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Block 8 week 1 > Mood Disorders - Jacobs > Flashcards

Mood Disorders - Jacobs Flashcards

1
Q

List the depression disorders.

A
  1. major depressive disorder
  2. dysthymic disorder or persisten depressive disorder
  3. premenstrual dysphoric disorder
  4. disruptive mood dysregulation disorder
  5. depressive disorder - NOS
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2
Q

List the bipolar disorders.

A
  1. bipolar I
  2. bipolar II
  3. cyclothymic disorder
  4. bipolar disorder NOS
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3
Q

List the secondary mood disorders.

A
  1. mood disorder due to a general medical condition

2. medication/substance induced mood disorder

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4
Q

Describe the epidemiology of unipolar depression.

A
  1. most common psychiatric illness likely to see in practice
  2. prevalence of 10% among primary care outpatients
  3. prevalence of 15% in medical patients
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5
Q

What co-morbidities are associated with unipolar disorder?

A
  1. substance use disorders
  2. pathological gambling
  3. personality disorder
  4. anxiety
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6
Q

What is the lifetime prevalence of depression?

A
  1. overall - 16.5%
  2. women are 70% more likely than men to experience depression during their lifetime
  3. annual prevalence is 7% among US adults (14.8 million adults)
  4. 8% of those over age 12 according to the CDC
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7
Q

What type of students are more prone to depression?

A

Medical students

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8
Q

What were the findings in a study of UCSF medical students?

A
  1. 1/4 were depressed

2. only 1/4 of those depressed seek treatment

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9
Q

What were the findings in a study of medical students by Schwenk et al?

A
  1. 14.3% of med students were moderately to severely depressed
  2. 3rd and 4th year students reported more suicidal ideation than 1st and 2nd year students
  3. stigma was associated with depression and use of mental health care services
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10
Q

What are some barriers to treatment experienced by medical students?

A
  1. lack of time
  2. high-functioning students believe they can handle depression without help
  3. afraid they will see a physician who will eventually be a colleague
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11
Q

Summarize the findings of depression among residents.

A
  1. female residents had higher depression scores than male
  2. proportion of unmarried residents with depression higher than married
  3. interns had a higher prevalence of depression than other residents
  4. prevalence varied by specialty
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12
Q

Describe the findings of the Michigan State Medical Society regarding depression in physicians.

A
  1. 11.3% of respondents reported moderate to severe depression
  2. 43% reported knowing another physician whose work had been compromised by depression
  3. physicians in the study tended to avoid treatment and self-prescribe antidepressants
  4. suicide is a disproportionally high cause of death among physicians
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13
Q

How many physicians per year commit suicide?

A

400 - in the US

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14
Q

Do physicians have a higher rate of completed suicides over non-physicians?

A

Yes

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15
Q

Amongst non-physicians, do males or females have higher rates of completed suicides?

A

Males

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16
Q

Amongst physicians do males or females have higher rates of completed suicides?

A

The rates are equal.

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17
Q

Describe the economics of depression.

A
  1. total annual cost is 83 billion
  2. direct treatment is 26.1 billion
  3. suicide-related mortality costs are about 5.4 billion
  4. lost productivity is about 51.5 billion
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18
Q

List some considerations when thinking of a diagnosis of depression.

A
  1. could it be bereavement?
  2. could it be a normal reaction to stress or loss?
  3. could it be an adjustment disorder?
  4. could the behavior be the result of cultural factors?
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19
Q

What is the diagnostic criteria for a major depressive episode (DSMV)?

A
  1. symptom duration of 2 weeks or more (symptoms occur daily for most of the day)
  2. 5 out of 9 of the following symptoms - depressed mood, loss of interest/pleasure, weight or appetite changes, sleep changes, agitation or retardation, fatigue, worthlessness or guilt, thinking problems, thoughts of death (one of the symptoms must be depressed mood or loss of interests)
  3. must have marked distress or functional impairment
  4. must rule out medical substance etiologies
  5. can specify - ‘with anxious distress’
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20
Q

Describe SIGECAPS.

A

SIGECAPS is a pneumonic to help with depression screening.
S = sleep disturbance (insomnia or hypersomnia)
I = interest reduced( reduced pleasure or enjoyment)
G = guilt or self blame
E = energy loss and fatigue
C = concentration problems
A = appetite changes (increased or decreased)
P = psychomotor changes (retardation, agitation)
S = suicidal thoughts

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21
Q

What are the neurovegetative symptoms of depression?

