Clinical Approach To Mood Disorders Dr. Hill Flashcards
Depression causes what neurotransmitters to change
- NE (decreases) B-adrenergic R downregulated
- Dopamine (decreases), it increases in mania
- 5-HT (decreased, SSRIs drugs helps with this)
- GABA : lower in depression (drugs for anxiety)
- Glutamate : NMDA involved (is low)
Major event that commonly causes depression
Death of parent or grandparent before 11yo
DSM 5 guide
Assesing with mood disorders
Major Depressive Episode
2 week period at least
(At least 5 of the listed criteria)
- sleep, apetite, feelinf on self, focus, feeling down, psychomotor retardating, suicidal thoughts
= total score says how severe it is
PHQ2
Depending on how pt scores you go in and do PHQ9 and then depending on that you clinically examine pt for depression
Major Depressive Disorder
Many depressive episodes with no manic, hypomanic or mixed episodes (mixed depression and mania)
= delusions
= anxious
= melancholic (not sleeping, eating)
= catatonic ( pt is frozen due to psychomotor slowing)
Major Depressive Disorder what should you rule out
- Substance obuse
- Medical condition (DM, thyroid problems)
- Normal Grief (bereavement) can last 2 years (Denial, anger, bargaining, depression, acceptance)
Grief vs depression
Grief comes in waves , not anti-depressant drugs needed just therapy
= no delusions or such features of depression
Major Depressive Disorder TX
- Hospitilization if severe enough
- TCA , MAO inhibitors (not used as much, first to come), SSRIs and Mirtazapine(can cause weight gain), Trazodone (for sleep), Bupropion (adolecents with no anxiety worried about weight gain),
Major Depressive Disorder for hard to tx how do you tx
- Electroconvulsive Therapy (ECT)= shock therapy inducing brief seizure during under anesthetic, very safe and no contraindications (can have some short term memory loss) , 9-12 treatments
- Transcranial Magnetic Stimulation = new tx with magnetic field stimulating neural pathways (in doctors office) (50% - 75% effective as ECG)
Transcranial Magnetic Stimulation (TMS) location it is done
Given with what anesthetic
On the DLPFC (LEFT and at times right Dorsolateral Prefrontal cortex = where depression lies)
= none
ECT what anesthetic is given
Succinylcholin
Newer treatments for Major Depressive Disorder
- Katamine = anesthetic antigonist to NMDA (similar to PCP)
- Can be obused
- 4-6 infusions about 45min-60min
= good imporvement
Spravato
Nasal spray approved Ketamine
= need to be taken at clinic, monitor vitals and stuff (cant drive home)
= rapid acting
= only for treatments resistant problems
Pshycodelics and Major Depressive Disorder
Psilocybin from muschrooms is an example (is like serotonin, given with psychologist or doctor)
= future of treating depression (Very effective however not socially accepted)
= breakthrough treatment (depression, OCD, alchohol and tobacco, end of life anxiety)
Keep in mind when prescribing drugs
That a lot of good drugs are not FDA approved due to not high money value of them and therefore they focus on drugs that are worth higher money
Things about attempting suicide that shows its is needing to be taken seriously
- Cuts that need sutures
- Repeated attmepts
- Not telling anyone
- Substance abuse
- Their children are better off without them
If you feel suicde risk outweights protective factors what do you do
Even if you have the gut feeling of the risk = affidavits of patient’s attempt documented (has to be held at psychiatric floor for at least 9 hours)
Persistent Depressive Disorder (Dysthymia)
Low to moderate depression constant for at least 2 years
= no not severe enough for Major Depressive Episode
Double Depression
Major depression + Persistant Depressive Disorder
Persistent Depressive Disorder (Dysthymia) TX
Cognitive Behavioral Therapy first and then add Drugs if needed (SSRIs, SNRIs, MOAIs)
= hard to treat
Seasonal Depression
Major Depression (middle fall/september) then imporves march/april
(Eat more, sleep more, fatgued)
= TX light therapy**, labuterine
Premenstrual Dysphoric Disorder (PMDD)
Mood instability like anxiety depression, irritablity, sleep problems 1 week before menses
TX : Exercise, diet, relaxation therapy yoga, SSRIs(Sertraline, Fluoxetine) 2 weeks before menses
Bipolar Manic Episode is what
Lasts at least 1 week with at least 3 of the following:
- Inflated self esteem/ grandiosity (think they are invincible), belive they can do anything*****, shopping sprees major
- Dont need to sleep
- Have so many racing thoughts and ideas and really talketive all the time hard to interrupt
- Very distracted non connecting thoughts (HYPER ADHD)
- If they start painting 1 door they then do all doors and neighboors door (increased goal oriented)
- Excessive involvement in pleasurable activites
A bipolar pt needs what
At least 1 manic episode
Antidepression meds can cause what if misdiagnosed
Manic episode
Hypomania Episode
Less severe then mania episode (lasts 4 days or more) and must not include psychotic features (no social occupational impariment)
= cleaning house middle of night
= annoying people
