Mood disorders Flashcards
overall state of emotion at a given time
Internal condition visible through external behaviors
mood
mood is influenced by ? factors
internal and external
Mood is regulated by what neurotransmitters in the brain?
Serotonin
Norepinephrine
Dopamine
what are the types of mood disorders
- Depressive Disorders
- Bipolar Disorders
5 types of depressive disorders
- Major Depressive Disorder
- Dysthymia/Persistent Depressive Disorder
- Seasonal Affective Disorder
- Premenstrual Dysphoric Disorder (PMDD)
- Disruptive Mood Dysregulation Disorder
3 types of bipolar disorders
- Bipolar I Disorder
- Bipolar II Disorder
- Cyclothymia
For ALL PSYCHIATRIC CONDITIONS, the DSM endorses a criteria-based diagnostic approach that requires 3 conditions:
- The condition is not caused by the 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.
MDD is MC in who?
- younger populations
- women (2-3x)
- Native Americans
- low socioeconomic status
MDD - Etiology / Risk Factors
- Genetics/Biological
- Neurotransmitter expression / sensitivity - Serotonin, norepinephrine, glutamate, GABA, dopamine
- Response to antidepressant drugs
- FH of depression or alcoholism - Life Events
- Adversity or loss of loved one, job, or relationship
- Early childhood trauma
- Postpartum period - Medications
- Glucocorticoids, Interferons - Personality
- Low self-esteem
- Sensitive to stressors
- Insecure or worried
- Dependent or unassertive
- Introverted - Social
- Lack of close relationships
- Close individuals with depression
- Maladaptive learned behaviors from close individuals - Medical Conditions
- Neurologic, Infectious, Cardiac, Endocrine (adrenal/thyroid), Cancer, Inflammatory
How does the DSM-5 diagnose MDD
A depressed mood or anhedonia for ≥ 2 weeks AND ≥ 4 of the following symptoms:
1. Sleep changes (hypersomnia or insomnia)
2. Feelings of worthlessness / guilt
3. Fatigue / ↓energy
4. ↓concentration
5. Significant appetite or weight change
6. Activity changes (psychomotor agitation or retardation)
7. Recurrent thoughts about death or suicide
(SIG E CAPS)
8 MDD episode subtypes
- Anxiety: high levels of accompanying anxiety
- Catatonic: major psychomotor disturbances
- Mixed: symptoms of mania (insomnia, racing thoughts, ↑ energy)
- Psychotic: with accompanying psychosis (hallucinations, delusions)
- Atypical: reactivity to pleasurable stimuli, hyperphagia, hypersomnia
- Melancholic: anhedonia, psychomotor changes, insomnia, ↓appetite
- Peripartum: during pregnancy or within 4 weeks of birth
- Seasonal: associated with a particular season
To have MDD, a patient has to have at least one ?
major depressive episode
describe the timelines of major depressive episodes (developing, resolution, reoccurence)
- develops over days to weeks
- avg time to resolution - 20 wks
- highest risk of recurrence - within first few months following episode’s resolution
how do the course of MDD varies?
- 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”
high rate of recurrence is during when?
lifetime
what are other differentials for MDD
- Other mood disorders
- Substance use/abuse - alcohol, amphetamines
- Medication side effects
- General medical disorders
- grief symptoms associated with ___
3 MDD screenings
- Two-Question Screen (PHQ-2)
- Quick, initial screening for depression
- Asks about the two key symptoms of a depressive episode (depressed mood and anhedonia)
- Not a stand-alone test - needs follow-up if positive! - Patient Health Questionnaire-9 (PHQ-9)
- Further evaluates presence and severity of depression
- Can be used for initial screening or follow-up evaluation - Zung Self-Rated Depression Scale
- Allows a more in-depth rating of current depressive symptoms
nonpharm management for MDD
- Psychotherapy
- Electroconvulsive Therapy (ECT)
- Vagal Nerve Stimulation
- Transcranial Magnetic Stimulation (TMS)
tx goals for MDD
- Provide thorough education
- Maintain patient safety
- Achieve full remission of symptoms
- Achieving remission lowers risk of relapse
- Return patient to baseline functioning
what is the preferred approach of MDD tx
- COMBINATION of pharmacotherapy AND psychotherapy
- It is acceptable to use either option by itself
- MC approach - pharmacotherapy only
what type of tx would a pt get if they present with:
- 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
outpatient tx
what type of tx would a pt get if they present with:
- 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
inpatient tx
- aka “counseling”
- CBT or Interpersonal Psychotherapy are most commonly used
- Family or couples therapy can also be useful
psychotherapy
Meditation, muscle relaxation
are what types of nonpharm tx?
