Depressive, Bipolar & Related Disorders

the patient will report a history of more mania than depression.

- severe mood disorder

- manic episodes, alternating w/ depression & psychosis during episodes

a. cyclothymic disorder

b. bipolar I disorder

c. bipolar II disorder

b. bipolar I disorder

2 multiple choice options

the patient will report a history of more depression than mania.

- low level mania w/ profound depression

- no psychosis

a. cyclothymic disorder

b. bipolar I disorder

c. bipolar II disorder

c. bipolar II disorder

2 multiple choice options

alternating hypomanic episodes with a long-standing low mood state (dysthymia)

- for at least 2 yrs

a. cyclothymic disorder

b. bipolar I disorder

c. bipolar II disorder

a. cyclothymic disorder

2 multiple choice options

bipolar I disorder

- squandering savings, destroying relationships, neglecting work activities, etc..

- manic episode w/ or w/o major depressive episodes

how does the DSM define mania?

mood disturbance that is sufficiently severe to cause:

marked impairment in occupational functioning

or

in usual social activities

or

relationships with others

to necessitate hospitalization to prevent harm to self or others

OR

there are psychotic features

what is considered a first-line medication for bipolar disorder (types I or II)?

lithium

in bipolar I, what can be given to treat acute mania?

- lithium

- valproate

- second generation antipsychotics (SGAs) [such as, olanzapine or aripiprazole])

- carbamazepine

in bipolar I, what can be given for mania maintenance?

- SGAs (olanzapine or aripiprazole)

- gabapentin

- lamotrigine (Lamictal)

in bipolar I, what can be given If agitation is present?

antipsychotics (haloperidol or risperidone)

or

benzodiazepines

along with lithium levels, which of the following laboratory levels should be monitored in patients taking lithium for bipolar disorder?

TSH

3 multiple choice options

which of the following is a symptom of lithium toxicity?

tremor

3 multiple choice options

bipolar II disorder

- bouts of sadness & distractibility, & an episode of decreased need for sleep, a flight of ideas, and buying sprees

- at least one hypomanic episode and at least one major depressive episode

- THERE HAS NEVER BEEN A MANIC EPISODE

how does the DSM define hypomania?

mood disturbance that is NOT severe enough to cause marked impairment in social or occupational functioning or to necessitate hospitalization, and there are NO psychotic features

in bipolar II, what can be given to treat depressive episodes?

- SSRIs (citalopram, fluoxetine, paroxetine, sertraline, vilazadone, etc)

- quetiapine

- olanzapine

=/- fluoxetine

52-year-old male is referred to psychiatry by his PCP after 3 weeks of erratic behavior. The patient has been driving to a casino 60 miles away after work every night to gamble and returning directly to work the following morning. He stresses, however, that "it isn't a problem" because he is still "full of energy" during the day at his banking job, which he "could do in [his] sleep anyway." He has not sought psychiatric treatment in the past, but reports an episode of self-diagnosed depression 2 years ago. The patient's medical history is significant for diabetes, hypertension, hepatitis C, stage II chronic kidney disease, and congenital long QT syndrome. The patient's toxicology screen is negative for illicit drugs in the PCP's office. Which of the following of the patient's medical conditions is a contraindication for lithium therapy?

chronic kidney disease (CKD)

3 multiple choice options

cyclothymic disorder

- alternating hypomanic episodes w/ long-standing low mood state (dysthymia)

- less intense, but often longer-lasting version of bipolar disorder

- both high & low mood, but never as severe as either mania or major depression

- episodes of depression & hypomania or at least 2 yrs

a mood disorder in which a person experiences (in the absence of drugs or a medical condition), 2 or more weeks of significantly depressed moods

- feelings of worthlessness & diminished interest or pleasure in activities

a. major depressive disorder (MDD)

b. persistent depressive disorder (dysthymia)

c. premenstrual dysphoric disorder

d. suicidal/homicidal behaviors

a. major depressive disorder (MDD)

3 multiple choice options

a mood disorder involving persistently depressed mood with low self-esteem, withdrawal, pessimism, or despair for at least 2 yrs

