Mood Disorders

Question 1

How likely is an individual in the US to experience clinical depression at some point in their lifetime?

Answer 1

1/8 chance

Question 2

“Masked depression”

Answer 2

In general medical settings, many patients with mood disorders present with unexplained somatic complaints, especially pain and insomnia, rather than a clearly stated emotional complaint

Question 3

Features of depression that are not seen in individuals dealing with external loss

Answer 3

Persistent self-criticism and lowered self-esteem

Question 4

Depressive bias or negative cognitive bias

Answer 4

Typically, a depressed patient views past events with undue criticism and guilt, feels worthless, and finds the world an unpromising place

Question 5

The mood disorders consist of ___

Answer 5

The mood disorders consist of the depressive and bipolar disorders

Question 6

A diagnosis of ___ can be made in the absence of depressive episodes

Answer 6

A diagnosis of bipolar I disorder can be made in the absence of depressive episodes

Question 7

“Vegetative” symptom

Answer 7

• Loss of apetite
• Insomnia
• Decrease in energy levels
• Decrease in sex drive

Question 8

Types of insomnia associated with depression

Answer 8

• Sleep-onset insomnia
• Sleep-maintenance insomnia
• Terminal insomnia

While sleep-onset insomnia is common and non-specific, the latter two are classic symptoms of depression.

Question 9

Atypical vegetative signs

Answer 9

• Sometimes called “reversed” vegetative signs
• 30% of depression patients
• Hypersomnia instead of insomnia
• Increased apetite

Question 10

Hypersomnia in depression

Answer 10

• More common in:
  
  • Adolescent depression
  • Bipolar disorders
  • Seasonal affective disorder

Question 11

Cognitive changes in depression

Answer 11

• Patients may say something along the lines of “I feel as if my mind just isn’t working properly”
• Inability to concentrate on immediate tasks
• Forgetting recent events
• Disorientation to time of day
• Frank confusion - sometimes called “pseudodementia”
  
  • Note that pseudodementia resolves with treatment of the depression

Question 12

Psychomotor changes in depression

Answer 12

• Usually diminished in depression patients
  
  • Thoughts, speech, and motor movements are often subjectively experienced and objectively observed to be slowed down
  • At the extreme, patients can appear mute and virtually immobile
• In contrast, some patients exhibit psychomotor agitation, in which they have rapid, repetitive thoughts and speech and frenzied movements
  
  • unstoppable crying, pacing, or hand wringing may be seen

Question 13

Persistent Depressive Disorder (aka Dysthymia)

Answer 13

• milder form of depression
• Lasts at least 2 years with little or no remission during that time
• Low mood, lack of energy and interest, low self-esteem, and irritability usually form the clinical picture
• Initial or intermediate insomnia, but rarely ever terminal insomnia
• Psychotic symptoms, such as delusions or hallucinations, are not present

Question 14

Two “groups” of patients with dysthymia

Answer 14

1. Those who have had depressive symptoms since childhood or late adolescence
2. Those who appear healthy when young but experience major losses, such as the death of a spouse or child, divorce, financial setback, or medical disability at some point in their adult lives and fall into a chronic state

Question 15

Premenstrual dysphoric disorder

Answer 15

Markedly depressed mood and anhedonia that present during the last week of the luteal phase, remit within a few days of the follicular phase, and are absent in the week following menses.

Question 16

The diagnosis of bipolar disorder is made as soon as a patient has ___

Answer 16

The diagnosis of bipolar disorder is made as soon as a patient has one manic episode, even if that person has never had a depressive episode.

Question 17

Bipolar I

Answer 17

Experience mania and a depressive disorder (although only manic episodes are necessary to establish the diagnosis)

Question 18

Bipolar II

Answer 18

Experience hypomania and, specifically, major depression

Question 19

Cyclothymia

Answer 19

Milder illness in which patients have hypomania and mild depressive symptoms that are not sufficiently severe to warrant the diagnosis of major depression.

