Mood Disorders

Question 1

MDD

Answer 1

Mood disorder characterized by 1 or more major depressive episodes. Male to female ratio is 1 to 2.

Lifetime prevalence is 15-25%

Onset usually in mid 20s; in elderly, prevalence increases with age. Chronic illness and stress increase the risk. Approximately 2-9% die by suicide

Question 2

What disorders can feature major depressive episodes?

Answer 2

MDD, BP I and BP II

Question 3

Symptoms of a depressive episode

Answer 3

SIG E CAPS. Need depressed mood or anhedonia plus 5 or more out for 2 wks

1) Sleep (too much or too little)
2) Interest (loss of interest or pleasures in activities)
3) Guilt (feelings of worthlessness or inappropriate guilt)
4) Energy (reduced or fatigue)
5) Concentration (reduced)
6) Appetite (any change) or weight (any change)
7) Psychomotor agitation or retardation
8) Suicidal ideation

Question 4

History and physical for MDD

Answer 4

Diagnosis requires depressed mood or anhedonia plus 5 or more signs/symptoms from SIG E CAPS for a 2 week period

1) Psychotic features: Typically mood-congruent delusions/hallucinatons
2) Postpartum: Occurs within 1 month postpartum - has 10% incidence and a high risk of recurrence. Psychotic symptoms are common.
3) Atypical: Characterized by weight gain, hypersomnia, and rejection sensitivity. Mood worse in evening. Extremities feel heavy. Tx is SSRI or MAOI. Usually for atypical depression, MAOIs are the answer on tests.
4) Seasonal: Depressive episodes tend to occur during a particular season, most commonly winter. Responds well to light therapy with or without antidepressants. Tx is phototherapy with bupropion or SSRIs. Patient should be 12-18 inches from light source of 10,000 lux of white fluorescent light without UV wavelengths for 30min each morning. Eyes should be kept open. Don’t need to stare at light though.
5) Double depression: major depressive episode with dysthymia. Has poorer prognosis than major depressive episode alone.

Question 5

Treatment of depression

Answer 5

1) Pharm. Effective in 50-70% of patients. Allow 2-6w to take effect; treat for 6 or more months.
2) Psychotherapy: Psychotherapy combined with pharm is more effective than either alone.

3) ECT
a) safe, highly effective and often lifesaving therapy that is reserved for refractory depression or psychotic depression, or if rapid improvement in mood is needed
b) May also be used for intractable mania and psychosis. Usually requires 6-12 treatments
c) Adverse effects include postictal confusion, arrhythmias, HA, and anterograde amnesia

4) Phototherapy - effective for patients whose depression has a seasonal pattern
5) TMS - Now approved for treatment of minor depression. TMS is about as effective as meds for some patients but not as effective as ECT

DISCONTINUE SSRIs AT LEAST 2 WEEKS BEFORE STARTING MAOI. WAIT 5 WEEKS IF PATIENT WAS ON FLUOXETINE

Question 6

Contraindications to ECT

Answer 6

1) Recent MI/Stroke
2) Intracranial mass
3) High anesthetic risk (relative contraindication)

Question 7

Summary of pharm treatment for MDD

Answer 7

First line is SSRIs like fluoxetine, paroxetine, sertraline, citalopram, escitalopram. SSRIs are chosen due to milder side effects and bc they are less toxic in OD than other antidepressants. Do not take with MAOI due to serotonin syndrome.

If no effect after 4 weeks, switch to another SSRI

If some improvement is noted, but not full response, increase the dose of the SSRI

Although TCAs can be used, their lethal potential argues against routine use

Second line is SNRI like venlafaxine, duloxetinem or desvenlafaxine. Side effects are HTN and sweating

Therapy like CBT is proven effective. Reduce depression by teaching patients to identify negative cognitions and develop positive ways of thinking.

