Lecture 11 Flashcards
What is mood?
Overall state of emotion at a given time
Influenced by internal and external factors
What is a mood disorder?
Condition that affects a person’s everyday emotional state/mood
AKA affective disorders
How many adults 18+ have a mood disorder?
1 in 4
What NT regulate mood?
Serotonin
Norepinephrine
Dopamine
What are the types of depressive disorders?
Major depressive disorder
Dysthymia/Persistent Depressive Disorder
Seasonal Affective Disorder
Premenstrual Dysphoric Disorder (PMDD)
Disruptive Mood Dysregulation Disorder
What are the types of bipolar disorder?
Bipolar I disorder
Bipolar 2 disorder (cyclothymia included)
What are the most recognized systems for psychiatric diagnosis?
DSM
ICD(International Statistical Classifications of Diseases and Related Health Problems)
What does the DSM require for all psychiatric conditions?
Criteria based diagnostic that requires 3 conditions…
Not caused by the direct effects of any drug or external exposure
Not caused by effects of a medical condition
Significant impairment of social functioning, occupational functioning, or both.
What percentage of people in the US have a MDD their lifetime? past 12months?
21%
10%
Who are more likely to have a MDD?
MC younger population (average age 30)
Rates higher in (25-44yo)
Low socioeconomic status
2-3x more in women
What race is the highest to have a MDD? lowest?
Native Americans
Asians/Pacific Islanders
What are some genetics/biological facts that increase the risk of MDD?
NT expression sensitivity (serotonin, norepinephrine, glutamate, GABA, dopamine)
Response to antidepressants
FH of depression or alcoholism
What are some life events that increase the risk of MDD?
Adversity or loss of loved one, job, or relationship
Early childhood trauma
Postpartum period
What are some medications that increase the risk of MDD?
Glucocorticoids
Interferons
What personalities increase the risk of MDD?
Low self-esteem
Sensitive to stressors
Insecure or worried
Dependent or unassertive
Introverted
What social factors increase the risk of MDD?
Lack of close relationships
Close individuals with depression
Maladaptive learned behaviors from close individuals
What medical conditions are increase the risk for MDD?
Neurologic
Infectious
Cardiac
Endocrine
Cancer
Inflammatory
How do you diagnose MDD according to the DSM?
Depressed mood or anhedonia for >2weeks and >4 conditions (on another card)
What are the conditions of the DSM criteria for MDD?
SIG E CAPS
Sleep disturbances
Interested decreased (anhedonia)
Guilt and/or feeling of worthlessness
Energy decreased
Concentration problems
Appteite/weight changes
Psychometer agitation or retardation
Suicidal ideation
What are the subtypes of MDD?
Catatonic (psychomotor disturbances)
Anxiety
Mixed (insomnia, racing thoughts, increase energy)
Psychotic (hallucinations, delusions)
Seasonal
Atypical (reactivity to pleasurable stimuli)
Melancholic
Peripartum
CAMPSAMP
How does a MDD present?
At least one major depressive episode that can last over days to weeks (average time 20weeks)
When is there the highest risk of recurrence for a major depressive episode?
Within the first few months following episodes resolution
What are the rates of recurrence of a major depressive episode in 1 year? lifetime??
40%
85%
What are some differentials of MDD?
Other mood disorders
Medication SE
General medical disorders
Substance use/abuse
NOT bereavement
What are the types of screening for MDD?
Two question screen (PHQ-2)
Pt health questionnaire-9 (PHQ-9)
Zung self-rated depression scale
What are the non-pharmacological management for MDD?
Psychotherapy
Electroconvulsive(ECT)
Vagal nerve stimulation
Transcranial Magnetic stimulation (TMS)
What are the pharmacological management for MDD?
Supplements
Herbals
Antidepressants
What are the goals of MDD treatment?
Maintain pt safety
Full remission of symptoms
Return to baseline functions
What is the preferred treatment for MDD? Whats the MC?
Pharmacotherapy AND psychotherapy
MC is just pharmacotherapy
What are a characteristics of a pt to be considered for outpatient treatment in MDD?
