mood disorders + geriatric depression Flashcards
major depression DSM 5
At least Five of the following within 2 weeks and is a change from baseline behavior:
- must include at least 1 of these: DEPRESSED MOOD for most of the day or nearly every day OR DIMINISHED INTEREST OR PLEASURE in all or almost all activities (elderly)
-symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.
-The episode is not attributable to the physiological effects of a substance or to another medical condition
Other 4 sx:
-Significant weight loss when not dieting or weight gain (more than 5% of body weight in a month), or decrease or increase in appetite nearly every day
-Insomnia or hypersonic nearly every day.
-Psychomotor agitation or retardation nearly every day (observable by OTHERS, not merely subjective feelings of restlessness or being slowed down)
-Fatigue or loss of energy nearly every day.
-Feeling of worthlessness or excessive or inappropriate guilt (which may be delusional) nearly every day (not merely self-reproach or guilt about being sick).
-Diminished ability to think or concentrate, or indecisiveness, nearly every day (from pts or others)
-Recurrent thoughts of death, recurrent suicidal ideation without a specific plan, or a suicide attempt or a specific plan for committing suicide
Depression = A SAD FACES
- Appetite: wt loss or gain
- Sleep changes: insomnia or hypersonic
- Anhedonia: loss of interest *
- Depressed mood/dysphoria *
-Fatigue
- Agitation or retardation (psychomotor)
- Concentration: cant think or indecisive
- Esteem/Guilt: feel worthless
- Suicidal ideation
Depression: what causes it on a biological level and describe each neurotransmitter
“catecholamine hypothesis”: Decreased levels of serotonin, NE, dopamine in the brain
Serotonin: Controls aggression, irritability, obsessions, compulsions, anxiety, overall well-being, pain
Norepinephrine: Controls alertness, energy, attention, pain
Dopamine: Controls cognition, motivation, pleasure and reward
depression risk factors
Genetics:
- fam hx: first degree relative increases risk by 2-5x
Environmental factors
- loss of loved one, status, employment
- poor family family functioning
- poor support system
- early loss of a parent
- limited coping mechanisms
- learned helplessness
- inwardly focused anger
“Person living by themselves vs person surrounded by good support system of family and friends “
atypical depression
-weight gain
-sleeping more
depression in the elderly: how does criteria change
-Low/depressed mood does NOT need to be present
-Persistent loss of pleasure and interest in previously enjoyable activities (anhedonia) MUST be present
Elderly pt will reject dx of depression:
-Masked depression or depression without sadness- mainly SOMATIC complaints
-Symptoms of minor depression
Somatic complaints: Persistent, vague, unexplained physical complaints:
-Agitation, anxiety
-Memory problems, difficulty concentrating
-Social withdrawal
depressive disorders that look like MDD
Bipolar Depression: A vegetative depression that alternates with mania
- 80% depressed, 20% mania; they will meet DSM 5 criteria -> treat organic cause
Mood Disorder Due to a General Medical Condition: Depression caused by physical medical condition
-ex. hypothyroidism, or pancreatic cancer.
Substance-Induced Mood Disorder: Depression caused by abuse of substances such as drugs, alcohol, medications, or toxins.
Seasonal Affective Disorder (SAD): Depression during winter
Postpartum Depression: depression occurring within 1 week to 6 months after delivery
Premenstrual Dysphoric Disorder: Depression affecting a small percentage of menstruating women
-cyclical -> depressed and irritable for 1-2 weeks before menses
depression in child/adolescents
-Frequent sadness, crying
-Feeling hopeless, helpless, withdrawn
-Change in behavior, loss of interest in usual activities
-Change in sleep, appetite or energy
-Missed school or poor school performance
-Frequent physical complaints
-Irritability, fighting, trouble concentrating
-Thoughts about death, suicide or running away
how do we dx depression
-Complete History, Physical Exam, and Bloodwork
-Complete Medication Review
-Structured Psychiatric Interview
-Depression Inventory Scales
~50% of suicide attempts occur within 30 days of a medical office visit = ALWAYS SCREEN IN EVERY SETTING!!!
how do we treat depression: PSYCHOTHERAPY
Cognitive Behavioral Therapy: Identify, challenge, and change dysfunctional thought processes such as:
-“All or Nothing” Thinking: A performance short of perfect is seen as failure
-Over-Generalization: A single negative event is seen as part of a pattern
-Rumination: A single negative detail is dwelled upon exclusively
depression scales
PHQ-9
Beck Depression Inventory
- Advantage is that the questions are very specific to how a patient may be feeling
Geriatric Depression Scale
how do we treat depression: pharmacotherapy main
SSRIs: Fluoxetine (Prozac)
- MOA: inhibits serotonin reuptake
- Side Effects: Insomnia, sedation, agitation, GI upset, headache, !decreased libido, erectile dysfunction, anorgasmia!
