Mood Disorders Flashcards
What is the definition of mood?
What do patients with mood disorders experience?
Mood disorders have also been called….
- Mood - description of one’s internal emotional state
- Patients with mood disorders experience an abnormal range of moods and lose some level of control over them
- Mood disorders = affective disorders
Mood disorders vs. Mood Episodes
-
Mood episodes
- Distinct periods of time in which some abnormal mood is present
-
Mood disorders
- Defined by patterns of mood episodes
- Some may have psychotic features (delusions or hallucinations)
What are the 4 types of mood episodes?
- Major depressive episode
- Manic episode
- Mixed episode
- Hypomanic episode
What are the 5 types of main mood disorders?
- Major depressive disorder (MDD)
- Bipolar I disorder
- Bipolar II disorder
- Dysthymic disorder
- Cyclothymic disorder
How is Major Depressive Episode defined by DSM-IV criteria?
Must have at least 5 of the following symptoms (must have either #1 or #2) for at least a 2-wk period:
- Depressed mood
- Anhedonia (loss of interest in pleasurable activites)
- Change in appetite or body weight (increased or decreased)
- Feelings of worthlessness or excessive guilt
- Insomnia or hypersomnia
- Diminished concentration
- Psychomotor agitation or retardation (restlessness or slowness)
- Fatigue or loss of energy
- Recurrent thoughts of death or suicide
*symptoms must not be due to substance use or medical conditions, must cause social/occupational impairment*
What is the acronym for symptoms of major depression?
SIG E CAPS
- Sleep
- Interest
- Guilt
- Energy
- Concentration
- Appetite
- Psychomotor activity
- Suicidal ideation
A person who has been previously hospitalized for a major depressive episode has a ___% risk of commiting suicide later in life.
15%
How is Manic Episode defined by DSM-IV criteria?
A period of abnormally & persistently elevated, expansive or irritable mood, lasting at least 1 wk and including at least 3 of the following (4 if mood is irritable)
- Distractibility
- Inflated self-esteem or grandiosity
- Increase in goal-directed activity (socially, at work, or sexually)
- Decreased need for sleep
- Flight of ideas or racing thoughts
- More talkative or pressured speech (rapid & uninterruptible)
- Excessive involvement in pleasurable activities that have a high risk of negative consequences (ex: buying sprees, sexual indiscretions)
*symptoms can’t be due to substance use or medical conditions, must cause social or occupational impairment, 75% of patients have psychotic symptoms*
What is the acronym for symptoms of mania?
DIG FAST
- Distractability
- Insomnia
- Grandiosity
- Flight of ideas
- Activity/agitation
- Speech (pressured)
- Thoughtlessness
What is the definition of a mixed episode?
- Criteria are met for both manic episode and major depressive episode
- These criteria must be present nearly every day for at least 1 week
- Psychiatric emergency
What is the definition of a hypomanic episode?
Distinct period of elevated, expansive or irritable mood that includes at least 3 of the symptoms listed for the manic episode criteria (4 if mood is irritable)
What are the fundamental differences between mania and hypomania?
-
Mania
- Lasts at least 7 days
- Causes severe impairment in social or occupational functioning
- May necessitate hospitalization to prevent harm to self or others
- May have psychotic features
-
Hypomania
- Lasts at least 4 days
- No marked impairment in social or occupational functioning
- Does not require hospitalization
- No psychotic features
What are medical causes of a depressive episode?
- Cerebrovascular disease
- Endocrinopathies
- Cushing’s syndrome, Addison’s disease, hypoglycemia, hyper/hypothyroidism, hyper/hypocalcemia
- Parkinson’s disease
- Viral illness (mononucleosis)
- Carcinoid syndrome
- Cancer (lymphoma & pancreatic carcinoma)
- Collagen vascular disease (SLE)
What are the medical causes of a manic episode?
- Metabolic (hyperthyroidism)
- Neurological disorders
- Temporal lobe seizures
- Multiple sclerosis
- Neoplasms
- HIV infection
What are some causes of medication/substance-induced depressive episodes?
- EtOH
- Antihypertensives
- Barbiturates
- Corticosteroids
- Levodopa
- Sedative-hypnotics
- Anticonvulsants
- Antipsychotics
- Diuretics
- Sulfonamides
- Withdrawal from psychostimulants (cocaine, amphetamines)
What are some causes of medication/substance-induced mania?
