Mood Disorders - Hill Flashcards
what is the most common psychiatric illness?
depression, followed by generalized anxiety disorder and bipolar
- 8 million American adults (9.5% of population)
- 3.4 million under the age of 18
- according to WHO, second-most disabling disease (after heart disease)
major depressive disorder
10-25% of patietns with what, have a first-degree relative with a mood disorder
mood disorder
50% of patients with what, have first-degree relative with a mood disorder
bipolar disorder
this NT down-regulates beta-receptors
- abnormal function in depression
NE
- lack of NE in synaptic terminal causes symptoms
this NT is decreased in depression and increased in mania (and coke/meth/stimulants)
dopamine
this NT is also decreased in depression
- SSRI’s proved effective as anti-depressants (they “numb” emotion
5HT
inhibitory NT
- site of action for anxiolytic agents and benzodiazepines
gamma-aminobutyric acid (GABA)
excitatory NT
- involved in dementia
- its receptor, (NMDA) involved in current antidepressant studies
glutamate
at least 5 of the following for a TWO-week period with either depressed mood or loss of interest/pleasure
- depressed mood
- diminished interest/pleasure in all or almost all activities
- significant weight loss/gain
- insomnia/hypersomnia nearly every day
- psychomotor agitation/retardation
- fatigue or loss of energy
- feelings of worthlessness or excessive guilt
- diminished ability to think/concentrate
- recurrent thoughts of death/suicide
major depressive episode
- symptoms not caused by direct effects of substance and are not accounted for by loss
diagnosis requires the presence of one or more major depressive episodes and the absence of any manic, hypomanic, or mixed episodes
associated features:
- psychotic
- anxious distress
- melancholic
- catatonic
- peripartum onset
major depressive disorder
what are the ddx of major depressive disorder?
- substance abuse disorder
- mood disorders from general medical condition
- normal grief (bereavement)
what is the tx of major depressive disorder?
hospitalization, ECT, transcranial magnetic stimulation, somatic therapies: - TCA's -MAOI's - SSRI's - triazolipyridines - buproprion - SNRI's - mirtazapine
this drug produces dissociative anesthesia
- NMDA antagonist
- overdose may lead to panic attacks and aggressive behavior, rarely seizures, increased ICP and cardiac arrest
- very similar in chemical makeup to PCP, but is shorter acting and less toxic
- 50% reduction in suicidal thoughts in 24hrs
ketamine
off-label use for treatment-resistant depression
- administered by psychiatrist
- 45-60 minute infusion time
- 4-6 infusions over 2-3 periods ($400-1000 per infusion)
- maintenance infusions
ketamine clinics
FDA approved nasal spay for treatment-resistant depression
- 800 health centers have been approved to administer this medication
- rapid-acting
- expensive
spravato (esketamine)
depressed mood for most of the day **(for at least two years in adults, 1 year in children) that has not been severe enough to meet criteria for major depressive episode
- symptoms are continuous during 2 years (cannot be without symptoms for >2 months at a time)
- patients must never have met criteria for manic episode, mixed episode, or hypomaniac episode
persistent depressive disorder (disthymia) KNOW this
what is double depression?
dysthymic disorder and major depression can occur simultaneously
what is the treatment for persistent depressive/dysthymic disorder?
SSRI’s, SNRI’s, MAOI’s (last resort)
- cognitive behavioral therapy
onset and remission of major depressive episodes at characteristic times of year
- often with change of seasons
- sleep more and eat more, fatigued
- can do light therapy
depression with season pattern
- formerly known as seasonal affective disorder (SAD)
- most cases begin in fall or winter and remit in summer
mood instability with anxiety, depression, irritability
- occur the week before menses
- consisten pattern over the year
premenstrual dysphoric disorder (PMDD)
what is the treatment for PMDD?
exercise, diet, relaxation therapy
- SSRI’s during cycles of 2 weeks preceding menses
abnormally and persistently elevated, expansive, or irritable mood lasting at least 1 week with at least 2 of the following:
- inflated self-esteem/grandiosity
- decreased need for sleep
- more talkative
- flight of ideas
- distractibility
- increased goal-oriented behavior
- excessive involvement in pleasurable activities
manic episode
why should you never treat bipolar with an antidepressant?
it can induce a manic episode
similar to manic episode, but less severe
- episodes only need to last 4 days and must not include psychotic features
- no social/occupational impairment
hypomanic episode
single manic episode is necessary to diagnose (pt only needs 1 “pole” of the bipolar
- at least one manic or mixed episode
- major depressive episode not required for diagnosis (but is usually the episode that presents first)
- can be psychotic episode (delusions/hallucinations)
- worse prognosis than MDD
bipolar 1 disorder
patients have had at least one major depressive episode and one hypomanic episode in the absence of any manic or mixed episodes
- more prevalent than bipolar 1
bipolar 2 disorder
what is the treatment for bipolar disorders?
