Depressive & Bipolar Disorders

Question 1

Major Depressive Disorder: Definition, Risks, Comorbidities, Protective Factors, Suicide Risk

Answer 1

• Definition:
  
  • discrete episodes of at least 2 weeks duration involving clear-cut changes in affect, cognition, and neurovegetative function and interepisode remissions
• Risks:
  
  • family hx, female, onset 25-35
• Protective Factors:
  
  • stable support system, active participant, access to tx, strong cultural identity
• Suicide Risk:
  
  • previous attempts, feelings of hopelessness, persistent anxiety, access to lethal means, substance use can negatively impact treatment (impulsivity)

Question 2

Major Depressive Disorder: S/sxs, Dx, & Tx

Answer 2

• S/sxs:
  
  • DSM-V Criteria:
  • 5+ of the following during the same 2-week period
    
    • -Depressed mood or loss of interest or pleasure
    • -Appetite disturbance
    • -Sleep disturbance
    • -Psychomotor abnormalities
    • -Fatigue, loss of energy
    • -Poor concentration
    • -Worthlessness, inappropriate guilt
    • -Thoughts of death, suicide
• Dx:
  
  • Diagnosis based on a single episode is possible, but disorder is usually recurrent. If a longer episode is present, more likely it will persist.
  • 50% will recur after 1st episode
  • 90% will recur after 4th episode
• Screening Tools:
  
  • -Beck Depression Inventory
  • -Hamilton Depression Rating Scale
  • -PHQ-9
  • -Quick Inventory of Depressive Sxs
  • -Geriatric Depression Scale
  • -Cornell Scale for Depression in Dementia
• Tx:
  
  • Mild: Exercise
  • Moderate: meds, psychotherapy
  • Severe: meds, psychotherapy, may require temporary hospitalization
• SSRIs: make take 4-8 weeks to be effective, switch to second SSRI if ineffective, may cause sexual dysfunction, exacerbation of bipolar disorder
• SNRIs: transient increase in BP (use with caution)
• TCAs: cardiac arrhythmias, lethal in overdose
• MAOIs: dietary restriction of tyramine
• Alternative Tx:
  
  • Light therapy: as effective as antidepressants, sit 2-3 feet from light box for 20-30minutes at 8am each day
  • Electroconvulsive therapy: 80% response rate with severe depression, can cause memory disturbance

Question 3

When do you Refer someone with Major Depressive Disorder?

Answer 3

• two adequate antidepressant trials ineffective
• Medically complicated (polypharmacy)
• Psychotherapy (if not offered via primary care)

Question 4

Persistent Depression Disorder (Dysthymic Disorder)

Answer 4

• Definition:
  
  • mild chronic form of major depression disorder lasting 2+ years in adults or 1+ year in children
• **Note: recurrent depressive episodes may also be caused by premenstrual dysphoric disorder, substance/medication, medical conditions.
• S/sxs:
  
  • -Chronic depressed mood lasting 2+ years
  • -patient not sxs free for >2 months at a time
  • -Never had a manic episode
• Tx:
  
  • Psychotherapy & pharmacotherapy combined is more efficacious than either alone

Question 5

Bipolar Disorders Tx

Answer 5

• -Lithium:
  
  • 1st line, narrow therapeutic window (toxicity), euphoric mania, weight gain, decreases suicide risk -Valproic Acid/Divalproex: mixed episodes, rapid cycling, weight gain, liver/pancreas inflammation, thrombocytopenia
• Anticonvulsants:
  
  • Carbamazepine, Lamotrigine (watch for rash→ SJS)
• Atypical antipsychotics:
  
  • potential metabolic effects, monitor fasting glucose, cholesterol panels, weight
• Interpersonal Therapy:
  
  • psychoeducation, focuses on interpersonal context
• Cognitive therapy:
  
  • focuses on automatic negative thoughts about self/world/future
• NAMI-group therapy:
  
  • for families & patient -Case-management → reduces hospitalizations
• Family therapy

Question 6

When do you refer out a pt with bipolar disorder?