Mild/moderate depression
No suicidal/homicidal ideation or behavior
No psychotic features
Minimal to no aggressiveness
Intact judgement
Able to perform basic ADL and maintain adequate nutritional/hydration status
What are the characteristics of a pt to be considered for inpt treatment in MDD?
Severe depression
Suicidal/homicidal ideation or behavior with specific plan or intent
Psychosis
Catatonia
Impaired judgement that puts patient/others at risk for harm
Grossly impaired functioning affecting ability to care for self
What are non-pharmacologic treatments for MDD?
Psychotherapy (CBT, interpersonal therapy)
Relaxation techniques
Exercise
Behavioral activation
Other(massage therapy, spirituality, yoga, acupuncture)
How does ECT work?
Small electric current to induce cerebral seizure while patient is under general anesthesia
What is indicated for ECT?
Severe, refractory depression
Severe suicidality, severe psychosis, catatonia, malnutrition d/t food refusal secondary to depressive illness
What is the most effective treatment for severe MDD?
ECT
What are SE of ECT?
Generally safe
Cardiopulmonary
HA
Nausea
Transiet cognitive impairment
Muscle aches
How does a vagal nerve stimulation work?
Device implanted in chest wall and connected to one(left) vagus nerve
What is indicated for vagal nerve stimulation?
Refractory epilepsy
Refractory depression(questionable efficacy)
How does TMS work?
Metal coil with magnetic field is placed against scalp to induce depolarization of neurons in a focal area
Output use without sedation or anesthesia
What is indicated for TMS?
Treatment-refractory depression
What is CI for TMS?
High seizure risk
Incompatible implants(metallic, electrical, cochlear)
What are the SE of TMS?
Seizures
HA
Scalp pain
Transient hearing loss
What are the supplements that could be used to treat MDD?
S-Adenosylmethionine (SAMe): raise dopamine levels
5-Hydroxytryptophan (5-HTP): precursor of serotonin
Omega-3 Fatty Acids
What herbals can be used for treating MDD?
St. John’s wort(increase serotonin, possibly noes and dopamine levels)
Saffron
Ginkgo biloba: improve mood for pts being treated for memory loss, increase sensitivity of serotonin
What herbs or supplements can increase the risk of bleeding?
Omega-3. Ginkgo biloba
When do you usually see improvement after taking oral antidepressants?
As soon as week 1, but can take up to 4-6 weeks
How long should. a pt be on antidepressants?
6+months after s/s improvement and then you gradual titrate down
What are the types of antidepressants?
SSRI: paroxetine, escitalopram
SNRI: venlafaxine
Serotonin Modulators: mirtazapine, vortioxetine
TCAs: amitriptyline
What are the first gen antidepressant classes?
MAOIs
TCAs
TeCAs
Litium
Antipsychotics
What are the 2nd gen antidepressant classes?
SSRIs
SNRIs
Atypical antidepressants
Serotonin modulators
Ketamine/Esketamine
What is the MC class of antidepressants?
2nd gen antidepressants
What do most SSRIs have a half life of?
24hours
What medication is usually best used to titrate off an SSRI?
Prozac
What causes serotonin syndrome?
Increased serotongeric activity
Usually when starting medications or dosing changes
What are the S/S of serotonin syndrome?
Diarrhea
Increased bowel sounds
Agitation
Hyperreflexia
Dry mucous membranes
Autonomic instability
Hyperthermia
HTN
Tremor
Clonus
Seizures
Death
How do we diagnose serotonin syndrome?
Clinically
How do you treat serotonin syndrome?
Supportive care
D/C serotonergic medications
Sedation with benzodiazepines
Normalize vitals and hydration status
How do you treat serotonin syndrome?
Supportive care
D/C serotonergic medications
Sedation with benzodiazepines
Normalize vitals and hydration status
What SSRIs do you not take if a pt is on tamoxifen(breast cancer med)
Fluoxetine and Paroxetine
What are usually first-line for MDD?
SSRIs
What do most SSRIs have a half life of?
24hours
