Mood Disorders

Question 1

Mood Disorders with Depressed Mood

Answer 1

1) Major depressive disorder (MDD)
2) Persistent depressive disorder (formerly dysthymic disorder)
3) Premenstrual dysphoric disorder
4) Adjustment disorder with depressed mood
5) Disruptive mood regulation disorder

Question 2

Mood Disorders with Depressed AND Elevated Mood

Answer 2

1) Bipolar 1 disorder
2) Bipolar 2 disorder
3) Cyclothymia

Question 3

Mood: Definition

Answer 3

The pervasive and sustained emotion that is felt subjectively.

“I feel sad”

Question 4

Affect: Definition

Answer 4

The observed expression of emotion.

“He looks sad.”

Question 5

Criteria for Major Depressive Disorder

Answer 5

A. at least 5 of the following 9 symptoms present during a 2-week period, nearly every day, including one of 1) and 2)

1. Depressed mood
2. Anhedonia (diminished interest or pleasure)
3. Anergia (fatigue or loss of energy)
4. Appetite/weight change (5% increase or decrease in 1 month)
5. Insomnia or hypersomnia
6. Psychomotor agitation or retardation
7. Feelings of worthlessness or guilt
8. Poor concentration
9. Recurrent thoughts of death or suicide

B. Significant distress or impairment in functioning

C. Not due to direct physiological effects of a substance or medication

D. Not better explained by another disorder

E. Never had a manic episode

Question 6

Other Symptoms of MDD

Answer 6

Loss of libido

Anxiety

Diurnal variation in mood (worse when wake up)

Hallucinations (MDD with psychotic features)

Delusions (MDD with psychotic features)

Worse in winter (MDD with seasonal pattern (SAD))

Onset of pregnancy or month after delivery

Pseudo dementia (patients can present with low scores on MMSE)

Question 7

Epidemiology of Major Depressive Disorder

Answer 7

F > M at a ratio of 2:1

20% female lifetime prevalence and 10% male

Peak age of onset = 40

Increased in lower SES

Avg # of episodes = 5

Single/divorced > married

Duration 13 months (untreated) or 3 months (treated)

50% recurrence after 1st episode

Question 8

Risk Factors for Major Depressive Disorder

Answer 8

Age > 40

Female

Substance use

1st degree relative

Chronic medical conditions

Lack of close interpersonal relationships

Anxiety disorder

Question 9

Etiology of Major Depressive Disorder

Answer 9

A. Biological - genetic risk factors because 1st degree relatives have a 10-15% risk associated and MZ twins have a 50% risk. There is also the monoamine hypothesis where decreased NE and 5HT are implicated.

B. Social - adverse life events increased the risk for depression, as do a lack of close confiding relationships for the individual.

Question 10

Investigations for Major Depressive Disorder

Answer 10

PHQ-9

Question 11

Treatment of Major Depressive Disorder

Answer 11

Antidepressants (SSRIs, TCAs, MAOIs) (not first line in kids/adolescents)

CBT (as effective as antidepressants)

ECT (electroconvulsive therapy)

Light treatment

Psychotherapy

Question 12

Cognitive Theory of Depression

Answer 12

Postulates that depressive and pessimistic thoughts are the primary reasons for depression, and cause the depressed effect and other symptoms.

Cognitive behavioural therapy aims to 1) identify automatic thoughts eg. “they didn’t speak to me because I’m worthless”, 2) test and re-evaluate automatic thoughts, 3) identify maladaptive assumptions eg. “If someone doesn’t like me, it means I’m unlovable”, and 4) test and re-evaluate maladaptive assumptions.

Question 13

Serotonin Specific Reuptake Inhibitors (SSRIs)

Answer 13

Have various uses but are used in the treatment of depression.

Examples include fluoxetine, fluvoxamine, paroxetine, sertraline, and citalopram.

Side effects include GI disturbance, insomnia, agitation, headaches, lower seizure threshold, precipitate mania, and sexual side effects.

Question 14

Tricyclic Antidepressants (TCAs)

Answer 14

Used in the treatment of depression.

Examples include amitryptiline, imipramine, desipramine, and clomipramine.

Side effects include them being an anticholinergic, cardiac ECG changes, antiadrenergic, sedation, weight gain, lower seizure threshold, and the precipitation of mania.

Question 15

Monoamine Oxidase Inhibitors (MAOIs)

Answer 15

Rarely used today but may be much more effective for atypical depression.

Major complications is the hypertensive crisis that is caused by ingesting tyramine or sympathomimetics. You need to avoid pickled herring, liver, salamis, broad bean pods, cheese and yogurt, beer and wine, and yeast extract.

Question 16

Which Drug to Use?

Answer 16

All drugs for depression (except MAOIs) are equally efficacious.

You want to consider past response, family response, side effect profiles, and drug/medical interactions.

Advantage to SSRI’s are that they are more tolerable, safer in overdose, and less of a need to titrate.