Answer 6

• Bipolar disorder can be managed in primary care but is usually referred due to complexity of mood stabilizers & antipsychotics
• -Suicidal thoughts, plans, or intentions
• -Psychosis

Question 7

Bipolar I Disorder

Answer 7

• Definition:
  
  • requires lifetime experience of at least one manic episode. Psychosis and major depressive disorder not required.
• Risks:
  
  • family hx
• Epidemiology:
  
  • 1.2% of adult population, onset 20-30s
• Criteria:
  
  • At least 1 manic** or **mixed episode
  • -symptoms not due to medical condition or substance use
• Manic Episode DSM-V:
  
  • *3+, 4+ if mood irritable only
  • -Abnormal & persistent elevated, expansive, or irritable mood lasting at least one week
  • -increased goal-directed activity
  • -grandiosity
  • -decreased need for sleep
  • -more talkative or pressured speech
  • -flight of ideas
  • -distractibility
  • -impulsivity
• Dx:
  
  • Screening Tools:
    
    • -Mood Disorder Questionnaire (MDQ): positive if endorse 7 items
• Manic Episodes with severe and marked impairment in functioning may necessitate hospitalization to prevent harm to self or others. Psychosis may be present.

Question 8

DSM-V of a Manic Episode

Answer 8

• *3+, 4+ if mood irritable only
• -Abnormal & persistent elevated, expansive, or irritable mood lasting at least one week
• -increased goal-directed activity
• -grandiosity
• -decreased need for sleep
• -more talkative or pressured speech
• -flight of ideas
• -distractibility
• -impulsivity

Question 9

Bipolar II Disorder

Answer 9

• Definition:
  
  • requires lifetime experience of at least one episode of major depression & at least one hypomanic episode. No manic episodes
• Epidemiology:
  
  • 5% of the population
• Criteria:
  
  • -At least 1 hypomanic episode
  • -at least 1 major depressive episode
  • -No manic episodes
• DSM-V of Hypomanic Episode:
  
  • *3+, 4+if mood irritable only
    
    • -Abnormal & persistent elevated, expansive, or irritable mood lasting at least 4 days
    • -increased goal-directed activity
    • -grandiosity
    • -decreased need for sleep
    • -more talkative or pressured speech
    • -flight of ideas
    • -distractibility
    • -excessive involvement in activities with consequences ($, sex, business involvement)
• Dx:
  
  • Mood Disorder Questionnaire (MDQ): positive if endorse 7 items
• Hypomanic episodes have a change in behavior that is not severe enough for hospitalization. No psychosis.

Question 10

DSM-V of Hypomanic Episodes

Answer 10

• *3+, 4+if mood irritable only:
  
  • -Abnormal & persistent elevated, expansive, or irritable mood lasting at least 4 days
  • -increased goal-directed activity
  • -grandiosity
  • -decreased need for sleep
  • -more talkative or pressured speech
  • -flight of ideas
  • -distractibility
  • -excessive involvement in activities with consequences ($, sex, business involvement)

Question 11

Cyclothymic Disorder

Answer 11

• Definition:
  
  • adults who experience at least 2 years (1 year for a child) of hypomanic and depressive episodes without ever fulfilling the criteria for an episode of mania, hypomania, or major depression
• Epidemiology:
  
  • 5% of population
• Screening Tools:
  
  • Mood Disorder Questionnaire (MDQ): positive if endorse 7 items

Question 12

Euthymic vs Dysphoric vs Elevated vs Expansive vs Irritable

Answer 12

Moods

• Euthymic:
  
  • usual contentment
• Dysphoric:
  
  • unpleasant state
• Elevated:
  
  • exaggerated state of well-being
• Expansive:
  
  • lack of restraint in expression
• Irritable:
  
  • easily annoyed or angered