Depressive Disorders and Bipolar Disorders Flashcards
MDD etiology psychodynamic theories
Object Loss Theory
Aggression Turned Inward Theory
Cognitive Theory
Learned Helplessness Hopelessness theory
MDD etiology Object Loss Theory
Early psych development issues as foundation for issues later in life
During development stage, the child experiences traumatic separation (maternal etc), or could be death/illness
Loss causes separation anxiety, grief, mourning, despair
MDD etiology Aggression Turned Inward Theory
Freud
Early psych development issues also highlighting loss (mother etc)
leads to anger and fear of further loss
uses defense mechanisms to deal with conflict. instead of outward anger, it turns inward
anger at oneself and excessive guilt
MDD etiology Cognitive Theory
Beck
development experience sensitize person to respond to stressful life events with depression
people with depression tendency look at world different and are more negative
this promotes low self esteem and belief that they deserve bad things
MDD etiology Learned Helplessness-Hopelessness Theory
Modified cognitive theory
depressed due to perceived lack of control
perceptions learned over time
this leads to not adapting or coping
they become passive/nonreactive
MDD etiology Biological Theories
Genetic
Endocrine
NT function abnormalities
Structural brain changes
Chronobiological theory
MDD etiology Genetic
Clearly there is genetic predisposition
parent is biggest indicator (3x more likely)
earlier age of onset and the more severe sx means that more likely genetic
MDD etiology Endocrine
Neurovegetative sx (sleep, appetite, libido, lethargy) r/t hypothalmus and pituitary hormones
high incidence postpartum is suggestive
dysphoria often triggered by changes in levels of sex steroids during menstrual cycle
deregulation of HPA (stress response)
MDD etiology Abnormal NT function
obviously dysregulation of dopamine, serotonin, norepinephrine
receptor sensitivity
low density of receptor sites
probably more than one NT
MDD etiology Structural Brain Changes
Neuroimaging shows abnormalities:
Hypovolemic hippocampus
Hypovolemic prefrontal cortex
common in those who have experienced brain damage from stroke/trauma
MDD etiology Chronobiological Theory
desynchronization of circadian rhythms
What percent of MDD receive tx ever
50%
MDD age of onset average
Mid 20s
what percent of MDD will die by suicide
15%
Untreated MDD lasts
4+ months usually
What percent of those with 1st episode of MDD have a 2nd episode
60%
Prevention of MDD
At risk family education
community education to reduce stigma and emphasize tx
Screening
Common MDD screening tools
PHQ-9
EPDS
BDI
HAM-D
Diagnostic Criteria for MDD
- Anhedonia or a depressed mood, or both
- Depressed mood most of the day, nearly every day (In children, irritable mood)
- Marked anhedonia in all or almost all ADLs
- 3 or more significant sx during same 2 wk period that are a change in previous functioning
- Significant, unintentional weight loss or gain (5% body weight)
- Hypersomnia or insomnia nearly every day
- Psychomotor agitation or retardation
- Fatigue or loss of energy
- Self-deprecating comments or thoughts
- Feelings of worthlessness or excessive or inappropriate guilt nearly every day
- Decreased concentration and memory
- Recurrent morbid thoughts or suicidal ideation
- Sx onset within 2 months of significant loss and do not persist beyond 2 months are generally considered bereavement and not MDD.