Advantage to TCAs are they have a much cheaper cost, and have better effect in severe depression.

Question 17

Continuation / Maintenance Treatment of Depression

Answer 17

Treat for at least 6 months initially.

Consider long-term medication if multiple relapses.

Maintenance treatment is proven effective if 3 episodes in less than 5 years because there is a 15% mortality from suicide if untreated.

Question 18

Manic Episode

Answer 18

1 week of abnormally elevated or irritable mood and increased energy or goal-directed activity. Also, you need 3 out of the following 7 symptoms (or 4 if only irritable)…

1. Grandiosity
2. Decreased need for sleep
3. More talkative than usual (pressure of speech)
4. Flight of ideas
5. Distractability
6. Increased in goal-directed activity
7. Excessive involvement in pleasurable activities with a high potential for painful consequences

These are severe enough to markedly impair functioning.

Other symptoms can include delusions and hallucinations.

Question 19

Hypomanic Episode

Answer 19

Same as a manic episode but only needs to last for four days. Need 3 out of the following.

1. Grandiosity
2. Decreased need for sleep
3. More talkative than usual (pressure of speech)
4. Flight of ideas
5. Distractability
6. Increased in goal-directed activity
7. Excessive involvement in pleasurable activities with a high potential for painful consequences

Question 20

Bipolar I

Answer 20

Major depressive episodes + manic episode

Question 21

Bipolar II

Answer 21

Major depressive episodes + hypomanic episode (4 days)

Less severe than bipolar I. Not as much marked impairment, psychosis, or hospitalization.

Question 22

Epidemiology of Bipolar I

Answer 22

1% lifetime risk

M = F

Peak age of onset is 20

Increase in higher SES

Avg # of episodes = 9

Single/divorced > married

90% get further episodes if untreated

Question 23

Treatment of Bipolar Disorders

Answer 23

You must first decide on whether you will treat the patient as an inpatient or an outpatient. Patients suffering from a manic episode usually require admission and often require certification.

Tx: mood stabilizers - lithium (gold standard) or valproate

antidepressants for depressive episodes

anti-psychotics

sedatives (acutely only)

Question 24

Teratogenic Effects of Mood Stabilizers

Answer 24

Lithium - 0.01% chance of Ebstein anomaly

Valproate - 8% chance of neural tube defects

Question 25

Treatment of Mania

Answer 25

Antipsychotics

Mood stabilizers

Question 26

Lithium Carbonate

Answer 26

Used as a mood stabilizer.

Treatment dose varies. In the acute episode you want to aim for a level of 0.8-1.2 MM and in the maintenance phase you want to aim for 0.6-1.0 MM.

Toxicity is seen at low doses (sometimes as little as 1.5 MM) which makes careful monitoring extremely important. Cleared through the kidney.

Question 27

Lithium Side Effects

Answer 27

At therapeutic levels… tremor, polyuria/polydipsia, weight gain, hypothyroidism, ECG changes, teratogenesis (rare)

At toxic levels… nausea and vomiting and diarrhea, coarse tremor, ataxia, dysarthria, seizures, coma, death.

Question 28

Prognosis of Bipolar Disorder

Answer 28

90% will get further episodes with an average of 9 in a lifetime

Prophylaxis is indicated long-term after 1st manic episode though patients are often wishing to retry without prophylaxis. Prophylaxis reduces the risk of recurrence by more than 50%.

15% mortality from suicide over their lifetime if untreated.

Question 29

Persistent Depressive Disorder

Answer 29

Fewer depressed symptoms but a longer time-course.

A. Depressed mood most of the day, more days than not, for a period of 2 years or longer.

B. 2 or more of…

poor appetite or overeating

insomnia or hypersomnia

anergia

poor concentration

hopelessness

low self-esteem

Typically has a longer course such as the patient stating that he/she, “I’ve been depressed all my life.”

This is common and has a 3% lifetime prevalence.

Psychological therapy is the most important.

Question 30

Adjustment Disorder with Depressed Mood

Answer 30

Emotional or behavioural symptoms occuring in response to a stressor.

Very common in hospital (5%).

Lasts less than 6 months and treatment, if necessary, involves supportive psychotherapy.

Question 31

Bereavement

Answer 31

May look very much like major depression however it is distinguished by…

Suicidal ideas not present

Psychosis not present (except visual hallucination of deceased)

Guilt doesn’t extend beyond deceased

Time scale

Treatment is psychological and talking about the deceased, social in terms of supports, and occasionally biological for a short period of time.

Question 32

Mood Disorder Due to Another Medical Condition

Answer 32

Mood disorder of any severity but “prominent and persistent and directly due to a medical disorder.”

Strokes (50%)

Parkinson’s (50%)

Mono

HIV

Hepatitis

Cushings

Hyperparathyroidism

Hypothyroidism

Cancer

Tx: Treat cause first +/- anti-depressants if needed.