Depressive D/os, Bipolar and related d/os Flashcards
Etiology of bipolar disorder
Cause unknown
Significant genetic component- multifactorial
Possibility of multiple biochemical pathways:
-Increase in epi and NE causes mania and decrease in the two causes depression
-Increase in monoamines (dopamine, serotonin, NE)
-Glutamate
Neuro causes:
Decreased activation and diminution of areas that regulate emotions
Increased activation in ventral limbic brain regions that mediate the experience of emotions and generation of emotion
White matter hyperintensities
Dx of bipolar I d/o
Requires the presence of a manic episode of at least 1 wk’s duration or that leads to hospitalization or other significant impairment in occupational or social functioning (episode cannot be caused by another medical illness or by substance abuse)
More details of manic episode
Characterized by elation, irritability, or expansiveness
At least 3 of the following must be present:
-Grandiosity
-Diminished need for sleep
-Excessive talking or pressured speech
-Racing thoughts or flight of ideas
-Clear evidence of distractibility
-Increased level of goal-focused activity at home, at work, or sexually
-Excessive pleasurable activities, often with painful consequences
Hypomanic episode (bipolar II)
Elevated, expansive, or irritable mood of at least 4 consecutive days’ duration
3 of the sx of manic episode must be present
The difference between that and a manic episode is that the episode is not severe enough to cause social or occupational impairment
What is often present in bipolar disorder?
Depression
Major depressive episode
For the same 2 wks, the person experiences 5 or more of the following sx, with at least one of the sx being either a depressed mood or characterized by a loss of pleasure or interest:
-Depressed mood
-Markedly diminished pleasure or interest in nearly all activities
-Significant wt loss or gain or significant loss or increase in appetite
-Hypersomnia or insomnia
-Psychomotor retardation or agitation
-Loss of energy or fatigue
-Feelings of worthlessness or excessive guilt
-Decreased concentration ability or marked indecisiveness
-Preoccupation with death or suicide; pt has a plan or has attempted suicide
Sx cause significant impairment and distress and are not the result of substance abuse or a medical condition
Labwork for bipolar disorders
CBC with diff ESR Fasting glucose level CMP Proteins Thyroid panel Liver and lipid panel ANA Urine copper level VDRL
Other workup for bipolar disorders
EKG
Reasons for inpt management for bipolar d/o
Danger to self Danger to others Delirium Marked psychotic sx Total inability to function Total loss of control Medical conditions that warrant medication monitoring
Considerations for partial hospitalization or day tx for bipolar d/os
Pt experiences severe sx but has some level of control and a stable living environment
4 major goals of outpt tx for bipolar disorders
Look at areas of stress and find ways to handle them
Monitor and support the medication
Develop and maintain the therapeutic alliance
Provide education
Pharmacologic tx for bipolar depression who is not currently being treated with a mood-stabilizing agent
Quetiapine, olanzapine (caution), or lamotrigine, with carbamazepine and lamotrigine as alternatives
Pharmacologic tx for bipolar depression who is already optimally treated with a mood-stabilizing agent
Lamotrigine
Pharm tx for bipolar d/o with severe mania or mixed episodes
Combined therapy with an antipsychotic agent and another antimanic medication
Consider combo of lithium with lamotrigine
Consider adding clozapine for augmentation
Pharm tx for mania/hypomania or mixed episodes
Initiate lithium, valproate, carbamazepine, aripiprazole, olanzapine, quetiapine, risperidone, or ziprasidone
Consider clozapine, haloperidol, or oxcarbazepine in pts with mania or mixed episodes
Consider lithium or quetiapine in those with mixed episodes
When is ECT useful for bipolar d/o?
