Mood D/O Flashcards
MDD characterization
depressed mood
lack of interest in usual acitivities
marked wt loss or gain
sleep distrubances, agitation, fatigue or loss of energy
feelings of worthlessness or inappropriate guilt
difficulty concentrating or making decisions
thoughts of death or suicide
MDD epidemiology
- after age of 13 the rate doubles for girls
- age of onset is early adulthood; late 20s with average age 27 y/o
- onset after 50 y/o frequently associated with brain lesions or strokes
MDD risk fx
female gender; personality traits of hypersensitivity to negative stimuli; prior episodes of anxiety or depression; fx hx; hx of SI and attempts; post-partum period; co-morbid medical px; substance abuse; lack of social support; widowed or divorced; lower socioeconomic and education; stressful life events
MDD etiology
genetic influence accounts for 37%; multiple genes operate in conjunction with environmental fx;
MDD theories
- kindling model: events or expereinces have long lasting effects on brain chemistry, structure, and fx; so it may begin with a life stressor but subsequent episodes don’t necessarily have to be precipitated by stressor
- dysregulation of neurotransmitters model: impairment of ability of neurons involved in emtion and cognitive circuitry to tolerate abnormal levels of certain neurotransmitters; decreased levels of SE associated with sx of depression and behavior; decreased NE associated with fatigue, apathy, cognitive disturbances, slowness in info processing and poor memory; DA may be involved in psychomotor retardation and lack of pleasure; neuropeptides are also thought to be involved
- psychosocial theories: having negative view of oneself, their life situations and future; one’s automatic assumptions determine feelings/associated with depression and negative self view elicits negative response from others;
- interpersonal theory: depression is viewed as result of distrubance in interpersonal relationships that impairs ability to cope with difficult situations and leads to depression
- learned helplessness theory proposes that individuals learn in inescapable, painful, and auncontrollable situaitons that they can not escape the stressor with any action of their own and they generalize this learning to other situations - attachment theory: failure of mother to sooth and provide security; results in lack of cortisol modulation in infnats brain development; this in turn could result in hypersensitivity of circuitry involved in emotions and cognition
- development theory: belief that early adverse expereinces lay foundation for lateral mental d/o like depression; buffereing provided by responsive cregivers may decreases reisk
biological theory of MDD
- abnormalities in brain dvelopment; enlargement of ventricles and sulcal prominence and decreased volumes of PFC, amygdala, hippocampus; fewer neurons in PFC triggers depression and mania and amy act as a brake for emotional responses; decreased density of glial cells in areas support hypothesis of dysfx of specific neurotransmitter systems NE, SE, glutamate, GABA
- those w/out depression have increased blood flow to frontal cortex, left amygdala, and decreased flow to right amygdala when sad mood occurs
- those w/ depression have reduced blood flow to frontal cortx in basal ganglia indicating less brain activity in area; have increased blood flow in amygdala, orbital cortex and thalamus
brain chemistry in MDD
- believed that cascades of NE, SE, dopamine, glutamate, GABA, acetylcholine, and cortisol play role in regulation of stress and depression
- SE modulates dopamine in limbic areas and plays role in maintaining synapses; low levels of SE associated w/ aggression, impassivity, and suicide
- stress depletes NE, SE, ACETYL, and increased cortisol; acute stress, chronic stress, anticpated stress or imagines losses may precipatiate incrased cotisol activity and may produce abnormal chemistry
SAD description
- sx appear in fall or winter and improve in spring
- onset and remission of episode must have occured during last 2 years w/out any non-seasonal episodes occuring during this period
- onset in early 20s
- rate is higher among women of childbearing age
- sx include overeating, carbohydrate cravings, wt gain, lethrgy, oversleeping, feelings of sadness, anxiety, irritability
- physical sx often appear first
- genetic finluence believed to be related to three areas of alteration (dysregulation in SE, circadian rhythms, and abnormal processing of environmental light by eyes)
- light serves as a time cue to help establish and reset underlying biological rhythms including circadian rhythm of various hormones sleep/wave and rest/activity rhythms
- comorbidities include anxiety d/o, personality d/o
MDD catatonic fx
- immobility
- mutism
- echolalia (repeating words or phrases of someone else)
- posturing
- negativism (resistance to passive movement or repeatedly turning away from examiner)