- Corticosteroids
- Sympathomimetics
- Dopamine
- Agonists
- Antidepressants
- Bronchodilators
- Levodopa
What is the DSM-IV criteria for major depressive disorder?
- At least one major depressive episode
- No history of manic or hypomanic episode
What is seasonal affective disorder?
- Subtype of MDD
- Major depressive episodes occur only during winter months (fewer daylight hours)
- Patients respond to treatment with light therapy
Major depressive disorder
- Lifetime prevalence: ___%
- Average age of onset is ___
- Women vs. men?
- SES differences?
- Prevalence in elderly from ___ to ___%.
- Lifetime prevalence: 15%
- Average age of onset is 40
- 2x as prevalent in women than men
- No ethnic/SES differences
- Prevalence in elderly from 25-50%
What are some sleep problems associated with major depressive disorder?
- Multiple awakenings
- Initial and terminal insomnia
- Hard to fall asleep and early morning awakenings
- Hypersomnia
- Rapid eye movement (REM) sleep shifted to earlier in night and stages 3 & 4 decreased
What are 4 likely etiologies of major depressive disorder?
- Abnormalities of serotonin/catecholamines
- Other neuroendocrine abnormalities
- Psychosocial/life events
- Genetic predisposition
Etiology of MDD
Abnormalities of serotonin & catecholamines
- Decreased brain & CSF levels of serotonin and its main metabolite 5-HIAA are found in depressed patients
- Abnormal regulation of beta-adrenergic receptors has also been shown
- Drugs that increase availability of serotonin, NE & dopamine often alleviate symptoms of depression
Etiology of MDD
Other neuroendocrine abnormalities
-
High cortisol
- Hyperactivity of hypothalamic-pituitary-adrenal axis as shown by failure to suppress cortisol levels in dexamethasone suppression test
-
Abnormal thyroid axis
- Thyroid disorders associated w/ depressive symptoms
- 1/3 MDD patients who have otherwise normal thyroid levels show blunted response of TSH to infusion of TRH
Etiology of MDD
Psychosocial/life events
- Loss of a parent before age 11 is associated with the later development of major depression
- Stable family and social functioning have been shown to be good prognostic indicators in the course of major depression
Etiology of MDD
Genetic predisposition
- 1st-degree relatives are 2-3x more likely to have MDD
- Concordance rate for monozygotic twins is about 50%, 10-25% for dizygotic twins
What is the typical course and prognosis of Major Depressive Disorder?
How many patients eventually commit suicide?
- If left untreated, depressive episodes are self-limiting but usually last from 6-13 months
- Episodes occur more frequently as the disorder progresses
- Risk of subsequent episode is 50% within the first 2 yrs after the first episode
- About 15% of patients eventually commit suicide.
How can medications be used to treat Major Depressive Disorder?
- Antidepressant medications signficantly reduce the length and severity of symptoms
- May be used prophylactically btwn major depressive episodes to reduce the risk of subsequent episodes
- 75% of patients are treated successfully with medical therapy
What are the 4 main treatment options for Major Depressive Disorder?
- Hospitalization
- Pharmacotherapy
- Psychotherapy
- Electroconvulsive therapy
When is hospitalization indicated for major depressive disorder?
Indicated if patient is at risk for suicide, homicide or is unable to care for self
What are the 3 categories of antidepressant medications?
- Selective serotonin reuptake inhibitors (SSRIs)
- Tricyclic antidepressants (TCAs)
- Monoamine oxidase inhibitors (MAOIs)
What are the side effects of SSRIs?
- Safer and better tolerated than other classes of antidepressants
- Side effects mild but include:
- Headache
- GI disturbance
- Sexual dysfunction
- Rebound anxiety
What are the side effects of TCAs?
- Most lethal in overdose
- Side effects
- Sedation
- Weight gain
- Orthostatic hypotension
- Anticholinergic effects
- Can aggravate prolonged QTC syndrome
What are the side effects of MAOIs?
