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Behavioral Dynamicssss > Lecture 11 - mood disorders part 1 (Billie) incomplete > Flashcards

Lecture 11 - mood disorders part 1 (Billie) incomplete Flashcards

1
Q

what regulates mood?

A

neurotransmitters in the brain, mostly serotonin, norepinephrine, and dopamine.

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2
Q

What are the depressive disorders

A

Major depressive disorder (MDD)
Dysthymia/persistent depressive disorder
Seasonal affective disorder
Premenstrual dysphoric disorder
Disruptive mood dysregulation disorder

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3
Q

What are the Bipolar disorders

A

Bipolar 1 disorder
Bipolar 2 disorder
Cyclothymia

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4
Q

What are the two most widely recognized systems used for psychiatric dianosis, billing, and coding

A

Diagnostic and Statistical Manual of mental disorders (DSM)
International Statistical Classifications of Diseases and Related Health problems (ICD)

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5
Q

For all psychiatric conditions, the DSM endorses a criteria based diagnostic approach requiring 3 conditions. What are they?

A
  1. the condition is NOT caused by direct effects of any drug or external exposure.
  2. the psychiatric disorder is not caused by effects of a medical condition
  3. there is SIGNIFICANT impairment of social functioning, occupational functioning, or both.
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6
Q

What is the lifetime prevalence of MDD? what about prevalence in the past 12 months?

A

21%
10%

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7
Q

What is the most common demographic affected by MDD
age
gender
race
socioeconomics

A

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

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8
Q

What are the genetic/biological factors that could be risk factors for MDD

A

Neurotransmitter expression/sensitivity
Response to antidepressant drugs
FH of depression or alcoholism

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9
Q

What are the life events factors that could be risk factors for MDD

A

adversity or loss of loved one, job, or relationship
early childhood trauma
postpartum period

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10
Q

What are the Medication factors that could be risk factors for MDD

A

glucocorticoids
interferons

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11
Q

What are the personality factors that could be risk factors for MDD

A

low self-esteem
sensitive to stressors
insecure or worried
dependent or unassertive
introverted

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12
Q

What are the social factors that could be risk factors for MDD

A

lack of close relationships
close individuals with depression
maladaptive learned behaviors from close individuals

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13
Q

What are the medical condition factors that could be risk factors for MDD

A

neurologic, infectious, cardia, endocrine (thyroid/adrenal), cancer, inflammatory

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14
Q

What is the diagnostic criteria for MDD

A

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

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15
Q

What are the MDD subtypes

A

Anxiety
catatonic
mixed
psychotic
atypical
melancholic
peripartum
seasonal

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16
Q

What is the Anxiety Subtype of MDD

A

High levels of accompanying anxiety in MDD

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17
Q

What is the catatonic Subtype of MDD

A

major psychomotor disturbances (lazy cat)

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18
Q

What is the Mixed Subtype of MDD

A

symptoms of mania accompanying MDD (insomnia, racing thoughts, increased energy)

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19
Q

What is the psychotic Subtype of MDD

A

MDD with accompanying psychosis (hallucinations and/or delusions)

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20
Q

What is the Atypical Subtype of MDD

A

MDD with reactivity to pleasurable stimuli, hyperphagia (insatiable hunger), hypersomnia (insatiable fatigue)

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21
Q

What is the melancholic Subtype of MDD

A

MDD with anhedonia, psychomotor changes, insomnia with decreased appetite.

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22
Q

What is the peripartum Subtype of MDD

A

MDD during pregnancy or within 4 weeks of birth

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23
Q

What is the seasonal Subtype of MDD

A

MDD associated with a particular season

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24
Q

To have MDD a patient must have

A

at least one major depressive episode SIG E CAPS for more than 2 weeks

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25
Q

What is the timeline of depressive episodes

A

develop over days to weeks and can take about 20 weeks to resolve.

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26
Q

when is the highest risk of recurrence for MDD?

