Depressive Disorders and Bipolar Disorders Flashcards

1
Q

MDD etiology psychodynamic theories

A

Object Loss Theory

Aggression Turned Inward Theory

Cognitive Theory

Learned Helplessness Hopelessness theory

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2
Q

MDD etiology Object Loss Theory

A

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

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3
Q

MDD etiology Aggression Turned Inward Theory

A

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

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4
Q

MDD etiology Cognitive Theory

A

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

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5
Q

MDD etiology Learned Helplessness-Hopelessness Theory

A

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

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6
Q

MDD etiology Biological Theories

A

Genetic

Endocrine

NT function abnormalities

Structural brain changes

Chronobiological theory

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7
Q

MDD etiology Genetic

A

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

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8
Q

MDD etiology Endocrine

A

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)

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9
Q

MDD etiology Abnormal NT function

A

obviously dysregulation of dopamine, serotonin, norepinephrine

receptor sensitivity

low density of receptor sites

probably more than one NT

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10
Q

MDD etiology Structural Brain Changes

A

Neuroimaging shows abnormalities:
Hypovolemic hippocampus
Hypovolemic prefrontal cortex

common in those who have experienced brain damage from stroke/trauma

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11
Q

MDD etiology Chronobiological Theory

A

desynchronization of circadian rhythms

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12
Q

What percent of MDD receive tx ever

A

50%

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13
Q

MDD age of onset average

A

Mid 20s

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14
Q

what percent of MDD will die by suicide

A

15%

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15
Q

Untreated MDD lasts

A

4+ months usually

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16
Q

What percent of those with 1st episode of MDD have a 2nd episode

A

60%

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17
Q

Prevention of MDD

A

At risk family education

community education to reduce stigma and emphasize tx

Screening

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18
Q

Common MDD screening tools

A

PHQ-9
EPDS
BDI
HAM-D

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19
Q

Diagnostic Criteria for MDD

A
  1. Anhedonia or a depressed mood, or both
  2. Depressed mood most of the day, nearly every day (In children, irritable mood)
  3. Marked anhedonia in all or almost all ADLs
  4. 3 or more significant sx during same 2 wk period that are a change in previous functioning
  5. Significant, unintentional weight loss or gain (5% body weight)
  6. Hypersomnia or insomnia nearly every day
  7. Psychomotor agitation or retardation
  8. Fatigue or loss of energy
  9. Self-deprecating comments or thoughts
  10. Feelings of worthlessness or excessive or inappropriate guilt nearly every day
  11. Decreased concentration and memory
  12. Recurrent morbid thoughts or suicidal ideation
  13. Sx onset within 2 months of significant loss and do not persist beyond 2 months are generally considered bereavement and not MDD.
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20
Q

MDD SI risk high for certain sx or hx

A

presence of psychotic sx

Hx of past attempts

Hx of 1st deg relative who committed suicide

Concurrent SUD

Current serious health problem

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21
Q

Top goal in acute phase of MDD

A

ensure client safety

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22
Q

Number of episodes of MDD to consider lifetime antidepressant tx

A

2+

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23
Q

Target sx of antidepressant tx

A

depressed mood
sleep-rest disturbances
anxiety
irritability
impaired concentration
impaired memory
appetite disturbance
agitation
anhedonia
impaired energy and motivation