MDD SI risk high for certain sx or hx
presence of psychotic sx
Hx of past attempts
Hx of 1st deg relative who committed suicide
Concurrent SUD
Current serious health problem
Top goal in acute phase of MDD
ensure client safety
Number of episodes of MDD to consider lifetime antidepressant tx
2+
Target sx of antidepressant tx
depressed mood
sleep-rest disturbances
anxiety
irritability
impaired concentration
impaired memory
appetite disturbance
agitation
anhedonia
impaired energy and motivation
antidepressant rebound
common with abrupt cessation
worse with drugs with short half lives
Classes of antidepressants
SSRIs
TCAs
MAOIs
SNRIs
NDRIs
SARIs
SSRI MOA
Primarily by increase 5ht in CNS by inhibiting presynaptic reuptake
TCA MOA
elevate 5ht and NE by inhibiting presynaptic reuptake
MAOI MOA
elevate 5ht and NE by inhibiting MAO
MAO is the enzyme that breaks down monoamine NTs
SNRI MOA
inhibit dual reuptake of NE and 5ht
action very selective on NTs
elevate both NTs by inhibiting presynaptic reuptake
NDRI MOA
inhibit dual reuptake of NE and dopamine
very selective on NTs
elevate both NTs by inhibiting presynaptic reuptake
SARI MOA
Dual action
agonist of 5HT receptors
very selective on NTs
elevate 5ht by inhibiting 5ht reuptake
SSRI drugs (agent and brand)
Citalopram–Celexa
Escitalopram–Lexapro
Fluoxetine- Prozac
Fluvoxamine–Luvox
Paroxetine- Paxil
Sertraline–Zoloft
SPARI and example
Serotonin Partial Agonist Reuptake Inhibitor
Vilazodone-Viibryd
Lower risk of sexual side effects noted
SSRI with longer half life
Fluoxetine– Prozac
SSRI with common discontinuation syndrome
Paroxetine–Paxil
SSRI with UNLIKELY discontinuation syndrome
Fluoxetine– Prozac
TCA drugs
Amitriptyline
Doxepin
Nortriptyline
Multiple others:
Clomipramine
Desipramine
Imipramine
Protriptyline
Trimipramine
TCA also used for insomnia
Doxepin
some amitriptyline
TCA also approved for OCD
Clomipramine
TCA also used off label for ADHD
Desipramine
Nortriptyline
TCA also used for chronic pain
amitriptyline
TCA also used to enuresis
Nortriptyline
Imipramine
MAOI drugs
Isocarboxazid
Phenelzine
Tranylcypromine
Selegiline
1st line tx for 1st epidose of MDD mild to moderate sx
SSRI
safer in OD than TCA
SSRI effective of these dx other than MDD
Panic disorder
OCD
bulimia
GAD
social phobia
PTSD
PMDD
2nd line tx for MDD
TCAs
Why TCAs have more AE than SSRI
and what AEs
affect many NTs
possibly poor adherence
Anticholinergic
antiadrenergic (orthostatic hypotension)
antihistaminergic (sedation and wt gain)
EKG
Unsafe in many co-occuring dx like cardiac
known to induce hypomania in those susceptible
TCAs and discontinuation
avoid abrupt withdrawal
TCA and suicidality
avoid those with high risk
TCA +SSRI
SSRI can elevate TCA so TCA needs monitoring of levels
Why isnt MAOI 1st or 2nd line for MDD
dangerous food and drug interactions
Food:
tyramine: causes hypertensive crisis
Cannot be reversed unless more MAO is produced in the body
Drug:
Meperidine, decongestants, TCAs, 2nd gen antipsychs, asthma rx, mult others
Also significant concern for serotonin syndrome
Note can be fatal in OD
Tx for hypertensive crisis from MAOI
d/c MAOI
Give phentolamine (blocks NE)
Stabilize fever
eval diet and adherence
symptoms of serotonin syndrome
Agitation/restlessness
rapid HR and elevated BP
HA
Sweating/Shivering/Goose Bumps
Myoclonic jerking and loss of coordination
confusion/fever/seizures/unconsciousness
Tx for serotonin syndrome
d/c agent and supportive tx of sx
Mild: d/c agent, close monitoring, use benzos
More severe: Hospitalization, tx with cyproheptadine, anticonvulsants, autonomic support
MDD and BP1
Can include psychotic features
Need to routinely assess for psychotic sx during periods of sx exacerbation
features are usually mood-congruent
can be managed with short term use of antipsych rx
SNRIs
Venlafaxine–effexor
Duloxetine–cymbalta
Levomilnscipran–Fetzima
What is Vortioxetine–Brintellix
5ht-3 and 5ht7 antagonist
5ht1a agonist
Antidepressant
Duloxetine concerns when using for depression
can elevate BP and LFTs
significant d/c syndrome if abrupt
Venlafaxine concerns when using for depression
Can elevate BP
significant d/c syndrome if abrupt
NDRI for depression
Bupropion–wellbutrin
Bupropion concerns
CI for those with sz disorder and eating disorder
caution with caffeine and people with panic disorder
Mirtazapine–Remeron class and use considerations
alpha2/5ht2 antagonist
inverse relationship b/t dosage and sedation
good for sleep need
SARI for depression
Nefazodone–serzone
—monitor LFT (failure risk)
—safer in OD than TCAs
—P450 concern
trazodone–desyrel
—safer in OD than TCAs
—priapism risk
—too sedating for use as antidepressant at dose
nonpharmacological tx options for MDD
ECT
TMS
VNS
Phototherapy
individual therapy
ECT for MDD
Its grand mal sz induced in anesthetized person
6-12 tx usually
ECT for MDD: MOA
MOA
—poss inc NTs
—poss release hormones
