Mood Disorders Flashcards
Define Mood
Overall state of emotion at a given time which is influenced by internal and external factors
What is a mood disorder?
A condition that affects a person’s everyday emotional state/mood (prevalence 1 in 4 adults)
What neurotransmitters effect mood? Where are they made?
Serotonin (Raphe nuclei)
Norepinephrine (Locus coeruleus)
Dopamine (Substantia nigra)
What are the types of mood disorders?
Depressive and bipolar
What criteria is required for ALL psychiatric conditions?
- Cannot be caused by a drug or external exposure
- Cannot be caused by a medical condition
- Must have significant impairment of social and/or occupational functioning
What is the prevalence of major depressive disorder?
21% in lifetime, 10% per year
Who is major depressive disorder most common for?
Women
Age ~30 years
Native Americans (lowest is asians)
Low socioeconomic status
What is the inheritability of major depressive disorder?
35-40%
What is the cause biologically of major depressive disorder?
Changes in neurotransmitter expression and sensitivity (serotonin, norepinephrine, glutamate, GABA, dopamine)
What medications can contribute to major depressive disorder?
Glucocorticoids, interferons
What is the diagnostic criteria for major depressive disorder?
A depressed mood or anhedonia for at least 2 weeks and at least 4 of the following:
-sleep changes
-feelings of worthlessness/guilt
- fatigue
- decreased concentration
- significant appetite or weight change
- activity changes
- recurrent thoughts about death or suicide
What is the mnemonic for major depressive disorder?
S - sleep
I - interest decrease
G - guilt
E - energy down
C - concentration down
A - appetite down
P - psychomotor agitation or retardation
S - suicidal ideation
What are the subtypes of major depressive disorder?
Anxiety - high levels of accompanying anxiety
Atypical - reactivity to pleasurable stimuli, hyperphagia, hypersomnia
Catatonic - major psychomotor disturbances
Melancholic - anhedonia, psychomotor changes, insomnia, decreased appetitie
Mixed - symptoms of mania
Peripartum - while pregnant or within 4 weeks or birth
Psychotic - with accompanying psychosis
Seasonal - associated with a particular season
What is the average time to resolution of a major depressive disorder episode?
20 weeks
When is the highest risk of recurrence of major depressive disorder?
Within the first few months following a episode’s resolution
What is the rate of recurrence of major depressive disorder?
40% in a year and 85% in a lifetime
What are the screening exams for major depressive disorder?
Quick initial -> Two question screen PHQ-2
Evaluate severity -> Patient Health Questionnaire-9 PHQ-9
Rating of sx -> Zung Self-Rated Depression Scale
What is the preferred approach to treating major depressive disorder?
A combination of pharmacotherapy and psychotherapy
What is the most common approach to treating major depressive disorder?
Pharmacotherapy only
What is electroconvulsive therapy?
Use of a small electric current to induce a cerebral seizure while patient is under general anesthesia
What is the indication for electroconvulsive therapy?
Severe, refractory depression
Esp if cannot tolerate other therapies (like pregnancy)
What are the adverse events for electroconvulsive therapy?
Cardiopulmonary, HA, nausea, transient cognitive impairment, muscle aches
What is vagal nerve stimulation?
A device is implanted in the chest wall and connected to one (left) vagus nerve
What is the indication for vagal nerve stimulation?
Typically used for refractory epilepsy but can be used for refractory depression
What is transcranial magnetic stimulation?
A metal coil with magnetic field is placed against scalp to induce depolarization of neurons in a focal area
What is the indication for transcranial magnetic stimulation?
Treatment-refractory depression
What are the CI for transcranial magnetic stimulation?
High seizure risk, incompatible implants (bc magnetic)
What are the SE for transcranial magnetic stimulation?
Seizures, HA, scalp pain, transient hearing loss
What supplements can be used in major depressive disorder?
S-Adenosylmethionine: raises dopamine levels but can trigger manic episodes, preg safe
5-hydroxytryptophan: precuror to serotonin
Omega- 3 Fatty Acids: antiinflammatory effects
What are herbals that can be used in major depressive disorder?
