Depression, Bipolar and Anxiety 36% Flashcards
Define GAD
chronic excessive worry >6 months + 3 or more of the following symptoms: (MISC RF)
- restlessness
- fatigue
- concentration problems
- irritability
- muscle tension
- sleep disturbance for 6 months or more
define panic disorder
anxiety disorder marked by unpredictable minutes-long episodes of intense dread in which a person experiences terror +
- accompanying chest pain
- choking
- or other frightening sensations.
>2 panic attacks w/ sx lasting >1 mo and woried about another attack
A group of anxiety disorders involving a pathological fear of a specific object or situation
Phobia
•Symptoms 10-15min prior to specific stress event
•6+ months of fear/anxiety about an object/situation
define panic attack
•Episode of intense fear or discomfort that develops abruptly; usually peaks within 10min, last <60min
Panic Disorder Criteria: + si/sx
Recurrent, unexpected panic attacks
2+ attacks x1 month and 1+ criteria sx
4/13 physical symptoms
Si/Sx
- persistent concern/worry of another attack
- worry of losing control during attack
- maladaptive behavior
define agorphobia
Tx?
Fear of going into places where you may not be able to escape
SSRI, CBT, or both
defien Social Phobia/ Anxiety
6+ months of intense fear of social situation or performance where you can be scrutinized
tx of phobic disorders
1st line
2nd line
triggers
agoraphobia
1st line: CBT/exposure therapy
2nd line: SSRI, Benzos
Specific, predictable trigger: Benzos
Agoraphobia: SSRI & CBT
tx of
panic attacks
panic disorder
acute panic attacks
Panic Attacks: Benzos (Lorazepam, Alprazolam)
Panic Disorder
- SSRI (Paroxetine, Sertraline, Fluoxetine)
- CBT
Acute Attacks: Benzos
Tx of GAD
SSRIs (Paroxetine, Escitalopram)
SNRI (Venlafaxine)
Benzos
Buspirone
•CBT x6-12 months
35-year-old female with a complaint of worry which she cannot control for the last year. She tells you that her symptoms daily consisting of sleep disturbances, difficulty concentrating, and irritability. She reports her symptoms started around age 17 but have worsened.
Dx??
Tx options
GAD: persistent and excessive worry pertaining to multiple events or domains that continues for 6 months or more
Treatment
- SSRIs: Paroxetine and escitalopram; SNRIs: Venlafaxine
- Buspirone is also effective; the starting dose is 5 mg PO bid or tid. However, buspirone can take at least 2 weeks before it begins to help
- BZD (short-term use), BBs
- Psychotherapy
26-year-old first-year PA student with a medical history significant for GERD comes to your office because of frequent episodes of palpitations. The palpitations are sudden in onset and are accompanied by sweating and a sense that she is going to “pass out.” The episodes typically last no more than 10 minutes, and although the patient feels as if she may pass out, she never has. The episodes first appeared when she started PA school and have increased in frequency to the point where she is afraid to attend lectures out of fear of having an “attack.”
Dx??
Tx??
Panic Disorder
Treatment
- SSRIs: Paroxetine, Sertraline, Fluoxetine
- Benzodiazepines: for acute attacks (watch for abuse)
- CBT (relaxation, desensitization, examining behavior consequences)
a lab technician calls to tell you that a 22-year-old man you have sent for a blood draw is very anxious. He says he is terrified of having his blood drawn and almost faints at the sight of the needle.
Phobia - Same as panic disorder – symptoms begin 10-15 minutes prior to stress event except in this case it is a specific stress event (i.e flying, blood, social situations, spiders etc. etc.)
