Mood Disorders Flashcards
What is a mood?
A description of one’s internal emotional state
Both external & internal stimuli can trigger moods, which may be labeled as sad, happy, angry, irritable, etc.
It is normal to have wide range of moods & to have a sense of control over one’s moods
What is a mood disorder?
Aka affective disorders
Patients w/ mood disorders experience an abnormal range of moods & lose some level of control over them
- Distress may be caused by severity of their moods & resulting impairment in social & occupational functioning
Defined by patterns of mood episodes
Include major depressive disorder (MDD), bipolar I disorder, bipolar II disorder, persistent depressive disorder, & cyclothymic disorder
Some may have psychotic features (delusions / hallucinations)
- When patients have delusions / hallucinations due to underlying mood disorders, they are usually mood congruent
With what disorders can major depressive episodes present in?
Major depressive disorder
Persistent depressive disorder (dysthymia)
Bipolar I / II disorder
What are mood episodes?
Distinct periods of time in which some abnormal mood is present
Include depression, mania, & hypomania
DSM-V criteria of major depressive episode
Must have at least 5 of the following symptoms (must include number 1 or 2), for at least 2 weeks: 1. Depressed mood most of the time 2. Anhedonia (loss of interest in pleasurable activities) SIG E CAPS 3. Sleep (insomnia / hypersomnia) 4. Interest (anhedonia) 5. Guilt or feelings of worthlessness 6. Energy (loss) or fatigue 7. Concentration (diminished) 8. Appetite (increased/decreased) 9. Psychomotor agitation or retardation 10. Suicidal ideation (recurrent thoughts of death / suicide)
Symptoms are not attributable to the effects of substance (drug / medication) or another medical condition
Must cause clinically significant distress or social / occupational impairment
DSM-V criteria of manic episode
Distinct period of:
- Abnormally & persistently elevated, expansive, or irritable mood
- Abnormally & persistently increased goal-directed activity or energy lasting at least 1 week (or any duration if hospitalization is necessary)
- Including at least 3 of the following (4 if mood is only irritable):
DIG FAST
1. Distractibility
2. Insomnia / impulsive behavior / decreased need for sleep
3. Grandiosity or inflated self-esteem
4. Flight of ideas / racing thoughts
5. Activity / `agitation (increase in goal-directed activity or psychomotor agitation)
6. Speech (pressured [rapid & uninterruptible] or more talkative than usual)
7. Thoughtlessness (excessive involvement in pleasurable activities that have a high risk of negative consequences - e.g. shopping sprees, sexual indiscretions)
Symptoms are not attributable to effects of substance (drug / medication) or another medical condition
Must cause clinically significant distress or social/occupational impairment
> 50% of manic patients have psychotic symptoms
Manic episode is a psychiatric emergency
What is a hypomanic episode?
Distinct period of abnormally & persistently elevated, expansive, or irritable mood
Abnormally & persistently increased goal-directed activity or energy
Lasting at least 4 consecutive days
Includes at least 3 of the symptoms listed for manic episode criteria (4 if mood is only irritable): DIG FAST
Differences between manic & hypomanic episodes
Time frame:
- Mania: lasts at least 7 days
- Hypomania: lasts at least 4 days
Impairment in social or occupational functioning
- Mania: severe impairment
- Hypomania: no marked impairment
Hospitalization:
- Mania: may necessitate hospitalization to prevent harm to self/others
- Hypomania: does not require hospitalization
Psychotic features:
- Mania: have psychotic features
- Hypomania: no psychotic features
Mixed features of mood episodes
Criteria are met for a manic or hypomanic episode & at least 3 symptoms of a major depressive episode are present for majority of the time
Criteria must be present nearly every day for at least 1 week
Diagnosis of mood disorders
Often have chronic courses that are marked by relapses w/ relatively normal functioning between episodes
Like most psychiatric diagnoses, mood episodes may be caused by another medical condition or drug (prescribed or illicit)
Always investigate medical / substance-induced causes before making primary psychiatric diagnosis
Differential diagnosis of mood disorders (depressive & manic episodes) due to other medical conditions
Medical causes of depressive episode:
- Cerebrovascular disease (stroke, MI) - stroke patients are at significant risk for developing depression & associated w/ poorer outcome overall
- Endocrinopathies (DM, Cushing syndrome, Addison disease, hypoglycemia, hyper/hypothyroidism, hyper/hypocalcemia)
- Parkinson’s disease
- Viral illnesses (e.g. mono)
- Carcinoid syndrome
- Cancer (lymphoma, pancreatic carcinoma)
- Collagen vascular disease (e.g. SLE)
Medical causes of manic episode:
- Metabolic (hyperthyroidism)
- Neurological disorders (temporal lobe seizures, MS)
- Neoplasms
- HIV infection
Substance / medication-induced mood disorders (depressive & bipolar disorder)
Substance/medication-induced depressive disorder:
- EtOH
- Antihypertensives
- Barbiturates
- Corticosteroids
- Levodopa
- Sedative-hypnotics
- Anticonvulsants
- Antipsychotics
- Diuretics
- Sulfonamides
- Withdrawal form stimulants (e.g. cocaine, amphetamines)
Substance/medication-induced bipolar disorder:
- Antidepressants
- Sympathomimetics
- Dopamine
- Corticosteroids
- Levodopa
- Bronchodilators
- Cocaine
- Amphetamines
What is major depressive disorder (MDD)?