St. John’s Wort: increases serotonin, maybe increases NE and dopamine
Saffron: MOA unclear
Ginkgo Biloba: Improved mood in memory loss patients, increases sensitivity to serotonin
How long should a patient be on an oral antidepressant before evaluation?
At least 4 weeks
How long should a patient be on an oral antidepressant?
At least 6 months after s/s improvement
What are the SSRI drugs?
Sertraline
Citalopram
Escitalopram
Fluoxetine
Paroxetine
Fluvoxamine
What is the MOA or SSRI?
Selectively decreases the action of 5-HT reuptake pump, leading to increased serotonin levels in the synapse
What are the common CI in all SSRIs?
Allergy, use of an MAOI within 2 weeks
What are the common SE of SSRIs?
GI upset
Sleep changes
Neuro (HA, dizziness)
Sexual dysfunction
Psych
Prolonged QT, weight gain, bleeding, orthostatic hypotension, serotonin syndrome
What is serotonin syndrome?
Diarrhea, increased bowel sounds, agitiation, hyperreflexia, dry mucus membranes, autonomic instability, hyperthermia, HTN, tremor, clonus, seizure, death
Caused by increase in serotonergic activity
What is the treatment for serotonin syndrome?
Supportive care
D/c serotonergic medications
Sedation with benzos
What is unique about sertraline?
More GI upset
Less QT prolongation
Higher insomnia
What is unique about citalopram and escitalopram?
Most QT prolongation
Minimal SE
Least hepatic cytochrome enzymes
What is unique about fluvoxamine?
Shortest half life
Most somnolence
Many DDI due to cytochrome inhibition
Good use with OCD
What is unique about fluoxetine?
Longest half-life
Higher insomnia
SE of anxiety
Cannot take tamoxifen
What is unique about paroxetine?
Anticholinergic SE
Increased weight gain, sexual disfunction
DDI 2/2 cytochrome inhibitor
Cannot take tamoxifen
What is the MOA for SNRIs?
blocks reuptake of 5-HT and norepinephrine, increasing their levels in the synapse
Which SNRIs have a greater effect on norepinephrine?
Savella/Fetzima
What are the SNRI drugs?
Venlafaxine
Desvenlafaxine
Duloxetine
Milnacipran
Levomilnacipran
What are the common CI for SNRIs?
Allergy
MAOI in 2 weeks
Serotonergic drugs
Angle closure glaucoma
What are the common SE of SNRIs?
GI upset esp constipation
Sleep changes
Neuro (HA, dizziness)
Sexual dysfunction (less than SSRI)
Psych
Diaphoresis, hypertension, serotonin syndrome
Note: less weight gain side effects
What is unique about venlafaxine?
More SE esp N/V
Most elevated BP
What is unique about desvenlafaxine?
Synthetic of venlafacixine’s major metabolite
Less SE than venlafaxine esp BP
What is unique about duloxetine?
Most likely to have DDI
Least elevated BP
Used for chronic pain relief
What is unique about milnacipran and levomilnacipran?
Anticholinergic SE
Milnacipran/Savella is more for fibromyalgia
What is the MOA of Bupropion?
Dopamine-norepinephrin reuptake inhibitor and antagonizes nicotonic receptors
What is the MOA of mirtazapine?
Antagonizes alpha-2 adrenergic receptors and 5-HT2 and 5-HT3 receptors, which causes increased release of serotonin and norepinephrine
What are the SE of bupropion?
Dry mouth, insomnia, nausea, increased risk of seizures
No weight gain or sexual dysfunction
Think energy boost and sex
What are the CI for bupropion?
allergy, seizure disorder, anorexia/bulimia, within 2 weeks of MAOI
What are the SE of mirtazapine?
Drowsiness and weight gain, sexual dysfunction
What are the CI of mirtazapine?
Allergy, within 2 weeks of MAOI
What is the MOA of serotonin modulators?
Block reuptake of 5-HT
What are the serotonin modulators?
