Lecture 11 - mood disorders part 1 (Billie) incomplete Flashcards
what regulates mood?
neurotransmitters in the brain, mostly serotonin, norepinephrine, and dopamine.
What are the depressive disorders
Major depressive disorder (MDD)
Dysthymia/persistent depressive disorder
Seasonal affective disorder
Premenstrual dysphoric disorder
Disruptive mood dysregulation disorder
What are the Bipolar disorders
Bipolar 1 disorder
Bipolar 2 disorder
Cyclothymia
What are the two most widely recognized systems used for psychiatric dianosis, billing, and coding
Diagnostic and Statistical Manual of mental disorders (DSM)
International Statistical Classifications of Diseases and Related Health problems (ICD)
For all psychiatric conditions, the DSM endorses a criteria based diagnostic approach requiring 3 conditions. What are they?
- the condition is NOT caused by direct effects of any drug or external exposure.
- the psychiatric disorder is not caused by effects of a medical condition
- there is SIGNIFICANT impairment of social functioning, occupational functioning, or both.
What is the lifetime prevalence of MDD? what about prevalence in the past 12 months?
21%
10%
What is the most common demographic affected by MDD
age
gender
race
socioeconomics
MC in younger populations (average age of onset = 30) and 2-3x more common in women.
Highest prevalence in native americans
Lower in asians/pacific islanders.
higher prevalence in low socioeconomic status
What are the genetic/biological factors that could be risk factors for MDD
Neurotransmitter expression/sensitivity
Response to antidepressant drugs
FH of depression or alcoholism
What are the life events factors that could be risk factors for MDD
adversity or loss of loved one, job, or relationship
early childhood trauma
postpartum period
What are the Medication factors that could be risk factors for MDD
glucocorticoids
interferons
What are the personality factors that could be risk factors for MDD
low self-esteem
sensitive to stressors
insecure or worried
dependent or unassertive
introverted
What are the social factors that could be risk factors for MDD
lack of close relationships
close individuals with depression
maladaptive learned behaviors from close individuals
What are the medical condition factors that could be risk factors for MDD
neurologic, infectious, cardia, endocrine (thyroid/adrenal), cancer, inflammatory
What is the diagnostic criteria for MDD
a depressed mood or anhedonia for equal to or more than 2 weeks AND one of the following:
SIG E CAPS
Sleep disturbance
Interest decreased
Guilt and/or feelings or worthlessness
Energy decreased
Concentration Problems
Appetite/ Weight Loss
Psychomotor Agitation or retardation
Suicidal Ideation
What are the MDD subtypes
Anxiety
catatonic
mixed
psychotic
atypical
melancholic
peripartum
seasonal
What is the Anxiety Subtype of MDD
High levels of accompanying anxiety in MDD
What is the catatonic Subtype of MDD
major psychomotor disturbances (lazy cat)
What is the Mixed Subtype of MDD
symptoms of mania accompanying MDD (insomnia, racing thoughts, increased energy)
What is the psychotic Subtype of MDD
MDD with accompanying psychosis (hallucinations and/or delusions)
What is the Atypical Subtype of MDD
MDD with reactivity to pleasurable stimuli, hyperphagia (insatiable hunger), hypersomnia (insatiable fatigue)
What is the melancholic Subtype of MDD
MDD with anhedonia, psychomotor changes, insomnia with decreased appetite.
What is the peripartum Subtype of MDD
MDD during pregnancy or within 4 weeks of birth
What is the seasonal Subtype of MDD
MDD associated with a particular season
To have MDD a patient must have
at least one major depressive episode SIG E CAPS for more than 2 weeks
What is the timeline of depressive episodes
develop over days to weeks and can take about 20 weeks to resolve.
when is the highest risk of recurrence for MDD?
within the first few months following episodes resolution
what are the three ways that the course of MDD can vary among patients
- single major depressive episode that resolves
- multiple episodes with few to no s/s between episodes
- persistent, fluctuating depressive s/s with no clear “remission”
What are the rates of recurrence for MDD
1 year = 40%
lifetime = 85%
What is the Two-Question Screen (PHQ-2)
Quick initial screening for depression that asks for 2 key symptoms of a depressive episode. (depressed mood and anhedonia)
NOT a stand alone test, needs follow up if positive!