When rapid, definitive medical/psychiatric tx is needed
When the risks of ECT are less than that of other tx
When d/o is refractory to an adequate trial with appropriate strategies
When pt prefers this tx modality
Diet considerations in bipolar d/o
If on lithium, increased salt intake may lead to reduced serum lithium levels and reduced efficacy
Reduced salt intake may lead to increased levels and toxicity
Pts should be advised not to make significant changes in salt intake
Bipolar with psychotic features
Categorized as mood congruent (in harmony with the mood disorder) or mood incongruent (not in harmony with the mood d/o)
With mood incongruent category, consider schizoaffective d/o or schizophrenia
Bipolar with melancholic features
Characterized by severe anhedonia, early morning awakening, wt loss, and profound feelings of guilt
Common to have suicidal ideation
Bipolar with atypical features
Categorized mainly by two specific, predictable characteristics: overeating and oversleeping
Tend to have younger age of onset, more severe psychomotor slowing, and more frequent coexisting diagnoses of panic d/o, substance abuse or dependence, and somatization d/o
Bipolar with catatonic features
Hallmark sx: Stuporousness Blunted affect Extreme withdrawal Negativism Marked psychomotor retardation
Postpartum onset
Within 4 wks postpartum
When are manic episodes considered distinct from each other?
When they are separated by at least 2 mos without significant sx of mania or hypomania
Rapid cycling
At least four manic episodes within a 12-mo period
How can depression manifest differently in children?
Can have school phobia and excessive clinging to parents
How can depression manifest differently in adolescents?
Poor academic performance Substance abuse Antisocial behavior Sexual promiscuity Truancy Running away
How can depression manifest differently in older people?
May be correlated with low SES, loss of spouse, concurrent physical illness, and social isolation
Appears more often with somatic complaints
Ageism may influence and cause clinicians to accept depressive sx as nl in older pts
Sx of mania in adolescents
Often misdiagnosed as antisocial personality d/o May include: Psychosis Alcohol or other substance abuse Suicide attempts Academic problems Philosophical brooding OCD sx Multiple somatic complaints Marked irritability resulting in fights Other antisocial behaviors Consider dx when severe and persistent
DDx of MDD
Test adolescents for mononucleosis Test for adrenal and thyroid dysfunctions Test homosexuals, bisexual men, prostitutes, and those who abuse substances for AIDS Evaluate older pts for viral PNA and other medical conditions Ask about the following meds: Cardiac drugs Antihypertensives Hypnotics Antipsychotics Antiepileptics Antiparkinsonian drugs Analgesics Antibacterials Antineoplastics Parkinson's Dementing illnesses Epilepsy Cerebrovascular diseases Tumors
Mental disorders that commonly have depressive features
Adjustment d/o with depressed mood Alcohol use disorders Anxiety d/os PTSD OCD Eating d/os Mood disorders MDD Minor depressive d/o Recurrent brief depressive d/o Substance-induced mood d/o Schizophrenia Schizophreniform d/o Somatoform d/os
Predictors of response to various txs with MDD
Low social dysfunction: good response to interpersonal therapy
Low cognitive dysfunction: good response to CBT and pharmacotherapy
High work dysfunction: good response to pharmacotherapy
High depression severity: good response to interpersonal therapy and pharmacotherapy
Etiology of major depressive disorder
Specific cause unknown
Multifactorial and heterogenous group of d/os involving both genetic and environmental factors
Studies indicate that when depression develops in early childhood, transmission appears to be related more to psychosocial influences
Adolescent and adult onset is more heritable but should still take environmental factors into consideration
Neurochemical hypothesis: deleterious effects of cortisol and other stress-related substances on neuronal substrate of mood in the CNS
RFs for MDD
Loss of a parent before age of 10 Chronic pain Medical illness Impaired social supports Caregiver burden Loneliness Bereavement Negative life events
Workup for MDD: screenings
Screening by asking the following two questions:
-During the past month, have you been bothered by feeling down, depressed, or hopeless?
-During the past month, have you been bothered by little interest or pleasure in doing things?