Nefazodone
Trazodone
Vilazodone
Vortioxetine
What is the MOA of nefazodone and trazodone?
antagonize 5-HT receptors causing increased release of serotonin
What is the MOA of vilazodone and vortioxetine?
Partial agonist of 5-HT receptors mimicking serotonergic effects
What are CI to serotonin modulators?
allergy, within 2 weeks of MAOI
What are SE of serotonin modulators?
HA, diarrhea, nausea
SI risk
Serotonin syndrome risk
What is unique about nefazodone?
Most DDI risk
BBW for hepatotoxicity, name brand pulled from market
SE: less GI and weight gain, no sexual side effects
What is unique about trazodone?
SE: sedation, nausea, dry mouth, fatigue, constipation, sexual dysfuction (incl priapism)
Doesn’t cause weight change and less sexual dysfunction
What is unique about vilazodone?
Faster onset of treatment
Less sexual dysfunction
What is unique about vortioxetine?
Faster onset of treatment
Less sexual dysfunction
What is the indication for Ketamine/Esketamine?
Patients who fail or do not respond to ECT
What is the effect of Ketamine/Esketamine?
A rapid robust improvement in depression that fades in about 2 weeks
What are the SE of ketamine/esketamine?
Abuse potential
Neurotoxicity
Psychotomimetic effects (induces psychosis)
What is the MOA of ketamine/esketamine?
Opioid and AMPA agonist, NMDA antagonist
What are the CI to ketamine/esketamine?
Allergy, aneurysmal disease or AV malformation, h/o ICH, inability to tolerate increase in BP
What are DDI for ketamine/esketamine?
CNS depressants (including opiates), other nasal sprays
What is the MOA of MAOa?
Breaks down serotonin and norepinephrine
What is the MOA of MAOb?
Works with MAOa to break down dopamine
What is the indication for MAOIs?
Treatment-resistant or atypical depression
What is an indication for selegiline?
Low dose used for Parkinson’s
What are the MAOI drugs?
Tranylcypromine
Phenelzine
Isocarboxazid
Selegiline
What are the CI for MAOI drugs?
Allergy, CV disease, pheochromocytoma, hepatic or renal impairment, 2 weeks of other serotonergic drugs
What are the DDI for MAOIs?
Many. Too many
What are the SE of MAOIs?
Hypotension, GI upset, urinary hesitancy, headache, myoclonic jerks, edema, SI
Hypertensive crisis when eating aged foods (tyramine)
What is the indication for TCAs?
Second line for depression 2/2 side effects
What is the MOA for TCAs?
Inhibits reuptake of 5-HT and norepinephrine
What are the tertiary amine TCAs?
Amitriptyline and Doxepin
prevent 5-HT>NE reuptake
What are the secondary amine TCAs?
Nortriptyline and desipramine
Prevent NE>5-HT reuptake
Higher tolerability
What are the CI to TCAs?
Allergy
2 Weeks of MAOI
Soon after MI
What are the SE to TCAs?
Anticholinergic
Drowsiness
Sexual dysfunction
Diaphoresis
Tremor
Weight gain/increased appetite
SI
Prolonged QT
What is the indication for TeCAs?
Refractory of atypical depression
What are the TeCAs?
Maprotiline (blocks reuptake of NE and 5-HT)
Amoxapine (blocks reuptake of NE, blocks dopamine receptors)
What are the TeCA side effects?
Similar to TCA, less anticholinergic but more antihistamine
What is lithium used for?
Typically bipolar, but can be unipolar depression
Many SE and high toxicity risk
What is persistent depressive disorder?
A patient with ongoing depressive sx most of the time for >2 years with no longer than 2 months w/o sx and at least 2 of the following:
-appetite changes
-sleep changes
-fatigue
- Diminished ability (mental)
- Low self-esteem
-Feelings of hopelessness
Cannot have mania!
Feeling SAD For Life
What is the prevalence of persistent depressive disorder?
1.5% in the past 12 months
What is the treatment for persistent depressive disorder?
1st: SSRIs
2nd: TCAs and MAOIs (2nd bc side effects)
