Chapter 4_Mood Disorders Flashcards
Definition of mood disorder in a nutshell
ABNORMAL RANGE OF MOODS and loss of some level of control over them
Symptoms of depression
SIG E CAPS yo!!!! (prescribe energy capsules) Sleep disturbances Interest (anhedonia) Guilt Energy level (loss) Concentration Appetite changes Psychomotor agitation/retardatation (restlessness/drowsiness) Suicidal thoughts
DSM-5 criteria for major depressive EPISODE
Must have at least 5 SIG E CAPS (one of them being either depressed mood or anhedonia) for at least a two week period. Cannot be attributable to effects of substance or other medical condition.
MUST CAUSE SIGNIFICANT IMPAIRMENT/DISTRESS
Symptoms of mania
DIG FAST
Distractibility, Impulsive behavior/irritability, grandiosity, flight of ideas/racing thoughts, activity/agitation (goal directed activity/psychomotor agitation), speech changes (pressured), thoughtlessness
DSM-5 criteria for manic episode (psychiatric emergency)
- 3 DIG FAST (or 4 if mood is only irritable)
- Symptoms lasting for at least one week (or any duration if hospitalization is required)
- Symptoms cannot be attributable to substance/other medical condition
- Must cause significant clinical impairment
Majority of manic episodes have psychotic symptoms
Difference between mania and hypomania
Unlike mania, hypomania…
- only lasts at least 4 days (unlike 7)
- does not cause significant impairment
- does not need hospitalization
- does not usually present with psychotic symptoms
Mixed features mood criteria?
Criteria met for either manic/hypomanic episode along with at least 3 symptoms of major depressive episode are present for majority of time. Symptoms must be present every day for at least one week.
T/F: Mood disorders often have chronic courses that are marked with abrupt changes between moods and periods of normal functioning are rare.
False. Mood disorders have chronic courses marked with relapses with relatively normal functioning between episodes
What psychiatric condition are stroke patients at significant risk for developing? (poor prognosis)
Depression
What medical conditions can cause a depressive episode?
- cerebrovascular disesase (stroke, MI)
- endocrinopathies (DM, Addison’s, Cushings, hyper/hypothyroid, calcemia, pit, glycemia)
- viral illnesses (i.e. mono)
- Parkinson’s disease
- carcinoid syndrome
- cancer (esp lymphoma and pancreatic carcinoma
- collagen vascular disease (SLE)
What medical conditions can cause a manic episode
- hyperthyroidism
- neoplasm
- HIV infection
- neurological disorders (temporal lobe seizures, multiple sclerosis)
What substances/medications can induce a depressive disorder? (lots)
- Withdrawal from stimulants (cocaine, amphetamines)
- Antihypertensives
- Barbituates
- Corticosteroids
- Levodopa
- Sedatives/ hypnotics
- Anticonvulsants
- Diuretics
- Sulfonamides
- antipsychotics
What substances/medications can induce bipolar disorder?
- Cocaine
- Amphetamines
- antidepressants
- sympatomimetics
- levodopa and dopamine
- bronchodilators
- corticosteroids (APPARENTLY THEY CAN CAUSE A BUNCH OF THINGS)
DSM-5 criteria for MDD?
- at least one major depressive episode
- no history of manic/hypomanic episode
Where do patients struggling with MDD usually seek help first?
PCP, most adults do not seek professional help for depression.
How does depression usually affect sleep?
- multiple awakenings
- initial and terminal insomnia (hard to fall asleep, early morning awakenings)
- hypersomnia less common
- REM sleep shifted earlier in the night and for greater duration (reduced stages 3 and 4 (slow wave) sleep
What can cause depression?
MULTI FACTORIAL DISEASE
- underlying theory: NT abnormalities (decreased catecholamines, decreased CSF levels of 5-HIAA serotonin metabolite
- high cortisol
- abnormal thyroid axis
- psychosocial life events (esp if there were multiple adverse events during childhood)
- genetics: increased risk 2-4 times if first degree relative with MDD
How long do untreated, depressive episodes usually last?
Self limiting, 6-12 months.
Risk of subsequent major depressive episode within first 2 years of first episode?
50-60%
Suicide risk in patients with MDD
2-12%
When to hospitalize for depression?