A
  1. sleep disturbances
  2. appetite problems
  3. loss of energy
  4. decreased libido
  5. psychomotor retardation or agitation
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22
Q

Describe what can be affected with insomnia.

A
  1. initial insomnia - trouble falling asleep
  2. middle insomnia - trouble staying asleep
  3. terminal insomnia - wakes up too early and can’t fall back asleep
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23
Q

What are the somatic symptoms of depression?

A
  1. nausea
  2. constipation
  3. headaches
  4. back pain
  5. dyspnea
  6. chest pain
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24
Q

Describe the course of illness for major depressive disorder.

A
  1. 50% onset between ages 20 and 50
  2. peak in incidence in 20’s (according to DSMV)
  3. median age of onset is 32
  4. can occur in children and elderly
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25
Q

How can depression present in children?

A

With children you may see a focus on somatic complaints, irritability, and social withdrawal in addition to sad mood.

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26
Q

How can depression present in elderly?

A

With the elderly you may see memory loss and memory issues, distractibility, disorientation and other cognitive issues as well as somatic symptoms and sad mood.

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27
Q

What is a type of depression in the elderly that mimics dementia?

A

Pseudo dementia.

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28
Q

Because of the way that the elderly with depression may present, what is important to rule out?

A

It is important to differentiate depression from other causes of cognitive decline.

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29
Q

Describe how long a single episode of major depressive disorder can last.

A
  1. if left untreated it may last 6-13 months (about 40%, another 20-30% may have incomplete resolution with subclinical depression). Other 40% will continue to have symptoms
  2. with treatment the episode may last 1-3 months and resolution can be faster with electroconvulsive therapy
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30
Q

Those who have had a single episode of major depressive disorder are at risk for what?

A

Repeat episodes. Depression can be a chronic relapsing disorder. 70% of people have a recurrence and 15% with chronic depression commit suicide.

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31
Q

Describe persistent depressive disorder (dysthymic disorder).

A

This disorder is longer lasting but milder than major depressive disorder. Lifetime prevalence in women is 8% and 4% in men. Diagnostic criteria includes:

  1. 2 years of low mood (1 year for children/adolescents)
  2. milder, more fluctuating symptoms
  3. presence of 2 additional symptoms - fatigue, sleep disturbance, appetite changes, self esteem issues, concentration issues, hopelessness
  4. distress or impaired functioning
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32
Q

What is double depression?

A

A major depressive episode with concurrent dysythmia.

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33
Q

Describe premenstrual dysphoric disorder.

A
  1. In the majority of menstrual cycles, greater than or equal to 5 symptoms present during the week before menses, improving within a few days of onset of menses, and becoming minimal/absent in the week after menses
  2. must have greater than/equal to one of the following - affective lability, irritability/anger/conflict, depressed mood, and anxiety
  3. must have greater than/equal to following - anhedonia, difficulty concentrating, lethargy, change in appetite, hypersomnia/insomnia, overwhelmed/out of control, physical symptoms like bloating, pain, weight gain
  4. clinically significant distress or interference with functioning
34
Q

Describe depressive disorder due to a general medical condition.

A

A prominent and persistent disturbance in mood that is judged to be due to the direct pathophysiological consequence of another medical disease. About 25% of people with certain medical disorders will have a depressive disorder.

35
Q

Give examples of neurologic medical conditions that cause depressive disorder.

A
  1. Parkinson’s
  2. Huntington’s
  3. TBI
  4. cerebral vascular accident
  5. dementia
  6. MS
36
Q

Give examples of metabolic conditions that cause depressive disorder.

A
  1. renal failure
  2. Wilson’s disease
  3. acute intermittent porphyria
37
Q

Give some examples of gastrointestinal conditions that cause depressive disorder.

A
  1. IBS
  2. chronic pancreatitis
  3. Crohn’s disease
  4. cirrhosis
  5. hepatic encephalopathy
38
Q

Give some examples of endocrine conditions that cause depressive disorder.

A
  1. hypothyroidism
  2. hyperthyroidism
  3. Cushing’s disease
  4. Addison’s disease
  5. Diabetes mellitus
  6. parathyroid disease
39
Q

Give some examples of cardiovascular conditions that cause depressive disorder.

A
  1. cardiomyopathies

2. MI

40
Q

Give some examples of malignancies that cause major depressive disorder.

A
  1. pancreatic cancer
  2. brain tumors
  3. paraneoplastic effects of lung cancer
41
Q

Give some examples of autoimmune conditions that cause depressive disorder.

