Week 7 Mood & affect Flashcards
What is the continuum of mood disorders ?
Mania
Hypomania
Normal/balanced mood/Euthymia
Mild to moderate depression
Severe depression
What is the DSM- 5 Diagnostic criteria for Major depressive disorder?
- At least a 2 week history of 5 or more symptoms
- symptoms are a change from baseline
- symptoms cause significant distress/impairment in functioning
What MUST be present for a diagnosis of major depressive disorder?
- Depressed mood most of the day, nearly everday
or - markedly diminished interest/pleasure in activities most of the day, nearly everyday
What are the other symptoms of major depressive disorder that can accompany one of the required symtoms?
- significant weight loss/gain/decreased appetite
- hard to sleep
- psychomotor agitation or retardation
- fatigue/loss of energy
- feeling worthless/inappropriate guilt
- can’t concentrate/indecisive
- recurrent thoughts of suicide/death
How do youth experience depression that is different than adults?
-Irritable or angry mood
-“Acting Out” behaviours
-Unexplained aches and pains
-Extreme sensitivity to criticism
-Withdrawing from some, but not all people
What can untreated depression lead to in youth?
-Low self-esteem
-Problems at school/running away
-Substance abuse
-Eating disorders
-Violence
-Self-injury
-Suicide: 15-19 years of age - 2nd leading cause of death - Indigenous Youth
-Comorbid diagnosis - with ADHD; Anxiety
What does depression look like in older adults (common)?
Focus on physical health symptoms
Weight loss
Poor appetite
Anhedonia
Social isolation
What is anhedonia?
not feeling like caring about anything
What are less common complaints of depression in older adults?
depressed mood/sadness/crying
weight gain
What is a significant risk of depression?
Suicide risk - 15% die by suicide if not treated
What are the causes of depression?
- Physical - endocrine & illness
- Neurotransmitters
- serotonin, norepi, monoamine oxidase - Cognitive distortions
- Genetic vulnerability
- psychosocial factors -
- ACES (childhood) - trauma & loss
What are the approaches to treatment /care of depression?
meds
ECT
TMS (rTMS)
CBT
Pychotherapy
Mindfulness
Psychosocial support
Education
Health promotion
Health & Wellness
What are the antidepressant drug class medications for Depression ?
SSRIs
SNRIs
NRIs
NDRIs
SNDIs
TCAs
MAOIs
What does norepinephrine control?
Attention
balanced mood
endurance
concentration
What does Dopamine control?
Alertness
- clarity
- motivation
- passive working memory
- Appetite
What does serotonin control?
Satisfaction
- relaxation / insomnia
- pleasure / anxiety
- learning memory - disability
What are the SSRIs?
Selective serotonin reuptake inhibitors (leave more in the synapse)
- Fluoxetine (prozac)
- Paroxetine (Paxil)
- Citalopram (Celexa)
- Sertraline
- Escitalopram
What meds for depression are used less and why?
TCAs
- cardiac issues
- anticholinergic symptoms
What is a SNRI?
selective serotonin and norepinephrine reuptake inhibitor
Venlafaxine (Effexor)
Duloxetine
What are atypical antidepressants?
Trazadone (Desyrel) - SARI
Buproprion - Wellbutrin - NDRI
Mirtazapine - Remeron- Tetracyclic
What are SSRSs indicated for?
Anxiety
Depression
OCD
PTSD
What is the MOA of SSRIs?
blocks reuptake of serotonin
so more is left available in synaptic cleft
What do we monitor for in SSRI use?
Serotonin syndrome
LFTs
CBC
Renal issues
What are the side effects of SSRIs?
stomach upset
serotonin syndrome
suicidal thoughts
weight gain
sexual dysfunction
sleep issues
stress
What should someone not take with SSRIs?
st john’s wart
Warfarin
Digoxin
What should we educate patients about with SSRIs?
insomnia
avoid alcohol
careful with NSAIDs- GI bleed
Change position slowly (BP) - orthostatic hypotension
What are SNRIs indicated for?
Anxiety
Depression
Neuropathic pain
Which antidepressants are also good for neuropathic pain?
SNRIs
Atypical antidepressants
TCAs
What should we monitor for in someone taking SNRIs?
- serotonin syndrome
agitation
fever
hallucinations
diaphoresis
tremors
What side effects do SNRIs have that SSRIs do not?
