Mood Disorders Flashcards
Which of the following is necessary for a diagnosis of major depressive disorder with seasonal pattern?
A. At least four episodes of depressive disturbance in the previous 2 years
B. Full remission must occur at a characteristic time of year
C. Seasonal episodes must be at least equal to nonseasonal episodes
D. Seasonal-related psychosocial stressors must be present
Full remission must occur at a characteristic time of year (i.e. Spring time)
A 27-year-old woman presents to the clinic reporting a depressed mood for the past 2 weeks. She states she has had significant weight gain, has been sleeping more than usual, has decreased interest in normally pleasurable activities, feels guilty, and has had decreased concentration. She states she had a hypomanic episode in the past while she was using amphetamines. What is the most likely diagnosis?
MDD (Unipolar Depression)
A 65-year-old man who does not have housing and has a history of diabetes mellitus and post-traumatic stress disorder is admitted to inpatient psychiatry approximately 24 hours after presenting to the emergency department with tremulousness and a report of “two voices laughing at me.” Upon initial psychiatric assessment, the patient states, “the voices are terrifying…they sound like demons” and then clarifies “but they aren’t bothering me anymore.” His ethanol level on admission was 300 mg/dL. Nursing notes that the patient slept 3.25 hours and appeared agitated at 02:00. Today, his morning vital signs are temperature 99.0°F, HR 98, BP 165/88, and RR 20. Based on his presentation, what is the primary diagnosis for this patient?
What is the best medical management for this patient?
Alcohol Hallucinations
Benzo’s (Lorazapam or chlordiazepoxide)
Antipsychotics may be given to reduce emergent agitation during alcohol hallucinosis but should be used sparingly. Antipsychotics may induce extrapyramidal symptoms or neuroleptic malignant syndrome and are not indicated for long-term use in patients with secondary psychoses.
A patient with symptoms of major depression is seeking help to stop smoking. Which medication would be most suitable to treat both conditions simultaneously?
What is the MOA of the most suitable medication?
Buproprion
Blocks reuptake NE and dopamine
What is the strongest risk factor associated with Bipolar I Disorder?
Are men or women affected more?
Family History
Men = Females
In patients with Bipolar is lithium associated with a decreased suicide rate?
Yes, why it is considered first-line for treatment
What is the difference between Bipolar and Schizophrenia?
Although they have similarities, bipolar disorder primarily causes extreme mood shifts, whereas schizophrenia causes delusions and hallucinations.
What is the definition of sucide gesture?
Suicide gesture is self-injurious behavior that is intended to lead others to think that one wants to die despite no intention of dying
What risk factor is the most associated with sucide?
Previous sucide attempt
Does asking patients about suicide increase the incidence of suicide?
What psych medication is contraindicated with suicide ideation?
No
monoamine oxidase inhibitors (MOI’s)
Contraindicated because they are lethal at high doses. In contrast, SSRI’s should be used in patients with sucidial ideations because they are safer if taken as an overdose.
What are some protective factors of suicide?
Marriage and Pregnancy
What dissociative anesthetic can be used to treat severe depression?
Ketamine
What is the MOA of Bupropion?
What adverse effect are you most worried about with Bupropion?
Bupropion is an aminoketone antidepressant
Mechanism by which depression is relieved is unclear but may be related to blockade of dopamine or NE reuptake
Seizures
Most common adverse effects are agitation, headache, dry mouth, constipation, weight loss, GI upset, dizziness, tremor, insomnia, blurred vision, and tachycardia
What is the mechanism of action of mirtazapine?
Mirtazapine is in a group of tetracyclic antidepressants (TeCA). Mirtazapine inhibits the central presynaptic alpha-2-adrenergic receptors, which causes an increased release of serotonin and norepinephrine.
When do most Seratonin Syndrome cases present?
Most cases present within 24 hours (usually within 6 hours) of initiating a new serotonergic medication, such as sertraline, or changing the dosage.
What can be given as serotonin antagonist in the treatment of seratonin syndrome?
What is the role of benzodiazepines?
Cyproheptadine
Given for agitation, to reduce hyperthermia, and to high HR and BP
What are the 5 stages of grief?
- Denial
- Anger
- Bargaining
- Depression
- Acceptance
What medications should not be given/taken with serotonergic drugs due to the increased risk of seratonin syndrome?