A

within the first few months following episodes resolution

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27
Q

what are the three ways that the course of MDD can vary among patients

A
  1. single major depressive episode that resolves
  2. multiple episodes with few to no s/s between episodes
  3. persistent, fluctuating depressive s/s with no clear “remission”
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28
Q

What are the rates of recurrence for MDD

A

1 year = 40%
lifetime = 85%

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29
Q

What is the Two-Question Screen (PHQ-2)

A

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!

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30
Q

What is the Patient Health Questionnaire-9 (PHQ-9)

A

Further evaluates presence and severity of depression
can be used for initial screening or follow up evaluation

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31
Q

What is the Zung Self-Related Depression Scale

A

Allow a more in-depth rating of current depressive symptoms

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32
Q

What are the non-pharmacological treatment options for MDD

A

Psychotherapy
Electroconvulsive Therapy (ECT)
Vagal Nerve Stimulation
Transcranial Magnetic Stimulation (TMS)

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33
Q

What are the pharmacological categories for treatment options of MDD

A

Supplements
Herbals
Antidepressants

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34
Q

What are the treatment goals when treating MDD

A

Provide thorough education
maintain patient safety
achieve full remission of symptoms
Return patient to baseline functioning

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35
Q

What is the preferred approach to treating MDD

A

Combination of pharmacotherapy AND pyschotherapy

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36
Q

Criteria for mild/moderate depression that is treated outpatient

A

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

37
Q

criteria for severe depression that is treated inpatient

A

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.

38
Q

what is psychotherapy

A

AKA “counseling”
Cognitive behavioral Therapy (CBT) or Interpersonal Psychotherapy are most commonly used.

39
Q

What is behavioral activation?

A

Restarting activities that ceased due to depression

40
Q

what is the recommended type and amount of exercise to use as non pharmacologic treatment?

A

aerobic or resistance
3-5x/week, 45-60 minutes each session

41
Q

what is Electroconvulsive therapy

A

Use of a small electric current to induce a cerebral seizure while patient is under general anesthesia

42
Q

what are the indications for Electroconvulsive therapy?

A

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.

43
Q

What is the most efficacious treatment for MDD

A

electroconvulsive therapy

44
Q

what are the CI for ECT

A

no absolute Ci
use with caution in patients with cardiopulmonary disease, neurologic disease or those on anticoagulants

45
Q

what are the side effects of ECT

A

overall considered safe.
MC adverse events are - cardiopulmonary, HA, nausea, transient cognitive impairment (brainfog), muscle aches

46
Q

what is vagal nerve stimulation as a treatment for MDD

A

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

47
Q

Describe the process of transcranial magnetic stimulation as a treatment for MDD

A

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.

48
Q

what are the indications for TMS

A

treatment for refractory depression

49
Q

what are CI for TMS

A

high seizure risk, incompatible implants (metallic, electrical, cochlear because of magnet)

50
Q

what are the SE of TMS

A

seizures, HA, scalp pain, transient hearing loss

51
Q

What are the three main supplements used in the treatment of MDD

A

S-Adenosylmethionine (SAMe)
5-Hydroxytryptophan (5-HTP)
Omega-3 fatty acids

52
Q

what is SAMe and how does it work

A

a supplement that already naturally occurs in the body.

May raise dopamine levels

53
Q

What is a group that SAMe may be helpful in

A

can be used as an adjunctive option for mild to moderate depression in pregnant patients

54
Q

what is the SE of SAMe

A

may trigger manic episodes

55
Q

what is 5-HTP

A

natural precursor to serotonin

56
Q

what are the SE of 5-HTP

A

GI upset, serotonin syndrome, eosinophilic myalgia syndrome

57
Q

How are omega 3 fatty acids used in MDD

A

may work better when combined with antidepressants

58
Q

what is the SE of omega 3 fatty acids

A

may increase risk of bleeding

59
Q

what are the herbal treatment options for MDD

A

st johns wort
saffron
ginkgo biloba

60
Q

What does St johns wart do

A

increases serotonin and possibly NE and dopamine levels

61
Q

what are the SE of St Johns wort

A

Risk of GI upset, serotonin syndrome, photosensitivity

NUMEROUS DRUG INTERACTIONS (DDIs)

62
Q

what is Safron

A

a herbal that may help with depression; MOA unclear

63
Q

what are the SE of saffron

A

GI upset
mania
bleeding
can be FATAL at high doses

64
Q

what does Ginkgo Biloba do

A

causes improved mood in patients being treated for memory loss; may increase sensitivity to serotonin

65
Q

what are the SE of Ginkgo Biloba

A

may increase risk of bleeding

66
Q

how long should you take to titrate someone onto an antidepressant

A

7-10 days if not longer.

