Depressive Disorders; Bipolar And Related Disorders

Question 1

Bipolar I disorder

Answer 1

• 1 or more manic or mixed episodes*
• often cycles with occasional depressive episodes*
  
  • major depressive episodes not required for diagnosis
• onset= age 20s-30s
• rare after age 50
• earlier onset= greater likelihood of psychotic features and poorer prognosis

Question 2

Bipolar I disorder- RF

Answer 2

• 1% of population
• men=women
• strongest= family history (first degree)*

Question 3

Bipolar I disorder- mania

Answer 3

• abnormal and persistently elevated, expansive, or irritable mood at least 1 week (less if hospitalization required)
• marked impairment of social/occupation function in 3 or more:
  
  • mood:
    
    • euphoria, irritable, labile, or dysphoric
  • thinking:
    
    • racing, flight of ideas, disorganized, easily distracted, expansive or grandiose thoughts (highly inflated self-esteem), judgment impaired (spending sprees)
  • behavior:
    
    • physical hyperactivity, pressured speech, decreased need for sleep (may go days without sleep), increased impulsivity and excessive involvement in pleasurable activating including risk-taking and hypersexuality, disinhibition, increased goal directed activity, psychotic symptoms (paranoia, delusions, hallucinations)

Question 4

Bipolar I disorder- management

Answer 4

• medication:
  
  • mood stabilizers:
    
    • first line= lithium*
    • anticonvulsants: valproic acid, carbamazepine
    • antipsychotics:
      
      • second generation: olanzapine
      • first generation: haloperidol
    • benzodiazepines if psychosis or agitations develops
  • other:
    
    • MAOIs
    • SSRIs
    • TCAs
      
      • antidepressants may precipitate mania
• ECT
• therapy: cognitive, behavioral, and interpersonal
• good sleep hygiene

Question 5

Bipolar II disorder

Answer 5

• 1 or more hypomanic episodes + 1 or more major depressive episodes*
• no mania or mixed episodes

Question 6

Bipolar II disorder- hypomania

Answer 6

• similar to mania
• at least 4 days clearly different from usual nondepressed mood
• does not cause marked impairment
  
  • no psychotic features
  • usually does not requires hospitalization
• does not include racing thoughts or excessive psychomotor agitation

Question 7

Bipolar II disorder- management

Answer 7

-similar to bipolar I

• mania:
  
  • lithium,* valproate, second generation antipsychotics
• depression:
  
  • lithium, valproate, carbamazepine, second generation antipsychotics
• mixed:
  
  • second generation antipsychotics, valproate

Question 8

Cyclothymic disorder

Answer 8

• similar to bipolar II disorder
  
  • less severe*
• prolonged period of milder elevations and depressions in mood
• ~15% may develop bipolar disorder
• men=women

Question 9

Cyclothymic disorder- symptoms

Answer 9

• recurrent episodes of hypomanic symptoms “cycling” with relatively mild depressive episodes
  
  • do not meet criteria for hypomania or MDD
• adults= at least 2 years
• children= 1 year
• may have symptom free periods
  
  • do not last longer than 2 months at a time
• no manic or mixed episodes

Question 10

Cyclothymic disorder- management

Answer 10

-similar to bipolar I disorder

• medication:
  
  • mood stabilizers
  • neuroleptics (antipsychotics)

Question 11

MDD

Answer 11

• depressed mood or anhedonia (loss of pleasure)
• loss of interest in activities
• 5 or more associated symptoms almost every day for most days for at least 2 weeks:
  
  • fatigue, insomnia or hypersomnia, feelings of guilty or worthlessness, recurring thoughts of death or suicide, psychomotor agitation, significant weight change, appetite change, decreased concentration/indecisiveness
• symptoms not due to substance use, bereavement, or medical conditions
• symptoms cause clinical distress or impairment in social, occupational, or other important areas of functioning
• absence of mania or hypomania

Question 12

MDD- somatic symptoms

Answer 12

• constipation
• HA
• skin changes
• CP
• abdominal pain
• cough
• dyspnea

Question 13

MDD- subtypes “course specifiers”

Answer 13

• seasonal affective disorder/seasonal pattern
• atypical depression
• melancholia
• catatonic depression

Question 14

Seasonal affective disorder/seasonal pattern

Answer 14

• presence of depressive symptoms at same time each year
  
  • MC= “winter blues” due to reduction of sunlight and cold weather
• management:
  
  • SSRIs
  • light therapy
  • bupoprion

Question 15

Atypical depression

Answer 15

• shares many typical symptoms of MDD, but add mood reactivity (improved mood in response to positive events)
• symptoms:
  
  • weight gain
  • appetitive increase
  • hypersomnia
  • heavy/leaden feelings in arms to legs
  • oversensitivity to interpersonal rejection
• management: MAOIs

Question 16

Melancholia

Answer 16

• anhedonia
• lack of mood reactivity
• depression
• weight loss
• appetite loss
• excessive guilt
• psychomotor agitation or retardation
• sleep disturbance (increased REM time and reduced sleep)
  
  • may lead to early morning awakening or worse mood in morning

Question 17

Catatonic depression

Answer 17

• motor immobility
• stupor
• extreme withdrawal

Question 18

MDD- pathophysiology

Answer 18

• alteration in neurotransmitters:
  
  • serotonin
  • epinephrine
  • norepinephrine
  • dopamine
  • acetylcholine
  • histamine
• genetic factors
• neuroendocrine dysregulation:
  
  • adrenal
  • thyroid
  • GH

Question 18

MDD- suicide

Answer 18

• 15% commit suicide
• men age 25-30
• women age 40-50
• higher rates with detailed suicide plan
• white males age >45 and concurrent substance abuse

-patient health questionnaire (PHQ)-2 form for initial screen, if positive, use PHQ-9

Question 19

MDD- management

Answer 19

• psychotherapy: principle therapy in mild-moderate depression
  
  • CBT- exposure/response prevention, psychoeducation, support groups
  • particularly beneficial when combined with medical therapy
• medication:
  
  • first line in mild-moderate= SSRIs,* SNRIs
  • second line= bupoprion and mirtazapine (remeron)
  • third line= TCAs and MAOIs
  • antidepressants should be continued for minimum of 3-6 weeks to determine efficiency*
• ECT: patients who fail to respond to medical therapy, had positive previous response, or for rapid response in patients with severe symptoms
  
  • safe in pregnancy and elderly

Question 20

Persistent depressive disorder (dysthymia)

Answer 20

• chronic depressed mood
  
  • most of day, more days than not
  • not symptom free for more than 2 months at a time
• milder than MDD, but can include same symptoms
• no symptoms of hypomania, mania, or psychotic features
• able to function
• adults= more than 2 years
• children/adolescents= more than 1 year
• MC in women
• onset= late teens-early adulthood
• may progress to MDD or bipolar disorder

Question 21

Dysthymia- symptoms

Answer 21

• generalized loss of interest, social withdrawal, pessimism, decreased productivity
• “I’ve always been this way”
• 2 or more:
  
  • insomnia or hypersomnia
  • fatigue
  • low self-esteem
  • decreased appetite
  • overeating
  • hopelessness
  • poor concentration
  • indecisiveness

Question 22

Dysthymia- management

Answer 22

-similar to MDD

• principle treatment= psychotherapy
• medication:
  
  • first line= SSRIs
  • second line:
    
    • SNRIs
    • bupropion
    • TCAs
    • MAOIs

Question 23

Mixed symptoms

Answer 23

-3 or more manic or hypomanic symptoms + depression