigue
-low self-esteem
-poor concentration or difficulty making decisions
-feelings of hopelessness
Risk factors of for MDD include…
- Prior episode of depression
- Family history of depressive disorder
- Lack of social support
- Stressful life event
- Substance use
- Medical co-morbidity
- Economic difficulties
Discuss the 2 Neurobiologic theories that exist regarding MDD
Genetics:
- 1.5 - 3 times more common among first degree relatives.
- There is increased risk of developing MDD when a first degree relative has/had a diagnoses of MDD
Biological hypotheses:
- norepinepherine and serotonin produced in very localized areas of the brainstem
- there is a dysregulation of serotonin and norepinephrine w/i the body
- MDD are influenced by this dysregulation or deficiency in [CNS] of the neurotransmitters norepinepherine, dopamine and serotonin or in their receptor functions
- PET scans – depressed persons do not metabolize glucose well in temporal and frontal lobes – normalizes when depression resolved
Discuss the Psychodynamic theory of MDD. What type of theory is this?
- Characterized as a psychological theory
- conflict between the ego (perception, memory, motor control) and the superego (ethics, standards, self-criticism)
- anger/aggression turned inward
- other contributors to this theory include:
- > avoidant coping styles that may be contribute to the onset of depression
- > distorded, negative beliefs and thoughts about the self, environment and the future are all psychological variants that can induce and perpetuate depressive symptoms
Discuss the parameters of “Object Loss Theory” with regards to MDD. What type of theory is this?
- Characterized as a psychological theory
- Bowlby’s theory of attachment - absence of a consistent mother/mother like caregiver in early life can lead to difficulties in later life
- Depression results from the loss of a parental figure through death or separation or lack of emotionally adequate parenting
- > these factors may prohibit or delay the realization of appropriate development milestones and inadequate coping strategies
Discuss the theory of “Learned Helplessness” with regards to MDD. What type of theory is this?
- Psychological theory
- Seligman –> there is no specific situation/event that causes depression
- individual’s belief that he/she cannot control life events
Discuss “Cognitive theory” as it relates to the development of MDD.
- focus is on how person thinks about his/her feelings
- correction of distorted or faulty thoughts
Discuss the “Social theories” pertaining to the development of MDD.
Family factors:
- > maladaptive circular patterns in family interactions contribut to the onset of depression in family members
- > disruption in family dynamics (b/c of multiple causes) can manifest as depression in a single family member
Social factors:
–> social isolation, poverty/deprivation and financial distress are risk factors that contribute to the development of MDD
What are 3 types of interventions use to treat MDD?
- Psychotherapy
- Somatic therapies: ECT, light Therapy for SAD
- Pharmacology
Discuss the various types of “Psychotherapy” treatment for MDD
- Brief, dynamic therapy –> the number of counseling sessions are limited
- Marital/family therapy –> address relationship issues that may contribute, or be affected by depression
- Cognitive therapy –> challenge distorted thinking patterns
What are two types of “Somatic therapies” used to treat MDD?
- ECT (Electroconvulsive therapy)
2. Light therapy
What is the main “Pharmacological” treatment for MDD?
- Antidepressants
- usually prescribed for 4-9 mos, however pts may remain on them indefinitely
What are the 4 classes of antidepressants?
- MAOIs (Monamine Oxidase Inhibitors) -> rarest
- Tricyclics (TCAs)
- Selective Serotonin Reuptake Inhibitors (SSRIs) -> usually first choice for pharmacological intervention
- Atypicals/Novel
Discuss the effectiveness and side effects commonly associated with many antidepressants
- Delayed onset for full clinical effects (3-6 weeks)
- Many side effects ARE NOT delayed
- Many potential drug interactions (St. John’s Wart)
- Need to taper off if the pt is discontinuing pharmacological treatment (prevention of Serotonin syndrome)
- Non-compliance with Rx is common -> attributed to: adverse side-effects; individuals may begin to feel better and decide they no longer need meds; may not feel benefits immediately and t/f stop taking them
What are MAOIs? Describe how they work and to whom they are commonly Rx to.
- Monamine Oxidase Inhibitors
- Decrease the breakdown of serotonin, epinepherine and norepinepherine, thereby increasing their concentrations in the CNS
- Not often prescribed because of dietary and OTC medication restrictions
- Only prescribed for treatment resistant depression
Examples of MAOIs: phenelzine, tranylcypromine
What dietary restrictions accompany the use of MAOI antidepressants?
- Avoid Tyramine rich foods (see list below) b/c they prevent the breakdown of MAOI’s and can result in severe hypertension
- > cheese (except cottage cheese and cream cheese)
- > smoked, dried, pickled, cured or preserved meats and fish
- > caviar
- > fava beans
- > avocados
- > yeast extracts
- > chianti
- > beer containing yeast
- > coffee & chocolate should be consumed in moderation
What medications are contraindicated with MAOI use?
Prescription: TCAs, Prozac, Demerol, Amphetamines
Non-prescription: Cold/allergy medications; Nasal decongestants; Cough medications except plain guaifenesin; Stimulants; Pain medications except for ibuprofen, aspirin, acetaminophen
What are the major side effects associated with MAOI use?
