Section 3: Mood Disorders Flashcards
Major Depressive Disorder
This disorder is characterized by depressed mood or anhedonia and depressive symptoms lasting at least 2 weeks.
List the symptoms of depression
Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kaplan Medical Usmle Master the Boards Step 3) (Kindle Locations 15469-15478). Kaplan Publishing. Kindle Edition.
Sleep disturbance
Loss of interest/apathy
Feeling of guilt or worthlessness
Lack of energy
Lack of concentration
Loss of apetite
Psychomotor agitation
Suicidal ideation
Use the mnemonic: “SIG E CAPS”
In the management of depression, it is important to look for other causes of depression where the first step in management is different.
List these differential and the tests to do
- Hypothyroidism: – Check TSH – First step in management is thyroxine
- Parkinson’s disease: – Treat with anti-Parkinson medications
- Medications: – Corticosteroids, ß-blockers, antipsychotics (especially in the elderly), and reserpine – Treat by discontinuing medication and switching to an alternative
- Substance Abuse disorders: – Alcohol (ask CAGE questionnaire), amphetamines – Treat with detoxification and antidepressants
Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kaplan Medical Usmle Master the Boards Step 3) (Kindle Locations 15473-15491). Kaplan Publishing. Kindle Edition.
Rx of MDD
Admit the patient if there is suicidal/ homicidal ideation or paranoia.
Begin antidepressant medications (SSRI is first drug of choice).
Give benzodiazepines if agitated.
Electroconvulsive therapy (ECT) is the best choice if the patient is acutely suicidal (works quicker than antidepressants) or for patients worried about side effects from medications.
Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kaplan Medical Usmle Master the Boards Step 3) (Kindle Locations 15505-15509). Kaplan Publishing. Kindle Edition.
Diagnosis:
- Low level depression symptoms
- Present on most days for at least 2 years
Rx of above condition
Dysthermic disorder
Rx
- Long term individual, insight-oriented psychotherapy
- SSRIs if above fails
Diagnosis
- Depressive symptoms in the winter mood
- No depressive symptoms in the summer
Rx
Seasonal Affective Disorder
Phototherapy or Sleep deprivation
Diagnosis:
Bipolar patient with > 4 episodes of mania
Rapid cycling bipolar
List the symptoms of mania
- Grandiosity
- Less need for sleep
- Excessive talking or pressured speech
- Racing thoughts or flight of ideas
- Distractibility
- Goal-focused activity at home or at work
- Sexual promiscuity
Use the mnemonic “DIGS FAR”
CCS Tip: If the history suggests drug use, first get a drug screen to rule out amphetamine use as a cause of mania. If the history gives elevated blood pressure or low TSH, consider medical conditions, such as pheochromocytoma and hyperthyroidism.
Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kaplan Medical Usmle Master the Boards Step 3) (Kindle Locations 15529-15534). Kaplan Publishing. Kindle Edition.
Outline the steps in the management of acute mania
- Hospitalize
- Mood stabilizers are used to induce remission. Lithium is the drug of choice (takes 1 week for effect)
- Antipsychotics are used until acute mania is controlled. Drug of choice is risperidone
- Give IM depot phenothiazine in noncompliant, severely manic patients.
- Give antidepressants only when there’s a history of recurrent episodes of depression and only together with mood stabilizers (to prevent inducing manic episode)
Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kaplan Medical Usmle Master the Boards Step 3) (Kindle Locations 15533-15549). Kaplan Publishing. Kindle Edition.
- What is the most common cause of progression to rapid cycling bipolar?
- How should you manage rapid cycling bipolar?
- What other medical conditions predispose a patient to rapid cycling bipolar?
- What drug has been shown to prevent suicidal ideation in bipolar disorder?
- A 32 year-old known bipolar patient who is undergoing maintenance therapy with lithium presents with a positive pregnancy test
Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kaplan Medical Usmle Master the Boards Step 3) (Kindle Locations 15546-15564). Kaplan Publishing. Kindle Edition.
- Use of antidepressants: Do not give antidepressants prophylactically unless the question describes previous severe depressive episodes. In that case, antidepressants are only given for a few weeks.
- Gradually stop all antidepressants, stimulants, caffeine, benzodiazepines, and alcohol.
- Hypothyroidism: Check TSH in any patient with rapid cycling bipolar and replace thyroid hormones if needed
- Lithium
- Discontinue lithium (to avoid heart abnormalities): Choose ECT therapy for first-trimester patients with manic episodes. Lamotrigine may be used in 2nd or 3rd trimester.
Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kaplan Medical Usmle Master the Boards Step 3) (Kindle Locations 15546-15564). Kaplan Publishing. Kindle Edition.