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24
Q

antidepressant rebound

A

common with abrupt cessation

worse with drugs with short half lives

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25
Classes of antidepressants
SSRIs TCAs MAOIs SNRIs NDRIs SARIs
26
SSRI MOA
Primarily by increase 5ht in CNS by inhibiting presynaptic reuptake
27
TCA MOA
elevate 5ht and NE by inhibiting presynaptic reuptake
28
MAOI MOA
elevate 5ht and NE by inhibiting MAO MAO is the enzyme that breaks down monoamine NTs
29
SNRI MOA
inhibit dual reuptake of NE and 5ht action very selective on NTs elevate both NTs by inhibiting presynaptic reuptake
30
NDRI MOA
inhibit dual reuptake of NE and dopamine very selective on NTs elevate both NTs by inhibiting presynaptic reuptake
31
SARI MOA
Dual action agonist of 5HT receptors very selective on NTs elevate 5ht by inhibiting 5ht reuptake
32
SSRI drugs (agent and brand)
Citalopram--Celexa Escitalopram--Lexapro Fluoxetine- Prozac Fluvoxamine--Luvox Paroxetine- Paxil Sertraline--Zoloft
33
SPARI and example
Serotonin Partial Agonist Reuptake Inhibitor Vilazodone-Viibryd Lower risk of sexual side effects noted
34
SSRI with longer half life
Fluoxetine-- Prozac
35
SSRI with common discontinuation syndrome
Paroxetine--Paxil
36
SSRI with UNLIKELY discontinuation syndrome
Fluoxetine-- Prozac
37
TCA drugs
Amitriptyline Doxepin Nortriptyline Multiple others: Clomipramine Desipramine Imipramine Protriptyline Trimipramine
38
TCA also used for insomnia
Doxepin some amitriptyline
39
TCA also approved for OCD
Clomipramine
40
TCA also used off label for ADHD
Desipramine Nortriptyline
41
TCA also used for chronic pain
amitriptyline
42
TCA also used to enuresis
Nortriptyline Imipramine
43
MAOI drugs
Isocarboxazid Phenelzine Tranylcypromine Selegiline
44
1st line tx for 1st epidose of MDD mild to moderate sx
SSRI safer in OD than TCA
45
SSRI effective of these dx other than MDD
Panic disorder OCD bulimia GAD social phobia PTSD PMDD
46
2nd line tx for MDD
TCAs
47
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
48
TCAs and discontinuation
avoid abrupt withdrawal
49
TCA and suicidality
avoid those with high risk
50
TCA +SSRI
SSRI can elevate TCA so TCA needs monitoring of levels
51
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
52
Tx for hypertensive crisis from MAOI
d/c MAOI Give phentolamine (blocks NE) Stabilize fever eval diet and adherence
53
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
54
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
55
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
56
SNRIs
Venlafaxine--effexor Duloxetine--cymbalta Levomilnscipran--Fetzima
57
What is Vortioxetine--Brintellix
5ht-3 and 5ht7 antagonist 5ht1a agonist Antidepressant
58
Duloxetine concerns when using for depression
can elevate BP and LFTs significant d/c syndrome if abrupt
59
Venlafaxine concerns when using for depression
Can elevate BP significant d/c syndrome if abrupt
60
NDRI for depression
Bupropion--wellbutrin
61
Bupropion concerns
CI for those with sz disorder and eating disorder caution with caffeine and people with panic disorder
62
Mirtazapine--Remeron class and use considerations
alpha2/5ht2 antagonist inverse relationship b/t dosage and sedation good for sleep need
63
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
64
nonpharmacological tx options for MDD
ECT TMS VNS Phototherapy individual therapy
65
ECT for MDD
Its grand mal sz induced in anesthetized person 6-12 tx usually
66
ECT for MDD: MOA
MOA ---poss inc NTs ---poss release hormones ---poss exerts anticonvulsant effect which then produces an antidepressant effect
67
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
68
ECT for MDD: possible contraindications
cardiac pulmonary Hx brain injury or brain tumor anesthesia medical complications
69
ECT for MDD: Adverse effects
Poss CV effects Systemic: HA, muscle ache, drowsy Cognitive: memory disturb, confusion
70
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
71
TMS for MDD: side effects
minimal but poss HA, discomfort
72
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
73
VNS for MDD: Side effects
usually during pulse generation: voice changes, hoarse, cough, spasm
74
phototherapy for MDD
2500-10000 lux for 30 min for up to 2 hrs 1-2x/day
75
therapy for MDD
psychodynamic therapy CBT Brief therapy (solution focused) group therapy family therapy
76
CBT for MDD goals
modify perceptions dec negativity inc sense of internal control enhance coping skills modify environmental factors contributing to illness
77
Brief therapy (solution focused) for MDD goals
focus on precipitant stressor cope with immediate impact of MDD on personal life modify contributory environmental factors
78
group therapy for MDD goals
improve decision making, socialization skills, and assessment of individual strengths gain new coping skills
79
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
80
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
81
Sx of MDD more pronounced in children
irritability somatic complaints social withdrawal
82
Sx of MDD less common in children before onset of puberty
psychosis motor retardation hypersomnia increased appetite
83
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
84
MDD in children strongly associated with
separation anxiety
85
older adults with MDD considerations
if in LTCF, significant shorter lifespan cognition/memory confused with dementia important to complete functional assessment
86