—poss exerts anticonvulsant effect which then produces an antidepressant effect
ECT for MDD: Situations to use
client preference
need for rapid response r/t severity
MDD with psychotic features
risk other tx outweigh risk of ECT
Tx resistance
ECT for MDD: possible contraindications
cardiac
pulmonary
Hx brain injury or brain tumor
anesthesia medical complications
ECT for MDD: Adverse effects
Poss CV effects
Systemic: HA, muscle ache, drowsy
Cognitive: memory disturb, confusion
TMS for MDD
option for those with inadequate response to rx and therapy (tx resistant)
place small coil on scalp to conduct current
performed in office without anesthesia
lasts about 40 min
course is 5x/wk for 6 wks
TMS for MDD: side effects
minimal but poss HA, discomfort
VNS for MDD
Vagal nerve stimulation
For tx resistant depression
pacemaker like device implanted in left side of chest to stimulate left branch of nerve
generally outpatient, needs anesthesia though
intended to be used along with traditional tx
VNS for MDD: Side effects
usually during pulse generation: voice changes, hoarse, cough, spasm
phototherapy for MDD
2500-10000 lux for 30 min for up to 2 hrs
1-2x/day
therapy for MDD
psychodynamic therapy
CBT
Brief therapy (solution focused)
group therapy
family therapy
CBT for MDD goals
modify perceptions
dec negativity
inc sense of internal control
enhance coping skills
modify environmental factors contributing to illness
Brief therapy (solution focused) for MDD goals
focus on precipitant stressor
cope with immediate impact of MDD on personal life
modify contributory environmental factors
group therapy for MDD goals
improve decision making, socialization skills, and assessment of individual strengths
gain new coping skills
family therapy for MDD goals
enhance family coping
improve knowledge base
plan for relapse
gain insight into effects of MDD on family unit
undertake psychoeducation for family members about the illness state of MSS
risk factors for suicide
45+ male
55+ female
divorced/single/separated
white
living alone
psych dx
physical illness
SUD
hx suicide attempt
recent loss
male
Sx of MDD more pronounced in children
irritability
somatic complaints
social withdrawal
Sx of MDD less common in children before onset of puberty
psychosis
motor retardation
hypersomnia
increased appetite
children and MDD rx choice considerations
kids dont usually respond well to TCAs
they do respond well to SSRIs
all have a black box warning about inc in SI and to monitor
MDD in children strongly associated with
separation anxiety
older adults with MDD considerations
if in LTCF, significant shorter lifespan
cognition/memory confused with dementia
important to complete functional assessment
considerations for older adults with MDD regarding memory vs dementia
dementia usually have premorbid hx of slowly declining cognition
MDD would be more acute onset
considerations for older adults with MDD and the need for functional assessments
determine if ability matches needs of life
determines impact of illness on overall functioning
skill deficit (dementia) vs performance deficit (depression)
good to correctly dx, track changes, set expectations
need to monitor ADLS, IADLS, executive functioning
Drug combos that can cause serotonin syndrome
SSRI and MAOI
drug and herbal interactions
SSRI and St Johns Wort
sx of serotonin syndrome
Autonomic instability
Altered sensorium
Restlessness
Agitation
Myoclonus
Hyperreflexia
Hyperthermia
Diaphoresis
Tremor
Chills
Diarrhea and cramps
Ataxia
Headache
Insomnia
sx of SSRI discontinuation syndrome
flu like sx
fatigue/lethargy
myalgia
decreased concentration
N/V
impaired memory
paresthesias
irritablity
anxiety
insomnia
crying without provocation
dizzy/vertigo
risk factors for discontinuation syndrome
rx with short half life
abrupt d/c
noncompliant/irregular
high dose range
long term tx
prior hx of d/c syndrome
how long to take antidepressant after remission
at least 12 months
Persistent depressive disorder is also known as
dysthymia
Dysthymia is different from MDD how
less acute sx
more protracted, chronic disease course
without any manifestation of psychotic sx
less discrete episodes of illness than MDD
vegetative sx less common than MDD
vegetative sx examples
sleep, appetite, wt changes
dysthymia sx
chronic depress mood
–most of the day
- more days than not
- at least 2 yrs
prominent presence of
–low self esteem
–self criticism
–perception of general incompetence
other sx
- low energy/fatigue
- poor concentration
-diff decision making
- hopelessness
-inadequacy
- mild anhedonia
- social withdrawal
- brooding about past issues
- subjective irritability or anger
- decreased productivity and activity
pharma mgmt of dysthymia
similar to MDD due to inc risk for development of MDD
double depression
MDD superimposed on dysthymia
normally more complex and outcomes less positive
dysthymia disorder is associated with..
