Depression and Bipolar Related Disorders Flashcards
What is the diagnostic criteria for major depressive disorder? Include amount of time and number of symptoms? READ ALL OF THESE
5 or more of the following symptoms over greater than 2 weeks:
At least one must be: Depressed mood or loss of interest / pleasure (anhedonia)
At least four must come from:
SIGECAPS (minus I which is interest)
Sleep -> increased or decreased
Guilt -> feeling excessively guilty or worthless
Energy -> decreased energy
Concentration -> impairment of concentration / decisionmaking
Appetite -> increased or decreased
Psychomotor retardation -> moving robotically or slowly, agitated in rare instances
Suicidality -> recurrent thoughts or attempted
For MDD, how often must these symptoms be present?
The criteria must be present EVERYDAY and represent a significant impairment in function (except for weight gain and suicidality)
What will the speech of a depressed person often be like?
Slow, monotonous, and delayed in production (sleep latency) -> thinking slow and have no emotion
What is the typical thought process in MDD? What is the most dangerous thought content?
Typical -> poverty of ideation - slowed thinking and low or no thoughts, often with negative ruminations and hopelessness / helplessness
Most dangerous: psychotic depression with perceptual disturbances / command hallucinations = “you should kill your wife then yourself”
How do you distinguish between bereavement and depression? Think in respect to time course, thought content, suicidality, and self-esteem
Time course: in grief - you may still have positive emotions, and the sadness tends to come in waves, decreasing in intensity overtime
In depression - persistent depression / anhedonia
Thought content: Grief = thinking of the deceased. Depression = self-critical / pessimistic ruminations / guilt
Suicidality: possible in both, but grief tends to be more related to joining loved ones later
Self esteem: preserved in grief, though may express regret due to failing the deceased. Depression it is severely reduced.
What medical condition is depression a risk factor for?
Cardiac events / CAD in patients with pre-existing heart condition
- > increased morbidity and mortality in co-occurring medical conditions
- > same risk for MI as LV dysfunction
True or False, depression is responsible for over half of suicides.
True
-> 2/3 of patients will contemplate suicide, 15% will complete
What is the peak onset of depression, who is more affected with regards to sex, and ethnicity, and what is the biggest risk factor?
In the early 20s, women are more affected than men, native americans are most affected followed by caucasians, biggest risk factor is previous MDE.
What is the logic with regards to keeping an MDD patient on longterm therapy?
Kind of like drug half lives to steady state:
1 previous episode: 50% chance of recurrence
2 previous episodes: 75% chance of recurrence
3 previous episodes: 90% chance
After 1 episode, can try weaning off. If a second episode occurs, depending on severity, can try to wean again. 3 episodes and it’s maintenance for life.
What sleep abnormalities are present in MDD?
Increased sleep latency
Decreased REM latency and greater proportion of REM sleep
How does the dexamethasone suppression test for MDD work?
Give dexamethasone
- > in non-depressed people, coristol production is suppressed
- > in depression, cortisol production is unchanged (increased cortisol levels in depression)
What does a positive dexamethasone test indicate?
That person with positive test + diagnosed depression is more likely to have melancholia, psychotic features, and at greater risk for suicide
Is there any clinically useful test for diagnosis of depression?
NO - sleep abnormalities and dexamethasone suppression are not specific enough lab tests
Why is Parkinson’s a risk factor for depression? How could this be treated?
By the monoamine hypothesis of depression, depletion of dopamine (a monoamine) will lead to increased depression risks
-> Bupropion (NDRI) and amphetamines could be used to treat this depresion
What is the monoamine / receptor hypothesis of depression? Where in the brain does this affect?
Monoamine -> deficiency or malfunctioning in monoamines in the brain leads to depression
Receptor hypothesis -> upregulation of postsynaptic neurotransmitter receptors in the setting of deficiency leads to depression
-> both lack significant clinical evidence
This affects just about everywhere in the brain
What are two hormonal axes changes that have been linked to depression?
Adrenal axis -> 50% have increased cortisol (think dexamethasone test)
Thyroid axis -> good percentage have hypothyroidism or decreased response to TRH
What are the nonspecific brain findings in MDD? With regards to size
Increased ventricle:brain ratio with smaller whole brain volume
Smaller hippocampal volume
What are the nonspecific brain findings in MDD? With regards to activity
Reduced activity in dorsolateral prefrontal cortex -> seat of reasoning = associated cognitive decline
Increased activity in amygdala and ventromedial prefrontal cortex -> leads to depressed mood and anxiety
-> hypoactivity of the cortex overall on PET scan
What psychological factor has the most compelling data that it causes depression? How?
Death of a parent prior to age 11
Stress alters neurotransmitters in brain, leads to neuronal loss / decrease in synapses
What is an important factor in early life which can lead to depression?
Maternal / parental neglect
-> animals deprived of attachment bonds have greater chance of depression + lifetime stress overactivity
What are two cognitive / thought patterns which predispose to depression?