- mannerisms (repeated movements that have no purpose)
- stereotypies (repeated movements of behaviors that are not goal directed)
MDD melancholic fx
- loss of pleasure in all or almost all activities
- lack of reactivity to a pleasurable event
- diurnal variation (depression is worse in morning)
- early morning awakening
- slowed motor acitivty or agitation
- loss of appetite and wt loss
- expression of inappropriate guilt
- melancholic depression is more likely to occur w/ severe MDD epidosdes and w/ + sx
MDD atypical fx
- mood reactivity (mood improves when something good or pleasure occurs)
- an unusually excessive need to sleep
- feeling that arms or legs are heavy
- overeating b/c of carbohydrate ans sweets cravings
- inability to anticipate pleasure, but no loss of actual ability to experience pleasure once involved in an activity
- anxiety
- rejection sensitivity
- changes of relationships d/t percieved rejection
- fluctutating course in response to events -impairment of fx (missed work, school, social)
- atypical depression is often co-morbid with bipolar d/o, substance abuse, axis II personality d/o like avoidant, histrionic, and BPD; pt w/ early onset before 20 tend to have lower levels of cortisol, more chronic course and poor response to TCAs; late onset after 20 tend to be more similar to those with depressive d/o w/ melancholic fx, elevated cortisol, and less chronic depression
MDD postpartum onset
- onset occurs in first 3 months after delivery
- risks: low levels of social suppor; conflicted marriages; being ambivalent about pregnancy; insecure attachment patterns; feel baby blues first 10 days after delivery; prior episodes of postpartum; prior hx of mood d/o; fx history; hx of drug/alcohol use; childhood separation or abuse from parents; single parenting
- w/o + sx: depression, lack of interest in baby; thoughts to hurt baby; anxiety; agitation; sleep px; thoughts of death or suicide
- w/ + sx: severe ruminations, delusional thoughts about infnat that are associated with increased risk of infnaticide or paranoia, grandiose or bizarre delusions and disorganized behaviors present a risk to mother and child
- can be cause by bipolar d/o in depression stage
medical conditions associated with MDD
- nutritional deficits; lack of exercise
- infections
- cancers
- lupus, RA, MS
- diabetes, lung disease
- fibroyalgia, PD
- chronic pain
Lab tests for MDD
CBC, liver and renal fx; TSH, rapid plasma regain (syphilis); VA, urine toxicology; alcohol level; pregnancy test; HIV serology
recovery definition
-an extended period of time where minimal or no sx are present for atleast 2months
recurrence definition
-appearance of a new episode of MDD during recovery
relapse definition
-return to a fully symptomatic state during remission
psychotherapy in MDD
- CBT and IPT found to be effective as medicaitons in treating MDD w/ exception of severe MDD
- chronic may respond better to combo (reserved for chronic because mild does not have increased response)
Pharmacology and MDD
- Venlafaxine and mirtazepine are recommended for severe
- ECT has been effective in severe and those with + sx
- those with + sx have good response rate with antidepressant and antipsychotic
- MDD w/ catatonic: may use ECT, lithium in combo with antidepressant; acute tx inclucdes BZD; if + sx may use atypical
- melancholic: mirtazepine, reboxetine; ECT, TCAs MAOIs have been more effective than SSRI’s
- postpartum: lithium, SSRIs
Switching atidepressants
- SSRI to another SSRI: first med tapered off over 1-2 weeks
- TCA to SSRI no wash out required but first med sould be tapered at time of intitation of second
- switching to MAOI requires wash out time
how long should antidepressant/pharmacotherapy continue for MDD tx?
- combined tx should continue for at least 6 months before tapering off one of the drugs
- to prevent relapse medications should continue for 2 years after remission of MDD sx
clinical presentation in children with MDD
Until the age of three, signs of depression include: feeding problems, tantrums, and lack of playfulness.
From 3-5 years of age, children may be accident prone, have many fears, blame themselves for things, and be apologetic for small mistakes.
From 6-8 years, they may show vague physical symptoms, aggressive behavior, or cling to their parents.
At 9-12 years, they may worry about school work and blame themselves for disappointing their parents.
Symptoms include: sadness, anhedonia (lack of pleasure in usual activities), lack of energy, irritability, anger, hostility, poor school performance, low self-esteem, fear of death, feelings of worthlessness, and somatic complaints.
In comparison to children who are not depressed, children with depression have more school related problems with behavior, attitude, and academic achievement, lower levels of social skills, and more problems with family and peer relationships.