- St. John’s wort
- MDMA (ecstacy)
- Cocaine
- Amphetamines
What criteria is used to diagnose seratonin syndrome?
Hunter Criteria
hypertonia, agitation, tremor, hyperreflexia, temperature and clonus
*Clonus is the most important criteria
In addition to women, which other demographic of the population should take a lower dose of zolpidem?
Older patients, regardless of gender should take the lowest dose (5mg) of zolpidem for sleep distrubance or insomnia
A 25-year-old man presents to the emergency department after being arrested for stealing from a department store. He states that he is the president of the United States. He also says that he has not slept for three days and does not feel like he needs to sleep. During the interview, he speaks rapidly and is easily distracted. He does not use substances, and the toxicology screen is negative. What is the most likely diagnosis?
Bipolar I Disorder
A 23-year-old woman presents to the clinic with depressed mood, irritability, increased appetite, breast tenderness, fatigue, and bloating that occurs monthly prior to the onset of menses. She states that the symptoms resolve after her menstrual period begins. The symptoms affect her productivity at work. What is the first-line treatment for this condition?
SSRI’s are first line treatment for Premenstrual Syndrome (PMS) and Premenstrual Dysphoric Disorder
(most commonly Fluoxetine)
Fluvoxamine is not approved for use to treat depression in the United States but has been approved to treat what psychiatric disorder?
What class of medications does Fluvoxamine belong?
Obsessive-compulsive Disorder
SSRI
What is the MOA of SSRI’s?
SSRI’s inhibit the serotonin reuptake pump and increase postsynaptic serotonin receptor occupancy.
SSRI’s are considered selective because they have little affinity for other types of receptors, such as norepinephrine and dopamine
One of the common side effects of SSRI’s is weight gain. What SSRI is associated with the highest risk for weight gain?
The risk of weight gain is most likely with paroxetine (Paxil) and least likely with fluoxetine (Prozac).
Should SSRI’s be tapered rather than abruptly discontinued?
SSRI’s should be tapered every 2-4 weeks when coming off the medication to not create adverse side effects.
Abruptly discontinuing an SSRI can cause dysphoria, dizziness, gastrointestinal symptoms, fatigue, and myalgias
What are the most prominent side effects of mirtazapine?
What drug class does mirtazapine belong?
Weight gain and sedation
Atypical Antidepressant
Which of the following antidepressants is known to have the most severe toxicity in overdose?
A. Amitriptyline
B. Fluoxetine
C. Sertraline
D. Venlafaxine
What is the first step in management of a TCA toxicity?
Amitriptyline (TCA’s) are at the highest risk for overdose toxicity
Airway resescitation.
Can then give benzos or activated charcoal (if 4 hours)
What are the available Serotonin-Norepinephrine Reptake Inhibitors?
- Venlafaxine
- Duoxetine
- Desvenlafaxine
Which of the following tests is initially required weekly to monitor patients who are prescribed clozapine?
A. Complete blood count
B. Complete metabolic panel
C. Hemoglobin A1C
D. Lipid panel
CBC due to high risk of agranulocytosis (absence of neutrophils)
A 33-year-old female patient presents after being found unresponsive in her bedroom. She has a past medical history of depression, and her mother found an empty bottle of amitriptyline by the bedside. On physical exam, pulse 138/minute, blood pressure 80/60 mm Hg, temperature 101.2°F (38.4°C), respirations 6/minute. She moves her limbs to painful stimuli. Her skin is flushed. The electrocardiogram demonstrates a wide complex tachycardia without ectopy. The patient is intubated and is being hyperventilated.
What is the diagnosis?
What is the next step in management?
TCA toxicity
Sodium bicarbinate boluses to reach a serum pH of 7.5
What are the symptoms associated with TCA toxicity?
- Mental status change
- Hyperthermia
- Cardiac arrhythmias (specifically tachy arrhythmias)
Is phenytoin effective in treating seizures associated with toxicity?
No. Benzo’s, phenobarb and intubation are the mainstay of treatment for seizures associated with medication toxicity.
A 21-year-old woman is markedly thin, and she describes being worried she is going to fail her college finals and not graduate. She presents because she cannot eat or sleep; she feels like she would be better off dead. She was doing well in classes until after a spring break trip to Europe. When queried about previous psychiatric treatment, she tells you that she went “a little nuts” when she was a freshman; it was her first semester and the first time she had lived so far from home. She stayed up for a week trying to write a novel, and during that time she bought two computers and a whole new wardrobe with her father’s credit card.