Cognitive distortions -> how you interpret life events / personal significance to things. Can include giving an external locus of control -> feeling powerless to change things.
Learned helplessness -> helplessness and entrapment thoughts can seed depression -> nothing you do will make a difference -> i.e. infants in orphanages who stop crying
What personality factors predispose to depression? How does this relate to chronicity of MDEs?
No single factor, but personality disorders can increase risk by changing stress response to favor depression
-> personality disorders and substance use increase likelihood of chronicity
Why are women thought to be more susceptible to depression?
Reproductive cycling influences hormones, and greater susceptibility to hypothyroidism
How do genetic factors relate to treatment of depression?
Polymorphisms of 5-HT receptor expression associated with response to SSRIs, or NET blockade polymorphisms associated with response to tricyclic antidepressants
Why do we treat to full remission and not just response?
For those who only achieve partial remission, there is a greater likelihood of developing additional depressive episodes
How is full remission defined for MDD?
A return to patient’s baseline level of symptom severity and functioning, which correlates with a HAMD score of <7.
What is the criteria for an MDE to be a separate episode?
> 2 month separation between when MDD criteria are not met.
What is the acute phase of depression defined as? How often is the patient seen?
The time period from diagnosis until initial reduction of symptoms (typically 6-8 weeks)
- > reduction in symptoms defined by >50% reduction in symptom severity, where patient no longer meets criteria for MDD
- > better than 50% will respond to their first antidepressant, up to 20% will be intolerant and need a change
Patient should be seen twice a month in this period
What are indications for hospitalization in the acute phase of depression and how long is the normal stay?
Suicide/homicide risk, lack of ability to care for self, rapid symptom progression, lack of social support system
5-7 days is usual
How long should patient be treated in continuation phase? How often should patient be seen in continuation / maintenance phase?
6 months to a year on pharmacotherapy
- > goal is to prevent relapse
- > requires monthly visits (can go to quarterly in maintenance)
What is recurrence vs relapse?
Recurrence -> new episode of MDD
Relapse -> same episode of MDD recovers, where there was remission but not full recovery (i.e. your HAMD score was <7 for only 1 month, and then you got depressed again)
What is dysthymia now called and what are its diagnostic criteria? What is the time table?
Persistent depressive disorder (PDD) Depressed mood and 2+ of HCASES H: Hopelessness C: Concentration decrease A: Appetite change S: Sleep change E: Energy decrease S: Self esteem reduction
Must be for MOST days x2 years, never without symptoms for >2 months
Not enough symptoms for MDD
When must symptoms be present for PMDD?
Premenstrual dysphoric disorder
-> in most menstrual cycles over the last year (>2 cycles), with at least 5+ symptoms during week before menses, with improvement within a few days of menses, and minimal / no symptoms a week post menses
What are the AT LEAST 1 required symptoms of PMDD?
Affective lability (i.e. mood swings)
Irritability / anger / conflict
Depressed mood
Anxiety / tension
What are the additional symptoms of PMDD?
Depression symptoms
Overwhelmed / out of control feeling
Physical symptoms - include breast tenderness, joint / muscle pain, bloating / weight gain
What are the treatments for PMDD, regarding lifestyle, nutrition, and pharmacotherapy?
Lifestyle - increase exercise
Nutrition: B6, E, calcium, and magnesium supplements, with reduction in sodium and caffeine intake
Pharmacotherapy: SSRIs are first line, oddly enough Luteal (2nd half of ovarian cycle) SSRIs are equally effective
What are the diagnostic criteria for a manic episode? Include time scale.
At least 1 week of:
Distinct period of abnormally / persistently elevated or irritable mood
AND
Persistently increased goal-directed activity or energy
PLUS 3+ of:
DIGFAST
Distractibility
Indiscretion - excessive pleasurable activities
Grandiosity
Flight of ideas / racing thoughts
Activity increase
Sleep deficit only (decreased need for sleep)
Talkativeness
How does a hypomanic episode differ from a manic episode?
Identical to manic episode except:
- Lasts at least 4 days (instead of one week)
- Less significant impairment in functioning -> just noticeable and uncharacteristic change
- NO associated psychotic symptoms
How is BPAD 1 (bipolar affective disorder) diagnosed?
At least one manic episode. Does NOT require depression for diagnosis
How is BPAD 2 diagnosed?
At least one hypomanic episode AND a major depressive episode
- > no history of full mania
- > hypomania does not interfere with functioning significantly, but MDE does
What is one thing that makes BPAD compliance to medication difficult?
Lack of insight into their own illness
-> don’t feel they need to be on meds
Who does BPAD 1 vs BPAD 2 preferentially effect?
BPAD 1 = equal prevalence in men and women
BPAD 2 = more women than men (remember, that’s because depression affects women more than men), typically slightly later onset
What is the nonspecific brain finding for BPD?