Relaxation Techniques
Restarting positive activities that ceased due to depression
is what type of nonpharm tx?
Behavioral Activation
Use of a small electric current to induce a cerebral seizure while patient is under general anesthesia
Electroconvulsive Therapy (ECT)
indications for Electroconvulsive Therapy (ECT)
- MC for severe, refractory depression
- 1st Line: severe suicidality, severe psychosis, catatonia, malnutrition d/t food refusal secondary to depressive illness
- Cannot tolerate other therapies
what is the most efficacious tx for severe MDD
Electroconvulsive Therapy (ECT)
be cautious with ECT in pts with ?
- cardiopulmonary disease
- neurologic disease
- anticoagulants
no absolute CIs
SE of ECT
- Overall, considered safe
- MC adverse events:
- cardiopulmonary
- HA
- nausea
- transient cognitive impairment
- muscle aches
A device is implanted in the chest wall
Used primarily for refractory epilepsy
Vagal Nerve Stimulation - connected to one (left) vagus nerve
May be helpful for refractory depression
Metal coil with magnetic field is placed against scalp to induce depolarization of neurons in a focal area WITHOUT sedation/anesthesia
Transcranial Magnetic Stimulation (TMS)
indications for Transcranial Magnetic Stimulation (TMS)
Treatment-refractory depression
CI for Transcranial Magnetic Stimulation (TMS)
- High seizure risk
- incompatible implants (metallic, electrical, cochlear)
SE of Transcranial Magnetic Stimulation (TMS)
- Seizures
- HA
- scalp pain
- transient hearing loss
what supplement:
- Naturally occurs in the body; may raise dopamine levels
- Can be used as an adjunctive option for mild to moderate depression in pregnant patients
- May trigger manic episodes
S-Adenosylmethionine (SAMe)
what supplement:
- Natural precursor to serotonin
- Risk of GI upset, serotonin syndrome, eosinophilic myalgia syndrome
5-Hydroxytryptophan (5-HTP)
what supplement:
- May work better if combined with antidepressants
- May increase risk of bleeding
Omega-3 Fatty Acids
what herbal:
- Increases serotonin, and possibly norepinephrine and dopamine levels
- Risk of GI upset, serotonin syndrome, photosensitivity
- Numerous drug-drug interactions (DDIs)
st. john’s wort
what herbal:
- May help with depression; MOA unclear
- Risk of GI upset, mania, bleeding; can be fatal at high doses
saffron
what herbal:
- Improved mood in pts being treated for memory loss; may increase sensitivity to serotonin
- May increase risk of bleeding
Ginkgo biloba
what supplements could be used as tx for MDD
- S-Adenosylmethionine (SAMe)
- 5-Hydroxytryptophan (5-HTP)
- Omega-3 Fatty Acids
what herbals could be used as tx for MDD
- st. john’s wort
- saffron
- ginkgo biloba
what are the guidelines for antidepressant use?