What is the Patient Health Questionnaire-9 (PHQ-9)
Further evaluates presence and severity of depression
can be used for initial screening or follow up evaluation
What is the Zung Self-Related Depression Scale
Allow a more in-depth rating of current depressive symptoms
What are the non-pharmacological treatment options for MDD
Psychotherapy
Electroconvulsive Therapy (ECT)
Vagal Nerve Stimulation
Transcranial Magnetic Stimulation (TMS)
What are the pharmacological categories for treatment options of MDD
Supplements
Herbals
Antidepressants
What are the treatment goals when treating MDD
Provide thorough education
maintain patient safety
achieve full remission of symptoms
Return patient to baseline functioning
What is the preferred approach to treating MDD
Combination of pharmacotherapy AND pyschotherapy
Criteria for mild/moderate depression that is treated outpatient
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
criteria for severe depression that is treated inpatient
Suicidal/homicidal ideation or behavior with a specific plan or intent
psychosis
catatonia
impaired judgement that puts patient/others at risk
Grossly impaired functioning affecting ability to care for self.
what is psychotherapy
AKA “counseling”
Cognitive behavioral Therapy (CBT) or Interpersonal Psychotherapy are most commonly used.
What is behavioral activation?
Restarting activities that ceased due to depression
what is the recommended type and amount of exercise to use as non pharmacologic treatment?
aerobic or resistance
3-5x/week, 45-60 minutes each session
what is Electroconvulsive therapy
Use of a small electric current to induce a cerebral seizure while patient is under general anesthesia
what are the indications for Electroconvulsive therapy?
patients with severe, refractory depression
1st line in patients with:
severe suicidality
severe psychosis
catatonia
malnutrition d/t food refusal secondary to depressive illness
or if patient cannot tolerate any other therapies.
What is the most efficacious treatment for MDD
electroconvulsive therapy
what are the CI for ECT
no absolute Ci
use with caution in patients with cardiopulmonary disease, neurologic disease or those on anticoagulants
what are the side effects of ECT
overall considered safe.
MC adverse events are - cardiopulmonary, HA, nausea, transient cognitive impairment (brainfog), muscle aches
what is vagal nerve stimulation as a treatment for MDD
a device is implanted in the chest wall and connected to one (left) vagus nerve.
may be helpful for refractory depression but recent studies show questionable efficacy
Describe the process of transcranial magnetic stimulation as a treatment for MDD
metal coil with magnetic field is placed against scalp to induce depolarization of neurons in a focal area.
this is performed WITHOUT sedation or anesthesia and has NO intentional seizure induction.
what are the indications for TMS
treatment for refractory depression
what are CI for TMS
high seizure risk, incompatible implants (metallic, electrical, cochlear because of magnet)
what are the SE of TMS
seizures, HA, scalp pain, transient hearing loss
What are the three main supplements used in the treatment of MDD
S-Adenosylmethionine (SAMe)
5-Hydroxytryptophan (5-HTP)
Omega-3 fatty acids
what is SAMe and how does it work
a supplement that already naturally occurs in the body.
May raise dopamine levels
What is a group that SAMe may be helpful in
can be used as an adjunctive option for mild to moderate depression in pregnant patients
what is the SE of SAMe
may trigger manic episodes
what is 5-HTP
natural precursor to serotonin
what are the SE of 5-HTP
GI upset, serotonin syndrome, eosinophilic myalgia syndrome
How are omega 3 fatty acids used in MDD
may work better when combined with antidepressants
what is the SE of omega 3 fatty acids
may increase risk of bleeding
what are the herbal treatment options for MDD
st johns wort
saffron
ginkgo biloba
What does St johns wart do
increases serotonin and possibly NE and dopamine levels
what are the SE of St Johns wort
Risk of GI upset, serotonin syndrome, photosensitivity
NUMEROUS DRUG INTERACTIONS (DDIs)
what is Safron
a herbal that may help with depression; MOA unclear
what are the SE of saffron
GI upset
mania
bleeding
can be FATAL at high doses
what does Ginkgo Biloba do
causes improved mood in patients being treated for memory loss; may increase sensitivity to serotonin
what are the SE of Ginkgo Biloba
may increase risk of bleeding
how long should you take to titrate someone onto an antidepressant
7-10 days if not longer.