Question 8

SSRIs

Answer 8

Fluoxetine, sertraline, paroxetine, citalopram, fulvoxamine

Indications: Depression, anxiety

Side effects:
1) Sexual side effects, GI, agitation, insomnia, tremor, diarrhea

2) Serotonin Syndrome - fever, AMS, CV collapse - can occur if SSRIs are used with MAOIs, illicit drugs or herbal meds
3) Paroxetine can cause pulmonary HTN in fetus. Avoid in pregnancy

Question 9

Atypicals

Answer 9

Bupropion, mirtazepine, trazodone

Indications: Depression, anxiety

Side effects:
1) Bupropion: Lowers seizure threshold; minimal sexual side effects. Contraindicated in patients with eating disorders as well as in seizure patients

2) Mirtazepine: Weight gain, sedation
3) Trazodone: Highly sedating, priapism

Question 10

SNRIs

Answer 10

Venlafaxine, Duloxetine

Indications: Depression, anxiety, chronic pain

Side effects:
Venlafaxine: Diastolic HTN

Question 11

TCAs

Answer 11

Nortriptyline, desipramine, amitriptyline, imipramine

Indications: Depression, anxiety, chronic pain, migraines, enuresis (imipramine)

Side effects:
1) Lethal with OD owing to cardiac conduction arrhythmias (prolonged conduction through the AV node, long QRS). Monitor in the ICU for 3-4d following and OD

2) Anticholinergic effects - dry mouth, constipation, urinary retention, sedation

Question 12

MAOIs

Answer 12

Phenelzine, tranylcypromine, selegiline (a patch form available)

Indications: Depression, esp atypical

Side effects:
1) HTN crisis if taken with high-tyramine foods (aged cheese, red wine)

2) Sexual side effects, orthostatic hypotension, weight gain.

Question 13

Exceptions to SSRI use

Answer 13

1) Depression and neuropathic pain: Use duloxetine since it is approved for depression and neuropathy
2) Patient with depression who is fearful of weight gain or sexual effects or is a smoker trying to quit: Use bupropion since it has less sexual side effects and less weight gain than SSRIs. Approved for smoking cessation. Can also be used as adjunct or replacement for SSRI-induced sexual side effects

Question 14

Mood disorder due to a medical condition

Answer 14

Hypothyroidism, Parkinson’s, CNS neoplasm, other neoplasms (pancreatic cancer), stroke (ESP ACA stroke), dementias, parathyroid disorders

Question 15

Susbtance-induced mood disorder

Answer 15

Illicit drugs, alcohol, antihypertensives, corticosteroids, OCPs

Question 16

Adjustment disorder with depressed mood

Answer 16

A constellation of symptoms that resemble a major depressive episode but do not meet the criteria for one. Occurs within 3 months of an identifiable stressor.

Question 17

Normal bereavement

Answer 17

Occurs after the loss of a loved one. Involves no severe impairment/suicidality

Usually lasts less than 6 months

Should resolve within 1 year.

May lead to MDD that requires treatment.

Illusions/hallucinations of the deceased can be normal as long as the person recognizes them as such.

Pharm is the wrong answer for treatment

Question 18

Dysthymia (Persistent Depressive Disorder)

Answer 18

Milder, chronic depression with depressed mood present most of the time for at least 2 years; often resistant to treatment

1 year in kids or adolescents

Tx = antidepressants and CBT

Question 19

Ddx of postpartum mood disorders

Answer 19

1) Postpartum Blues - Immediate to within 2w of delivery. Sadness, moodiness, emotional lability. No thoughts about hurting baby. Tx = supportive. Usually self limited.
2) Postpartum psychosis (Bipolar disorder with peripartum onset or Brief Psychotic Disorder with peripartum onset) - from pregnancy to within 2-4w postdelivery. Delusions and depression. May have thoughts about hurting baby. Tx is lithium, antipsychotics and maybe antidepressants
3) Postpartum depression - 1-3months postpartum. Same as above plus sleep disturbances and anxiety. Thoughts of hurting baby. Tx = antidepressants.

Question 20

Bipolar Disorder

Answer 20

Prevalence is about 1% for type 1 and an extra 3% for type 2. Males and females affected equally. A family history of bipolar illness significantly increases the risk.

Avg age of onset is 20, and frequency of mood episodes tends to increase with age. Up to 10-15% of those affected die by suicide.

Question 21

Bipolar 1

Answer 21

At least 1 manic or mixed episode (usually requiring hospitalization)

“Mania and depression”

Question 22

Bipolar 2

Answer 22

Involves at least 1 major depressive episode and 1 hypomanic episode.

Patients do not meed criteria for full manic or mixed episodes.