- Start low and go slow
-
Trial of at least 4 weeks to evaluate full benefit
- may see improvement as early as week 1, but it generally takes 4-6 weeks to see a response - Rx should be continued for 6+ months after s/s improvement
- Gradual down titration is recommended when discontinuing antidepressants
what are the 1st gen antidepressants
- MAOI
- TCA
- TeCA
what are the 2nd gen antidepressants
- SSRI
- SNRI
- atypical antidepressants
- serotonin modulators
- ketamine/esketamine
- Commonly used as 1st line treatment for MDD
- Selectively decreases the action of 5-HT reuptake pump, leading to increased serotonin levels in the synapse
SSRIs
Sertraline (Zoloft)
SSRI
Citalopram (Celexa)
SSRI
Escitalopram (Lexapro)
SSRI
Fluoxetine (Prozac)
SSRI
Paroxetine (Paxil)
SSRI
Fluvoxamine (Luvox)
SSRI
Use caution in ____ with SSRIs
hepatic impairment
(metabolized mostly by the liver)
CI for SSRI
Allergy to SSRI; use of MAOI within 2 weeks
which SSRI must wait 5 weeks before starting MAOI
Fluoxetine
SE of SSRI
- GI Upset
- nausea
- diarrhea
- anorexia - Sleep Change
- insomnia
- hypersomnia - Neuro
- HA
- dizziness - Sexual Dysfunction
- ↓libido
- anorgasmia
- ED - Psych:
- anxiety
- ↑ risk of suicide (MC young adults) - Other:
- prolonged QT
- weight gain
- bleeding
- orthostatic hypotension
- serotonin syndrome
what is serotonin syndrome? when does it happen?
- Caused by increased serotonergic activity
- Typically occurs within 24 hrs (often w/n 6 hrs) of starting/changing medication or overdosing
serotonin syndrome is MC associated with what specific medication?
SSRI
s/s of serotonin syndrome
Diarrhea
increased bowel sounds
agitation
hyperreflexia
dry mucous membranes
autonomic instability
hyperthermia
HTN
tremor
clonus
seizure
death
tx for serotonin syndrome
- Supportive care
- D/C serotonergic medications
- Sedation with benzodiazepines
- Normalize vitals and hydration status
which SSRI:
- More GI upset than others in the class, esp. diarrhea
- Less likely to cause prolonged QT, drowsiness
- Slightly higher chance of insomnia SE
Sertraline (Zoloft)
which SSRI:
- Most associated with prolonged QT
- Minimal SE profile for this class otherwise
- Least inhibition of hepatic cytochrome enzymes
Citalopram (Celexa) / Escitalopram (Lexapro)
- Escitalopram is an isomer of citalopram
which SSRI:
- Shortest half-life (~ 15 hrs)
- Frequently causes somnolence
- Potent inhibitor of 2 cytochrome systems → potential for DDIs
Fluvoxamine (Luvox)
which SSRI:
- Longest half-life of any in the class (up to 3 days)
- Slightly higher risk of insomnia SE
- SE of anxiety
Fluoxetine (Prozac)
which SSRI:
- Causes anticholinergic SE, unlike others in the class
- Slightly higher risk of orthostatic hypotension, weight gain, & sexual dysfunction than other SSRIs
- Potential inhibitor of 2 cytochrome systems, so potential for DDIs
Paroxetine (Paxil)
tamoxifen should NOT be written with ?