personality disorders
borderline
histrionic
narcissistic
avoidant
dependent
dysthymia associated with several childhood disorders
ADHD
conduct
anxiety
learning
dysthymia length of sx for kids vs adult
1 year for kids
dysthymia mood in kids vs adult
irritable for kids
sad for adults
may report both tho
for grief and bereavement, how different from MDD
self esteem usually preserved in grief
how to separate normal grief from abnormal
consider
–severity of response
–duration of response
–effect on normal daily functioning
–persons perception of impact of stressor
often called adjustment disorder in absence of other clinical sx
PMDD
dysphoric sx in response to changing sex steroid hormnones from ovulation
sx usually begin during luteal phase (1 wk before onset menses)
sx usually lift within a day or 2 after menses has begun
must be sx free period in follicular phase
PMDD sx
marked lability
irritability
depressed mood
anxiety
low energy
sleep disturbances
PMDD tx
hormonal contraceptives
SSRI
both
Bipolar patterns
single polarity (mania)
distinct sx patterns of alternating polarity
mixed co-occurring sx
bipolar presentation
excessive or distorted degree of sadness or elation or both
bipolar manifests with
behavioral, affective, cognitive, and somatic sx
bipolar and precipitating event
possibly but often occurs without any precipitating stressor identified
bipolar etiology theories
biological
- GABA deregulation
- inc NE
- voltage gated ion channel abnormalities
- abnormalities lead to abnormal balances of intra and extra cellular levels of NT
- Kindling: process of neuronal membrane threshold sensitivity dysfunction
bipolar and onset/early recognition
significant and protracted prodromal sx period usually noted before full onset
usually mild manifestations of criteria sx before full clinical
longer time b/t onset and dx means more difficult to interrupt the cyclicity of illness
depressive episodes predominate which makes misdiagnosis common
Bipolar dx criteria
abnormal or persistently elevated/expansive/irritable mood lasting 1+ wk
mood episode rapid development and escalation of sx over a few days
poss precipitated by significant environ stressor
mood disturbance may result in brief psychotic sx
manic epi lasts days to several months
briefer duration and ending more abruptly than MDD episodes
60% get a major depressive episode before or after manic episode
other suggestive sx of bipolar
dec need for sleep
rested after 3 hours sleep avg
marked diff from normal baseline sleep
inflated self esteem
grandiosity
inc goal directed activities
excessive involvement in pleasurable activities with high potential for painful consequences
buying sprees
sexual indiscretions
unsound business ventures
excessive substance use/abuse
highly recurrent depressive episodes
hypomania
similar to mania
more brief in duration
episode not as severe as mania
no hospitalization
no significant functional impairment
bipolar 1 vs 2
bipolar 1
- characterized by occurrence of 1 or more manic or mixed episodes
bipolar 2
- characterized by occurrence of 1 or more major depressive episodes accompanied by at least one manic or hypomanic episode
-poss more rapid cycling
rapid cycling in bipolar
recurrent shifts in polarity
4+ mood episodes in the previous 12 months
either major depressive or manic
more frequent but the episodes are same as non rapid
20% of BP have rapid
90% women
poorer prognosis
bipolar diff dx
if onset of manic after 40yo, most likely another medical condition
–endocrine
–hyperthyroid
–intoxication
–medications
–precipitated by MDD tx
medications that can cause mani
-Captopril
- Cimetidine
- Corticosteroids
-Cyclosporine
-Disulfiram
- Hydralazine
- Isoniazid
MDD tx that can lead to mania
antidepressants
ECT
light therapy
Mood stabilizing agents
Lithium
anticonvulsants
gold standard for tx of manic episodes
lithium
well established long hx
evidence of anti suicidal effect
some effectiveness on depressive sx too