Risk for suicide, homicide, or unable to care for himself
Classes of pharmacotherapy for depression?
SSRIs, TCAs, MAOIs
Which class of pharmacotherapy is most EFFECTIVE in treating depression?
NONE. All classes are equally effective. Differences are in side effect profile (ex: SSRIs are more safe, better tolaerated, TCAs most lethal in overdose due to QTc prolongation, MAOI risk of hypertensive crises with sympathomimetics)
What are some adjunct medications for depression?
- atypicals! First line for MDD with psychotic features, also useful in refractory/resistant MDD with or without psychotic features
- Lithium, T3/T4 useful in augmenting treatment of refractory MDD
- Stimulants (only in certain patients, efficacy limited)
What are some effective options for psychotherapy in treating depression?
- CBT, interpersonal psychotherapy (MOST EFFECTIVE)
- psychodynamic psychotherapy, family/couples therapy, problem-solving therapy
- can all be used alone or in conjunction with medications
When is ECT indicated for depression?
When patient is unresponsive to or cannot tolerate pharmoacotherapy or if rapid reduction of symptoms is required
How is ECT performed?
Performed with premedication (i.e. atropine) followed by general anesthesia (.e. methohexital) and administration of muscle relaxant (succinylcholine). A generalized seizure is then induced (usually bilateral, but can be done unilateral), that lasts from 30-60 seconds.
How many ECT treatments are usually done?
6-12, avg 7, administered over 2-3 week period. Significant improvement tends to be seen after first treatment.
Side effects of ECT
Retrograde/anterograde amnesia (usually resolves in 6 months), nausea, headache, muscle soreness.
ECT very safe, most side effects are for anesthsia
Symptoms of serotonin syndrome
autonomic instability, hyperthermia, hyperreflexia, seizures. Coma/death may result.
Risk for when SSRIs and MAOIs are combined
What are some atypical features of depression?
hypersomnia, mood reactivity (mood brightens in response to happy events), leaden paralysis (feeling like being weighed down), increased appetite, interpersonal rejection sensitivity
What is the first line treatment in depression with atypical features specifier?
SSRIs. Combo pharmaco and psychotherapy has been shown to be more effective in treating mild-moderate depression than either of the two alone
What are melancholic features in depression?
anhedonia, early morning awakenings, depression worse in morning, psychomotor disturbance, excessive guilt, anorexia
What is the catotonia specifier for depression and what is an effective treatment?
Catalepsy (immobility), purposeless motor activity, extreme negativism/mutism, bizarre posturing, echolalia. ECT effective.
What is the anxious distress specificer?
Defined by feeling keyed up/tense, restless, difficulty concentrating, fear of something bad happening, feelings of loss of control
What is the peripartum onset specifier?
Onset of MDD symptoms occurs during pregnancy or 4 weeks postpartum
What is the seasonal pattern specifier?
temporal relationship between onset of MDD and particular time of the year (I.e. “winter depression”)
What is the triad of seasonal affective disorder?
Irritability, carbohydrate craving, hypersomnia
How to distinguish between bereavement and MDD?
Bereavement doesn’t usually involve psychomotor disturbances, psychosis, disorganization, or active suicidality
DSM-5 criteria for bipolar I disorder
ONLY REQUIREMENT = OCCURRENCE OF MANIC EPISODE
although bipolar I involves episodes of major depression and mania, major depression is NOT a requirement for diagnosis. Can present with interspersed euthymia, major depressive episodes, or hypomanic episodes (but none of these are required for diagnosis)
T/F: Bipolar I has the highest genetic link of all major psychiatric disorders
TRUE! First degree relatives of patients with bipolar disorder are 10 times more likely to develop illness
What is rapid cycling?
Occurence of four or more mood episodes in 1 year (major depressive, hypomanic, manic)
How does bipolar usually progress?
Untreated manic episodes generally last several months, course is usually chronic with relapses; as disease progresses episodes may become more frequent. 90% of individuals will have a repeat mood episode within 5 years of first manic episode
T/F: Bipolar disorder has a better prognosis than MDD
FALSE
What are options for pharmacotherapy for mania?