Question 20

Criteria for a “major depressive episode”

Answer 20

Question 21

Characteristics of manic episode

Answer 21

Characterized by irritability or abnormal euphoria, and increased goal-directed activity or energy must be present, for one week’s duration (unless the patient requires hospitalization).

Note that people often tend to assocaited euphoria/elevated mood with mania, and this can and does occur, but the feeling of being “uncomfortably wound up” and irritable is what is more commonly described.

Manic elation quickly blends with irritability if their desires are frustrated. Indeed, anger is often the dominant emotion

Question 22

Features of mania

Answer 22

• Irritability/anger
• Heightened self esteem
• Feeling of being able to do anything, but frustration to any barriers
• Impaired insight (near-delusional, ubiquitous among manic patients)
• Perceived decreased need for sleep (this symptom is specific to bipolar disorder and stimulant use disorder, so clinical suspicion should be high if observed)
• Increased sexual drive and uninhibited social and sexual behavior together with poor judgment may lead to grossly indiscreet behavior
• Cognitive changes: racing thoughts, impulsivity, distractability, difficulty focusing on tasks requiring prolonged attention

Question 23

Speech changes in mania

Answer 23

One of the first indications that a patient is becoming manic may be a family member’s observation about pressured speech. Typically, they exhibit rapid or pressured speech, frequently interrupt others, and have difficulty listening.

Sequence of thoughts in speech becomes disorganized and illogical, and patients may skip rapidly between topics. Manic patients sometimes exhibit clang associations, when words are used only for their phonetic sound and not their meaning.

Question 24

Impulsive behavior in manic patients

Answer 24

Many manic patients behave in impulsive ways: spending sprees, extravagant traveling, sexual affairs, and risky business ventures are the hallmarks of their social dysfunction. Catastrophic ruin may result; marriages, jobs, lifetime savings, and reputations may be lost.

Question 25

Hypomania

Answer 25

• Less functional impairment than manic patients
• If psychotic symptoms occur, the episode is, by definition, manic and not hypomanic
• Energetic, goal-oriented, and may be well organized
• Enhanced creativity, sexual capacity, and leadership ability are not unusual
• If all activity is pleasurable, the condition does not come to the attention of a doctor. Many bipolar patients view hypomania as a silver lining and resent its being taken away through treatment​
• Hypomania may last for months, or it may precede by a few days a full-blown manic episode.

Question 26

Psychotic symptoms in mood disorders

Answer 26

• Can occur in both depressive and manic episodes
• Delusion is most common, sometimes hallucination, in addition to the other symptoms of major depression or mania
• Occur only during mood episodes and not at other times in their lives
• Mood-congruent delusions/hallucinations focus on a depressive theme such as guilt, pessimism, disease, impoverishment, or deserved punishment. The most typical mood-congruent manic themes are related to grandiosity, which may take a euphoric form or a hostile, paranoid form
  
  • Grandiose delusions of being on a special mission or having special abilities or powers are classic in manic patients
• Psychotic symptoms may be a major risk for suicide

Question 27

Seasonal affective disorder

Answer 27

• Usually fall/winter depression, but spring/summer depression has also been described
  
  • Lethargy and fatigue are common symptoms of winter seasonal pattern
  • Note that many people feel something like this in the winter, it is only SAD when it meets criteria for major depression and causes significant impairment
• Atypical features of hypersomnia and overeating are frequent but not universal
• Usually related to light deprivation and is more common in northern latitudes
  
  • Light therapy is an effective treatment

Question 28

Major depression with peri-partum onset

Answer 28

• In the weeks after they deliver a child, 10% of women experience mood disorders
  
  • Distinct from the transient “baby blues” that 50% of women experience for a few days immediately after giving birth
  • Depression with peripartum onset often recurs after subsequent pregnancies and often heralds bipolar disorder.
• Psychotic features rarely occur but are of grave concern
• In women thought to be at risk, antidepressants can be given or psychotherapy can be started immediately after birth as a preventive measure
• Hormonal treatments are ineffective

Question 29

Rapid cycling

Answer 29

Refers to distinct, sustained periods of mania, hypomania, or depression occurring at least four times a year, in the context of bipolar disorder

Question 30

Mood episodes with mixed features

Answer 30

Mixed features are defined by the simultaneous coexistence of depressive and manic symptoms in the same mood episode.