Headache, blurred vision, drowsiness, weight loss, dry mouth and throat, postural hypotension, nausea, agitation, dizziness, constipation, sedation, urinary retention, decrease memory, hypertensive crisis
What is a “Hypertensive Crisis”? What antidepressant is this a side effect of?
- Sudden, severe pounding headache, racing pulse, flushing, stiff neck, chest pain, nausea and vomiting
- Adverse side effect of MAOI use
What are TCA’s? What is a major concern regarding TCA use?
-Tricyclic antidepressants
-Highly lethal when overdosed -> t/f not commonly Rx to suicidal pt’s
- has been mostly replaced with other antidepressants with safer side effects
- still used for treatment resistant depression that has failed to respond to other therapy with newer antidepressants
Examples: amitriptyline, doxepin, clomipramine
What are the common side effects associated with TCA use?
-Sedation, drowsiness
-Anticholinergistic effects –> dry mouth, constipation, blurred vision, urine retention
-Tachycardia
-prolonged QT
orthostatic hypotension
-Weight gain
-Memory disruption
-death (when overdosed)
What are SSRIs? How do they work?
-Selective Serotonin Reuptake Inhibitor
-Prevent the re-uptake of serotonin in the synaptic cleft (leaving more serotonin available at receptor sites)
Examples: fluoxetine (prozac), sertraline (Zoloft), fluvoxamine (Floxyfral,Luvox, Fevarin), paroxetine (Paxil), citalopram (Celexa), escitalopram (Lexapro)
What side effects are commonly associated with SSRI use?
- much fewer than TCAs!!
- “activating side effects include: agitation, insomnia, nervousness and anxiety
- sedation
- headache
- weight gain
- EPS
- GI upset (common)
- sexual dysfunction (> 30%) -> typically presents as diminished interest and performance
- Serotonin syndrome
“Venlafaxine” is what type of antidepressant? What is its common brand name? What are its common side effects?
- Novel agent
- Effexor
- S/E: weight gain, sedation, low GI distress, sexual dysfunction
What are 3 types of Novel agent antidepressants?
- Venlafaxine (Effexor)
- Buproprion (Wellbutrin)
- Mirtazapine (Remeron)
What is “Serotonin syndrome”?
- Drug induced excess of intra-synaptic serotonin
- Most often occurs when patients are taking two or more meds that increase CNS serotonin levels by different mechanisms
- Rapid onset -> syndrome can develop w/i hrs or days after implementing increase in dose of seratogenergic med or adding a drug w/ serotimimetic properties
- ex: use of St. John’s Wort, use or abuse of recreational drugs such as ecstasy/MDMA
What are the symptoms of “Serotonin Syndrome”?
- Mental changes (agitation, confusion, hypomania)
- Altered muscle tone (rigidity, twitching or tremor)
- Autonomic changes (hyper/hypotension, tachycardia, diaphoresis/sweating)
- CNS changes (discoordination, coma, seizures)
- Hyperthermia
Who is more likely to suffer from bi-polar disorders? What is the typical age of onset for bi-polar disorder?
- Women no more likely to have bipolar disorder compared to men
- Age of onset: can occur at any age; on average occurs in the 30s or before
What is the diagnostic criteria for bi-polar disorder (I or II)
- Manic or hypomanic episodes in addition to depressive episodes
What are the 3 types of Bi-polar disorders? Describe the presentation/diagnostic criteria of each.
Bipolar I: periods of major depressive, manic and/or mixed episodes
Bipolar II: periods of major depression and hypomania
Cyclothymia: periods of hypomanic episodes and depressive episodes that do not meet the criteria for major depressive episode
Describe the “Neurotransmitter Hypothesis” theory with regards to bi-polar disorder.
Presentation of bipolar disorder is the result of excess Nor-epinephrine and serotonin - research results were inconclusive regarding this
Discuss the ‘chronobiologic theory” as it relates to expression of bi-polar disorder
- Neurotransmitter and hormone levels follow circadian rhythms – sleep disruption may impact mood (mania in bipolar patients)
- sleep disturbance or deprivation may lead to biochemical abnormalities in the body ultimately impacting mood
Discuss the “sensitization and kindling” theory as it relates to bi-polar disorder.
- Sensitization: a stimulus (S) that initially causes little or no observable response (R), eventually, with repetition, produces a full response. Given further exposure to the same stimulus, the full response will soon occur even with lower stimulus levels than the original stimulus.
- Kindling: a process by which a seizure or other brain event is both initiated and its recurrence made more likely
- repeated chemical or electrical stimulation of certain regions of the brain produces stereotypical behavioral responses or seizures (may explain why anti-seizure meds may be effective in stabilizing moods of those suffering from bi-polar disorders)
- repeated affective episodes might be accompanied by the progressive alteration of brain synapses that lower the threshold for future episodes and increase the likelihood of illness
Discuss the “Genetic” theory as it relates to bi-polar disorder
-First degree relatives of those with Bipolar I disorder are 4-24% more likely; Bipolar II (1-5%)
Discuss “Psychological and Social theories” as they related to bi-polar disorder.
