Mood disorders- Part 2 Flashcards
____ is persistent depressive disorder. What are the DSM criteria?
Dysthymia
Patients with ongoing depressive symptoms for two years or longer
Do not have to be in full major depressive episode for all of the two-year span PLUS 2 more of the following:
Appetite changes (poor appetite or overeating)
Sleep changes (insomnia or hypersomnia)
Fatigue or loss of energy
Diminished ability - thinking, concentration or decision-making
Low self-esteem
Feelings of hopelessness
aka more times than not in a depressed mood
T/F: Dysthymia patients sometimes will have manic episodes.
FALSE! Cannot have manic symptoms or secondary cause
What is the treatment for Dysthymia?
1st: SSRIs with therapy
2nd: TCAs and MAOIs have shown success in studies
____ is a depressed mood in response to an identifiable psychosocial stressor
Adjustment Disorder with Depressed Mood
T/F: Adjustment Disorder with Depressed Mood is classified as a true depressive disorder. Why or why not?
FALSE! NOT classified as a true depressive disorder
Significant depressive symptoms, in response to a stressor, that do not meet criteria for a more specific depressive disorder
What is the DSM for Adjustment Disorder with Depressed Mood?
Low mood, tearfulness, or feelings of hopelessness in response to a stressor within 3 months of onset
Symptoms are significant, as evidenced by one or both of the following:
Significant distress exceeding what would be expected given the nature of the stressor
Impaired functioning (social or occupational)
Syndrome is not bereavement¹
Syndrome resolves within 6 months after stressor and its consequences have ended
Recurrent major depressive symptoms occurring consistently at particular times of year is _____. Is it considered a separate mood disorder?
Seasonal Affective Disorder
NO, In conjunction with MDD or Bipolar I/II
For seasonal affective disorder ____ onset is considered a “winter depression”. _____ is considered a “Summer depression”
Begins late fall-early winter; remits in summer
Begins in late spring; remits in winter
Seasonal affective disorder is believed to be linked to ??? What types of areas is it worse?
abnormal serotonergic activity
more prevalent in higher latitudes
**What are some s/s of fall onset seasonal affective disorder?
Increased sleep
Increased appetite
Carbohydrate craving
Increased weight
Irritability
Interpersonal difficulties
Rejection sensitivity
Leaden paralysis (extreme heaviness in the arms and legs)
**What are some s/s of spring onset seasonal affective disorder?
Decreased sleep
Decreased appetite
Decreased weight
Dysphoria
What is the treatment for SAD? When will you see a response?
light therapy for non-psychotic, non-suicidal patients
4-6 weeks to see a response
SSRIs, psychotherapy
What are some SE of phototherapy?
Photophobia, HA, fatigue, irritability, insomnia, hypomania
What is the basic bipolar requirments?
major depressive episode with manic episode
What is the criteria for a major depressive episode?
2+ weeks with five or more of the following symptoms nearly all the time/nearly every day:
Depressed mood
Anhedonia
Significant change in weight or appetite
Sleep changes (insomnia or hypersomnia)
Activity changes (psychomotor agitation or retardation)
Fatigue or loss of energy
Feelings of worthlessness or guilt (excessive, inappropriate)
Diminished ability - thinking, concentration, or decision making
Recurrent thoughts about death or suicide
and must cause distress or functional impairment and must NOT be due to other cause (substances or medication)
What is the criteria for a manic episode? **What is the big key here that is underlined and starred in the PP?
1+ week (7+ days) of abnormally expansive, elevated, or irritable mood and abnormally increased activity or energy
Along with disturbed mood and energy/activity, 3+ of the following are present (4+ if the mood is only irritable):
Inflated self-esteem or grandiosity
Decreased need for sleep
More talkative than usual / pressured speech
Racing thoughts or flight of ideas
Distractibility
Increase in goal-directed activity or psychomotor agitation
Excessive involvement in activities with high potential for bad consequences / “risky” behavior
and must cause distress or functional impairment and must NOT be due to other causes
What is the criteria for a hypomanic epidose?