START LOW GO SLOW

67
Q

how long should you wait to see the full benefit of oral antidepressents

A

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.

68
Q

when should you consider treatment modification in oral antidepressants

A

if <25% improvement in baseline s/s after 4-6 weeks of using medication.

69
Q

How long should oral antidepressants be continued?

A

6+ months after s/s improvement

70
Q

What are the first generation antidepressants

A

Monoamine Oxidase inhibitors (MAOIs)
Tricyclic Antidepressants (TCAs)
tetracyclic Antidepressants (TeCAs)

71
Q

what are the second generation antidepressants

A

Selective Serotonin Reuptake inhibitors (SSRIs)
Serotonin-Norepinephrine reuptake inhibitors (SNRIs)
Atypical Antidepressants
Serotonin Modulators
Ketamine/Esketamine

72
Q

What is the most common class of antidepressants used for MDD

A

Second generation Antidepressants

73
Q

what is the 1st line pharmacological treatment for MDD

A

SSRIs

74
Q

what is the MOA for SSRIs

A

selectively decreases the action of 5-HT reuptake pump, leading to increased serotonin levels in the synapse.

75
Q

what are the drugs in the SSRI class?

A

Fluvoxamine
Fluoxetine
Sertraline
Citalopram
Escitalopram
Paroxetine

FF SCEP

76
Q

What is the dosing for SSRIs

A

usually given in the morning but doses can be split if SE are burdensome

start low and go slow!!!

77
Q

How are SSRIs metabolized

A

mostly hepatically so use caution in hepatic impairment

78
Q

What are CI for SSRIs

A

allergy to SSRI
Use of MAOI within 2 weeks
FLUOXETINE = wait 5 weeks for MAOI!!!

79
Q

what are SE of SSRIs

A

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

80
Q

what SE of SSRIs are more common in adolescents and early 20s

A

risk of suicide and serotonin syndrome

81
Q

what is serotonin syndrome

A

caused by increased serotonergic activity
typically occurs within 24 hours (often within 6 hours) of starting/changing medications or overdosing.

82
Q

what are s/s of serotonin syndrome

A

diarrhea, increased bowel sounds, agitation, hyperreflexia, dry mucous membranes, autonomic instability, hyperthermia, HTN, tremor, clonus, seizure, DEATH.

83
Q

how do you diagnose Serotonin syndrome

A

clinically
5-HT levels DO NOT correspond

84
Q

what is the treatment for serotonin syndrome

A

supportive care
D/C serotonergic medications
sedation with benzodiazepines
normalize vitals and hydration status

85
Q

What are the specific side effects of sertraline

A

More GI upset, Esp diarrhea
Less likely QT prolongation and drowsiness
slightly higher chance of insomnia

86
Q

what are the specific side effects of citalopram/escitalopram

A

most associated with Prolonged QT
Minimal SE otherwise
LEAST INHIBITION OF HEPATIC ENZYMES

87
Q

what are the specific side effects of fluvoxamine

A

frequently causes somnolence
DDIs
SHORTEST HALF LIFE 15 hrs

88
Q

what are the specific side effects of fluoxetine

A

LONGEST half life (up to 3 days)
slightly higher risk of insomnia
DO NOT USE w Tamoxifen

89
Q

What are the specific side effects of paroxetine

A

Only one that causes anticholinergic SE
slightly higher risk of hypotension, weight gain, and sexual dysfunction than others
SHOULD NOT BE USED w Tamoxifen

Behavioral Dynamicssss (21 decks)

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