Enlarged third ventricles
Is bipolar disorder or MDD more heritable? What disease typically co-occurs with this?
Bipolar disorder -> family history is a major risk factor
-> high risk of co-morbidity with schizophrenia since they share a similar origin
How does BPAD1 typically first present and why is this dangerous?
Typically with depression -> dangerous because SSRIs can precipitate manic episode
What behaviors tend to precipitate manic episodes?
Psychosocial stressors or sleep disturbances -> BPD patients should be sure to get enough sleep
What is defined as rapid cycling?
BPAD 1 patients who experience 4+ distinct episodes a year
What is the prognosis of BPD with respect to MDD? Suicidality?
Poorer prognosis -> many do not recover to baseline function during episodes and have significant social decline
Account for 25% of all completed suicides -> most often in depressed episodes
What is the diagnostic criteria for cyclothymia?
It’s literally the BPD equivalent of PDD (dysthymia)
> 2 years, not >2 months without symptoms, hypomania and depressive symptoms which do not meet criteria for MDE
How do you diagnose depressive or bipolar disorder due to another medical illness?
- Anhedonia or depressed mood
OR - Manic mood / increased energy
plus:
Evidence that cause is another medical condition (from history, labs, or physical exam
Not better explained by another psych disorder
Significant distress or decrease in function
Other than obvious neurologic / endocrine causes (i.e. thyroid / parathyroid, adrenal), what are some infectious and cancer causes of depression or bipolar?
Infectious: Hepatitis and HIV
Cancer: Pancreatic
How are substance induced depressive and bipolar disorders diagnosed?
Same criteria as medical-illness induced, except symptoms develop within 1 month of starting or withdrawing from a substance
+
evidence of association with intoxication or withdrawal and the diagnostic mood symptoms
What features would suggest that the MDD or BPD are not medication-induced?
Symptoms last for >1 month after substance is stopped
History of recurrent mood episodes before substance use started
What is one common medication known to induce depression?
Birth control pills
What is one substance known to induce both depression and mania?
Steroids
How are MDE criteria changed for children?
Depressed mood may be changed to include irritability
Weight loss may be replaced with growth retardation / lack of expected weight gains
How is PDD criteria changed for children?
Needs to be persistent for 1 year rather than two, and irritability can replace depressed mood
Are there changes in mania / hypomania / cyclothymia related to children?
Mania / hypomania = no changes
Cyclothymia = criteria reduced to 1 year (like PDD)
What are specifiers to diagnoses like MDE and BPAD?
Specific features to add onto a particular diagnosis to make it more clear and show you extra risk factors.
What are the criteria for the “anxious distress” modifier?
2+ during majority of time patient is MDE or manic: A. Keyed up or tense B. Unusually restless C. Concentration issues due to worry D. Fear of something awful happening E. Fear of losing control
tense, restless, fear of bad things / loss of control, concentration problems
What does anxious depress put you at risk for?
Increased risk of suicide, longer illness, and treatment non-response
What are the criteria for the “mixed features” modifier? What is this associated with?
A combination of symptoms of both mania / hypomania and a MDE simultaneously
If mixed features associated with MDD -> higher risk of future development of BPAD 1 or 2
What are the criteria for the “seasonal pattern” modifier?
Association between onset of symptoms and time of year.
During past 2 years, 2+ episodes demonstrate a pattern, with NO nonseasonal episodes. Seasonable episodes outweigh non-seasonal episodes throughout the patient’s lifetime.
What two modifiers can be applied to BPD 1 and MDE, but not BPD2?
Psychotic features, catatonic features
What two modifiers can only be applied to MDE, and not BPD1/2?
Atypical features, melancholic features
What are the diagnostic criteria for psychotic features? How do these present?
Delusions and hallucinations
These present in a mood-congruent fashion -> in depression: delusions of guilt / punishment. In mania: delusions of grandeur.
What are the diagnostic criteria for catatonic features?
Immobility -> catalepsy and stupor
Excessive purposeless activity and extreme negativitism
Posturing, sterotypies, mannerisms / grimacing
Mutism
Echolalia / echopraxia
Basically looks like autism and negativity
What are echolalia and echopraxia?
Echolalia - repeating of a word or phase or sound which was just spoken, sometimes as a means to process speech, other times just to fill in space
Echopraxia - imitating or repeating an action of someone else
What are the diagnostic criteria for atypical features?
MDE only: High mood reactivity Significant weight gain / increase of appetite with hypersomnia Leaden paralysis - feeling stiff / heavy Oversensitivity to rejection
What are the diagnostic criteria for melancholic features?
Opposite of atypical: Low mood reactivity / complete anhedonia, significant anorexia / weight loss, early morning awakening / insomnia, worse in the morning.
Marked psychomotor abnormalities.
What is the peripartum onset modifier?
MDE or BPD with symptoms starting during pregnancy or within 4 weeks of delivery