- Useful for treatment of refractory depression
- Risk of hypertensive crisis when used with sympathomimetics or ingestion of tyramine-rich foods (wine, beer, aged cheeses, liver, smoked meats)
- Risk of serotonin syndrome when used in combination with SSRIs
- Most common side effect: orthostatic hypotension
- Tyramine is an intermediate in the conversion of tyrosine to NE
What are 3 common adjuvant medications used for major depressive disorder?
Why are they used?
-
Stimulants (methylphenidate)
- Terminally ill, patients w/ refractory symptoms
- Action rapid, but potential for dependence limits use
-
Antipsychotics
- Patients w/ psychotic features
-
Liothyronine (T3), Levothyroxine (T4), lithium, L-tryptophan (serotonin precursor)
- Convert nonresponders to responders
What type of psychotherapy is useful for major depressive disorder?
- Behavioral therapy
- Cognitive therapy
- Supportive psychotherapy
- Dynamic psychotherapy
- Family therapy
- May be used in conjunction with pharmacotherapy
When is electroconvulsive therapy indicated for MDD?
Is it safe?
- Indicated if:
- Patient is unreponsive to pharmacotherapy
- Patient cannot tolerate pharmacotherapy
- Rapid reduction of symptoms is desired (suicide risk, etc)
- ECT is safe and may be used alone or in combination with pharmacotherapy
How is ECT performed?
What is a common side effect?
- Premedication with atropine
- General anesthesia, admin of muscle relaxant
-
Generalized seizure induced
- Passing current of electricity across the brain (unilateral or bilateral)
- Seizure lasts <1 min
- 8 treatments administered over 2-3 week period, significant improvement often noted after 1st treatment
- Common SE: retrograde amnesia (disappears w/i 6 months)
What is Melancholic Depression?
- 40-60% of hospitalized patients with major depression
- Characterized by:
- Anhedonia
- Early morning awakenings
- Psychomotor disturbance
- Excessive guilt
- Anorexia
- Example: MDD with melancholic features
What is Atypical Depression?
- Characterized by:
- Hypersomnia
- Hyperphagia
- Reactive mood
- Leaden paralysis
- Hypersensitivity to interpersonal rejection
What is Catatonic Depression?
- Characterized by:
- Catalepsy (immobility)
- Purposeless motor activity
- Extreme negativism or mutism
- Bizarre postures
- Echolalia
- May also be applied to bipolar disorder
What is Psychotic Depression?
- 10-25% of hospitalized depressions
- Characterized by:
- Delusions
- Hallucinations
Bipolar I disorder is traditionally known as….
Manic Depression
What is the DSM-IV Criteria for Bipolar I Disorder?
- Only requirement is the occurence of one manic or mixed episode
- 10-20% of patients experience only manic
- May be interspersed euthymia, major depressive episodes, dysthymia or hypomanic episodes (but none required for diagnosis)
Bipolar Disorder I
- Lifetime prevalence: ___%
- Women vs. men
- Ethnic differences?
- Onset usually before age ___
- Lifetime prevalence: 1%
- Women and men equally affected
- No ethnic differences seen
- Onset usually before age 30
What factors contribute to the etiology of Bipolar I?
What is the difference in family members?
- Biological, environmental, psychosocial and genetic factors are all important
- 1st degree relatives of patients with bipolar disorder are 8-18x more likely to develop the illness
- Concordance rates
- Monozygotic twins: 75%
- Dizygotic twins: 5-25%
How long do untreated manic episodes last?
What is the typical course?
- Untreated manic episodes generally last about 3 months
- Course usually chronic w/ relapses
- As disease progresses, episodes may occur more frequently
- Only 7% of patients do not have a recurrence of symptoms after their 1st manic episode
What is the prognosis of Bipolar I?
What is used for prophylaxis?
- Worse prognosis than MDD
- Only 50-60% of patients treated w/ lithium experience significant improvement in symptoms
- Lithium prophylaxis btwn episodes helps to decrease the risk of relapse
What are the 3 treatment options for Bipolar I disorder?
- Pharmacotherapy
- Psychotherapy
- ECT
What type of pharmacotherapy is used to treat Bipolar I disorder?
-
Lithium
- Mood stabilizer
-
Anticonvulsants (carbamazepine, valproic acid) & mood stabilizers
- Useful for rapid cycling bipolar disorder & mixed episodes
-
Olanzapine
- A typical antipsychotic
What type of psychotherapy is used for Bipolar I?