- Lithium (mood stabilizer)
- Anticonvulsants carbamazepine and valproic acid (mood stabilizers)
- atypicals (risperidone, olanzapine, quetiapine, ziprasodone), can be used as mono or adjunctive therapy for acute mania. Studies support combo therapy
T/F: Antidepressants are encouraged as monotherapy for mania
FALSE. Antidepressants alone can be activating. They are occasionally used with mood stabilizers in treating depressive episodes
What are some side effects of lithium?
Weight gain, tremor, GI disturbances, fatigue, arrhythmias, seizures, goiter/hypothyroidism, leukocytosis, coma, polyuria (nephrogenic DI), polydipsia, alopecia, metallic taste
BE CAREFUL. Can be fatal; low therapeutic index
Which mood stabilizer has been shown to reduce suicide risk with long-term use?
lithium (gold standard!)
What forms of psychotherapy are useful in treating bipolar?
supportive psychotherapy, family therapy, group therapy
T/F: ECT is not indicated in treatment for bipolar
False. Works well to treat manic episodes, although some patients require more treatments than for depression. Very effective in refractory or life threatening acute mania
Another name for bipolar I?
manic depression
Another name for bipolar II?
recurrent major depressive episodes with hypomania
DSM-5 criteria for bipolar II?
History of one or more major depressive episodes and at least one HYPOmanic episode…
remember ANY MANIC episode, even in the past, gives dx of bipolar I
What is the best treatment option for a pregnant woman who is having a manic episode?
ECT :)
What are the symptoms of persistent depressive disorder (dysthymia)?
2 or more of CHASES
Concentration (poor) Hopelessness Appetite (poor or overeating) Sleep (insomnia) Energy (low/fatigued) Self esteem (low)
DSM-5 criteria for PDD?
PDD = 2D’s
- 2 years of depression (majority of days)
- 2 of the CHASES criteria
- Never been asymptomatic for more than 2 months
also cannot have had a manic/hypomanic episode in this time
Prognosis for PDD?
Depressive symptoms much less likely to resolve than MDD. Treat the same as MDD though.
DSM-5 criteria for cyclothymic disorder
- Numerous periods of hypomanic symptoms (but not full hypomanic episode) and periods with depressive symptoms (but not full major depressive episode) for at least 2 years
- cannot have been asymptomatic for greater than 2 months
- No history of major depressive episode, hypomania, or manic episode
What personality disorder can cyclothymic disorder co-exist with?
borderline
What do approximately 1/3rd of patients with cyclothymic disorder develop?
Bipolar I/II
How to treat cyclothymic disorder?
Same as bipolar (mood stabilizers, atypicals, etc)
Characteristics of premenstrual dysphoric disorder?
mood lability, irritability, dysphoria, and anxiety that occur repeatedly during premenstrual phase of cycle
DSM-5 criteria for premenstrual dysphroric disorder
- at least 5 symptoms present in most menstrual cycles; must be present final week leading up to menses, be relieved with menses, and minimal/absent in week of post menses
- at least one of the following are present: affective lability, irritability/anger, depressed mood, anxiety
- at least one present (anhedonia, concentration problems, appetite changes/food craving, hypersomnia/insomnia, feeling of out of control, physical symptoms
- cause IMPAIRMENT
- symptoms not only exacerbation of other disorder like MDD
- not due to another substance/medical condition
Treatment for premenstrual dysphoric disorder
SSRIs (first line) either daily or during luteal phase only (day 14 of cycle then stop upon menses).
OCPs and GnRH agonists have also been used
DSM-5 criteria for disruptive mood dysregulation disorder (DMDD)
- severe, recurrent verbal/physical outburts out of proportion to situation
- outbursts inappropriate for developmental age
- mood between burts is mostly angry/irritable and is observed by others
- At least outburst per week, going on for at least one year with no more than 3 months without symptoms
- age of onset before 10 (but can be diagnosed 6-18 yo)
- cannot meet criteria for manic/hypomanic episode lasting more than 1 day
- symptoms in at least 2 settings (home/school)
- symptoms do not occur during MDD and not better explained by other mental disorder/substance/medical condition
Treatment for DMDD
not much evidence. Parental management training (PMT) still first line….can also treat primary symptoms with stimulants, ssris, mood stabilizers, and atypicals