Diagnosis
- History of recurrent episodes of depressed mood and hypomanic mood for at least 2 years,
Rx
Cyclothymia
It resembles a milder form of bipolar affective disorder
Psychotherapy is the first step in management. Many people function without medications and learn to manage their hypomanic dispositions (especially artists). Start divalproex when functioning is impaired. Divalproex is more effective in cyclothymia than lithium.
Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kaplan Medical Usmle Master the Boards Step 3) (Kindle Locations 15565-15593). Kaplan Publishing. Kindle Edition.
Compare grief and depression.
Sadness, tearfulness, decreased sleep, decreased appetite, decreased interest in the world are common to both
Symptoms wax and wane in GRIEF BUT symptoms are pervasive and unremitting in DEPRESSION
Shame and guilt are less common in GRIEF than in DEPRESSION
Suicidal ideation is less common in GRIEF than in DEPRESSION
Symptoms can last up to 1 year in GRIEF while symptoms continue for more than 1 year in DEPRESSION
Patient usually returns to baseline level of functioning within 2 months in GRIEF; Patient does not return to baseline functioning in DEPRESSION
Treatment includes supportive therapy in GRIEF; Treatment includes antidepressant medications in DEPRESSION
Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kaplan Medical Usmle Master the Boards Step 3) (Kindle Locations 15565-15593). Kaplan Publishing. Kindle Edition.
A 32-year-old woman who gave birth 4 months ago is brought in by her husband because of depressed mood. The husband reports that she has been depressed since the birth of her child, refuses to eat, has trouble sleeping, and is unable to concentrate. The woman reports that she has lost interest in everything and sometimes can’t even get out of bed. She reports that she’s recently had visions of seeing her deceased mother talking to her and criticizing her skills as a new mother. She also admits that she hears her voice talk to her constantly too. She denies homicidal or suicidal ideation. Which of the following is the best initial treatment?
a. Psychotherapy
b. Behavioral therapy
c. Sertraline
d. Risperidone
e. Phenelzine
Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kaplan Medical Usmle Master the Boards Step 3) (Kindle Locations 15594-15614). Kaplan Publishing. Kindle Edition.
D. Patients with both mood and psychotic symptoms respond to both antidepressants and antipsychotic medication. However, you must treat the worst symptom first. In this case, the antipsychotic would be most indicated to reduce her psychotic symptoms.
Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kaplan Medical Usmle Master the Boards Step 3) (Kindle Locations 15594-15614). Kaplan Publishing. Kindle Edition.
A 45-year-old woman presents 2 months after the sudden loss of her son in a car accident. She reports “not being able to cope well.” She is constantly teary, has lost her appetite, and has decreased 2 dress sizes. She finds herself laying out a dinner plate every night for him. Recently, she believes she has heard his voice and every night she has nightmares about the car accident. She denies suicidal ideation. Which of the following is the most appropriate next step in management?
a. Group therapy
b. Amitriptyline
c. Fluoxetine
d. Zolpidem
e. Supportive therapy
Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kaplan Medical Usmle Master the Boards Step 3) (Kindle Locations 15594-15614). Kaplan Publishing. Kindle Edition.
E. This patient is undergoing normal grief reaction. Auditory hallucinations without other psychotic symptoms are normal in grief reaction. Antidepressants are indicated when symptoms last longer than 6 months and the patient’s symptoms can be classified as major depression.
Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kaplan Medical Usmle Master the Boards Step 3) (Kindle Locations 15614-15646). Kaplan Publishing. Kindle Edition.
Compare Post-Partum Blues (PPB), PostPartum Depression (PPD) and PostPartum Psychosis (PPP)
Onset After any birth (PPB); Usually after 2nd birth (PPD) Usually after 1st birth (PPP)
Mother’s emotions toward baby Cares about baby (PPB); Many have thoughts about hurting the baby (PPD); Many have thoughts about hurting the baby (PPP)
Symptoms Mild depressive (PPB); Severe depressive (PPD); Look for psychotic symptoms along with severe depressive symptoms (PPP)
Treatment Self-limited; no treatment necessary (PPB); Antidepressants (PPD); Mood stabilizers or antipsychotics and antidepressants (PPP) TIP: Avoid medications if patient is breastfeeding; instead choose electroconvulsive therapy (ECT).
Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kaplan Medical Usmle Master the Boards Step 3) (Kindle Locations 15614-15646). Kaplan Publishing. Kindle Edition.
List the risk factors for suicide
- History of suicide threats and attempts is the most important predictor of suicide
- Family history of suicide
- Perceived hopelessness (demoralization)
- Schizophrenia/ borderline or antisocial PD
- Drug use, especially alcohol
- Males/ Age > 65
- Socially isolated/ recently divorced or widowed
- Chronic physical illness
- Low job satisfaction or unemployment
Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kaplan Medical Usmle Master the Boards Step 3) (Kindle Locations 15651-15680). Kaplan Publishing. Kindle Edition.