why serum lithium level needed
narrow therapeutic window
determine effect and potential for AE sx
how to get serum lithium level
draw at trough level
12 hours post dose
therapeutic range 0.5-1.2
baseline labs before lithium
thyroid panel
serum Cr
BUN
pregnancy
ECG for over 50yo
How may lithium effect endocrine
wt gain
impaired thyroid function
How may lithium effect CNS
fine hand tremors
fatigue
mental cloudiness
HA
coarse hand tremors with toxicity
nystagmus
How may lithium effect derm
maculopapular rash
pruritis
acne
How may lithium effect GI
GI upset
D
V
cramps
anorexia
How may lithium effect renal
polyuria/polydipsia
diabetes insipidus
edema
microscopic tubular changes
How may lithium effect cardiac
T wave inversions
dysrhythmias
How may lithium effect hematological
leukocytosis
rapid cycling BP and lithium
rarely respond to monotherapy
anticonvulsant rx for mood
carbamazepine
lamotrigine
valproic acid
carbamazepine
AE and monitoring
AKA Tegretol
Black box: agranulocytosis and aplastic anemia
More common AE: N, dizzy, sedation, HA, dry mouth, skin rash, constipation
SJS asians (HLA)
Monitor LFT (hepatic enzyme inducer)
lithium toxicity
slurred speech
confusion
severe GI
concurrent rx with lithium to watch
NSAID
ACEI
may double lithium level
Valproic acid
AEs
black box: hepatotoxicity and pancreatitis
common AE: N/D, abd cramps, sedation, tremor
rare: inc liver enzymes
SJS but not HLA so no screening
depakote vs lithium
depakote more effective for rapid cycling and mixed bipolar
baseline labs before carbamazepine/depakote
CBC
LFT
1 wk after start needs
12 hour serum trough
CBC
LFT
response to tx for lithium and anticonvulsant
1-2 wks
lamictal AE, indications, note on how to prescribe
Black box: serious rash
Common: dizzy, ataxia, somnolence, diplopia, nausea, HA, hepatotoxicity
rare: SJS, no HLA screen
indicated for maintenance only
Helps in depressive phase of bipolar affective disorder
-titrate slow
-Note than with depakote, level may double so factor into dosing
-note with keppra may inc metabolism and should factor into dosing
- often combo with lithium, 2nd gen antipsych, antidepressants
SJS
Stevens Johnson Syndrome
Tx by stopping agent and supportive measures
- often in hospital burn unit
Sx
- facial swelling
-tongue swelling
- macules, papules, and burning confluent erythematic rash
- skin sloughing
-prodromal HA, malaise, arthralgia, mucous membrane pain
non pharm tx for acute phase of mania
monitor and help meet nutrition needs
help meet sleep needs
monitor safety
non pharm tx of mania during less acute periods
CBT
behavioral therapies
interpersonal therapies
supportive groups
milieu therapy
client/family education
relapse prevention plan
overall health promotion
common comorbid for bipolar
hypothyroid
substance abuse
adolescent manic episode vs adult episodes
-more psychotic
-often associated with antisocial behavior and substance abuse
-prodromal period of significant
-behavioral problems like truance and failing grades
follow up needs for bipolar
initially weekly to titrate rx and monitor serum levels
duration varies
relapse plan
client teaching
dietary and fluid needs on lithium
pregnancy warning
routine lab needs
assess for suicidality
watch for AEs
standard rating scales for monitoring clinical status, establish baseline
- YMRS
-Daily mood chart
Cyclothymic disorder
chronic fluctuating mood disorder with sx similar to BP but less severe
numerous periods of hypomania and dysthymic sx
common hx for cyclothymic disorder than need assessing
fluctuating mood episodes
can function well during hypomanic episodes
may have clinically significant distress or impaired function r/t cyclicity
unpredictable mood changes
often seen as temperamental, moody, unpredictable, inconsistent, unreliable
no psychotic episodes
differential for cyclothymic disorder
BP
dysthymia
substance abuse
pharma mgmt of cyclothymic disorder
similar to MDD and BP
because of inc risk for development of BP, commonly tx with medication