A
  1. SLE
  2. RA
  3. fibromyalgia
42
Q

What pulmonary and infectious conditions can cause depressive disorder.

A
  1. obstructive sleep apnea

2. HIV

43
Q

Describe substance induced depressive disorder.

A

A prominent and persisten disturbance in mood that is judged to be due to the physiological effect of a substance or medication.

44
Q

What kinds of drugs/substances can cause substance induced depressive disorder?

A
  1. alcohol
  2. benzodiazepines
  3. opioids
  4. hallucinogens - including marijauna
  5. withdrawal from stimulants like meth or cocaine
  6. oral contraceptives
  7. steroids
  8. antihypertensives such as reserpine and beta blockers
45
Q

Describe disruptive mood dysregulation disorder.

A

Characterized by severe recurrent temper outbursts in response to common stressors. The temper outbursts are manifest verbally and or behaviorally, such as in the form of verbal rages, or physical aggression towards people or property.

46
Q

What are the diagnostic criteria of disruptive mood dysregulation disorder?

A
  1. reaction to stressor is grossly out of proportion in intensity or duration to the situation or provocation
  2. responses are inconsistent with developmental level
  3. outbursts occur on average 3 or more times a week
  4. nearly every day, the mood between temper outbursts is persistently negative (irritable, angry and or sad)
  5. negative mood is observable by others
  6. above criteria have been present for at least 12 months and the patient has never been without the symptoms above for than 3 months at a time
  7. temper outbursts or negative mood are present in at least two different settings and must be severe in at least one setting
  8. chronological age is at least 6 years or equivalent developmental level, age is not more than 18 years and onset is before age 10 (can be diagnosed up to age 12)
47
Q

Describe depressive disorder NOS.

A

Used for clinically significant depressive syndromes not meeting criteria for established categories of depression. Clinician can specify or not specify reasons full criteria are not met

48
Q

What is different about guidelines concerning bereavement in DSMV?

A

In DSMIV - symptoms of grief should clear in two months. For DSMV there is no two month exclusion - bereavement should not induce a major depressive episode.

49
Q

List some theories on the etiology of depression.

A
  1. Learned helplessness model - exposure to uncontrollable negative events plus attributional style
  2. cognitive theory - depression results from cognitive errors
  3. genetics of depression
  4. biology of depression
50
Q

What is attributional style?

A

A personality trait in which someone blames themselves for everything that they perceive goes wrong in their lives.

51
Q

Describe the genetics of depression.

A
  1. strong familiar pattern between depression and genetics
  2. children of depressed parents who are adopted out are at increased risk for depression
  3. concordance among monozygotic twins is 40-70%
  4. concordance among dizygotic twins is 11-19%
  5. among first degree relatives - 2-5 times the risk of the general population
52
Q

Describe some biologic theories of depression.

A
  1. it is thought that an imbalance in biogenic amines may be related to depression. Examples include dopamine (catecholamine hypothesis), epinephrine, acetycholine, norepinephrine (catecholamine hypothesis), histamine and serotonin (indoleamine hypothesis).
  2. cholinernic-adrenergic balance hypothesis - depression occurs when NE and DA are low relative to Ach, and mania occurs when the reverse occurs.
  3. neuroendocrine model - the hypothalamus hyper secretes CRF in depression resulting in elevated ACTH, which then triggers the adrenal cortex to release extra cortisol.
  4. infectious model - the Borna virus and other infectious agents can cause depression.
53
Q

Patients with unipolar and bipolar depression often have elevated what?

A

Cortisol. In these patients the elevated cortisol cannot be suppressed with dexamethasone. Ketoconazole does lower cortisol levels.

54
Q

What are the diagnostic criteria for a manic episode in Bipolar I disorder?

A
  1. mood - elevated/irritable/labile (mood all over the place) lasting at least 1 week
  2. activity - increase in goal directed activity or energy lasting at least 1 week
  3. At least 3 of the following symptoms (4 if the mood is irritable) - grandiosity, decreased need for sleep, pressured speech, flight of ideas/racing thoughts, distractibility, increased goal directed activity or psychomotor agitation, risky behaviors
  4. psychosis, need for hospitalization or functional impairment
  5. rule out medical or substance etiologies
55
Q

Bipolar disorder is defined by what?

A

The presence of either a manic or hypomanic episode.

56
Q

What are the different types of Bipolar I disorder?

