Mood. Disorders And Suicide Management Part 2

Question 1

Disorders in which high mood is a common theme:

Answer 1

Bipolar 1 disorder

Bipolar 2 disorder

Cyclothymic disorder

Question 2

What are diagnostic criteria of BP1 disorder?

Answer 2

A person must experience atleast 1 manic episodes

Note: must people also experience a depressive episode, but this is not necessary for the BP1 diagnosis, despite the term bipolar

Mania occurs without having a history of MDEs

Or

Mania occurs with a history of MDEs

Question 3

What are the symptoms of a manic episode?

Answer 3

Abnormally elevated mood (or irritability) AND increased activity or energy PLUS at least 3 additional symptoms:

• inflated self-esteem/grandiosity
• decreased need for help
• pressured speech
• flight of ideas(and/or racing thoughts)
• distractibility
• Increased goal-directed activity or psychomotor agitation (purposeless activity)
• Excessive involvement in risky activities

Question 4

Without naming symptoms, what other requirements are needed for manic episode diagnosis?

Answer 4

Symptoms of manic episode must:
-Last at least 1 week (or any duration if hospitalization is required)

-cause marked functional impairment

If hallucinations/delusions occur, then diagnose BPI with mood

• Mood-congruent psychotic features
• Mood-incongruent psychotic features

Question 5

What are the differentials of Bipolar 1 disorder?

Answer 5

• rule out medical condition

- rule out substance intoxication(e.g. cocaine, amphetamine)

Question 6

Describe the course of illness of Bipolar 1 disorder

Answer 6

• Manic episodes occur directly before/after an MDE

- Manic episodes last approx. 3 months

Question 7

Describe the etiology of Bipolar 1 episode

Answer 7

Genetic

• One of the most heritable psychiatric disorders
• Specific genes are unknown
• Family history of BP1 is useful for diagnosis and prognosis

Neurochemical
-Manic episodes involve increased monoaminergic activity, especially of dopamine

-Recall that MDD results from under activity of the monoamines

Question 8

Describe treatment for BP1 disorder

Answer 8

Mood stabilizers: drugs that level the highs and lows of bipolar disorders

• lithium
• Some anticonvulsants and antipsychotics

ECT- helps with both manic and depressive phases

Psychotherapy

Notes:
Antidepressants: are not FDA approved for BP depression
-they are contraindicated due to risk of manic induction
-if used off-label, then a mood stabilizer is added to help prevent the mood swing

Medication non-compliance: during manic episodes is common due to patients’ dislike of feeling blunted

Question 9

How is psychotherapy used to treat Bipolar 1 disorder?

Answer 9

Used for secondary issues (e.g., self esteem, occupational/marital problems)

-Not used to treat primary symptoms of Bipolar 1

Question 10

What are diagnostic criteria of bipolar 2 disorder?

Answer 10

A person experiences atleast 1 MDE and at least 1 hypomania episode(alternating MDE and hypomania)

Question 11

What are the symptoms of a hypomania episodes?

Answer 11

• Hypomania and mania have the same symptoms but of different severity
  
  • Mania causes “marked” impairment in functioning; hypomania does not
  • Mania can cause psychosis; hypomania cannot
  • Mania can result in hospitalization; hypomania cannot
• change in mood must be “unequivocal” and “uncharacteristic” of person
• Hypomania episodes must last 4 or more days

Question 12

How can bipolar 2 disorder be treated?

Answer 12

Mood stabilizers

• use those stabilizers that are particularly effective in treating the depressed phase of BPII
• MDEs are the more problematic phase than hypomania episodes

Question 13

What is cyclothymic disorder?

Answer 13

• For 2 or more years, a person experiences periods of hypomania symptoms that fluctuate with periods of depressive symptoms
• Criteria for an MDE or a manic episode have never been met

Cyclothymia is similar to bipolar 1, but the mood shifts are not as extreme

Question 14

What is the course of cyclothymia?

Answer 14

The person may ultimately have an MDE or manic episode, which changes the diagnosis from cyclothymia to a bipolar disordering

Question 15

How can cyclothymia be treated?

Answer 15

Mood stabilizers( as for BP1)

Question 16

Explain the relevance of suicide

Answer 16

Suicide and suicide attempts are common

- suicide is one of the top 5 leading causes of death for most age ranges
 - Attempts are exponentially more common than completed suicides

Many suicidal patients have given warning signs that were overlooked by family, friends, and their physicians

Question 17

List mental health risk factors for suicide

Answer 17

Mental health

• depression
• other mental illnesses(e.g., schizophrenia, eating disorders)
• substance abuse
• hopelessness
• impulsivity
• prior suicide attempt

Question 18

Give the contextual risk factors to suicide

Answer 18

• exposure to suicidal behavior(e,g., family history)
• access to lethal means (firearms)
• lack of social support
• losses(e.g., financial, releationship)
• medical illnesses
• being victimized

Question 19

Give the demography risk factors of suicide

Answer 19

Age
-Older age (atleast 75) is associated with increased completion rate of suicide

Gender
-Males are more likely to COMPLETE suicide due to lethality of suicide method

-Femakes are more likely to ATTEMPT

Question 20

What is the first thing to do in suicide management?

Answer 20

1. Ask about suicidal ideation
   
   • ask direct questions(asking doesn’t put the idea in their heads) Do you feel life is worth Living? Do you think you would be better off dead?
     - ask about frequency and duration of thoughts

How Often do You have these thoughts? How long have you been having these thoughts?

Question 21

What is the second thing to be done in suicide management?

Answer 21

Evaluate the severity of suicidal intent

• suicidal plan
  
  • presence, specificity and lethality of plan
  • availability of means

-preparations for death
-Have you taken steps towards taking your own life?
Stocking pills, getting a gun
-making a will, getting affairs in order, giving possessions away, suicide nite, saying goodbye

-prior attempts

Question 22

What is the third thing to do in suicide management?

Answer 22

Evaluate behavioral controls

What stops the person from acting on these thoughts?

• reasons for living(e.g. religion, children)
• support system

Is the person on drugs/alcohol?
-substance use increases suicide risk due to diminished inhibition

Question 23

What is the 4th thing to do in suicide management?

Answer 23

Consider mental health, contextual and demographic risk factors

Question 24

What is a suicidal action plan?

Answer 24

-any suicidal ideation is a basis for suggesting treatment is a basis for suggesting treatment

General risk levels

• low, moderate, high levels
• action plans for low-risk and high-risk situations are clearer
• assessment of risk levels is imprecise and involves clinical judgement

Question 25

Describe a low risk action plan

Answer 25

Low risk

• non-specific thoughts of suicide with few risk factors
• refer for out-patient patient psychotherapy and/or evaluation for antidepressant medication

Question 26

Describe a high risk action plan

Answer 26

• specific plan for suicide with many risk factors
• Need for medications and/or psychotherapy immediately in an in-patient setting
• hospitalization:voluntary or involuntary (engage police to assist, if involuntary)

Question 27

Describe a moderate risk action plan

Answer 27

Suicide risk is present but crisis intervention is not needed

-refer for out-patient psychotherapy and/or evaluation for antidepressant medication

• create a safety plan
  
  • a document that supports and guides a person to help them avoid a suicidal crisis
  -includes early warning signs, internal and external coping strategies, people to contact in a crisis, steps for safety proofing environment, and reasons for living