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Board Certification > Mood disorders > Flashcards

Mood disorders Flashcards

1
Q

MDD prevalence

A
  • Lifetime prevalence is 12%

- 3 times higher for young adults than people over 60

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2
Q

Bipolar prevalence

A

BP I and II are both around 1% to 1.5%

BP I is equal in men and women

BP II is greater in women

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3
Q

MDD onset

A

Mean age at 40 years

50% have onset between ages 20 to 50 years

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4
Q

Bipolar age of onset

A

Can start at 5 years old and all the way to 50+

Mean onset is 30

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5
Q

MDD risk factors

A

conduct disorder

low education

and other obvious stuff

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6
Q

Bipolar risk factors

A

Very strong genetic effects

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7
Q

MDD prognosis

A

Untreated episodes last 6 months to a year

50% will recover in 1st year after hospitalization

5 to 10% will have a manic episode after a while

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8
Q

Bipolar prognosis

A

50% will have a 2nd manic episode within 2 years.

50 to 60% of patients achieve significant control on lithium

15% suicide rate

Example of a poor prognostic indicator is male gender

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9
Q

Criteria for Dysthymic Disorder (persistent depressive disorder)

A

2 or more of the MMD symptoms for at least 2 years (1 year for children)

Has never been without symptoms for more than 2 months

Impaired functioning

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10
Q

MADRS

A

Montgomery-Asberg Depression Rating Scale

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11
Q

EPDS

A

Edinburgh Postnatal Depression Scale

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12
Q

Adjustment disorder with depressed mood

A

Psychological symptoms present within 3 months of the stressor

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13
Q

PMDD

A

depressed prior to menses and end at the start of menses

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14
Q

Mania criteria

A

Mood change +
Increased goal directed activity or increased energy +
3 or more other symptoms (4 or more if mood is irritable) +
Present for a week

Not due to substances/antidepressants

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15
Q

Hypomania criteria

A

Same except only lasts 4 days

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16
Q

Mixed episode criteria (mania and depression)

A

Meets both mania and depressive criteria nearly everyday for a week

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17
Q

MDQ

A

Mood disorder questionnaire

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18
Q

YMRS

A

young mania rating scale

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19
Q

BSDS

A

bipolar spectrum disorder scale

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20
Q

Treatment guidelines for MDD

A

Medication
Psychotherapy

Possibly medication +psychotherapy
Possible ECT

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21
Q

Treatment guidelines for Severe MDD without psychotic features

A

Medication
Medication + psychotherapy
ECT

Not psychotherapy alone

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22
Q

Some indicators of severe MDD

A

PHQ 9 over 20

Duration over 2 years

3 or more episodes

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23
Q

Treatment guidelines for Severe MDD with psychotic features

A

Medication (antidepressant + antipsychotic)
Medication + psychotherapy
ECT

Not psychotherapy alone

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24
Q

Examples of situations that support the use of psychotherapy

A

Pregnancy

comorbid personality disorder

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25
Q

Pregnancy and psychotropics

A

There is limited data

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26
Q

FDA pregnancy risk categories

A

B - There may or may not be harm in animals, but no evidence of harm in people

C - Harm to animals, but THERE ARE NO studies in humans

D - There is evidence of risk to humans, but occasionally you may still want to use it

X - do not use it

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27
Q

Lactation Risk categories

A

L2 - limited number of studies without significant risk

L3 - minimal/non-life-threatening risk

L4 - Hazardous, may be used if the mother’s condition is life-threatening

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28
Q

Are you required to notify a patient about off label use?