A
  1. single manic episode
  2. most recent episode hypomanic
  3. most recent episode manic
  4. most recent episode depressed
  5. most recent episode unspecified
57
Q

What is the prevalence of Bipolar I disorder?

A

0.4-1.2% of the population

58
Q

What is the age of onset of Bipolar I episode?

A

20’s or 30’s

59
Q

How long can manic episodes last?

A

weeks to months

60
Q

Is the first episode in Bipolar I disorder manic?

A

It can be manic or depressed (might be confused with depression initially )

61
Q

Are patients who have had one manic episode at risk for having additional episodes?

A

Yes

62
Q

When is a bipolar patient especially at risk for a suicide?

A

When they are transitioning from a manic to a depressive episode.

63
Q

What is rapid cycling?

A

A less common type of Bipolar I disorder in which the patient has 4 plus episodes in one year.

64
Q

Does a patient have to have a depressive episode to be diagnosed with Bipolar I disorder?

A

No. They can be diagnosed if they have only had one manic episode.

65
Q

Describe the genetics of Bipolar I disorder.

A
  1. greater than 60% of those with bipolar I will have a positive family history for a major mood disorder
  2. concordance among monozygotic twins is about 79%
  3. concordance among dizygotic twins is about 19%
  4. likely to multifactorial - includes genetics and environment
66
Q

What is Bipolar II disorder?

A

This disorder is like Bipolar I but is milder - they experience a hypomanic episode.

67
Q

What other disorders may be on the differential diagnosis for Bipolar I disorder?

A
  1. Bipolar due to drugs or medical illness
  2. Bipolar II
  3. Schizoaffective disorder
  4. cyclothymia - like a mild and long lasting bipolar I
68
Q

Describe the characteristics of bipolar disorder caused by a medical condition.

A
  1. disturbance in mood due to the direct pathophysiological consequences of another medical condition
  2. examples of medical conditions are - metabolic, infectious, neoplasm (including meningioma, glioma, thalamic mets), CVA (thalamic stroke), head trauma, MS, Wilson’s disease
69
Q

head trauma in the right frontal lobe may result in what?

A

Mania

70
Q

Head trauma in the left frontal lobe may result in what?

A

Depression

71
Q

Head trauma in the orbitofrontal lobe may result in what?

A

Symptoms of irritability, irresponsibility and increase use of profanity.

72
Q

Head trauma to the medial frontal lobe may result in what?

A
  1. apathy - limited spontaneous movement, gesture and speech
73
Q

Describe drug induced mania?

A
  1. disturbance due to effects of a drug
  2. drugs include - LSD, PCP and other stimulants like meth and cocaine
  3. can occur with medication also - these include steroids, L dopa, thyroxine, captopril and withdrawal from clonidine
74
Q

What is Bipolar II disorder?

A

Defined by the presence of a hypomanic episode plus a major depressive episode with NO history of a manic episode. Treatment is the same as for bipolar I disorder.

75
Q

If a patient has ever had a full manic episode can they be diagnosed with bipolar II disorder?

A

No.

76
Q

Describe a hypomanic episode.

A
  1. at least 4 days of elevated mood plus an increase in goal-directed activity or mood
  2. 3 or more other symptoms (4 if mood is just irritable)
  3. change in functioning
  4. not severe enough to severely impair functioning or necessitate hospitalization
  5. no psychosis
77
Q

How is bipolar I disorder different from bipolar II disorder?

A
  1. involved occurrence of one or more manic episodes with or without a history of one or more major depressive episodes
  2. lifetime prevalence of 0.4-1.6%
  3. equally common in males and females
78
Q

How is bipolar II disorder different from bipolar I disorder?

A
  1. involves at least one major depressive episode and one hypomanic episode with NO history of manic episodes
  2. lifetime prevalence of 0.5%
  3. more common in females
79
Q

What is Schizoaffective disorder?

A
  1. has symptoms of schizophrenia - psychosis, negative symptoms
  2. has prominent affective mood symptoms
  3. psychotic symptoms present even when mood symptoms absent
80
Q

What is cyclothymic disorder?

A
  1. chronic mood disturbance (over 2 years) - like a milder and low grade bipolar
  2. has hypomanic symptoms that don’t meet criteria for a hypomanic episode
  3. depressive symptoms that don’t meet criteria for a major depressive episode
  4. no history of depressive, manic or hypomanic episodes
  5. clinically significant distress or functional impairment

Block 8 week 1 (13 decks)

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