Depressive and Bipolar Disorders

Question 1

Depression/Bipolar Epidemiology

Answer 1

• Major depression women > men
• Women improve with age
• Men worsen with age
• Higher incidence of depression in lower socioeconomic class
• Higher is single/divorced
• Mania more common in men

Question 2

Depression: Cognitive/Behavioral Perspective

Answer 2

• Depression is the result of negative experience/thoughts
• Cognitive triad: self-perception negative, world experienced as hostile, expectations of failure/suffering in the future
• Schemas
• Arbitrary inference
• Cognitive distortions
• overgeneralization
• specific abstraction
• personalization
• dichotomous thinking

Question 3

Major Depressive Disorder

Answer 3

• 2 weeks of five symptoms
• single or recurrent
• With mixed features: 3 manic features, insufficient to meet criteria for mania
• With anxious distress
• Absence of symptoms less than two months: partial remission
• Absence of symptoms more than 2 months: full remisssion

Question 4

MDD treatment: Continuation phase

Answer 4

• Sustained remission (more than 2 months)
• Continue medications for 4-9 months
• Depression focused psychotherapy

Question 5

MDD Maintenance & Discontinuation phase

Answer 5

• If three or more MDD or chronic MDD, indefinite psychotherapy
• Maintenance treatment 9-12 months
• Taper medications over several weeks to 2 months

Question 6

Bipolar Disorders: Predisposing factors

Answer 6

• Children of bipolar parents 4 times greater risk
• Implicated chromosomes 8, 13, 18,21, 22 same as schizophrenia
• Cell loss in the basal ganglia, frontal cortex, temporal lobes
• Changes in sleep/wake cycles

Question 7

Mania

Answer 7

• three or more symptoms; four if mood is only irritable and not expansive
• 1 week duration or any duration if hospitalization is indicated
• Marked impairment in functioning
• Hospitalization
• Psychotic features

Question 8

Hypomania

Answer 8

• Same features as mania
• symptoms lasting four days
• unequivocal change in functioning, observable by others
• No marked impairment in functioning, hospitalization or psychotic features

Question 9

Bipolar Disorders

Answer 9

Bipolar I: Occurrence of at least one manic or mixed episode

Bipolar II: Occurrence of at least one hypomanic episode and one or more major depressive episodes but no manic or mixed episodes

Question 10

Unipolar Depression: Treatment

Answer 10

• SSRI, SNRI
• CBT
• For treatment resistant monotherapy may add a low dose antipsychotic
• Lifestyle changes
• Assess suicide risk each visit

Question 11

Bipolar I Disorder: Treatment

Answer 11

• Mood stabilizers
• CBT
• May add antipsychotics
• Nay add SSR/SNRI for depression, not TCA
• Lifestyle changes
• Asses for suicide each visit

Question 12

Cyclothymic Disorder

Answer 12

• At least two years for adults (1 year for children) hypomania & depressive episodes
• Hypomania or depressive symptoms persist for two month periods, and more than 50% of the 2 year time span

Question 13

Psych testing tools

Answer 13

Global Index of Intensity of Symptoms: Zung
Severity of Depression by Patient Report: Raskin
Hamilton Rating Scale for Depression (evaluates severity of depressive symptoms)
Mood Disorder Questionnaire
Young Mania Rating Scale

Question 14

Bipolar I: Pharmacotherapy

Answer 14

• Mood Stabilizers
• Lithium, first line: therapeutic range .6-1.3, toxicity 2.0; most neuroprotective
• Divalproex: suicide 10-20 times greater
• Olanzapine
• Risperidone
• Gabapentin

Question 15

Mania Treatment

Answer 15

• Lithium
• Valporic acid
• Carbamazepine
• Clonazepam
• Lorazepam
• Haloperidol
• Risperidone

Question 16

Bipolar Treatment

Answer 16

• Adequate trial 4-5 weeks
• Elapsed time between switching drugs: 2 weeks
• Antidepressant + antipsychotic for depression with psychotic features/mania

Question 17

Bipolar treatment: Lithium

Answer 17

• Remains first line treatment
• 300-2,400 mg/day/divided dose
• More effective against mania than depression
• Not as effective for rapid cyclers
• Neuroprotective and neural regenerative properties
• Takes 5-10 days to respond
• Acute stabilization (.8-1.5) & Maintenance (.6-1.2)
• Side effects immediate: GI, Fine hand tremor, polyuria, polydipsia
• Long term: Weight gain, dermatological, leukocytosis, hypothyroidism, diabetes
• Toxicity: coarse tremor, NVD, confusion, ataxia, slurred speech ……. CNS depression, arrhythmias, seizures, coma

Question 18

Bipolar Treatment: Mood Stabilizers

Answer 18

• Valporic acid (Depakote): 250-1500 mg/day; used in addition to lithium or first line for rapid cyclers; more effective for mania; SE: NVD, drowsiness, tremor, alopecia, weight gain.
• Gabapentin (Neurontin): 300-3600 mg/day/day
• Carbamazepine (Tegretol): 400-1,600 mg/day; SE: rash, leukopenia, hepatic dysfunction
• Oxcarbazepine (Trileptal): 600-2,400 mg BID; SE: sam as carbamazepine but better tolerated

Question 19

Bipolar Treatment: Mood Stabilizers

Answer 19

• Lamotrigine (Lamictal): 50-500 mg/day; more effective for depression; 10% Stevens Johnson
• Topiramate (Topamax): 50-400 mg/day; may develop myopia/glaucoma
• When patient is acutely agitated and psychotic use antipsychotic in addition to lithium or mood stabilizer: Haldol 1-30 mg/day; SE: EPS, tardive dyskinesia

Question 20

Persistent Depressive Disorder

Answer 20

• Symptoms for 2 years; 1 year in children