Mood Disorders Flashcards
(35 cards)
MDD
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
What disorders can feature major depressive episodes?
MDD, BP I and BP II
Symptoms of a depressive episode
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
History and physical for MDD
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.
Treatment of depression
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
Contraindications to ECT
1) Recent MI/Stroke
2) Intracranial mass
3) High anesthetic risk (relative contraindication)
Summary of pharm treatment for MDD
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.
SSRIs
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
Atypicals
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
SNRIs
Venlafaxine, Duloxetine
Indications: Depression, anxiety, chronic pain
Side effects:
Venlafaxine: Diastolic HTN
TCAs
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
MAOIs
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.
Exceptions to SSRI use
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
Mood disorder due to a medical condition
Hypothyroidism, Parkinson’s, CNS neoplasm, other neoplasms (pancreatic cancer), stroke (ESP ACA stroke), dementias, parathyroid disorders
Susbtance-induced mood disorder
Illicit drugs, alcohol, antihypertensives, corticosteroids, OCPs
Adjustment disorder with depressed mood
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.
Normal bereavement
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
Dysthymia (Persistent Depressive Disorder)
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
Ddx of postpartum mood disorders
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.
Bipolar Disorder
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.
Bipolar 1
At least 1 manic or mixed episode (usually requiring hospitalization)
“Mania and depression”
Bipolar 2
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”
Rapid cycling
Involves 4 or more episodes (MDE, manic, mixed, or hypomanic) in 1 year
Cylcothymic
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