“Hypomania and depression”

Question 23

Rapid cycling

Answer 23

Involves 4 or more episodes (MDE, manic, mixed, or hypomanic) in 1 year

Question 24

Cylcothymic

Answer 24

Chronic and less severe, with alternating periods of hypomania and moderate depression for more than 2 years

Tx = lithium, valproic acid, or antipsychotics and therapy

Question 25

Symptoms of mania

Answer 25

DIG FAST

1) Distractibility
2) Insomnia (less need for sleep)
3) Grandiosity (increased self esteem)/more Goal directed
4) Flight of ideas (or racing thoughts)
5) Activities/psychomotor Agitation
6) Sexual indiscretions/other pleasurable activities
7) Talkativeness/pressured speech

Question 26

History and exam for bipolar

Answer 26

1) DIG FAST for mania symptoms
2) Patients may report excessive engagement in pleasurable activities (excessive spending, sex), reckless behaviors, and/or psychotic features
3) Antidepressant use may trigger manic episodes**

Question 27

Diagnosis of bipolar

Answer 27

1) A manic episode is 1 week or more of persistently elevated, expansive or irritable mood PLUS 3 dig fast symptoms. Psychotic features are also common. Mania affects functioning and usually warrants hospitalization.
2) Symptoms are not due to a substance (cocaine or meth - get UTox) or medical condition and lead to significant impairment socially, occupationally or familially.
3) Hypomania is similar but does not involve marked functional impairment or psychotic symptoms and does not require hospitalization. Less than 1 week.

Question 28

Tx of BPD

Answer 28

1) Bipolar mania - mania is considered a psych emergency owing to impaired judgment and great risk of harm to self and others.
a) Acute therapy - antipsychotics**
b) Maintenance therapy - Mood stabilizers
c) Use benzos for refractory agitation

For acute mania, use lithium, valproic acid, and atypical antipsychotics**. Do not need to check levels in acute setting. Treat BEFORE you admit.

2) Bipolar depression - Mood stabilizers plus or minus antidepressants. Start mood stabilizers first to avoid inducing mania. ECT may be needed if refractory.

Lithium, quetiapine, lurasidone, lamotrigine. Lurasidone is the only category B pregnancy drug in this class that is approved for this. If kidneys are compromised, never use lithium

3) In patients with severe depression or bipolar 2 with predominantly depressive features, antidepressant treatment can be augmented with low dose lithium - blood levels of 0.4-0.6

Question 29

Lithium

Answer 29

Indications: First line mood stabilizer. Used for acute mania (in combo with antipsychotics), for ppx in BPD, and for augmentation in depression treatment

Side effects
1) Thirst, polyuria, diabetes insipidus, tremor, weight gain, hypothyroidism, nausea, diarrhea, seizures, teratogenicity (1st trimester), acne, vomiting

2) Narrow therapeutic window (but blood level can be monitored)
3) Li toxicity - greater than 1.5. Presents with ataxia, dysarthria, delirium, and acute renal failure. Avoid Li in patients with lower renal function.

Question 30

Carbamazepine

Answer 30

Indications: Second line mood stabilizer; anticonvulsant, trigeminal neuralgia

Side effects:
1) nausea, skin rash, leukopenia, AV block

2) Rarely, aplasitc anemia (monitor CBC biweekly).
3) SJS

Question 31

Valproic acid

Answer 31

Indications: BPD, anticonvulsant

Side effects:
1) GI side effects (n/v), tremor, sedation, alopecia, weight gain

2) Rarely, pancreatitis, thrombocytopenia, fatal hepatotoxicity, agranulocytosis

Question 32

Lamotrigine

Answer 32

Indications: Second line mood stabilizer, anticonvulsant

Side effects:
1) Blurred vision, GI distress, SJS. Increase dose slowly to monitor for rashes.

Question 33

Treatment of Serotonin Syndrome

Answer 33

Stop SSRI. Symptomatic relief of fever, diarrhea, HTN.

Cyproheptadine (serotonin antagonist)

Question 34

Side effects of ECT

Answer 34

HA, transient memory loss

Question 35

What is the most effective treatment for depression?

Answer 35

ECT

If question asks for most effective, always pick ECT even if it may not be indicated specifically for that question.