-Hypertension d/t norepi increase
- Adrenergic effects
- Tachycardia
(also has all the ones from SSRIs)
What do SNRIs interact with?
St. john’s wort
What are Atypical Antidepressants indicated for?
Depression
Neuropathy
Fibromyalgia
Anxiety
Insomnia
What is the MOA of atypical antidepressants?
SLOWS (not blocks) rate of reuptake of serotonin and norepi
What are the 2 things people can experience if stopping or changing SSRIs suddenly?
Withdrawl symptoms - discontinuation syndrome
Serotonin syndrome - excessive serotonin
What are discontinuation syndrome symptoms?
flu- like symptoms
nausea
electric shock in brain
headache
vertigo
anxiety/irritable
insomnia
What are symptoms of Serotonin syndrome?
MSE changes - delirium
Fever
Tachycardia
Hypertension
Tremor
Diarrhea
Neuromuscular symptoms
What drugs can cause Serotonin Syndrome?
SSRIs
SNRIs
TCAs
Buspirone
MAOIs
Lithium
St John’s Wort
Trazadone
LSD, MDMA (ecstacy), cocaine
What is the triad of clinical features in Serotonin syndrom?
Mental status changes
Neuromuscular abnormalities (muscle rigidity)
Autonomic hyperactivities (BP and HR increase)
What is the acrynom for Serotonin syndrome?
HARMFUL
H- hyperthermia
A- agitation, delirium, confusion
R - restlessness, increase reflexes
M - Myoclonus - twitch/jerk
F- Fast heart rate
U- Unconsciousness
L- Loss of GI control - nausea & diarrhea
What is the onset of Serotonin syndrome?
Quick onset (within hours)
What two medications do we use to counter serotonin syndrome and why?
benzos- sedation
cyproheptadine - block serotonin production
What drug class is very dangerous in overdose and why?
TCAs
cardiotoxicity
What are MAOIs?
TIPS
Tranylcypromine
Phenelzine
Isocarboxazid
Selegiline
What are MAOIs indicated for?
Depression
What is the MOA of MAOIs?
inhibits monoamine oxidase
- monoamine neurotrasmitters can’t be broken down
- stops reuptake of serotonin, melatonin, epinephrine, and norepi
What 2 things do we monitor for with MAOIs?
Hypertensive crisis
Serotonin syndrome
What are the side effects of MAOIs?
Agitation/anxiety
Orthostatice hypotension
Hypertensive crisis
What antidepressants can cause hypertensive crisis?
MAOIs
What antidepressants can cause orthostatic hypotension?
Atypical Antidepressants
MAOIs
TCAs
What should we teach patients who are taking MAOIs?
- no foods with tyramine
- avoid caffeine
-OTC cold medications = hypertension - 2 week washout period needed
What is IV ketamine used for?
treatment-resistant depression
How long is the treatment of Ketamine?
8 treatments
2-3 x/week
What is the MOA of ketamine?
causes excitation of the neurons and neuroplasticity
glutamate allows new pathways to be formed in the brain
What is one of the most effective treatments for acute depression?
ECT
how many hours should someone be NPO before ECT?
6 hours
What are the side effects of ECT?
-Disorientation/confusion
- STM loss around time of treatment
- Muscle aches/pains
- headache
- N&V
What is rTMS/TMS?
transcranial magnetic stimulation
- electromagnetic coil on scalp
- stimulates brain cells we think relate to depression
- 30 min
- patient is awake
What are the 3 principles of CBT?
1.thoughts create feelings
2. feelings created behaviours
3. behaviours reinforce thoughts
it’s a cycle
What’s important for caring for someone with depression?
- therapeutic relationship
- meet physical health needs
- make positive decisions for clients if they are unable to
- promote coping skills that are empowering to the person
- Promote problem solving skills
- positive self regard
- encourage social support network
- Support for families or caregivers
Which is worse, bipolar I or bipolar II?
Bipolar I
What is different between bipolar I and bipolar II?
Bipolar I - at least 1 MANIA (can’t function) episode
WITH depression/anxiety
Bipolar II - at least one HYPOMANIC (function too well) episode AND at least ONE major depressive episode
What is Cyclothymia?
numerous periods of hypomanic symptoms
WITH depressive symptoms over at least 2 years
What is different between Bipolar II and Cyclothymia?