A

It’s not legally required, but recommended

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29
Q

Citalopram

A

Limit to 40 mg (20 mg for people over 60) due to prolonged QT effect

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30
Q

Serotonin syndrome can be associated with giving SSRIs plus

A

MAOIs

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31
Q

SSRI pregnancy categories

A

Most are C

Paroxetine is D (cardiac effects)

The baby can have SSRI withdrawal

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32
Q

SSRI lactation category

A

Sertraline paroxetine are L2

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33
Q

3 pearls about SNRIs

A

Before starting an SNRI and periodically after starting, measure blood pressure

Avoid them in alcoholism/liver disease due to rare liver toxicity

Contraindicated within 2 weeks of having an MAOI

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34
Q

SNRI pregnancy and lactation categories

A

C

L3

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35
Q

Bupropion pearls

A

Watch out for seizure history

C

L3

36
Q

TCA neurotransmitters

A

serotonin and NE

Clomipramine is more serotonin

Desipramine is more NE

37
Q

4 TCA pearls

A

The 2 types of prominent side effects: Anticholinergic and Cardiac

Can be used for chronic pain

Monitor drug level

Do an ECG for kids

38
Q

TCA pregnancy and lactation

A

C or D

L2

39
Q

Mirtazapine neurotransmitters

A

Serotonin and norepinephrine

40
Q

Mirtazapine pregnancy and lactation

A

C and 3

41
Q

Vilazodone (Viibryd) mechanism of action

A

SSRI and serotonin 1A partial agonist

42
Q

Vilazodone is good for sexual functioning and good for

A

not gaining weight

43
Q

Vortioxetine (Trintellix) mechanism of action

A

serotonin modulator and stimulator.

It works on more than one serotonin receptor site: partial agonism at some and antagonism at others.

44
Q

MAOI examples

A

Phenelzine
Selegiline
Tranylcypromine
Isocarboxazid

45
Q

MAOI adverse effects

A

combining them with anything that increases norepinephrine can raise blood pressure.

Also, combining it with anything that increases serotonin can cause serotonin syndrome

46
Q

MAOI pregnancy and lactation

A

Pregnancy is C and lactation is unknown

47
Q

Paroxetine half life

A

21

48
Q

Sertraline half life

A

26

49
Q

Lexapro half life

A

27 to 32

50
Q

Citalopram half life

A

33

51
Q

Fluoxetine half life

A

84 hours (3.5 days), metabolite is 1 to 2 weeks

52
Q

Antidepressant discontinuation syndrome can be remembered with the mnemonic Finish

A 
Flu like
Insomnia
Nausea
Imbalance 
Sensory disturbances
Hyperarousal (agitated) and Headache
53
Q

Best psychotherapy for MDD

A

EBP:

CBT 
IPT
Problem solving
ACT (acceptance and commitment therapy)
Mindfulness based cognitive therapy

Not EBP but is an option:

Psychodynamic

Group, marital, or family style as needed

54
Q

How long until you can fairly evaluate your treatment for MDD

A

4 to 8 weeks

55
Q

Has the MDD has improved 100% in a month?

A

If “yes,” move to continuation phase of treatment

If “no,” reassess the diagnosis, adverse effects, comorbid conditions, psychosocial factors, quality of therapeutic alliance, treatment adherence

Modify treatment

Reassess in 4 to 8 weeks. If there’s still not enough improvement, repeat the steps above or maybe get a consultation

56
Q

If the MDD treatment is inadequate, you can maximize the initial treatment approach by

A

Raising the dose
Consider going above the FDA approved dose
Extend the trial time

Adjust the frequency or type of therapy

57
Q

If the MDD treatment is inadequate, you can try changing to other treatments by

A

Switching from therapy to an antidepressant

Switching from one antidepressant to another, including to an MAOI

58
Q

If the MDD treatment is inadequate, you can trying augmenting and combining treatments, such as

A

Adding another antidepressant (not MAOI because of the d-d interaction)

Adding lithium, thyroid hormone, or SGA

Less supporting evidence for adding anticonvulsant, omega 3, folate, vitamin D, psychostimulant, benzo, buspar

59
Q

Treatment resistant depression

A

ECT is the most effective treatment for treatment resistant depression

Other options are TMS, vagus nerve stimulation, deep brain stimulation, and ketamine

60
Q

Continuation phase of MDD

A

Goal is to reduce the risk of relapse

Continue antidepressants for 4 to 9 months

Continue psychotherapy

For ECT responders, provide antidepressants and/or continuation ECT

Involve family and patient to identify early warning signs

61
Q

Maintenance phase of MDD

A

Comes after continuation phase

Acknowledge that 20% of patients relapse in 6 months, and 50 to 85% will have at least one relapse over the lifetime

