Mood Disorders

Question 1

What defines a depressive episode?

Answer 1

• 5/9 (1 must be anhedonia OR depressed mood) nearly everyday for 2 weeks; functional impairment
  
  • Anhedonia - impaired ability to experience pleasure
  • Depressed mood
  • Insomnia or hypersomnia
  • Weight loss or gain
  • Psychomotor agitation or retardation
  • Fatigue/loss of energy
  • Worthlessness/guilt
  • Dec conc
  • Recurrent thoughts of death or suicide

Question 2

Poss Depression Etiologies (Psych and Bio)

Answer 2

• Psych Theories
  
  • Dysfunctional maturation (Freud), dec response to pos reinforcement, learned helplessness, disrupted affectional bonds b/n mom and infant, neg world view
• Bio
  
  • Catecholamine/serotonin def
  • Cortisol abnormalities
  • Inflammatory cytokines
  • Circadian rhythm off
  • Genetics
  • Lesions (esp frontal)

Question 3

MDD Epidemiology

Answer 3

• Women 2x > men
• Onset - mid 30s
• COMMON (20% female 10% male lifetime prevalence)
• MZ 30-50% heritability

Question 4

MDD Presentation

Answer 4

• Look for masked depression… unexplained physical symptoms, inadequate response to normal meds, irritability, marital or interpersonal probs
• Adolescence = mood/irritable
• Elderly = anhedonia
• Symptoms (SIGECAPS)
  
  • S- sleep
  • I - interest
  • G- guilt
  • E - energy
  • C- concentration
  • A- appetite
  • P - psychomotor activity (retardation/agitation)
  • S- suicidal thoughts or behaviors

Question 5

MDD Tx

Answer 5

• Pharm - SSRIs, SNRIs, TCAs, buproprion, lithium, MAOIs (diet restrictions), mirtazapine
  
  • Side effects = GI, headache, changes in sleep, weight gain, dec libido, restless
• Psychotherapy - CBT, interpersonal therapy, family therapy, psychoanalysis (high functioning adults)
• ECT - highest remission rates (OR transcranial magnetic stimulation OR vagal nerve stimulation)
• Surgery - esp BA25 region near anterior cingulate
• Ketamine infusion (NMDA antagonist)- for treatment resistant depression (OFF LABEL); works in hours but transient so need re-infusions every few days
• Alternatives - exercise, yoga, St Johns Warts (CYPs), omega FAs

Question 6

MDD Evaluation

Answer 6

• Screen - Have you felt down, depressed or hopeless? Have you lost interest or pleasure in things you used to enjoy?
• DETRE
  
  • Diagnose
  • Education
  • Treat (treat for 6 mo after episode even if feeling better)
  • RE-evaulate
• *- Assess in 1-2 wks
• May inc dose after 3-4 wks then re-evaulate again; if still no response switch; if partial response may augment
• Consider risk of suicide or mania

Question 7

DSM Manic Episode

Answer 7

• Elevated, expansive, irritable mood and inc energy for 1 week+ or if any hospitalization is needed
• 3 of the following (4 if mood is only irritable)
  
  • Inflated self esteem
  • Dec need for sleep
  • More talkative
  • Flight of ideas; jump b/n subjects
  • Distractible
  • Inc goal oriented activity or inc purposeless activity
  • Excessive involvement in pleasurable but risky activities
• Must cause impairment in social or occupational functioning OR have psychotic features
• Not due to substance or other medical condition

Question 8

Hypomanic Episode

Answer 8

• Same as above but only 4 days AND no hospitalizations

- Change is observable to others but not severe enough to cause marked impairment

Question 9

Bipolar I v Bipolar II

Answer 9

• I- at least 1 manic episode (usually preceded or followed by at least one depressive episode)
• II - 1+ major depressive episodes, 1+ hypomanic episodes, NO MANIC EPISODES

Question 10

Bipolar Epidemiology

Answer 10

• MZ 45-75% heritability

- More likely to get major depressive disorder if have family member w/ bipolar disorder

Question 11

Bipolar Prognosis

Answer 11

• Most spend more time in depression than mania
• Poor prognosis if… family hx, early age of onset, severity of manic episode, rapid-cycling (> 3 episodes / yr), psych co-morbidity, hx suicide attempts

Question 12

Bipolar Tx

Answer 12

• Acute - prevent harm and start educating; mood stabilizers
• Continuation - complete mood stabilization and start relapse prevention
• Maintain - usually treated indefinitely
• Pharm
  
  • Mood stabilizers (lithium and anti-convulsants like CBZ) and atypical anti-psychotics + adjunctive anti-dep (only use co-currently) and benzos (initiate sleep and dec agitation)
• Psych
  
  • CBT for neg or distorted thoughts
  • Education
  • Interpersonal and Social Rhythms Therapy (regulate social cues and circadian)
  • Family focused therapy

Question 13

Bipolar Co-Morbidities

Answer 13

• Other psych - anxiety, personality disorders, substance use disorders, ADHD
• General Medical - obesity, hyperlipiedmia, DN, cardio, migraine, thyroid disease
• Can be pro-inflammatory