Cyclothymia:
time- must be at least over 2 years
frequency- numerous hypomanic symptoms
How do we distinguish Bipolar from depressive disorders?
the occurance of mania or hypomania (mild manic)
IN ADDITION to
Depressive episodes
what is the onset age of bipolar?
21-30 years old
What is rapid cycling?
4 or more episodes in 12 months
What is secondary mania?
it’s caused by something else like a tumour
“Mania secondary to tumour”
What is hypomania?
elated behaviour that is atypical for the person
over at least 4 consecutive days, most of the day, nearly everyday
Which progresses into psychosis, Mania or hypomania?
Mania only
Does hypomania cause marked impairment to daily, social, or occupational functioning?
No - that’s mania
How long do symptoms of Mania have to be present according to the DSM 5?
at least 1 week
present most of the day, nearly everyday
represents a change for the person
What symptoms must be present for a mania diagnosis?
- persistent elevated (euphoric), expansive or irritable mood
- very goal directed activity/energy
- 3 or more of the other symptoms (or 4 if there is only irritable mood)
What are the other symptoms of Mania that go along with the required two for diagnosis according to DSM 5?
- inflated self-esteem or grandiosity
- don’t need sleep
- pressured speech - talkative
- flight of ideas - racing thoughts
- distracted to external stimuli
- purposeless non-goal directed activity / psychomotor agitation
- Excessive buying sprees, sexual indiscretions, reckless business investments
What is different between schizophrenia from bipolar in the common symptoms?
schizophrenia- when they sleep delusions go away
bipolar - sleep doesn’t make things better
How does lithium toxicity differ from serotonin syndrome?
lithium toxicity - more of a tremor and rigidity until they become unconscious
- think of G4 guy with what looked like seizures but very random and he was unconscious
What medications are used first line for bipolar?
*Anti-psychotics
- quetiapine
- Seroquel
*Sedatives/Hypnotics
- zoplicone
- trazadone (for sleep)
Antianxiety - benzos (short term)
Antidepressants
What medication is used after first line meds have been tried for bipolar?
Lithium
What can lithium toxicity result in ?
severe kidney damage (check urine and creat/urea!)
death
What affects lithium levels and how?
salt
too much salt makes lithium not work well
too little salt can allow lithium to become toxic
dehydration or N&V can cause toxicity
What is lithium indicated for?
acute mania - bipolar
long term management of bipolar
What is the MOA of lithium?
acts on CNS
strengthen nerve connections in the brain - mood, thinking, behaviour
What bloodwork do we monitor with lithium?
Creatinine/BUN
Lithium levels - 12 hrs after last dose
Na
What are the side effects of lithium?
nephrotoxicity - kidney harm
polyuria - pee a lot
increased thirst
fine hand tremors
hypothyroid
electrolyte changes
leukocytosis (high white blood cells)
what should we teach someone on Lithium?
no diuretics
no NSAIDS
careful Na intake
careful fluid intake
careful when sweating, dehydrated, diarrhea, illness
no preggers or breastfeeding
What are some clinical symptoms of lithium toxicity?
confusion
slurred speech
incoordination
What do we do if we suspect someone has lithium toxicity?
activated charcoal or pump stomach
bolus with fluid (likely dehydrated or not enough salt)
sometimes hemodialysis
What drug classes are used for bipolar?
Mood stabilizers - lithium
Anticonvulsants -
-carbamazepine
- valproate
- gabapentin
- topiramate
What are anticonvulsants indicated for?
acute mania
maintenance of bipolar disorder
What is the MOA of anticonvulsants?
carbamazepine - decreases synaptic transmissions in CNS
Valproic acid - increases GABA (inhibitory behaviour and mania decrease)
what do we monitor with carbamezapine?
“my love of CARBS is in my blood - cbc”
LFTs, CBC
leukopenia & aplastic anemia
What do we monitor in valproate?
(if you VALue your liver)
*LFT
*PLATELETS
drowsiness
mood
ideations
What do we educate people about with carbamazepine?
fever or sore throat (leukopenia)
lowers effectiveness of most hormonal BC
What do we educate about valproate?
not for preggers
maybe jaundice
watch for bleeding
What are the goals of care for ACUTE mania?
safety
prevent injury with drugs when needed
ADLs
Calm voice
Short convos
Reduce stimulation