4+ days of abnormally expansive, elevated, or irritable mood and abnormally increased activity or energy
Along with disturbed mood and energy/activity, 3+ of the following are present (4+ if the mood is only irritable):
Inflated self-esteem or grandiosity (less delusional than mania)
Decreased need for sleep
More talkative than usual / pressured speech
Racing thoughts or flight of ideas
Distractibility
Increase in goal-directed activity or psychomotor agitation
Excessive involvement in activities with high potential for bad consequences
Spending sprees, sexual indiscretions, foolish business investments
Must be a change from baseline mood/behavior that is observable by others
Must not cause functional impairment or require hospitalization
Must not be due to other causes (substances, medication)
What is the difference between hypomania and mania?
Hypomania: is 4+ days and generally not as severe as mania
mania is 7+ days and more severe
Bipolar ____ is more extreme than bipolar ____
Bipolar I is MORE severe than Bipolar II
What is the criteria for bipolar I? Bipolar II?
Bipolar I:
1 or more manic episodes
Nearly always also have hypomanic and major depressive episodes
Bipolar II:
1 or more hypomanic episodes
1 or more major depressive episodes
No manic episodes
What is cyclothymia? What is the criteria?
s/s of both mania and depression but not enough criteria for a dx of either
Periods of hypomanic symptoms - fall short of criteria for a hypomanic episode with
Periods of depressive symptoms - fall short of criteria for a major depressive episode
Bipolar disorder has a higher incidence in those with ____ socioeconomic status
higher
What some risk factors for bipolar?
-Expression and sensitivity to neurotransmitters
Response to psych drugs
(+) Family history of BPD in ⅔ of patients
Increased paternal age
What are some bipolar disorder subtypes?
anxiety
catatonic
mixed
psychotic
atypical
melancholic
peripartum
seasonal
How does the atypical subtype present?
reactivity to pleasurable stimuli, hyperphagia (always hungry, can never be satisfied)
hypersomnia
Manic and hypomanic episodes develop over a ____
→ Manic - resolves over _____
→ Hypomanic - resolves over _____
few days
15-20 weeks
4-8 weeks
Depressive episodes develop ????
→ Major depressive episode - resolves over ____. When is the highest risk of recurrent depressive episodes?
more slowly, days to weeks
20 weeks
months following the resolution
What is the criteria for rapid-cycling BPD? The majority of these patients are ____. How would you describe their bipolar?
4+ mood episodes a year
women: 80-95%
Longer and more refractory course of illness
_____ : especially common in women with rapid-cycling BPD
Hypothyroidism
MDQ screens for symptoms of _____ or ____
mania or hypomania
What does the PHQ-2 test for?
quick initial screening for a depressive episode
What does the PHQ-9 test for?
Further evaluates presence and severity of depression
Can be used for initial screening or follow-up evaluation
**What is the Zung self-rated scale used for?
Depression, more in-depth rating of current depressive episodes
Treatment of Bipolar I/II varies depending on if the patient is in an _____ or ______
acute mood episode
needing maintenance therapy
What are the goals of bipolar treatment?
Control acute mood symptoms
Induce remission of mood symptoms
Reduce or prevent recurrence of mood episodes
What are the criteria for severe mania that they would need to be treated inpatient?
Suicidal/homicidal ideation or behavior with specific plan or intent
Psychosis
Catatonia
Impaired judgement that puts patient/others at risk for harm
Grossly impaired functioning affecting ability to care for self
Which drug classes are considered antimanic?
lithium
anticonvulsants:
carbamazepine (Tegretol), valproate/valproic acid (Depakene), divalproex sodium (Depakote)
Lamotrigine (Lamictal)
Antipsychotics:
quetiapine (Seroquel), lurasidone (Latuda)
**______ prevents mania, but does not treat an acute manic episode?
Lamotrigine
What do you do for a severe acute manic/hypomanic episode?
antipsychotic + lithium or valproate
What do you do for a mild/moderate acute manic/hypomanic episode?