Children tend to have fewer melancholic symptoms, delusions and suicide attempts than adults.
clinical presentation in adolescents with MDD
Symptoms include: depressed mood, self-deprecatory ideation, anger, restlessness, grouchiness, aggression, sulkiness, reluctance to participate in family activities, and hypersensitivity to criticism rather than sadness, anxiety, and guilt.
They may be uncommunicative and annoying to others.
They may show poor academic achievement, drop out of school, have problems with relationships with others, and exhibit delinquent behavior.
Individuals who experience clinical depression during adolescence are at increased risk for other psychiatric disorders, impairments of functioning in adulthood, and suicide.
comorbid illnesses in adolescents and children with MDD
MDD and dysthmia in children are frequently accompanied by other psychiatric disorders: anxiety disorders, disruptive behaviors, ADHD.
Anxiety disorders are nine times more frequent in depressed children than in those without depression.
Conduct disorder and oppositional defiant disorder are six times more frequent and attention deficit hyperactivity disorder is five times more frequent.
High rates of comorbid medical conditions: diabetes mellitus, asthma and epilepsy.
Substance abuse is comorbid in 25% to 48% of adolescent and tends to follow the onset of depression.
Suicide ideation, suicide attempts, and suicide are comorbid conditions among depressed children and adolescents.
Treatment of older adults with MDD
Laboratory tests include complete blood count with differential, chemistries, electrolytes, urinalysis, BUN, creatinine clearance, renal and liver panels, thyroid function test (T3, T4), vitamin B12, thiamine and folate, syphilis screening, drug levels when indicated, ECG, and toxicology screen.
- SSRIs cause less orthostatid hypotension; fewer anticholinergic effects; are associated with increased risk of px with balance and falls
- citaolpram and sertraline are well tolerated and seem to produce fewer drug to drug interactions
dysthymic d/o main characteristics
Dysthymic disorder is a chronic unipolar depressive disorder with depressive symptoms present most of the day, for two years.
Symptoms include: poor appetite or overeating, insomnia or hypersomnia, fatigue, lack of energy, low self-esteem, difficulty concentrating and making decisions, and feelings of hopelessness.
It is characterized by a relatively mild level of symptoms, a chronic course, and disability.
essential features of dysthymic disorder are: gloom, brooding, lack of joy in life, and preoccupation with their own inadequacy; patients may be chronically complaining, demanding, brooding, sarcastic, introverted, morose and self-deprecating.
A major depressive episode may occur after the onset of dysthymia and that occurrence is called double depression
Patients with dysthymic disorder have been found to have a greater severity of depressive symptoms, more suicide attempts, and more hospitalization than patients with MDD.
dysthymic d/o in older adults
-often chronic with increased risk for cardiovascular and cerebrovascular morbidity, mortality, and suicide.
Clinicians often take a “pseudoempathic approach” in which they consider the depression to be a normal reaction to aging or illnesses associated with aging. As a result, older adults with dysthymic disorder often do not receive treatment.
dysthymic d/o in children and adolescents
Irritability Pessimism Depression Low self-esteem Poor social skills Impairment of school performance and social interactions Changes in appetite Sleep problems Fatigue Problems with making decisions Feelings of hopelessness More than two-thirds of children with dysthymic disorder develop MDD.
treatment in dysthymic d/o
IPT and CBT have been found to be effective in the treatment
SSRI’s, bupropion (Wellbutrin)
Sertaline (Zolft) was found to be more effective than interpersonal psychotherapy for adults with dysthymic disorder and sertraline (Zoloft) has been found to be effective in treating dysthymic disorder among adolescents
good response to mirtazapine (Remeron) and bupropion SR.
For double depression, dysthymia and coexisting major depression, sertraline (Zolft) has been found to be effective.
-older adults: nothing proven efficient at this time
characteristics of bipolar I
-occurrence of one or more manic episodes or a mixed episode or episodes w/ or w/ out depressive episode
characteristics of bipolar 2
- at least one hypomanic episode
- occurrence of MDD episode or episodes
- absence of hx of a manic episode and significant distress or impairment of social, vocational, or important areas of fx
characteristic of cyclothymic d/o
- recurrent hypomanic episodes without full MDD
- fluctuating mood disturbances w/ presence of numerous periods of hypomanic sx and numerous periods of depressive sx
- hypomanic sx must be present for at least two years for adults and 1 year for children