Longer self-report screenings:
-PHQ-9
-Beck Depression Inventory or Beck Depression Inventory II
-BDI for primary care
-Zung self-rating depression scale
-Center for Epidemiologic Studies-Depression Scale
Hamilton Depression Rating Scale performed by a trained professional
Geriatric Depression Scale
Labs to r/o organic causes from MDD
CBC TSH Vit B12 RPR HIV test CMP LFTs BAC Blood and urine toxicology screen ABG Dexamethasone suppression test Cosyntropin stimulation test
When should MDD tx be altered?
If the pt does not have an adequate response to pharmacotherapy within 6-8 wks
How long should MDD be continued once satisfactory response is achieved?
Customize a tx plann for each pt based on a careful assessment of sx
How should initial modality for MDD tx be based?
Clinical assessment Presence of other d/os Stressors Pt preference Reactions to previous tx
1st line pharm tx for MDD
SSRIs
2nd line pharm tx for MDD
SNRIs
Examples of SNRIs
Venlafaxine
Desvenlafaxine
Duloxetine
Levomilnacipran
Which SSRI is not recommended in pts with congenital long QT syndrome?
Citalopram
What dosage of citalopram is recommended in pts >60 yrs?
20 mg/day
Examples of atypical antidepressants
Bupropion
Mirtazapine
Nefazodone
Trazodone
Which atypical depressant is associated with a high risk of wt gain?
Mirtazapine
What are examples of serotonin-dopamine activity modulators?
Brexpiprazole
Aripiprazole
Efficacious therapies for MDD
Interpersonal psychotherapy
CBT
Problem-solving therapy
Behavioral activation/contingency management
Mindfulness-based cognitive therapy to prevent relapse/recurrence
Prior CBT to prevent relapse
Indications of ECT for MDD
Need for a rapid antidepressant response Failure of drug therapies Hx of good response to ECT Pt preference High risk of suicide High risk of medical morbidity and mortality
Considerations in tx-resistant depression
Accuracy of dx and possible comorbid medical conditions
Adequacy of medication dose and duration of tx, as well as adherence to tx regimen
Possible comorbid psychiatric conditions
Possible interventions for tx-resistant depression
Increasing the med dose to the max tolerated
Augmenting the current medication with another antidepressant
Changing to a different antidepressant
Adding psychotherapy or more intensive care if not already completed
Considering ECT
Contributing factors to dysthymic disorder
Genetic predisposition
Biological factors, such as alterations in neurotransmitters, endocrine, or inflammatory mediators
Chronic stress
Chronic medical illness
Psychosocial factors
Ruminative coping strategies
Antisocial, borderline, dependent, depressive, histrionic, or schizotypal personality traits
DSM-5 criteria for persistent depressive d/o
Depressed mood for most of the day, for more days than not, for at least 2 yrs
Presence, while depressed, of two or more of the following:
Poor appetite or overeating
Insomnia or hypersomnia
Low energy or fatigue
Low self-esteem
Poor concentration or difficulty making decisions
Feelings of hopelessness
During the 2-yr period of the disturbance, the individual has never been without the sx in the first 2 criteria for more than 2 mos at a time
There has never been a manic episode or a hypomanic epsiode and criteria have never been met for cyclothymic d/o
Workup for persistent depressive d/o
CBC with sed rate
Thyroid function tests
Homocysteine and methylmalonic acid levels
Tx of dysthymic d/o
Combo of psychotherapy and meds Psychotherapy options: CBT Interpersonal therapy Psychodynamic Meds: SSRIs first line SNRIs second line Mixed serotonergic and noradrenrgic drugs
DSM-5 criteria for cyclothymic d/o
For at least two years there have been numerous periods with hypomanic sx that do not meet criteria for a hypomanic episode and numerous periods with depressive sx that do not meet criteria for a major depressive episode
During the 2 year period, the hypomanic and depressive periods have been present for at least half the time and the individual has not been without the sx for more than 2 mos at a time