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
87
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
88
Drug combos that can cause serotonin syndrome
SSRI and MAOI drug and herbal interactions SSRI and St Johns Wort
89
sx of serotonin syndrome
Autonomic instability Altered sensorium Restlessness Agitation Myoclonus Hyperreflexia Hyperthermia Diaphoresis Tremor Chills Diarrhea and cramps Ataxia Headache Insomnia
90
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
91
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
92
how long to take antidepressant after remission
at least 12 months
93
Persistent depressive disorder is also known as
dysthymia
94
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
95
vegetative sx examples
sleep, appetite, wt changes
96
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
97
pharma mgmt of dysthymia
similar to MDD due to inc risk for development of MDD
98
double depression
MDD superimposed on dysthymia normally more complex and outcomes less positive
99
dysthymia disorder is associated with..
personality disorders borderline histrionic narcissistic avoidant dependent
100
dysthymia associated with several childhood disorders
ADHD conduct anxiety learning
101
dysthymia length of sx for kids vs adult
1 year for kids
102
dysthymia mood in kids vs adult
irritable for kids sad for adults may report both tho
103
for grief and bereavement, how different from MDD
self esteem usually preserved in grief
104
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
105
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
106
PMDD sx
marked lability irritability depressed mood anxiety low energy sleep disturbances
107
PMDD tx
hormonal contraceptives SSRI both
108
Bipolar patterns
single polarity (mania) distinct sx patterns of alternating polarity mixed co-occurring sx
109
bipolar presentation
excessive or distorted degree of sadness or elation or both
110
bipolar manifests with
behavioral, affective, cognitive, and somatic sx
111
bipolar and precipitating event
possibly but often occurs without any precipitating stressor identified
112
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
113
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
114
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
115
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
116
hypomania
similar to mania more brief in duration episode not as severe as mania no hospitalization no significant functional impairment
117
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
118
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
119
bipolar diff dx
if onset of manic after 40yo, most likely another medical condition --endocrine --hyperthyroid --intoxication --medications --precipitated by MDD tx
120
medications that can cause mani
-Captopril - Cimetidine - Corticosteroids -Cyclosporine -Disulfiram - Hydralazine - Isoniazid
121
MDD tx that can lead to mania
antidepressants ECT light therapy
122
Mood stabilizing agents
Lithium anticonvulsants
123
gold standard for tx of manic episodes
lithium well established long hx evidence of anti suicidal effect some effectiveness on depressive sx too
124
why serum lithium level needed
narrow therapeutic window determine effect and potential for AE sx
125
how to get serum lithium level
draw at trough level 12 hours post dose therapeutic range 0.5-1.2
126
baseline labs before lithium
thyroid panel serum Cr BUN pregnancy ECG for over 50yo
127
How may lithium effect endocrine
wt gain impaired thyroid function
128
How may lithium effect CNS
fine hand tremors fatigue mental cloudiness HA coarse hand tremors with toxicity nystagmus
129
How may lithium effect derm
maculopapular rash pruritis acne
130
How may lithium effect GI
GI upset D V cramps anorexia
131
How may lithium effect renal
polyuria/polydipsia diabetes insipidus edema microscopic tubular changes
132
How may lithium effect cardiac
T wave inversions dysrhythmias
133
How may lithium effect hematological
leukocytosis
134
rapid cycling BP and lithium
rarely respond to monotherapy
135
anticonvulsant rx for mood
carbamazepine lamotrigine valproic acid
136
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)
137
lithium toxicity
slurred speech confusion severe GI
138
concurrent rx with lithium to watch
NSAID ACEI may double lithium level
139
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
140
depakote vs lithium
depakote more effective for rapid cycling and mixed bipolar
141
baseline labs before carbamazepine/depakote
CBC LFT 1 wk after start needs 12 hour serum trough CBC LFT
142
response to tx for lithium and anticonvulsant
1-2 wks
143
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
144
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
145
non pharm tx for acute phase of mania
monitor and help meet nutrition needs help meet sleep needs monitor safety
146
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
147
common comorbid for bipolar
hypothyroid substance abuse
148
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
149
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
150
Cyclothymic disorder
chronic fluctuating mood disorder with sx similar to BP but less severe numerous periods of hypomania and dysthymic sx
151
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
152
differential for cyclothymic disorder
BP dysthymia substance abuse
153
pharma mgmt of cyclothymic disorder
similar to MDD and BP because of inc risk for development of BP, commonly tx with medication