mood disorders Flashcards
major depression DSM 5
-5+ of the following during the same 2 week period and represent change from previous functioning:
-at least one symptom is either (1) DEPRESSED MOOD or (2) LOSS OF INTEREST OR PLEASURE
-Depressed most of the day, nearly every day, as indicated by pts or others
-Markedly diminished interest or pleasure in all, or almost all, activities most of the day (from pts or others)
-Significant weight loss when not dieting or weight gain (more than 5% of body weight in a month), or decrease or increase in appetite nearly every day
-Insomnia or hypersonic nearly every day.
-Psychomotor agitation or retardation nearly every day (observable by OTHERS, not merely subjective feelings of restlessness or being slowed down)
-Fatigue or loss of energy nearly every day.
-Feeling of worthlessness or excessive or inappropriate guilt (which may be delusional) nearly every day (not merely self-reproach or guilt about being sick).
-Diminished ability to think or concentrate, or indecisiveness, nearly every day (from pts or others)
-Recurrent thoughts of death, recurrent suicidal ideation without a specific plan, or a suicide attempt or a specific plan for committing suicide.
-symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.
-The episode is not attributable to the physiological effects of a substance or to another medical condition
atypical depression
-weight gain
-sleeping more
what causes depression
-Genetics: family hx, especially first degree relatives -> increases risk 2-5x
-Environmental Factors: stressors (loss of a loved one, of status, of employment), poor family functioning, poor support system, early loss of parent, limited coping mechanisms, learned helplessness, inwardly focused anger.
-Biology: “Catecholamine Hypothesis” Decreased levels of Serotonin, Norepinephrine, Dopamine in the brain (high in bipolar)
-Serotonin: Controls aggression, irritability, obsessions, compulsions, anxiety, overall well-being, pain.
-Norepinephrine: Controls alertness, energy, attention, pain.
-Dopamine: Controls cognition, motivation, pleasure and reward.
depression in the elderly
-Low/depressed mood does NOT need to be present
-Persistent loss of pleasure and interest in previously enjoyable activities (anhedonia) MUST be present
-Reject diagnosis of depression
-Masked depression or depression without sadness- mainly SOMATIC complaints
-Symptoms of minor depression
-Somatic complaints: Persistent, vague, unexplained physical complaints:
-Agitation, anxiety
-Memory problems, difficulty concentrating
-Social withdrawal
depression in child/adolescents
-Frequent sadness, crying
-Feeling hopeless, helpless, withdrawn
-Change in behavior, loss of interest in usual activities
-Change in sleep, appetite or energy
-Missed school or poor school performance
-Frequent physical complaints
-Irritability, fighting, trouble concentrating
-Thoughts about death, suicide or running away
depressive disorders that look like MDD
-Bipolar Depression: A vegetative depression that alternates with mania.
-Mood Disorder Due to a General Medical Condition: Depression caused by physical medical condition
-ex. hypothyroidism, or pancreatic cancer.
-Substance-Induced Mood Disorder: Depression caused by abuse of substances such as drugs, alcohol, medications, or toxins.
-Seasonal Affective Disorder (SAD): Depression during winter
-Postpartum Depression: depression occurring within 1 week to 6 months after delivery
-Premenstrual Dysphoric Disorder: Depression affecting a small percentage of menstruating women
-cyclical -> depressed and irritable for 1-2 weeks before menses
how do we dx depression
-Complete History, Physical Exam, and Bloodwork
-Complete Medication Review
-Structured Psychiatric Interview
-Depression Inventory Scales
-ASK!!!
how do we treat depression: PSYCHOTHERAPY
-Cognitive Behavioral Therapy: Identify, challenge, and change dysfunctional thought processes such as:
-“All or Nothing” Thinking: A performance short of perfect is seen as failure
-Over-Generalization: A single negative event is seen as part of a pattern
-Rumination: A single negative detail is dwelled upon exclusively
how do we treat depression: pharmacotherapy
-SSRIs (Prozac): Inhibit the reuptake of Serotonin.
-Side Effects: Insomnia, sedation, agitation, GI upset, headache, !decreased libido, erectile dysfunction, anorgasmia!
-SNRIs (Effexor): Inhibit the reuptake of Serotonin and Norepinephrine.
-Side Effects: Insomnia, anxiety, hypertension, headache, decreased libido, erectile dysfunction, and anorgasmia, lowers threshhold for seizures, less ED
-NDRIs (Wellbutrin): Inhibit reuptake of dopamine and norepinephrine
Side Effects: Decreased seizure threshold, headache, insomnia, agitation, tachycardia, dizziness, less ED
-!Fewer sexual side effects!
-Off-Label and Adjunctive Drugs:
-Antipsychotics: Often added in resistant or psychotic depression
-Antiepileptics: Some anticonvulsants may be used in resistant or agitated depression.
-Phenytoin, ethosuximide, carbamazepine, oxcarbazepine, gabapentin, sodium valproate, pregabalin and lamotrigine
-Lithium: May be used as an adjunct in resistant depression
-Psychostimulants: May improve effectiveness of antidepressants in resistant depression while specifically targeting sadness, anhodenia, decreased energy, and decreased cognition.
-ex. ritalin, Adderall
how do we treat depression: electroconvulsive therapy
-Used for rapid antidepressant response or when drug therapies have failed
-Electric shocks delivered to the brain cause brief seizures.
-Absolute Contraindications: None
-Relative contraindications: Elevated ICP, intracerebral hemorrhage, space-occupying lesion, unstable aneurysms
-Can be used in pregnant patients
-Side Effects: Postictal confusion and anterograde amnesia, arrhythmia
depression prognosis
-Without tx -> up to 60-80% will recover spontaneously, usually within 1st year
-With tx -> 80-90% will recover.
-risk of relapse after 1 episode is 50%
-risk of relapse after 2 episode is 90%
-risk of relapse after 3 episodes is ~ 100%
-10-15% will convert to Bipolar Disorder.
-Approx 15% will attempt suicide -> MC within first 6-9 months of tx
what predicts good prognosis for depression
-Good:
-No family hx
-Acute Onset
-Late Onset
-Early Intervention
-Good Support System
-No Psychotic Symptoms
-No Substance Abuse
-Good Response to Prior/Current Treatment
-Poor:
-Family hx
-Gradual Onset
-Early Onset
-Late Intervention
-Poor Support System,
-Psychotic Symptoms
-Substance Abuse
-Poor Response to Prior/Current Tx
when do we refer to psychiatrist/specialist
-Evaluation for pharmacotherapy
-Failure of adequate antidepressant trial
-Psychiatric comorbidities
-Complicated medical comorbidities
-Suicidal ideations, gestures
-Pt in need of hospitalization
suicidal risk assessment
-PRIMARY RULE FOR ASSESSMENT: Know difference between:
-Ideation: “I wish I were dead “
-Intent: “When no one is home, I’m going to kill myself”
-Plan: “I am going to hang myself with the garden hose my husband keeps in the garage”
suicide: risk factors
-Previous Attempt: MOST important risk factor
->Increased risk if attempt within last 2 years
-Psychiatric Disorder: >90% of completers had mental illness
-Age: Highest prevalence < 19yo and > 45 yo
-Men >65 yo have highest rate of completion