- *mood stabilizers 1st line choice for long-term** (lithium, valproic acid)
- carbamazepine
- SGA’s (the -pine’s, p for pig -> think weight gain)
- lamotrigine (for bipolar with depression - Hill called it Lithium “light”)
what medication should make us think of Steven’s-Johnson syndrome?
lamotrigine
- rash from the neck up that is serious side effect of med
- should stop lamotrigine immediately
dysthymic disorder with intermittent hypomanic periods
- pt who over the last 2 years (1 year for kids), experiences repeated episodes of hypomania and depression (not severe enough to meet criteria for major depressive disorder)
- during the first 2 years the pt may not have major depressive, manic or mixed episode
cyclothymic disorder
what is the tx for cyclothymic disorder?
- mood stabilizers
- antidepressants
- supportive psychotherapy
what are the psychosocial symptoms of anxiety disorders?
- apprehension, worry
- sense of doom or panic
- hypervigilence
- difficultly concentrating
- derealization (world seems strange)
what are the somatic (physical) symptoms of anxiety disorders?
headache dizziness lightheaded palpitations lump in throat restlessness shortness of breath
what are the physical signs of anxiety disorders?
diaphoresis, cool/clammy tachycardia flushing hyperreflexia, tremor fidgeting
worry about actually circumstances, events or conflicts
- often accompanies panic anxiety
- symptoms of generalized anxiety fluctuate more than those of panic anxiety
generalized anxiety
- recurrent unexpected panic attacks
- at least one attack followed by 1 month or more of:
- persistent concern about additional attacks
- worry about the implications of the attack or its consequences
- significant change in behavior related to the attacks
panic disorder
- must have both 1 and 2
a discrete period of intense fear or discomfort, in which 4 or more of the following developed abruptly and reached peak within 10 minutes and usually lasts <25 minutes
- palpitations
- sweating
- trembling/shaking
- SOA
- chest pair/discomfort
- feeling dizzy/unsteady/lightheaded
- fear of losing control/going crazy
- paresthesias
- chills/hot flashes
panic attack
women 2-3 times more likely to be affected
- average age of presentation is 25
- strong genetic component
- 50% of all patients have at least 1 affected relative
panic disorder
anxiety about being in situations from which escape might be difficult or embarrassing, or for which help may not be available in the event of panic
- ex: being away from home, being in an elevator or plane
- associated with panic disorder
agoraphobia
the fear, anxiety, or avoidance is persistent, typically lasting 6+ months
- persistent fear of one or more social or performance situations in which the person is exposed to unfamiliar people or to possible scrutiny by others
- exposure to the feared situation almost invariably provokes anxiety, which may take the form of a situationally bound or pre-disposed panic attack
- the person recognizes that this feat is unreasonable/excessive
- the feared situations are avoided or else endured with intense anxiety and distress
social phobia (social anxiety disorder)
excessive anxiety and worry, occurring more days than not for at least 6 months, for most of the day
- difficult to control the worry
- the anxiety and worry are associated with at least three persisting for more days than not of the past 6 months:
- restlessness, feeling on edge
- easily fatigued
- difficulty concentrating
- irritability
- muscle tension
- sleep disturbance
generalized anxiety disorder
- recurrent and persistent thoughts, impulses, or images experienced as intrusive and inappropriate and causing marked anxiety or distress
- not simply excessive worries about real-life issues
- person attempts to ignore r suppress these thoughts
- the person recognizes them s a product of their own mind
obsessions
- repetitive behaviors or mental acts that the person feels driven to perform
- aimed at preventing or reducing distress or preventing some dreaded event/situation
compulsions
what is the difference between OCD and OCPD?
OCPD: they don’t perceive they have a problem
OCD: they know their compulsions/obsessions are not reasonable (most of the time)
- contamination
- safety/harm
- unwanted acts of aggression
- unacceptable sexual or religious thoughts
- need for symmetry/exactness
types of obsessions
- excessive cleaning
- checking, ordering and arranging rituals
- counting, repeating routine activities
- some are performed as unobservable mental rituals (silent recitation of nonsense words to vanquish a horrific image)
types of compulsions
latrophobia
fear of doctors
acrophobia
fear of heights
what are the tx for antiety?
psychotherapy
- supportive
- psychodynamic psychotherapy
- cognitive behavioral therapy
psychopharmacology
- SSRI’s best for anxiety
- SNRI’s, MAOI’s, buspirone, benzodiazepines,
- antipsychotics
what is the helpful pneumonic for depression?
SIG E CAPS (all lack of:)
- sleep
- interest-anhedonia
- guilt
- energy
- concentration
- appetite
- psychomotor
- suicidal ideation
what is the helpful pneumonic for mania?
DIG FAST
- distractibility
- inflated self-esteem
- grandiosity
- flight of ideas
- activity/agitation
- speech
- thoughtlessness
what is the helpful pneumonic for dysthymic?
CHASES
- concentration (poor_
- hopelessness
- appetite
- insomnia
- energy (low)
- self-esteem (low)
what is important to rule out with depression?
any underlying substance, medication or medical condition, especially if the patient does not have a prior hx of depression
what are the first-line treatment options for major depressive disorder?
SSRI’s
- bupropion, venlafaxine, mirtazapine