Used specifically to apply to mood episodes that meet the full criteria for mania, hypomania, or major depression and have at least three symptoms that belong to the opposite pole

Patients with mixed features have a high risk of suicide​

Question 31

Dysphoric mania

Answer 31

Example of a mixed mood disorder

Characterized by a sad, tearful mood, often with suicidality, and motor and cognitive signs of mania, such as irritability, pressured speech, racing thoughts, insomnia, and excessive energy.

Question 32

Asking about suicide

Answer 32

Doctors and laypersons sometimes fear that asking about suicide will make it happen. In fact, the opposite is true.

The best rule is to ask the patient calmly and directly: “Do you have thoughts of hurting yourself?” “Are you suicidal?” This phrasing is much preferable to the following: “You’re not suicidal, are you?”

When depressed patients reveal suicidal intent, the following empathic but firmly optimistic approach is suggested: “Right now, you feel that your life is not worth continuing. My view is that your illness has greatly impaired your capacity to judge your own self-worth and the circumstances of your life. I will do everything I can to ensure your safety until the illness has been treated, because I think you will view your situation differently when you are well.”

Question 33

Passive suicidal thoughts

Answer 33

Many depression patients transiently wish they would somehow disappear, not wake up from sleep, or be killed in an accident

Question 34

Late onset mood disorders

Answer 34

• Beginning after ~50 years of age
• Believed to have causes different to depression in younger individuals
  
  • Such as early subcortical cerebrovascular disease
• Depression is NOT a normal part of aging
• While late-onset bipolar disorder is relatively rare, recurrence of remitted disease frequently occurs in late life

Question 35

Cyclic episodes of bipolar disorder

Answer 35

Patients with bipolar disorder and the more recurrent forms of unipolar depression have a striking pattern of decreasing cycle lengths or increasing frequency of episodes over time

The average well period between the first and second episodes is 3 to 5 years. The cycle becomes progressively shorter, reaching a mean of less than 1 year after the sixth cycle

Psychosocial stress is especially likely to trigger episodes early in the course of the illness. These disorders often begin when patients first assume adult responsibilities, such as leaving home, going to college, getting married, or starting to work. After several recurrences, episodes are more likely to occur spontaneously, “out of the blue,” with no apparent precipitants

Question 36

Risk factors for chronicity of major depression

Answer 36

• FHx
• older age,
• longer duration of illness before treatment is sought,
• alcohol use disorder,
• medical illness.

Question 37

Interviewing depressed patients

Answer 37

• Show your empathy
• Give the patient time
• Be aware that they are likely to underreport out of self-shame or self-doubt
• May be difficult historians due to the pathology of the disease – their memory may be impacted and they may have difficulty concentrating
• Establishing a baseline is important – so try asking about prior behavior and changes in behavior as well as the characteristics of the depressive episode

Question 38

Interviewing manic patients

Answer 38

• Interviewing a patient who is suffering from severe psychotic or thought-disordered mania is virtually impossible
• For safety reasons, another person should be present when a patient with severe mania is being interviewed.
• It is counterproductive to ever argue with or counter the illogical thinking of a manic patient
• patients may exert control through such means as humor, uninterruptible speech, sexual seductiveness, or flashes of intimidating anger
• A good way to start if you feel an interview may be helpful is to try and elicit something with which the manic patient WOULD like your help, rather than addressing whether their manic symptoms are directly a problem

Question 39

Children and adolescents with mood disorders

Answer 39

• They may present primarily with behavioral problems at home and in school rather than with a clear, verbal description of their moods
  
  • Withdrawal, sullenness, truancy, poor grades, and tantrums
• Difficult to distinguish extreme mood shifts from developmentally appropriate rebelliousness in teenagers
• Controversy concerning the diagnosis of pediatric bipolar disorder has focused attention on children with chronic irritability and hyperarousal.
  