Treatment
- Exposure therapy (first line), teach to relax and try to understand/overcome the fear
- SSRI + CBT
- Benzodiazepines (i.e prior to flying)
- Treat agoraphobia just as GAD with SSRIs and CBT
Name indication and MOA of Buspirone
Add on for anxiety
5HT-1a receptor agonist
•dopamine receptors
Hydroxyzine (Vistaril, Atarax) DDI & CI
DDI :
- Potassium
- MAOIs
- CNS depressants
CI
- Allergy
- 1st trimester prego
- *only use po route
CI for BZDs
- Pregnancy
- Allergy
- Myasthenia gravis
- Glaucoma
Tx optiosn for Bipolar
Lithium - (1st line)
Valproate (Depakote enteric coated) *increase GABA
Lamotrigine – *inhibit glutamate
Carbamazepine
side effect we are concerned for w/ Lithium
Ebstein anomaly is a rare heart defect in which the tricuspid valve — isn’t formed properly
Carbamazepine side effects
Nausea, rash, pruritis,
hyponatremia, fluid retention
leukopenia
when tx Bipolar what medications do you need LFTs?
Renal labs?
LFTS- valporate, carbamazepine, lamotrigine
Renal - Lithium
•SJS, TEN need to be watched for when starting what bipolar medications?
lamotrigine
carba
acute and long term effects of lithium
Acute: GI, tremor, thirst, polyuria, weight gain, loose stools
Long term: LITH-PA
- Leukocytosis
- insipidus (renal)
- tremor
- hypothyroidism
- parathyroid
- arrhythmia
what bipolar med is CI in pregnancy and safest in preg
safest - lamictal
CI - lithium, valporate, carba
Differentiate b/w Bipolar 1 and Bipolar 2
Bipolar 1 – (mania > Depression)
- manic episodes alternating with depression; psychosis during manic episodes
Bipolar 2 - (depression > Mania)
- Low-level mania with profound depression; no psychosis
*
27-year-old man accompanied by his girlfriend. In the office, he seems to be running from topic to topic without a clear message. His speech is pressured. The patient’s girlfriend reports that he took steroids recently for a bad sinus infection and since he started them, his behavior has been abnormal. After discontinuing the medication, he has still been having symptoms. He has not had a normal night of sleep for the past ten days, and he just bought a new sports car though he has no need for one or the money to afford it. She also reports that she has caught him with multiple other women in the past few days, though they were in a committed relationship
Dx??
Txx?
Bipolar 1
Tx:
- Lithium (first line )
- Acute mania: Lithium, valproate, SGAs (olanzapine, aripiprazole), carbamazepine
- Mania maintenance: SGAs, Gabapentin, lamotrigine (Lamictal)
- If agitation add antipsychotics (haloperidol, risperidone) or benzodiazepines
Tx of:
Acute mania:
Mania maintenance:
If agitation
Acute mania:
- Lithium
- valproate
- SGAs (olanzapine, aripiprazole)
- carbamazepine
Mania maintenance: SGAs, Gabapentin, lamotrigine (Lamictal)
If agitation
- add antipsychotics (haloperidol, risperidone) or benzodiazepines
SGAs used to tx acute mania
olanzapine, aripiprazole
19-year-old male who has had bouts of sadness for the course of 1 year in which he says that oftentimes cannot even get out of bed so he tells his parents he is ill. Jim states that he recently felt so energized that he could not keep his thoughts straight and jumped from one idea to another. During this energized state, he did become irritable and others stated that he was louder than usual and wondered if he took something that increased his energy. During the week of high energy, he maxed out two of his credit cards and is not sure how he will pay them off before he goes to school in the fall. It was only a week later that he became so depressed that he did not find any pleasure in anything he did, was so tired he did not want to get out of bed which has continued to be a struggle today.
Dx?
Tx??
Bipolar 2
Treatment:
- Lithium First line
- Depressive episodes-
- SSRIs
- quetiapine
- or olanzapine + fluoxetine
24-year-old male with c/o episodes of depression alternating with times of increased energy, restlessness, and decreased sleep for 2 years.
dx??
Cyclothymic disorder
Alternating hypomanic episodes with a long-standing low mood state (dysthymia)
tx of cyclothymic disorder
Lithium first line
Anticonvulsant medications, (valproate and carbamazepine,)
Psychotherapy
define MDD
5 or more SIEGECAPS for≥ 2 weeks nearly every day and at least one of the symptoms is depressed mood or anhedonia
- Sadness
- Interest/anhedonia
- Guilt
- Energy
- Concentration
- Appetite
- Psychomotor activity
- Suicidal
define PDD
Chronic depression - depressive symptoms for > 2 years
- never been without the depressive symptoms in for more than 2 months at a time.