It’s indicated for patients with 3 or more episodes, patients with recurrence risk factors, comorbid psych and medical issues

62
Q

Risk factors for MDD relapse

A 
persistent mild symptoms 
history of MDD episodes 
severe episodes 
early onset
comorbid disorders
medical disorders 
family history 
psychosocial stressors 
negative coping style 
sleep disturbance
63
Q

Discontinuing MDD treatment

A

Stopping psychotherapy has less risk than stopping meds

Advise against stopping before a stressful event

Schedule a follow up in 2 months after stopping treatment

64
Q

Psychiatric management of bipolar disorder: Besides the obvious stuff, other interventions can include

A

Limiting access to bank accounts during mania

Tell them that 50% of people who go off lithium will relapse in 5 months

65
Q

Are SGAs off label for the treatment of mania?

A

No, they are FDA approved

66
Q

Besides SGAs, what are good adjuncts for manic agitation, insomnia, bipolar dysphoria, and bipolar panic

A

High potency benzos like ativan and klonopin

67
Q

What kinds of meds would we give for Severe mania or mixed episodes

A

Mood stabilizer plus SGA, and benzos can help too

68
Q

what would be the medication for not so severe mania

A

monotherapy with lithium, valproate, or an SGA (just monotherapy)

69
Q

What should you know about the comparison between lithium and valproate in treating mixed episodes of bipolar

A

Valproate is better than lithium for mixed episodes

70
Q

In addition to medications, what’s another important intervention for mania

A

psychosocial therapy

71
Q

What do you do if there is a break through episode of mania

A

Check serum levels

Restart the 2nd generation antipsychotic

Use a benzo on a short term basis

72
Q

If mania is not controlled after 10 to 14 days, what do you do

A

Add another first-line medication, such as carbamazepine, add a SGA, or switch to another SGA

73
Q

What are some options for severely refractory mania

A

ECT or clozapine

74
Q

What are the first line options for acute bipolar depression

A

Lithium, lamotrigine, or if severe started lithium plus an antidepressant (though there is little data to support this)

75
Q

What is an antidepressant and antipsychotic combination that could be used for acute bipolar depression

A

fluoxetine and olanzapine

76
Q

When should you consider ECT for acute bipolar depression

A

life-threatening suicidality

psychosis

pregnancy

Very severe cases

77
Q

What are 2 good therapies for acute bipolar depression

A

IPT and CBT

78
Q

What do you do for breakthrough bipolar depression

A

Check serum levels

add lamotrigine, bupropion, or paroxetine

79
Q

What do you do if psychotic features arise with bipolar depression

A

add SGA

80
Q

What are the 2 first line meds for rapid cycling, and what is the alternative

A

Lithium and valproate, and lamotrigine

81
Q

Which medications have the best evidence for maintenance treatment of bipolar disorder, and what are alternative meds

A

Lithium and valproate

Lamotrigine, carbamazepine, oxcarbazepine

82
Q

What about antipsychotics in the maintenance treatment of bipolar?

A

Usually discontinue adjunctive antipsychotics unless psychosis is/could be a concern. Sometimes you will continue the SGA even without psychosis, but there’s not as much evidence to support it as there is for Li and valproate

83
Q

Which SSRI interacts with warfarin and how?

A

Fluoxetine effects the metabolism of warfarin

84
Q

A patient drinks a lot of alcohol daily. Which antidepressant should you avoid

A

duloxetine, it can cause liver toxicity

85
Q 
Which is an EARLY warning sign of Li toxicity?
A) Nausea 
B) Convulsions 
C) Coarse hand tremor
D) Thirst
A

Coarse hand tremor is an early sign.

Convulsions is a LATE sign,

Nausea and thirst are expected side effects.

86
Q

SSRIs can combined oral contraceptives and sumatriptan (for migraines)

A

Ok with COCs

Contraindicated with sumatriptan (too much serotonin)

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