  • Children or adolescents who present persistent rather than episodic symptomatology are now eligible for the diagnosis of disruptive mood dysregulation disorder (DMDD)

Question 40

Differential for mood disorders

Answer 40

• Parkinson’s disease shares some symptoms with major depression, such as bradykinesia, decreased or even expressionless facial mimic, bradyphrenia, stooped posture, loss of interest and concentration, and reduced libido
• Dementia: Particularly late life onset mood disorder with no FHx
• Sleep apnea and subsequent disrupted sleep
• Schizophrenia will appear more like a psychosis with gradual decline than cyclic/episodic psychosis
• Schizoaffective disorder is a condition in which a patient is psychotic during an episode of a mood disorder but continues to have psychotic symptoms for at least 2 weeks after the mood episode has resolved
• Substance use can mimic either form depending on the drug, and is often comorbid
• Generalized anxiety disorder and panic disorder
• Personality disorders may exhibit signs of depression, and borderline disorder in particular may present similarly to mania

Question 41

Medical evaluation for mood disorder patients

Answer 41

• Goals are to exclude mood disorders that are caused by another medical condition and to ensure the safety of treatment with medications
• Full physical exam
• Hepatic and thyroid function tests
• Electrolytes, calcium, BUN, creatinine
• CBC
• Urinalysis w/ urine toxicology

Question 42

An increase in ____ has been documented in major depression

Answer 42

An increase in proinflammatory cytokines has been documented in major depression

Question 43

Neurologic reason why stress may impact memory

Answer 43

Chronic stress negatively regulates hippocampal function, whereas antidepressants ameliorate the effects of stress on neuronal morphology and activity, such as upregulation of hippocampal neurogenesis that is compromised in depression

Question 44

Glutamate theory of depression

Answer 44

Evidence supporting the glutamate hypothesis comes from directly targeting glutamatergic neurotransmission. Ketamine and other NMDA antagonists have demonstrated rapid antidepressant responses (within hours of administration) in treatment-resistant depressed patients.

Question 45

For patients with severe depression, ___ alone is ineffective.

Answer 45

For patients with severe depression, psychotherapy alone is ineffective.

Question 46

Non-pharmacologic Interventions for patients with depression

Answer 46

• Major undertakings and decisions should be postponed.
• If the physician gives the order, the patient may feel less guilty about postponing plans or taking temporary sick leave
• It may be helpful to gently talk over precipitating events and soften self-blame and hopelessness
• Family therapy to defuse crises and support a household in stress may be helpful
• Hospitalization is sometimes necessary
  
  • In addition to providing physical protection, it may provide a welcome sense of being taken care of and relief from responsibility

Question 47

Effectiveness of antidepressants vs placebo

Answer 47

Sixty to seventy percent of patients respond to antidepressants, whereas only 10% to 20% of severely depressed patients improve when given placebo.

Question 48

First line anti-depressant

Answer 48

SSRI

because of their safety and tolerability

Question 49

Major families of anti-depressants

Answer 49

• SSRIs
• MAOIs (monoamine oxidase inhibitors)
• TRAs (tricyclic antidepressants)

Question 50

The most concerning drawback of MAOis and TCAs

Answer 50

While they are most certainly effective, especially for mild to moderate depression, they have dangerous side effects that may be lethal if patients overdose, which is a huge concern for depression patients who are at risk for suicidal ideation.

Question 51

Treating patients with psychotic depression

Answer 51

• These patients rarely respond to any of the pharmacologic antidepressants alone, and will require either addition of an antipsychotic or electroconvulsive therapy

Question 52

Antidepressants must be taken for ___ before their complete effect is felt

Answer 52

Antidepressants must be taken for 4 to 6 weeks at the full therapeutic dosage before their complete effect is felt

A full response, however, may occur only after 8 to 12 weeks.