- never been a manic episode or a hypomanic episode
tx MDD
SSRIs are the first line treatment
- Continue to increase dosage q3–4wk until symptoms in remission.
- Full medication effect is complete in 4–6 weeks. Augmentation with 2nd medication may be necessary.
- See within 2–4 weeks of starting medication and q2wk until improvement, then monthly to monitor medication changes
tx PDD
SSRIs and other antidepressants
Psychotherapy
Physical exercise
Repeated episodes of significant depression and related symptoms during the week before menstruation??
Premenstrual dysphoric disorder
Tx Premenstrual dysphoric disorder
Treatment:
-
SSRIs first-line treatment (fluoxetine, sertraline, paroxetine, escitalopram)
- can be used continuously or instituted the week prior to menses.
- Birth control, low-dose estrogen,
- SNRIs venlafaxine
- (GnRH) -
MDD Substypes and Tx (4)
Seasonal: depressive sx at the same time each year, MC winter
- TX: SSRI, light therapy, Bupropion
Atypical: mood reactivity with depression (improve in response to positive events)
- TX: MAOI Inhibitors (A/B: Nardil, Parnate, Marplan; B only: Selegiline)
Melancholia: anhedonia (inability to find pleasure in things), lack of mood reactivity, depression, severe weight loss/loss of appetite, excessive guilt, psychomotor agitation, or retardation & sleep disturbance (increased REM time and reduced sleep). Sleep disturbances may lead to early morning awakening or mood that is worse in the morning
Catatonic: motor immobility, stupor, extreme withdrawal
define types of bipolar:
mania
hypomania
mixed
rapid
- Mania: abnormal or persistently elevated, expansive or irritable mood for at least 1 WEEK
- Hypomania: mania sx for 4 DAYS; no impairment
- Mixed: criteria for one and 3+ sx of other
- Rapid: 4+ ep/yr
Dx??? Tx??
Fear of going into places where you may not be able to escape
•6+ months of fear/anxiety about 2+ scenarios
Agoraphobia
Tx: SSRI, CBT, or both
define social anxiety
Tx? performance anxiety Tx?
6+ months of intense fear of social situation or performance where you can be scrutinized
Tx: CBT, SSRI/SNRI or both
Performance: Beta Blockers
define phobic disorders
tx?? (1st, 2md, triggers, agoraphobia)
•Symptoms 10-15min prior to specific stress event
•6+ months of fear/anxiety about an object/situation
Tx
1st line: CBT/exposure therapy
2nd line: SSRI, Benzos
Specific, predictable trigger: Benzos
Agoraphobia: SSRI & CBT
define Bipolar 2
>1 hypomanic episode w/ at least 1 depressive episode where sx last >4 days
define bipolar 1
1 manic episode (hospitalization) and >3 sx going on for >1 wk
(DIG FAST)
- Distractibility
- insomnia
- grandiosity
- flight of ideas
- activity (increased)
- Speech (rapid/pressured)
- thoughtlessness
define adjustmnt disorder
tx
occurs w/in 3 mo of stimuli and resolves w/in 6 mo
tx: psychotherpay
SSRI w/ longest 1/2 life
fluoxetine
SSRI also tx OCD
fluvoxamine
most sedating SSRI
paroxetine
Bupripion is CI in what disorders??
Why
anorexia, bullemia, epilepsy – dec Sz thershold
common side effect of trazodone
priapism
tyramine induced HTN crisis is a concern w/ what class od meds?
MAOI (segelline)
class of meds that is cardiotoxic and prolong QTc
TCA
TI of Lithium
is it cleared renally or hepatically?
0.6-1.2
renally
valporic acid TI
CI in??
monitor???
60-120
pregnancy - NTD
LTFs- spike in transaminases