Fluoxetine (Prozac)
Paroxetine (Paxil)
what is often used as first-line therapy, or as second-line therapy for patients who cannot tolerate SSRIs
SNRIs
Difference between SNRIs and SSRIs
SNRIs - works more on NOR
SSRIs - works more on serotonin
MOA of SNRIs
Blocks reuptake of 5-HT and norepinephrine (NE), increasing their levels in the synapse
which SNRI has greater effect on NE
Milnacipran (Savella) / Levomilnacipran (Fetzima)
Venlafaxine
SNRI
Desvenlafaxine (Pristiq)
SNRI
Duloxetine (Cymbalta)
SNRI
Milnacipran (Savella)
SNRI
Levomilnacipran (Fetzima)
SNRI
CI with SNRIs
- Allergy to SNRIs
- use within 2 weeks of an MAOI
- Caution if using with other serotonergic drugs
- Caution if angle closure glaucoma
what SE is not heavily seen in SNRIs compared to SSRIs
weight gain
which SNRI:
- Higher risk of SE
- More N/V
- Most associated with elevated BP
Venlafaxine (Effexor)
which SNRI:
- Synthetic form of the major metabolite of venlafaxine
- Less risk of HTN, general SE than venlafaxine
Desvenlafaxine (Pristiq)
which SNRI:
- Only SNRI with hepatic cytochrome inhibition → most likely to have DDIs
- Least associated with elevated BP
- Has indication for chronic pain relief
Duloxetine (Cymbalta)
which SNRI:
1. Most likely SNRIs to have pseudo-anticholinergic SE
- Urinary retention, constipation, dry mouth, etc.
Milnacipran (Savella) / Levomilnacipran (Fetzima)
___ is marketed as more for pain relief than for depression
Milnacipran (Savella)
what is often used as second-line therapy if pts fail SSRIs; may be first-line in special cases
Atypical Antidepressants
Bupropion (Wellbutrin; Zyban)
Atypical Antidepressants
Mirtazapine (Remeron)
Atypical Antidepressants
Acts as a dopamine-norepinephrine reuptake inhibitor (also antagonizes nicotinic receptors)
Bupropion (Wellbutrin; Zyban)
which antidepressant antagonizes alpha-2 adrenergic receptors and 5-HT2 and 5-HT3 receptors, which causes increased release of serotonin and norepinephrine
Mirtazapine (Remeron)
SE of Bupropion (Wellbutrin)
- Dry mouth, insomnia, nausea, increased risk of seizures
- Not associated with weight gain or sexual dysfunction
- Risk of suicidal thoughts/ideation
Helpful in patients with depressive symptoms who also need help with tobacco cessation
Bupropion (Wellbutrin)
CI of Bupropion (Wellbutrin)
- Allergy to bupropion; seizure disorder
- high seizure risk
- anorexia or bulimia hx
- use within 2 weeks of an MAOI
SE of Mirtazapine (Remeron)
- Dry mouth, drowsiness, sedation, increased appetite, weight gain, sexual dysfunction
- weight gain > SSRIs, SNRIs
- sexual dysfunction < SSRIs
- Risk of suicidal thoughts/ideation
- orthostatic hypotension < other antidepressants
which antidepressant has SE that is helpful in patients with depressive symptoms who also are suffering from insomnia
Mirtazapine (Remeron)
which antidepressant does have hepatic cytochrome enzyme inhibition, so can cause DDIs
Bupropion (Wellbutrin)
CI for Mirtazapine (Remeron)
Allergy to mirtazapine; use within 2 weeks of MAOI
type of antidepressant that fully blocks reuptake of 5-HT
Serotonin Modulators
which serotonin modulators also antagonize 5-HT receptors, causing increased release of serotonin
Nefazodone and trazodone
which serotonin modulator also partial agonist of 5-HT receptors, mimicking serotonergic effects
Vilazodone and vortioxetine
Nefazodone (Serzone)
Serotonin Modulators
Trazodone (Desyrel)
Serotonin Modulators
Vilazodone (Viibryd)
Serotonin Modulators
Vortioxetine (Brintellix/Trintellix)
Serotonin Modulators
CI of Serotonin Modulators
- Allergy to drug
- use within 2 weeks of an MAOI
- Caution if using with other serotonergic drugs
SE of Serotonin Modulators
- Headache, diarrhea, nausea are common
- Increased suicide risk
- Serotonin syndrome risk
which serotonin modulator have these specific SE:
- headache, diarrhea, nausea, sexual dysfunction
- May have faster onset and less sexual dysfunction than SSRIs, SNRIs
Vilazodone (Viibryd)
which serotonin modulator has these specific SE:
- dizziness, N/V/D/C, sexual dysfunction
- May have faster onset and less sexual dysfunction than SSRIs, SNRIs
Vortioxetine (Trintellix)
Newly approved to treat severe, refractory depression w/o psychosis
ketamine/esketamine
why is ketamine/esketamine indicated for short-term therapy only
- Abuse potential due to SE of euphoria/intoxication - controlled rx
- May have neurotoxicity in the long-term setting
- Can cause psychotomimetic effects → may induce psychosis
if ketamine/esketamine is used long term, what is the treatment?