Question 53

Augmenting agents in antidepressive pharmacologic therapy

Answer 53

• Should be added for patients who have only a partial response to an antidepressant
• Include lithium and stimulants, buspirone, and thyroid hormone, as well as the second generation antipsychotics quetiapine and aripiprazole

Question 54

In the treatment of a single episode of major depression, continuation treatment at the full dosage that was used to resolve the depression should be maintained for ___ in order to prevent relapse.

Answer 54

In the treatment of a single episode of major depression, continuation treatment at the full dosage that was used to resolve the depression should be maintained for at least 6 months after the acute phase in order to prevent relapse.

After 6 to 12 months of continuation treatment, the dosage should be gradually tapered and the patient should be observed for signs of relapse. When the medication should be stopped depends on individual factors.

Question 55

Adjunctive agents in treating depression

Answer 55

Since antidepressants take a while to start working, adjunctive medications can be helpful at the beginning of treatment to provide immediate relief from insomnia, anxiety, and agitation

For example, some antidepressants may cause insomnia, which is often alleviated by trazodone, zolpidem, or the benzodiazepines.

Question 56

If antidepressant drugs are given for bipolar depression, without an antimanic on board, . . .

Answer 56

If antidepressant drugs are given for bipolar depression, without an antimanic on board, they may cause a switch to mania or a mixed state, or they may induce rapid cycling!

Lithium and the anticonvulsants, which do not cause mania, are therefore safer for acute bipolar depression.

Question 57

Treating manic depression

Answer 57

The antidepressant drugs are the same as those used in unipolar illness, although they are sometimes given in lower dosages and for shorter periods of time as a precaution Many experts begin with bupropion or the SSRIs. The MAOIs may be most effective but also have the most side effects. The TCAs may be more likely to cause mania than other antidepressants.

Lithium and the anticonvulsants help prevent manic episodes.

Lamotrigine is a specific anticonvulsant that seems to be effective, but it is high risk for Stevens-Johnson syndrome and is therefore high risk. Patients should be instruted to see their physician if they develop a rash.

Quetiapine and lurasidone are also effective treatment for depressive episodes in bipolar disorder.

Question 58

Mood-Stabilizing Medication in Bipolar Disorder

Answer 58

Lithium bicarbonate and the anticonvulsants valproate and carbamazepine are considered the “traditional” non-antipsychotic mood stabilizers. All of the second-generation antipsychotic medications are also FDA approved for mood stabilization in bipolar disorder, for acute mania, and, in most cases, for long-term prevention.

Anticonvulsants appear to be more effective than lithium in patients with dysphoric or mixed mania, in rapid cycling bipolar disorder

The two may also be used in combination.

Question 59

After an initial manic episode, bipolar patients are usually treated . . .

Answer 59

. . . indefinitely

Question 60

Electroconvulsive therapy

Answer 60

Used for depressed patients who are psychotic, extremely suicidal, or medically ill because of dehydration due to severely decreased oral intake

Electroconvulsive therapy has powerful, rapid antimanic effects. It should be considered in life-threatening cases of manic violence, delirium, or exhaustion

Question 61

Psychotherapy is most effective for patients with. . .

Answer 61

. . . mild to moderate depression, and to prevent relapse and recurrence. 1-2 months can help significantly.

Cognitive therapy and interpersonal psychotherapy have been extensively evaluated in well-designed studies of efficacy in depressed patients and have been codified in concisely written manuals

Question 62

Benefits from pharmacologic therapy and psychotherapy are typically ___.

Answer 62

Benefits from pharmacologic therapy and psychotherapy are typically additive.

Question 63

Psychotherapy in bipolar disorder

Answer 63

• Can only really be done after the patient is on medication
• The major goal of psychotherapy is not so much to relieve acute symptoms as it is to enhance long-term psychosocial stability
  
  • Importance of complying with their medication schedule and recognizing early signs of relapse are central tasks