- May be looked at as an effort to compensate for depression
- Generally accepted that environment is an influence, but not a cause -> environmental conditions contribute to the timing of an episode of illness rather than causing the episode
- mania usually arises from an attempt to overcompensate for depressed feelings rather than a disorder in its own right
Describe the supportive treatment provided for a diagnosis of “Serotonin Syndrome”
- Antipyretics, cooling devices
- Ativan (sedative)
- Cogentin for muscle rigidity
- Anticonvulsants to prevent/treat seizures
- Implementation of IV fluids to promote hydration and re-electrolyte balance
What is “Anhedonia”?
- loss of interest in previously rewarding or enjoyable activities including loss of interest in hobbies, friends, work, food and even sex
- it is one of the main symptoms of major depressive disorder
What is “ECT”? How is it utilized to treat MDD? What are some of the limitations/stipulations of ECT?
- Electroconvulsive therapy
- Sedative and muscle relaxer (general anesthetic) admin to pt prior to treatment
- Typically Rx 6-12 therapy sessions (usually on given 6-9)
- Shock is administered on one of the temporal lobes only
- Causes pt to experience mild/brief seizure
- There is no understanding as to why ECT works, all we know is that when ppl experience seizures their mood improves
- treatment can sometimes work so well that it pushes clients towards hypomania - at this point treatment course is typically discontinued
- ECT is usually used as a last resort treatment when pharmacological interventions are no longer effective
What are the major side effects associated with ECT?
- headache
- memory loss (however this is usually confined to the time of treatment)
What is “Light Therapy”? What system does it impact?
- Somatic treatment used to treat MDD
- Most often used to treat Seasonal Affective Disorder (SAD)
- Effects the circadian rhythmic system
“Phenelzine” is what type of antidepressant? What is its common brand name?
- MAOI
- Nardil
“Tranylcypromine” is what type of anitdepressant? What is its common brand name?
- MAOI
- Parnate
“Fluoxetine” is what type of antidepressant? What is its common brand name?
- SSRI
- Prozac
“Sertraline” is what type of antidepressant? What is its common brand name?
- SSRI
- Zoloft
“Fluvoxamine” is what type of antidepressant? What is its common brand name?
- SSRI
- Luvox
“Paroxetine” is what type of antidepressant? What is its common brand name?
- SSRI
- Paxil
“Citalopram” is what type of antidepressant? What is its common brand name?
- SSRI
- Celexa
“Escitalopram” is what type of antidepressant? What is its common brand name?
- SSRI
- Lexapro or Cipralex
“Amitriptyline” is what type of antidepressant? What is its common brand name?
- TCA
- Elavil, Levate, Endep
“Doxepin” is what type of antidepressant? What is its common brand name?
- TCA
- Deptran, Sinequan
“Clomipramine” is what type of antidepressant? What is its common brand name?
- TCA
- Anafranil
“Bruproprion” is what type of antidepressant? What is its common brand name? What are its common side effects?
- Novel agent
- Wellbutrin
- S/E: seizures, less weight gain (compared to venlafaxine), less sexual dysfunction (compared to venlafaxine)
“Mirtazapine” is what type of antidepressant? What is its common brand name? What are its common side effects?
- Novel agent
- Remeron
- S/E: weight gain, sedation, low GI distress, sexual dysfunction, dry mouth
To diagnose “Serotonin Syndrome” what symptoms must be present? How many must be present?
At least 3 of the following must be present:
- Mental status changes
- Agitation
- Myoclonus (Myoclonus refers to a quick, involuntary muscle jerk)
- Hyperreflexia
- Fever
- Shivering
- Diaphoresis (Profuse perspiration/sweating)
- Ataxia (Ataxia describes a lack of muscle coordination during voluntary movements, such as walking or picking up objects. A sign of an underlying condition, ataxia can affect your movements, your speech, your eye movements and your ability to swallow)
- Diarrhea
What defines a “manic episode”?
- characterized by euphoria
- a state of elation experienced as a heightened sense of well-being
- manifestation of expansive mood wherein an individual shows inappropriate lack of restraint in expressing feelings and frequently overvalues their own importance
- may also consist of alterations b/t states of euphoria and irritability
- marked impairment of social or occupational functioning
- Diagnoses requires 3-4 of the following 7 symptoms:
1. Inflated self-esteem
2. Decreased need for sleep
3. Being more talkative or having pressure speech
4. Flight of ideas or racing thoughts
5. Distractibility
6. Increase in goal-directed activity or psychomotor agitation
7. Excessive involvement in pleasurable activities that have a high potential for painful consequences
What is a “mixed episode”?
-when criteria for both a manic episode and a major depressive are met and present for at least a week
What is a “hypomanic episode”?
- the criteria is the same for a manic episode
- symptoms are only required to be present for at least 4 days as opposed to 7
- no marked impairment of social or occupational functioning is noted