= very hyper
Mania epidose what can you find in patient
- Preg
- Bankrupt
- Jail
= all same week
Bipolar 1 Disorder
DX
SX
- Only 1 manic or mixed episode needed to diagnose
- Major depression can present first, worse prognosis then Major depression
- Dellusins can happen
= in episodes
Bipolar 2 Disorder
DX
SX
- At least 1 major depressive episode and 1 hypomania episode needed, NO Mania episodes
- More prevalent then type 1
Bipolar type 1 TX
Mood stabilizers **
- Lithium
- Valproic Acid
- Carbamazepine
Cyclothymic Disorders
Intermittent hypomanic periods (2 years , repeated episodes of hypomania, depression not severe enough for major depressive disorder
1. Cycle from hypomania to moderate depression
Cyclothymic Disorders TX
- Mood stabilizer
2. Life style changes to keep stress and caos out from thier lives
Substance related problems can look like
Mood disorder
Anxiety Disorders SX
- Worry / apprehension
- Sense of doom
- Hypervigilance
- Focus problems
- Derealization (out of touch from world around them)
- Headache, dizzy, palpitations, restless, SOB, sweating, dry mouth
Anxiety Disorders Signs
Cool clammy skin , sweaty Tachy Flushing Hyperreflex, tremor Fidgity
Anxiety Disorders can be casued by what that needs to be checked
Medical condition
Medications
Panic Attacks
1 and 2 present always
- Recurrent unexpected panic attack
- 1 attack followed by a month or longer of fear from more attacks, behavior change due to the attacks, change behavior to avoid attacks,
- scared to leave house (due to maybe getting an attack = agoraphobia)
Panic Attack DX
Peak at 10min lasts 25min-3min = intense fear and discomfort = palpitations, sweating, CP, SOB, shaking, dizzy, hot flash, chills = feel like an MI = can happen in the middle of night
Anxiety Disorders prevalence and risk
- Women, 25yo average age , strong genetic component
2. Suicide due to feeling completley worn out and overwhelmed
Agoraphobia
Afraid of environment where they cant exit if they have an attack
= afraid to leave home or be in public
Social Phobia what and ABCD DX
= uncomfortable being around anyone FOR 6 OR MORE MONTH**, usually come in grade school
= shake hand and its sweaty
A : feel like they will screw up when bein around others and talking, feel like they are being judge, can use drugs or alcohol before meeting others
B : exposure to feared situation causes anxiety
C : person knows this fear is unreasonable
D : feared situation is avoided or endured with intense anxiety and distress
Generalized Anxiety Disorder SX
For more then 6MONTHS**** for most of day and more days then not 1. Restlessness, on edge 2. Easily fatigued 3. Focus problemss 4. Irritability 5. Muscle tension 6. Sleep problems = affects life
OCD Obsessions what is is and Examples
Recurrent persistant thoughts, impulses, imagening things or images causing anxiety
= not worring about real life issues
= attempts to ignor or suppress thoughts
= person knows this is from their mind
1. Fear of dirt, germs
2. Feeling responsibel for something bad
3. Unexeptable religious thoughts
OCD Compulsions what is it and examples
= repetitive behaviors or menta acts the person needs to do
= they do for reduced anxiety and disress, or prevent a dreaded event
1. Excressive cleaning
2. Rechecking and ordering some things in like a ritual way
3. Counting , repeated counting activity
4. Some are unobservable mental rituals
OCD is related to what
- Hair pulling (Trichotillomania), skin picking (Excoriation)
- Hoarding
- Substance mediacrtion caused
- Strep throat in children can cause OCD later
OCD vs OCPD
OCPD dont know they have a problem
TX anxiety disorders
- Psychotherapy***** (EDUCATE them about the condition, this is something youre NOT, just something you have)
- Psychodynamic psychotherapy (Froyian)
- CBT**
Good drugs for anxiety
SSRIs**
SNRIs**
TCAs
Benzodiazapines = Lorazapam (ER panic attack) = short term (Zanex)
Buspirone
Beta-blocker = very good for social anxiety, performance anxiety, public speaking anxeity, can help with PTSD nighmares —- >Prezosen
DEPRESSION PNEUMOINC
SIG E CAPS S : sleep lack I : Interest decrease G : Guilt E : energy low C : Consentration probs A : appetite low or high P : Psychomotor decrease S : Suicidal thoughts can happen
Manic pneumoina
DIG FAST D : Distracted I : Inflated self esteem, + Impulsive **** G : Grandiosity**** F : flight ideas (racing thoughts) A : Activity high (agitation) S : Speech pressured T : thoughtlessness
PEARLS for CLINICAL PRACTICE
- Rule out medication, medical condition, substance obuse causing any SXS or problems (esp in pts with no previous depression PMH or family history)
- 50% with 1 episode will not have another one, 50% with one will have another one
- More episodes of depression the more likely they need to be on meds for a long time many years
- TX that was successful in past and then didnt work anymore in a pt that is trying to find a working medication has HIGH chance that going back to that medication what worked in the past will work now
- SSRI ** 1st line tx for anxiety and depression, (bupropion, venlafaxine, mirtazaine)