What is the most likely diagnosis?
What is the first line treatment?
Bipolar I Disorder
Mood stabilizers (Lithium first line); or valproic acid or carbomazepine
Are antidepressants recommended as monotherapy for severe depression assoicated with Bipolar I disorder?
No, because of the risk of precipitating mania or hypomania. Can be used as adjunctive treatment with mood stabilizers (Lithium).
What are some second generation antipsychotics?
- Risperidone
- Quetipine
- Olanzapine
- Ziprasidone
Along with lithium levels which of the following laboratory levels should be monitored in patients taking lithium for bipolar disorder?
TSH should be monitored at least annually
Which of the following is a symptom of lithium toxicity?
A. weight gain
B. psoriatic rash
C. agranulocytosis
D. tremor
E. polyuria
Tremor
Weight gain, hypothyroidism, polyuria, and exacerbation of psoriasis can occur at therapeutic lithium levels.
What is hypomania?
Less severe then mania
Abnormal and persistently elevated, expansive or irritable mood < 1 week
*Does not impact social or occupational function
*Does not require hospitalization
Which of the following criteria is essential for the diagnosis of cyclothymic disorder according to the DSM-5?
A. At least one episode of major depression
B. Symptoms present for a minimum of 1 year in adults
C. History of manic episode
D. Presence of psychotic features during mood swings
E. Chronic, fluctuating mood disturbance for at least 2 years in adults
Chronic, fluctuating mood disturbance for at least 2 years in adults and 1 year in children
What are the normal stages of grief?
- Denial
- Anger
- Bargaining
- Depression
- Acceptance
ECT is typically used in refractory cases of major depression after failed pharmacologic therapy. What are some indications to use ECT as first-line treatment?
ECT provides a rapid response and is thus indicated in certain urgent clinical scenarios (e.g., severe suicidality, severe psychosis, catatonia, malnutrition in patients with food refusal secondary to depressive illness).
What are the safest SSRI’s to use in pregnancy?
Sertraline or esciltalopram are considered safe
Paroxitine should not be used due to the small risk of PPHN or anencepholy
Additionally, citalopram should be avoided due to possible risk of septal defects and omophacele
What neurotransmitters are off balance in MDD?
- 5-HT
- NE
- Epinephrine
- Histamine
- Can also have neuroendocrine disfunction (thyroid, adrenal, growth hormone)
What does SIGECAPS stand for?
*Sadness
*Lack of interest/anedonia
*Guilt
*Lack of energy
*Lack of concentration
*Appettite loss
*Psychomotor activity
*Suicide ideation
How many symptoms is required in order to diagnose MDD?
5 out of the 9 SIGECAPS symptoms. At least one has to be depressed mood or anedonia. Symptoms must be present for at least 2 weeks.
What is the screening tool for postpartum depression?
Beck’s Depression Scale
Is depression required for the diagnosis of Bipolar?
No, just mania or hypomania
Is lithium more effective in treating depressed mood or mania?
Mania, which is why patients usually require dual therapy with antidepressants
What are some comorbid conditions associated with bipolar disorder?
Comorbid psychiatric disorders are common, especially anxiety disorders, impulse control disorders, attention deficit hyperactivity disorders, cluster B personality disorders, and substance use disorders.
How is Bipolar I defined?
How is this different from Bipolar II?
Bipolar I disorder is characterized ≥ 1 manic episode that is present for most of the day, almost every day, for ≥ 1 week and is associated with hospitalization, impaired social or occupational functioning, and/or psychotic features
Mania is not present in Bipolar II, limited impact on daily function
How is Bipolar II defined?
Bipolar II disorder is characterized by ≥ 1 current or past hypomanic episode and ≥ 1 current or past major depressive episode (but no manic episodes)
What is the classic presentation of seratonin syndrome?
Symptoms include a classic triad of mental status change, autonomic dysregulation, and neuromuscular hyperactivity.
- Mental Status Change: anxiety, delirium, confusion, restlessness
- Autonomic Dysregulation: diaphoresis, tachycardia, hypertension, hyperthermia, diarrhea, hyperactive bowel sounds, mydriasis
- Neuromuscular Hyperactivity: hyperreflexia, tremor rigidity, myoclonus, ocular clonus