SNRIs venlafaxine (Effexor):
- MOA: Inhibit the reuptake of Serotonin and NE
-Side Effects: Insomnia, anxiety, HTN!!!!!!, headache, decreased libido, erectile dysfunction, and anorgasmia, lowers threshhold for seizures, less ED
NDRIs: Bupropion (Wellbutrin):
- MOA: Inhibit reuptake of DOPAMINE and NE
- Side Effects: Decreased SEIZURE threshold, headache, insomnia, agitation, tachycardia, dizziness
- fewer ED/sexual side effects (bumproprion)
- 4 S’s: seizures, sex, smoking - first line tx for cessation, skinny!!!!
what are some adjunctive or second line options to treat depression?
-Antipsychotics: added in resistant or psychotic depression
Antiepileptics: may be used in resistant or agitated depression.
-Phenytoin, ethosuximide, carbamazepine, oxcarbazepine, gabapentin, sodium valproate, pregabalin and lamotrigine
Lithium: adjunct in resistant depression
Psychostimulants: May improve effectiveness of antidepressants in resistant depression while specifically targeting sadness, anhedonia, decreased energy, and decreased cognition.; ex. ritalin, Adderall
what treatment for MDD when rapid antidepressant response is needed or when drug therapies have failed
Electroconvulsive therapy:
-Electric shocks delivered to the brain cause brief seizures
-Absolute Contraindications: None
-Relative contraindications: Elevated ICP, intracerebral hemorrhage, space-occupying lesion, unstable aneurysms
-Can be used in pregnant patients
-Side Effects: Postictal confusion and anterograde amnesia, arrhythmia
- Memory hazy 30 min before or 30 min after
depression prognosis
-Without tx -> up to 60-80% will recover spontaneously, usually within 1st year
-With tx -> 80-90% will recover.
-risk of relapse after 1 episode is 50%
-risk of relapse after 2 episode is 90%
-risk of relapse after 3 episodes is ~ 100%
-10-15% will convert to Bipolar Disorder
-Approx 15% will attempt suicide -> MC within first 6-9 months of tx
good prognostic predictors vs poor prognosis predictors
Good:
-No family hx
-Acute Onset
-Late Onset
-Early Intervention
-Good Support System
-No Psychotic Symptoms
-No Substance Abuse
-Good Response to Prior/Current Treatment
Poor:
-Family hx of MDD
-Gradual Onset
-Early Onset
-Late Intervention
-Poor Support System
-Psychotic Symptoms
-Substance Abuse
-Poor Response to Prior/Current Tx
when do we refer to psychiatrist/specialist
-Evaluation for pharmacotherapy
-Failure of adequate antidepressant trial: If the meds don’t work -> refer to specialist
-Psychiatric comorbidities
-Complicated medical comorbidities
-Suicidal ideations, gestures
-Pt in need of hospitalization
- Call 911 and send them to ER if they have active suicidal ideology
suicidal risk assessment: PRIMARY RULE FOR ASSESSMENT: Know difference between:
-Ideation: “I wish I were dead “
-Intent: “When no one is home, I’m going to kill myself”
-Plan: “I am going to hang myself with the garden hose my husband keeps in the garage”
suicide: risk factors
-Previous Attempt: MOST important risk factor
->Increased risk if attempt within last 2 years
-Psychiatric Disorder: >90% of completers had mental illness
-Age: Highest prevalence < 19yo and > 45 yo
-Men >65 yo have highest rate of completion
-Male gender
-White race
-Advanced age
-Medical illness
-Hopelessness
-History of attempts
-Available means and plan
-Substance abuse ( self or family )
-Family history of suicide
-Psychotic symptoms
-Living alone
-Insomnia
-Uncontrolled Anxiety
-Sex (male gender)
-Age (Under 19 years or over 45 years)
-Depression
-Previous attempt (consider lethality)
-Ethanol
-Rational thinking (neurologic trauma)
-Support (family, friends)
-Organized plan
-No spouse
-Sickness
bipolar disorder: criteria and specific criteria for mania vs hypomania
Three or more Manic Symptoms and significant change from usual behavior: DIGFAST
-Distractability
- Impulsivity: Activity increases that have potential for painful consequences (unrestrained buying sprees)
-Grandiosity orInflated self-esteem
- Flight of ideas: Racing thoughts
- Activity increase or psychomotor agitation
- Sleep deficit: decreased need for sleep
- Talkativeness
-To be considered mania -> at least 1 week and present most of day, nearly every day
-To be considered hypomania -> at least 4 consecutive days and present most of day, almost every day
what is manic episode?
Manic Episode: Abnormally elevated, expansive, or irritable mood, lasting at least 1 week
DIGFAST sx: at least 3
-1) Inflated self-esteem or grandiosity
-2) Decreased need for sleep
-3) More talkative than usual; pressure to keep talking
-4) Flight of ideas or racing thoughts
-5) Distractibility
-6) Increase in goal-directed activity or psychomotor agitation
-7) Excessive involvement in pleasurable activities that have negative consequences
label type of mania
-Bipolar Disorder Type I: Alternating periods of Depression and Mania
-Bipolar Disorder Type II: Alternating periods of Depression and Hypomania