START LOW GO SLOW
how long should you wait to see the full benefit of oral antidepressents
should do a trial of at least 4 weeks
patients could see improvement as early as week 1 but it generally takes 4-6 weeks to see a response.
when should you consider treatment modification in oral antidepressants
if <25% improvement in baseline s/s after 4-6 weeks of using medication.
How long should oral antidepressants be continued?
6+ months after s/s improvement
What are the first generation antidepressants
Monoamine Oxidase inhibitors (MAOIs)
Tricyclic Antidepressants (TCAs)
tetracyclic Antidepressants (TeCAs)
what are the second generation antidepressants
Selective Serotonin Reuptake inhibitors (SSRIs)
Serotonin-Norepinephrine reuptake inhibitors (SNRIs)
Atypical Antidepressants
Serotonin Modulators
Ketamine/Esketamine
What is the most common class of antidepressants used for MDD
Second generation Antidepressants
what is the 1st line pharmacological treatment for MDD
SSRIs
what is the MOA for SSRIs
selectively decreases the action of 5-HT reuptake pump, leading to increased serotonin levels in the synapse.
what are the drugs in the SSRI class?
Fluvoxamine
Fluoxetine
Sertraline
Citalopram
Escitalopram
Paroxetine
FF SCEP
What is the dosing for SSRIs
usually given in the morning but doses can be split if SE are burdensome
start low and go slow!!!
How are SSRIs metabolized
mostly hepatically so use caution in hepatic impairment
What are CI for SSRIs
allergy to SSRI
Use of MAOI within 2 weeks
FLUOXETINE = wait 5 weeks for MAOI!!!
what are SE of SSRIs
GI upset
sleep change
HA, dizziness
decreased libido, anorgasmia, ED
increase anxiety and risk of suicide
prolonged QT, weight gain, bleeding Orthostatic Hypotension
SEROTONIN SYNDROME
what SE of SSRIs are more common in adolescents and early 20s
risk of suicide and serotonin syndrome
what is serotonin syndrome
caused by increased serotonergic activity
typically occurs within 24 hours (often within 6 hours) of starting/changing medications or overdosing.
what are s/s of serotonin syndrome
diarrhea, increased bowel sounds, agitation, hyperreflexia, dry mucous membranes, autonomic instability, hyperthermia, HTN, tremor, clonus, seizure, DEATH.
how do you diagnose Serotonin syndrome
clinically
5-HT levels DO NOT correspond
what is the treatment for serotonin syndrome
supportive care
D/C serotonergic medications
sedation with benzodiazepines
normalize vitals and hydration status
What are the specific side effects of sertraline
More GI upset, Esp diarrhea
Less likely QT prolongation and drowsiness
slightly higher chance of insomnia
what are the specific side effects of citalopram/escitalopram
most associated with Prolonged QT
Minimal SE otherwise
LEAST INHIBITION OF HEPATIC ENZYMES
what are the specific side effects of fluvoxamine
frequently causes somnolence
DDIs
SHORTEST HALF LIFE 15 hrs
what are the specific side effects of fluoxetine
LONGEST half life (up to 3 days)
slightly higher risk of insomnia
DO NOT USE w Tamoxifen
What are the specific side effects of paroxetine
Only one that causes anticholinergic SE
slightly higher risk of hypotension, weight gain, and sexual dysfunction than others
SHOULD NOT BE USED w Tamoxifen