- Supportive psychotherapy
- Family therapy
- Group therapy (once the acute manic episode has been controlled)
What is the usefulness of ECT in Bipolar I?
- Works well in treatment of manic episodes
- Usually requires more treatments than for depression
What is “rapid cycling”?
Occurrence of 4 or more mood episodes in 1 year
What are the side effects of lithium?
- Weight gain
- Tremor
- GI disturbances
- Fatigue
- Arrhythmias
- Seizures
- Goiter/hypothyroidism
- Leukocytosis (benign)
- Coma
- Polyuria
- Polydipsia
- Alopecia
- Metallic taste
Bipolar II disorder is alternatively called…
recurrent major depressive episodes w/ hypomania
What is the DSM-IV criteria for Bipolar II disorder?
- Hx of one or more major depressive episodes and at least one hypomanic episode
- If there has been a full manic episode even in the past, then the diagnosis is not bipolar II disorder, but bipolar I
Bipolar II Disorder
- Lifetime prevalence: ___%
- Women vs. men
- Onset usually before age ___
- Ethnic differences?
- Lifetime prevalence: 0.5%
- Slightly more common in women
- Onset usually before age 30
- No ethnic differences seen
Bipolar II disorder
- Etiology
- Course and prognosis
- Treatment
- Etiology same as bipolar I disorder
- Tends to be chronic, requiring long-term treatment
- Treatment same as bipolar I disorder
What is the DSM-IV criteria for Dysthymic Disorder?
- Depressed mood for the majority of time of most days for at least 2 years (children for at least 1 yr)
- At least 2 of the following:
- Poor concentration or difficulty making decisions
- Feelings of hopelessness
- Poor appetite or overeating
- Insomnia or hypersomnia
- Low energy or fatigue
- Low self-esteem
- During the 2-year period
- The person has not been without the above symptoms for >2 months at a time
- No major depressive episode
For Dysthymic Disorder, the patient must never have had…..
a manic of hypomanic episode
would make diagnosis bipolar or cyclothymic disorder
What is Double Depression?
Patients w/ major depressive disorder with dysthymic disorder during residual periods
What is the acronym for Dysthymic Disorder?
CHASES
- poor Concentration or difficulty making decisions
- feelings of Hopelessness
- poor Appetite or overeating
- inSomnia or hypersomnia
- low Energy or fatigue
- low Self-esteem
Dysthymic Disorder
- Lifetime prevalence: ___%
- Women vs. men
- Onset before age ___ in 50% of patients
- Lifetime prevalence: 6%
- 2-3x more common in women
- Onset before age 25 in 50% of patients
What is the course and prognosis of Dysthymic Disorder?
- 20% of patients will develop major depression
- 20% will develop bipolar disorder
- >25% will have lifelong symptoms
How is Dysthymic Disorder treated?
- Cognitive therapy and insight-oriented psychotherapy are the most effective
- Antidepressant medications are useful when used concurrently (SSRIs, TCAs, MAOIs)
What is cyclothymic disorder?
Alternating periods of hypomania and periods with mild to moderate depressive symptoms
What is the DSM-IV criteria for cyclothymic disorder?
- Numerous periods with hypomanic symptoms and periods with depressive symptoms for at least 2 years
- The person must never have been symptom free for >2 months during those 2 years
- No hx of major depressive episode or manic episode
Cyclothymic Disorder
- Lifetime prevalence: ___%
- May coexist with _________.
- Onset usually age _____.
- Males vs. Females
- Lifetime prevalence: <1%
- May coexist with borderline personality disorder
- Onset usually age 15-25
- Males = Females
Cyclothymic Disorder
- Course & prognosis
- Treatment
- Chronic course
- 1/3 of patients eventually diagnosed with bipolar disorder
- Antimanic agents used to treat bipolar disorder
What are 6 other disorders of mood in DSM-IV?
- Minor depressive disorder
- Episodes of depressive symptoms that do not meet criteria for MDD
- Euthymic periods are also seen, unlike dysthymic disorder
- Recurrent brief depressive disorder
- Premenstrual dysphoric disorder
- Mood disorder due to a general medical condition
- Substance-induced mood disorder
- Mood disorder not otherwise specified (NOS)