Antipsychotics - risperidone (Risperdal), olanzapine (Zyprexa), others
Lithium (5-10 day latency)
Anticonvulsants:
carbamazepine (Tegretol)
valproate (Depakene)
divalproex (Depakote)
What things would you want to consider to “add on” for an acute manic/hypomanic episode?
benzodiazepines (for acute agitation), psychotherapy (adjunct)
ECT (refractory)
**In a bipolar patient, what do you want to avoid for their acute depressive symptoms? Why?
Recommended to avoid antidepressant monotherapy (especially TCAs) because they have a risk of triggering manic symptoms
What are the medication options for an acute depressive symptom in a bipolar patient?
Anticonvulsants - carbamazepine (Tegretol), valproate (Depakene), lamotrigine (Lamictal)
Lithium (few weeks latency)
Antipsychotics - lurasidone (Latuda), quetiapine (Seroquel), olanzapine (Zyprexa), others
What are first line meds for bipolar maintenance therapy? 2nd line?
Lithium, valproate (Depakene), quetiapine (Seroquel)
Lithium (if not already tried), or quetiapine (Seroquel), valproate (Depakene), lamotrigine (Lamictal)
What bipolar medications are anticonvulsants used as mood stabilizers?
Valproate (Depakene) / Divalproex (Depakote)
Lamotrigine (Lamictal)
Carbamazepine (Tegretol)
_____ mainly for acute mania/hypomania, or maintenance. How long does it take the antidepressant take effect? Has an (increased/decreased) risk of suicide?
Lithium
several weeks to onset
decreased risk of suicide
**When do you need to check levels on a pt taking lithium?
Check levels 5 days after dose change, 12 hrs after last dose (trough)¹
What are the pt education points for lithium?
Taken on a daily basis with food, not PRN
What are the CI for lithium?
Severe CKD, dehydration, sodium depletion, Severe cardiovascular disease - can cause dysrhythmias
Pregnancy
**What are the DDI with lithium?
Diuretics, NSAIDs, ACEIs, tetracyclines, metronidazole, theophylline
What are some side effects of lithium? What lab do you want to check?
L - leukocytosis
I - insipidus (nephrogenic diabetes insipidus)
T - tremor / teratogenesis
H - hypothyroidism
P - parathyroid
A - arrhythmia (dysrhythmia)
thyroid panels
What is Ebstein’s anomaly? What drug is it associated with?
congenital heart defect resulting in an abnormal, leaking tricuspid valve and ASD (atrial septal defect)
Lithium
What baselines labs do you need to get before starting a patient on lithium?
Labs - Renal function (BUN/Cr), Calcium, Urinalysis (UA), Thyroid function
Pregnancy test - if female of childbearing age
ECG - if at risk for cardiac disease
What is the serum lithium levels testing schedule?
5 days after start and after each dose change
Periodically once stabilized on a given dose
q. 1-2 weeks until serum at desired level
q. 2-3 months for first 6 months
Lithium has a very (narrow/wide) therapeutic index. What is the target range? What is toxic? Is lithium toxicity dangerous?
narrow therapeutic index
Target - 0.6-1.2 mEq/L
Toxicity - 1.5 mEq/L
toxicity can be fatal if not recongized and treated
Early - GI upset (N/V/D)
Late - tremor, ataxia, confusion, encephalopathy, seizures
What am I?
What is the treatment?
Lithium toxicity
supportive care: ABC, IV hydration, benzos for seizures
Hemodialysis if severe
What are the CI to valproic acid?
Allergy to drug; liver disease; mitochondrial disease; pregnancy
Need to get pregnancy test!
______ is an anticonvulsant that increases GABA levels and effectiveness. What is the target serum level?
Valproic acid
50-125mg/dL
What are the common SE of valproic acid? What labs do you need to monitor?
