Depressive Disorders; Bipolar Etc.

Question 1

Major depressive disorder

Answer 1

• one or more major depressive eps, MC psychiatric disorder in gen pop, MDD is more frequent in families of bipolar indivs, but the reverse is not true, increases risk of developing CAD, 66% present with somatic complaints (HA, back probs, chronic pain)
• sxs: syndrome with >/= 5 sxs lasting >/= 2 consecutive wk (depressed mood nearly qd, most of day), loss of interest/pleasure nearly qd, appetite disturbance (significant wt loss or gain), sleep disturbance (insomnia or hypersomnia), psychomotor disturbance (restlessness or feeling slowed down), fatigue, feelings of shame, guilt/worthlessness, hopelessness, impaired concentration, SI, abnl self-perception, not attributable to seasonal affective disorder, schizophrenia, schizophreniform disorder, delusional disorder, absence of manic or hypomanic ep (differs from bipolar)
• dx: clinical (CBC, CMP, UA, hCG, urine tox, TSH, vitB12, folate, EKG)
  
  • screening: PHQ9, PHQ2, beck depression inventory for primary care
• ​tx: SSRI (first line), bupropion (wellbutrin), TCA, MAOIs, psychotherapy
  
  • tx for . 6-12 wks before deciding if . med effective

Question 2

bipolar disorder

Answer 2

• mood disorder characterized by episodes of mania, hypomania, and major depression, pathogenesis unkown
• sxs: mood disorder at onset (major depression, mania, mixed)
• dx: clinical dx, psychiatric and med hx, mental status, PE, labs (TSH, CBC< CMP, utox), mood . disorder questionnaire, PHQ9 (screens for major depression

Question 3

bipolar I, bipolar II

Answer 3

• Bipolar I: mean onset 18y, M=F
  
  • at least one manic ep (3+ sxs for 7d), major depression (not required), hypomanic eps
  • dx: clinical dx
• Bipolar II: mean onset 20y, M=F, more prevalent than bipolar I
  
  • at least one hypomanic ep (3+ sxs for 4d), at least one major depressive ep (5+ sxs for 2wk), absence of manic eps
  • dx: clinical dx

Question 4

mania vs hypomania

Answer 4

• mania: DIGFAST (distractibility, impulsivity, grandiosity, flight of ideas/racing thoughts, activity (increased), sleep (dec need), talkativeness)
  
  • >/= 7d (or requiring hosp) and including >/= 3 of the DIGFAST sxs
  • sxs not result of substance or general med condition
  • tx: lithium OR valproic acid PLUS antispychotics (haloperidol, olanzapine, risperidone, etc.), benzos, ECT, Clozapine
• hypomania: >/=4d (not requiring hosp) and including >/=3 of DIGFAST
  
  • impairs psychosocial fn only mildly and does not require hosp
  • tx: monotx risperidone OR olanzapine PLUS antipsychotics (ariprprazole, quetiapine, ziprasidone), anticonvulsants (valproic acid, carbamazepine), lithium
• acute agitation tx: antipsychotics (haloperidol = 1st line, aripiprazole, olanzapine)

Question 5

Persistent Depressive Disorder (dysthymia)

Answer 5

• F:M (2:1), greater incidence with older age
• RF: 1st degree relative
• Ongling depressive sxs that are less severe and/or less numerous
• occur in 2% of gen pop
• Most potent stressors: death of relative, assault, severe marital or relationship problems
• sxs: depressed mood (dysphoria) lasting 2+ y (chronic) and incuding ≥ 2 of the following: ACHESS
  
  • Appetite disturb (inc or dec)
  • Concentration prob
  • Hopelessness
  • Energy (low)
  • Sleep disturb (hypersom or insom)
  • Self-esteem (low)
  • NO manic or hypomanic eps, causes psychosocial impairment or distress, never asxatic >2mo, no MDD eps during 1st 2y
• Signs: many pts have profile of pessimism, disinterest, low self-esteem
• dx: clinical dx
• tx: pharm + psychotx
  
  • SSRI, buproprion, psychotx (CBT, interpersonal tx)

Question 6

Cyclothymic Disorder

Answer 6

• sxs: numerous hypomanic periods (3+ sxs for 4d) and mild depressi ve periods over ≥2 consecutive yrs; no major depressive eps or manic eps during 1st 2y, sxatic ≥50% of time, not sx free for more than 2mo, causes significant distress or psychosocial impairment, not substance induced
• dx: clinical dx

Question 7

Acute Mania Tx

Answer 7

• Lithium
  
  • OR
• anticonvulsants (valproic acid)
  
  • PLUS
• Antipsychotics (ariprazole, halo, olanzapine, quetiapine, risperidone), benzos (for pts who cant tolerate lithium, anticonvulsants, or antipsychotics - clonazepam, lorazepam), ECT (refractory mania - doesnt respond to 4-6 meds), Clozapine (refractory to meds, decline ECT)

Question 8

Hypomania Tx

Answer 8

• Monotx = 1st line
• risperidone
  
  • OR
• olanzapine
  
  • PLUS
• antipsychotics (ariprazole, quetiapine, ziprasidone), anticonvulsants (valproic, carbamazepine), Lithium
• If pt fails monotx within 2wk of target dose or doesnt tolerate drug, dc med over 1wk and titrate new med
• may combine anttipsychotic with lithium or valproic acid if pt fails 3-5 monotx trials

Question 9

Acute Agitation Tx

Answer 9

antipsychotics (mainstay - aripiprazole, halo, olanzapine)

Question 10

Maintenance tx

Answer 10

• tx acute mania
• monotx: lithium, valproate, quetiapine, lamotrigine
  
  • second line antipsych: aripiprazole, olanzapine, risperidone
  • third line: carbamazepine, lurasidone, oxcarbazepine
  • ECT
• psychotx: group psychoed (1st line), cognitive behavioral tx, family tx

Question 11

Haloperidol potential side effects

Answer 11

• can cause movement disorders and may inc risk of bipolar major depression

Question 12

Why is lithium used so much

Answer 12

• widely studied and efficacious for long-term tx and may reduce risk of suicide attempts and death

Question 13

Olanzapine potential side effects

Answer 13

• not used as first line for concerns of wt gain and DM

Question 14

Valproic acid contraindications

Answer 14

• cant be used in women of childbearing age - teratogenicity and risk of PCOS

Question 15

Lithium and valproate efficacy together

Answer 15

• reduce risk of relapse by 30%