eventually be switched to antidepressants and/or antipsychotics for the longer term
which tx acts as an opioid and AMPA (glutamate) agonist, NMDA antagonist
Unclear what exact mechanism causes antidepressant effects
Ketamine/Esketamine
SE of ketamine/esketamine
- Psychomimetic, HTN, tachycardia, anxiety, dizziness, HA, N/V
- Long-term - abuse/addiction, neurotoxicity, bladder toxicity, hepatotoxicity
- May see fewer psychotomimetic effects with esketamine
CI with ketamine/esketamine
- Allergy to medication
- aneurysmal disease or AV malformation
- hx of ICH (intracranial hemorrhage)
- inability to tolerate increase in BP
DI of ketamine/esketamine
- CNS depressants (including opiates)
- other nasal sprays
which MAO breaks down serotonin and norepinephrine
MAOa
what works with MAOa to break down dopamine
MAOb
Tranylcypromine (Parnate)
MAOI
Phenelzine (Nardil)
MAOI
Isocarboxazid (Marplan)
MAOI
Selegiline (Eldepryl)
MAOI
CI of MAOI
- Allergy to drug
- cardiovascular disease
- pheochromocytoma
- hepatic or renal impairment
- use within 2 weeks of other serotonergic drugs
which MAOI has less CI than other MAOI
Selegiline
SE of MAOI
- Hypotension
- GI upset
- urinary hesitancy
- headache
- myoclonic jerks
- edema
- Risk of suicidal ideation
- Hypertensive Crisis
how does Hypertensive Crisis happen with MAOIs?
- when consuming foods with tyramine
- Aged cheese, soy sauce, cured meats, tap beer, tofu, sauerkraut
(Less common with transdermal selegiline)
Used as second-line treatment for depression due to side effects
Also treat anxiety disorder, pain disorders such as neuropathy and headaches
TCAs
which TCA class is more potent in blocking 5-HT reuptake than NE reuptake
Tertiary Amines
which TCA class is more potent in blocking NE reuptake than 5-HT reuptake
Secondary Amines
Amitriptyline (Elavil)
Tertiary Amines - TCA
Doxepin
Tertiary Amines - TCA
Imipramine (Tofranil), Clomipramine (Anafranil), Trimipramine (Surmontil)
Tertiary Amines - TCA
Nortriptyline (Pamelor)
Secondary Amines - TCA
metabolite of amitriptyline
Desipramine (Norpramin)
Secondary Amines - TCA
metabolite of imipramine
Protriptyline (Vivactil)
Secondary Amines - TCA
CI of TCA
- Allergy to med
- use within 2 weeks of an MAOI
- use in acute recovery phase of an MI
SE of TCA
- Anticholinergic; drowsiness; sexual dysfunction; diaphoresis; tremor; weight gain; increased appetite
- Risk of suicidal ideation
- Risk of cardiotoxicity (prolonged QT)
- High potential for fatality in overdoses
- Cardiac arrhythmia, seizures, anticholinergic toxicity
- Nortriptyline and desipramine have highest overall tolerability
Very similar to TCAs - have an extra cyclic ring
Also used for refractory or atypical depression
TeCAs
Maprotiline (Ludiomil)
TeCAs
Amoxapine (Asendin)
TeCAs
which TeCA blocks reuptake of NE and 5-HT (more potent for 5-HT)
Maprotiline (Ludiomil)
what TeCA blocks reuptake of NE; blocks dopamine receptors (antipsychotic)
Sometimes classified as secondary amine TCA
Amoxapine (Asendin)
SE of TeCAs
- Comparable to TCAs; less anticholinergic SE but more antihistamine-like SE than TCAs
- Still have risk for suicidal ideation
- often used in bipolar; may also be helpful for unipolar depression
- Numerous side effects, risk for toxicity
- Not as efficacious as antidepressant drugs
lithium
typically used as add-on to antidepressants
Antipsychotics
Aripiprazole (Abilify)
antipsychotics
brexpiprazole (Rexulti)
antipsychotics
quetiapine (Seroquel)
antipsychotics
Symbyax (fluoxetine + olanzapine)
antipsychotics
In order to be diagnosed with PDD (Dysthymia), pts must have ongoing depressive symptoms
for ?