N/V, HA, hair loss, bruising, weight gain, tremor, dizziness
serum drug levels, liver function tests (LFTs)
_____ anticonvulsant; inhibits release of glutamate
Lamotrigine
**What is the titration schedule for lamotrigine?
25 mg QD initially, titrated up every 2 weeks
_____ is safer in pregnancy than lithium or other anticonvulsants
lamotrigine
Nausea, rash, pruritus, drowsiness, dizziness
Rare - multiorgan hypersensitivity reaction, derm reaction
Stevens-Johnson Syndrome and Toxic Epidermal Necrolysis
These are CI to _____
Lamotrigine
______ anticonvulsant; anticholinergic; antimanic; antidepressant; antidiuretic; antineuralgic and is chemicall related to TCAs
Carbamazepine
allergy to drug or TCAs; bone marrow suppression; use within 14 days of MAOI. Not recommended in pregnancy. These are the CI to _____
Carbamazepine
**Which psych med has numerous DDI?
Carbamazepine
N/V/D, HA, rash, pruritus, hyponatremia, fluid retention, leukopenia
Rare - bone marrow suppression, aplastic anemia, agranulocytosis
Stevens-Johnson Syndrome and Toxic Epidermal Necrolysis
These are SE of _____
Carbamazepine
If you miss 2-3 days of _____ you need to start over at 25mg
Lamotrigine
________ were initially developed for psychotic d/o, schizophrenia
Used as adjunct therapy for other psych d/o, such as depression
May be used as initial or add-on therapy for bipolar disorder
Antipsychotics
____ MOA works on serotonin and dopamine antagonists. List them
Antipsychotics
quetiapine (Seroquel), lurasidone (Latuda)
tardive dyskinesia, GI, dyslipidemia, hyperglycemia, headache, sedation
These are the SE of _____
Antipsychotics
** What is the specific SE of Quetiapine? Lurasidone?
HTN
Akathisia (no feelings or emotions)
**Patients taking an antipsychotic (typical or atypical) are at risk of developing _____. If a patient is taking an antipsychotic, you should be assessing their ______ score regularly.
tardive dyskinesia
AIMS (Abnormal Involuntary Movement Scale)
Persistently fluctuating mood beyond the normal range of mood symptoms is _____
cyclothymia
What is the presentation of Cyclothymia?
2+ years with numerous periods of hypomanic symptoms and numerous periods of depressive symptoms
Symptoms are present at least half of the time
No more than 2 consecutive months free of symptoms
Patient does not meet full criteria for a mood episode
_______
Symptoms cause distress or functional impairment
Symptoms are not due to substance use
Symptoms are not better accounted for by another psych disorder
What is the treatment for cyclothymia?
meds and therapy
may try mood stabilizer such as lithium
If frequent or refractory depressive s/s, may use low-dose antidepressant in conjunction
What is Disruptive Mood Dsyregulation Disorder? What will they go on to develop as adults?
Persistently abnormal mood (irritable, sad or angry) with severe, frequent temper tantrums that interfere with ability to function at school or at home
depression
What is the Disruptive Mood Dsyregulation Disorder presentation? What is the important point?
1+ year of abnormal mood-related symptoms, including:
3+ severe temper outbursts per week
Reaction is out-of-proportion for the stressor
Reaction is not consistent with developmental level
Sad, irritable, or angry mood nearly every day
Child must be at least 6 years old at time of diagnosis AND
Symptoms must have manifested before age 10
must happen in more than 1 place
not another psych dz
Suicide is the ___ cause of death in the US for all ages
12
____ are more likely to have suicidal thoughts
Attempt suicide 3x as often
Preferred method - poisoning/overdose
Females
____ 4x as likely to successfully commit suicide
Preferred method - firearms
Males
What ethnicities commit suicide most often?
American Indian, Alaska Native, White
What are suicide risk factors?
Elderly white men (young pts more likely to attempt)
family hx
present or anticipated poor health
access to firearms
inability to accept help
living alone: never married, widowed, divorced or separated
lack of support
psych illness
What are to major red flags for suicide?
if they have specific detailed plan
lack of protective factors
_____ scale is given to patients who have a plan to harm themselves to determine in pt vs out pt
Columbia suicide severity rating scale
When do you want to hospitalize a pt for suicide?
Patients who have actually made a suicide attempt
Patients with moderate-severe suicidal ideation: Stated intent, specific plan
What is the protocol to ensure a suicidal patient’s safety?
Have staff member present
Limit access to objects that could cause harm
Transport to inpatient facility via ambulance
____ and ____ are often used as an inpatient treatment of comorbid disorders
lithium and ECT
