Mood disorders Flashcards
What percentage of patients with MDD attempt suicide?
15%
Which systems are most noticeably affect by MDD?
- HPA axis
- immune system
What worsens the outcome of MDD?
- unRx MDD
- with comorbid conditions
What is the criteria for MDD
- 5 or more sx
- in same 2 wks
- change from prev functioning
- no hx of manic / hypomanic episodes
What are the sx of depression?
M SIGE CAPS
- mood - depressed/low
- sleep - incr/decr
- interest / pleasure decr
- guilt, worthlessness
- energy - decr
- concentration - decr
- appetite - incr/decr
- psychomotor - incr/decr
- suicidal ideation
What is meant by Melancholic features? When are they most prominent?
- despondent, despiar
- excessive guilt
- lack of reactivity
- worse in morning
What is meant by atypical features?
- weight gain
- hypersomnia
- leaden paralysis
What is meant by peripartum onset?
- within 4wks after child birth
What are the core affective sx of MDD in adults?
- low mood
- anhedonia
What are the core affective sx of MDD in children?
- irritability
- behavioral problems
What are the 3 areas of depressive sx?
- neurovegetative
- cognitive
- behavioral
List the Neuro-vegetative sx (PALES)
- Pain
- Appetite loss
- Libido loss
- Energy decr
- Sleep disturbed
List the Cognitive sx (GASH)
- Guilt
- Attention + concentration impaired
- Self esteem loss
- Hopelessness
List the Behavioral sx (PASS)
- Psychomotor slowing
- Agitation
- Social withdrawal
- Self neglect
Describe Grief (bereavement)
- significant stressor present
- predominant feeling of loss + emptiness
- occurs in waves with reminders
- decr in intensity with time
- thoughts/memories of loss
- thoughts of death focused on deceased
- preserved self esteem
How does MDD differ from Grief?
- depressed mood + anhedonia
- persistent
- not tied to specific thoughts
- self critical + self loathing
- pessimistic
- worthlessness
- suicidal / undeserving of life
What is the Primary Rx Goal of MDD?
Complete remission
- but only achieved in about 40%
What Pharmacotherapy will you give for MDD?
- 1st line = SSRI
- 2nd line = TCA
- BZD for sx rx (eg. insomnia)
- psychosis - 2nd gen AP (Olanzapine) or augment with Lithium
How long after initiating Rx do you expect a response?
- 4-6 wks newer drugs
- 6-8 wks older drugs
At what stage in the cycle do mood sx in PMDD occur? When do they resolve?
- occur shortly after ovulation (week before menses)
- remit within days of menses
- minimal/absent week after menses
How many sx present? How many cycles must sx occur in for PMDD?
- at least 5 sx
- more than 2 cycles
Which pharmacotherapeutic agents are effective in the mx of PMDD?
- SSRI
- BZD
- Ovulation suppressor (OCP, GnRHa)
What is the criteria for Persistent Depressive Disorder (PDD)?
- persistent depressed mood
- > 2 yrs adults
- > 1 yr children
- never without sx for > 2 mo
- NO suicidal thoughts + psychomotor changes
How do you manage PDD?
- mild = psychotherapy
- mod to severe = meds + psychotherapy (out pt)
- cx / severe / resistant = refer + admit
What was Persistent Depressive Disorder previously known as?
Dysthymia
How many episodes typically occur in BPD?
- 4 or less per year
- >4 per year = rapid cycling
What is Mania?
- distinct period
- abnormally + persistently
- elevated, expansive or irritable mood
- for 1 wk or longer
- or any duration requiring hospitalization
What is Hypomania?
- distinct period
- abnormally + persistently
- elevated, expansive, irritable mood
- for 4 or more days
- no psychotic sx
- no hospitalization required
What are the sx of a manic episode? DIGFAST
- Distractibility
- Impulsivity (sexual, risky behav)
- Grandiosity (inflated self esteem)
- Flight of ideas
- Activity incr (PMA)
- Sleep need decr
- Talkative (pressure of speech)
Define a mixed episode
- Manic + major depressive sx
- for at least 1 week
When would you dx Bipolar 1?
- at least 1 prev manic episode
- or any duration with psychosis
When would you dx Bipolar 2?
- predominantly MDE + hypomanic
- less than 4 days
- no psychosis
- no hx of manic episodes
What is a cyclothymic disorder?
- hypomanic + depressive sx
- that dont meet criteria for hypomanic / MDE
What are the specifiers or BPD?
- Current/latest episode
- Severity (mild/mod/severe)
- Associated sx - Lifetime pattern
- rapid cycling (>4/yr)
- seasonal pattern (winter)
- partial remission (sx improve but not all / not long enough)
- full remission (sx free > 2months)
What are clues that a depressive may be Bipolar and not Unipolar? (5,4,5)
- early age sx onset
- psychotic depression <25yo
- pospartum depression esp with psychotic fts
- short episodes with rapid onset + offset
- recurrent, multiple episodes
- seasonal pattern
- atypical fts
- fam hx of bipolar
- episodes with marked psychomotor abnormalities
- hyperthymic temperament
- severe anxiety
- hypomania ass w Antidepressant Rx
- rapid improvement on Antidepressant Rx
- Antidepressant poop out
When will you admit a pt with BPD for Rx?
- suicide / homicide risk
- rapidly progressive sx
- psychosis
- manic, MDE, mixed episodes
- relapse + no access to food/shelter/support
- can be voluntary / involuntary
When will you treat BPD as an out pt?
- maintenance
- hypomanic + mild-mod depressive episodes with frequent evaluation
What are the Contra-indications to psychotherapy in BPD?
- manic
- MDE
- mixed
- psychotic
Most common causes of relapse?
- stressful life events
- substances
- non adherence
What is the correct way to use antidepressants in the Rx of bipolar depression?
- avoid as far as possible -> hypomania + rapid cycling
- if necessary to use them
- always use in combo with at least 1 (preferably 2) mood stabilizers
Which mood stabilizer is effective in treating depression?
Lamotrigine
- start low go slow
- SJS
How would you Rx psychotic depression?
atypical AP
- Olanzapine, Quetiapine
- avoid Haloperidol -> dysphoria
Which mood stabilizers would you use in Rx manic and hypomanic episodes?
- Valproate (up titrate fast)
- Lithium (start low go slow)
Which AP is preferred in manic and hypomanic episodes?
Haloperidol
What additional measures must be taken in rx
- emergency sedation
- stop AD if using one
What is the rx of choice for mixed fts and rapid cycling?
Valproate
If a patient shows poor response to treatment, what should you then consider?
- previous response
- comorbid conditions
- side effect profile
- compliance
- substance use
- dx