two years or longer
- Do not have to be in full major depressive episode for all of the two-year span
presentation of PDD (dysthymia)
- 2+ years of depressed mood most of the time, with no more than 2 months free of s/s, plus two or more of the following:
- Appetite changes (poor appetite or overeating)
- Sleep changes (insomnia or hypersomnia)
- Fatigue or loss of energy
- Diminished ability - thinking, concentration or decision-making
- Low self-esteem
Feelings of hopelessness - Cannot have manic symptoms or secondary cause
- Similar subtypes to major depressive episodes in MDD
- “With persistent major depressive episode” - full episode criteria for 2 yrs
most efficacious tx type for PDD (Dysthymia)
combination of pharmacotherapy and psychotherapy
1st line pharm tx for PDD (Dysthymia)? 2nd?
- SSRIs
- May use other antidepressants - TCAs and MAOIs have shown success in studies
- Caution with side effects!
Type of depression where the depressed mood is in response to an identifiable psychosocial stressor
Adjustment Disorder
- Single or multiple stressors
- May be recurrent or continuous stressor
which depressive disorder is not classified as a true depressive disorder
adjustment disorder
- Significant depressive symptoms, in response to a stressor, that do not meet criteria for a more specific depressive disorder
Presentation of adjustment disorder
- Low mood, tearfulness, or feelings of hopelessness in response to a stressor (within 3 months of onset)
- Symptoms are significant, as evidenced by one or both of the following:
- Significant distress exceeding what would be expected given the nature of the stressor
- Impaired functioning (social or occupational) - Syndrome does not meet criteria for another psych disorder
- Syndrome is not an exacerbation of a preexisting psych disorder
- Syndrome is not bereavement
- Syndrome resolves within 6 months after stressor and its consequences have ended
Recurrent major depressive symptoms occurring consistently at particular times of year
Seasonal Affective Disorder
Seasonal Affective Disorder is MC during what seasons?
- Fall-Onset (“Winter depression”)
- Begins late fall-early winter; remits in summer
- May also see Spring-Onset (“Summer depression”) (not as common)
why does SAD happen?
Hypothesis that decreased daylight in winter months triggers depressive symptoms in predisposed individuals
difference between Fall vs spring onset for SAD
- fall
- Increased sleep
- Increased appetite - Carbohydrate craving
- Increased weight
- Irritability
- Interpersonal difficulties - Rejection sensitivity
- Leaden paralysis (limbs feeling heavy) - spring
- Decreased sleep
- Decreased appetite
- Decreased weight
- Dysphoria
Tx for SAD
- Light Therapy
- Effective tx for fall-onset SAD
- Non-psychotic, non-suicidal patients
- Daily therapy until sufficient daily light is available from other sources (e.g., springtime sun) - SSRIs, psychotherapy have been shown to be useful
SE of light therapy for SAD
- usually few and reversible
- Photophobia
- HA
- fatigue
- irritability
- insomnia
- hypomania