Marked by episodes of depressed mood associated w/ loss of interest in daily activities
Patients may not acknowledge their depressed mood or may express vague, somatic complaints (fatigue, headache, abdominal pain, muscle tension, etc.)
Most common disorder among those who complete suicide
Most adults w/ depression do not see mental health professional, but they often present to primary care physician for other reasons
Diagnosis & DSM-V criteria of MDD
At least 1 major depressive episode
No history of manic / hypomanic episode
Epidemiology of MDD
Lifetime prevalence: 12% worldwide
Onset at any age, but age of onset peaks in 20s
1.5.-2 times as prevalent in women than men during reproductive years
No ethnic or socioeconomic differences
Lifetime prevalence in elderly: <10%
Depression can increase mortality for patients w/ other comorbidities (e.g. DM, stroke, cardiovascular disease )
Sleep problems associated w/ MDD
Multiple awakenings
Initial & terminal insomnia (hard to fall asleep, early morning awakenings)
- 2 most common types of sleep disturbances
Hypersomnia (excessive sleepiness) is less common
Rapid eye movement (REM) sleep shifted earlier in night & for greater duration, w/ reduced stages 3 & 4 (slow wave) sleep
Etiology of MDD
Precise cause is unknown, but it is believed to be a heterogeneous disease, w/ biological, genetic, environmental, & psychosocial factors contributing
Likely caused by neurotransmitter abnormalities in brain
- Antidepressants exert their therapeutic effect by increasing catecholamines
- Decreased CSF levels of 5-HIAA (main metabolite of serotonin)
Increased sensitivity of beta-adrenergic receptors in brain has also been postulated in pathogenesis of MDD
High cortisol: hyperactivity of hypothalamic-pituitary-adrenal axis
- Shown by failure to suppress cortical levels in dexamethasone suppression test
Abnormal thyroid axis: thyroid disorders are associated w/ depressive symptoms
GABA, glutamate, & endogenous opiates may additionally have role
Psychosocial / life events: multiple adverse childhood experiences are risk factor for later developing MDD
Genetics: first-degree relatives are 2 to 4 times more likely to have MDD
- Concordance rate for monozygotic twins is <40%, & 10-20% for dizygotic twins
What is used to screen for MDD?
Hamilton Depression Rating Scale: measures severity of depression & is used in research to assess effectiveness of therapies
PHQ-9: depression screening form often used in primary care setting
Course & prognosis of MDD
Untreated, depressive episodes are self-limiting, but last from 6-12 months
- Episodes occur more frequently as disorder progresses
- Risk of subsequent major depressive episode is 50-60% within first 2 years after first episode
Loss of parent before age 11 is associated w/ later development of major depression
Depression is common in patients w/ pancreatic cancer
2-12% of patients w/ MDD eventually commit suicide
Approx. 60% of patients show significant response to antidepressants
- Combined treatment w/ both antidepressant & psychotherapy produce significantly increased response for MDD
Treatment of MDD
Only 1/2 of patients w/ MDD receive treatment
HOSPITALIZATION
Indicated if patient is at risk for suicide, homicide, or is unable to care for him/herself
PHARMACOTHERAPY Antidepressant meds (all are equally effective, but differ in side effect profiles; usually take 4-6 weeks to fully work): - SSRIs - TCAs - MAOIs
Adjunct meds;
- Atypical (second-generation) antipsychotics
- T3, levothyroxine (T4), & lithium
- Stimulants
PSYCHOTHERAPY
Cognitive behavioral therapy (CBT), interpersonal psychotherapy, supportive therapy, psychodynamic psychotherapy, problem-solving therapy, family/couples therapy
- May be used alone or in conjunction w/ pharmacotherapy
ELECTROCONVULSIVE THERAPY (ECT)
ECT treatment & its side effects for MDD
Indicated if patient is unresponsive to pharmacotherapy, if patient can’t tolerate meds (pregnancy, etc.), or if rapid reduction of symptoms is desired (e.g. immediate suicide risk, refusal to eat/drink, catatonia)
Extremely safe & may be used alone or in combination w/ pharmacotherapy
Often performed by premedication w/ atropine, followed by general anesthesia (usually w/ methohexital) & administration of muscle relaxant (typically succinylcholine)
Generalized seizure is induced by passing current of electricity across the brain (generally bilateral)
- Seizure should last between 30-60 seconds, & no longer than 90 seconds
6-12 (average of 7) treatments are administered over 2- to 3-week period, but significant improvement is sometimes noted after first treatment
Side effects:
- Retrograde & anterograde amnesia are common side effects, which usually resolve within 6 months
- Headache
- Nausea
- Muscle soreness
SSRI treatment & its side effects for MDD
Safer & better tolerated than other classes of antidepressants
Side effects are mild:
- Headache
- GI disturbance
- Sexual dysfunction
- Rebound anxiety
Medications for MDD that activate neurotransmitters
SSRIs
SNRIs: venlafaxine (Effexor), duloxetine (Cymbalta)
Alpha2-adrenergic receptor antagonists: mirtazapine (Remeron)
Buproprion (Wellbutrin) - dopamine-norepinephrine reuptake inhibitor
TCA treatment & its side effects for MDD
Most lethal in overdose due to cardiac arrhythmias
Side effect:
- Sedation
- Weight gain
- Orthostatic hypotension
- Anticholinergic effects
- Can aggravate prolonged QTc syndrome
MAOI treatment & its side effects for MDD
Considered particularly useful in treatment of “atypical” depression, but SSRIs remain first-line treatment for major depressive episodes w/ atypical features
Older meds occasionally used for refractory depression
Risk of hypertensive crisis when used w/ sympathomimetics or ingestion of tyramine-rich foods (e.g. wine, beer, aged cheeses, liver, & smoked meats)
Risk of serotonin syndrome when used in combo w/ SSRIs:
- Autonomic instability
- Hyperthermia
- Hyperreflexia (including myoclonus)
- Seizures
- Coma or death may result
Most common side effect is orthostatic hypotension
When is adjunctive treatment done in MDD? What are they?
Usually performed after multiple first-line treatment failures
Atypical (second-generation) antipsychotics w/ antidepressants
- First-line treatment in patients w/ MDD w/ psychotic features
- May be prescribed in patients w/ treatment resistant / refractory MDD without psychotic features
Triiodothyronine (T3), levothyroxine (T4), & lithium have demonstrated some benefit when augmenting antidepressants in treatment refractory MED
While stimulants (e.g. methylphenidate) may be used in certain patients (e.g. terminally ill), the efficacy is limited & trials are small
Specifiers for depressive disorders of patients w/ MDE
- More likely in severely ill patients
- Characterized by anhedonia, early morning awakenings, depression worse in the morning, psychomotor disturbance, excessive guilt, & anorexia
Atypical features:
- Characterized by hypersomnia, hyperphagia, reactive mood, leaden paralysis, & hypersensitivity to interpersonal rejection
Mixed features:
- Manic/hypomanic symptoms present during majority of days during MDE: elevated mood, grandiosity, talkativeness/pressured speech, flight of ideas/racing
Melancholic features
Atypical features
Mixed features
Catatonia
Psychotic features
Anxious distress
Peripartum onset
Seasonal pattern
Melancholic features of depressive disorders
Present in 25-30% of patients w/ MDE
More likely in severely ill patients
Characterized by anhedonia, early morning awakenings, depression worse in the morning, psychomotor disturbance, excessive guilt, & anorexia
Atypical features of depressive disorders
Characterized by hypersomnia, hyperphagia, reactive mood, leaden paralysis, & hypersensitivity to interpersonal rejection
Mixed features of depressive disorders
Manic/hypomanic symptoms present during majority of days during MDE:
- Elevated mood
- Grandiosity
- Talkativeness/pressured speech
- Flight of ideas/racing
- Increased energy / goal-directed activity
- Excessive involvement in dangerous activities
- Decreased need for sleep
Catatonia of depressive disorders
Features include:
- Catalepsy (immobility)
- Purposeless motor activity
- Extreme negativism or mutism
- Bizarre postures
- Echolalia
Especially responsive to ECT
Psychotic features of depressive disorders
Characterized by presence of delusions and/or hallucinations
Present in 24-53% of older, hospitalized patients w/ MDD
Anxious distress of depressive disorders
Defined by feeling keyed up/tense, restless, difficulty concentrating, fears of something bad happening, & feelings of loss of control
Peripartum onset of depressive disorders
Onset of MDD symptoms occurs during pregnancy or 4 weeks following delivery