- with no absence of symptoms for more than 2 months

a. major depressive disorder (MDD)

b. persistent depressive disorder (dysthymia)

c. premenstrual dysphoric disorder

d. suicidal/homicidal behaviors

b. persistent depressive disorder (dysthymia)

3 multiple choice options

a disorder marked by repeated episodes of significant depression and related symptoms

- during the week before menstruation

a. major depressive disorder (MDD)

b. persistent depressive disorder (dysthymia)

c. premenstrual dysphoric disorder (PMDD)

d. suicidal/homicidal behaviors

c. premenstrual dysphoric disorder (PMDD)

3 multiple choice options

mood disturbances, somatic complaints, feelings of hopelessness, worthlessness, &/or helplessness

a. major depressive disorder (MDD)

b. persistent depressive disorder (dysthymia)

c. premenstrual dysphoric disorder (PMDD)

d. suicidal/homicidal behaviors

d. suicidal/homicidal behaviors

3 multiple choice options

what is SIGECAPS?

depression symptoms:

Sleep disturbances (either insomnia or hypersomnia)

Interest loss (anhedonia, or loss of interest in previously enjoyed activities)

Guilt feelings or worthlessness

Energy loss or fatigue

Concentration difficulties

Appetite changes (wither increased or decreased, leading to weight loss or gain)

Pyschomotor agitation or retardation (observable restlessness or slowing down)

Suicidal thoughts or behaviors

define major depressive disorder (MDD):

5 or more SIGECAPS symptoms for >/= 2 wks, nearly every day, at least one of the symptoms is depressed or anhedonia

what is the first line treatment for depressive disorders?

SSRIs

- d/t less morbidity, but TCAs & MAO-Is may also be helpful

how long may it take for therapeutic effects to be felt after initiation of an SSRI?

4-6 wks

- increase dosage every 3 to 4 wks until symptoms are in remission

what is the follow-up after starting an SSRI?

- within 2 to 4 wks of starting

- every 2 wks until improvement

- then monthly to monitor medication changes

persistent depressive disorder

- chronic depression for 2 or more years

- NEVER been without the depressive symptoms for more than 2 months at a time

- NEVER been a manic episode or a hypomanic episode

- same treatments (SSRIs, other antidepressants, psychotherapy, exercise)

a 27-year-old man accompanied by his girlfriend. In the office, he seems to be running from topic to topic without a clear message. His speech is pressured. The patient’s girlfriend reports that he took steroids recently for a bad sinus infection and since he started them, his behavior has been abnormal. After discontinuing the medication, he has still been having symptoms. He has not had a normal night of sleep for the past ten days, and he just bought a new sports car though he has no need for one or the money to afford it. She also reports that she has caught him with multiple other women in the past few days, though they were in a committed relationship. The physical exam is benign and the patient’s vital signs are within normal limits.

bipolar I disorder

a 19-year-old male who has had bouts of sadness for a course of 1 year in which he says that often he cannot even get out of bed so he tells his parents he is ill. Jim states that he recently felt so energized that he could not keep his thoughts straight and jumped from one idea to another. During this energized state, he did become irritable and others stated that he was louder than usual and wondered if he took something that increased his energy. During the week of high energy, he maxed out two of his credit cards and is not sure how he will pay them off before he goes to school in the fall. It was only a week later that he became so depressed that he did not find any pleasure in anything he did, was so tired he did not want to get out of bed which has continued to be a struggle today.

bipolar II disorder

a 24-year-old male with c/o episodes of depression alternating with times of increased energy, restlessness, and decreased sleep for 2 years.

cyclothymic disorder

a 33-year-old woman complaining of fatigue and decreased interest in “the things that used to make me happy.” She is sleeping less and eating less, and she says that she is forcing herself to eat “because I know I have to eat something.” She finds herself spending less time with her kids and husband as she retreats to her room. She feels guilty that she lacks the energy and enthusiasm she used to have.

major depressive disorder (MDD)

a 30-year-old married male who feels down most of the time for the past three years. He experiences frequent, intrusive thoughts that he is not good enough, despite personal and professional successes. He tries to overcompensate for his thoughts by taking on more than he can handle, which leads to failure and furthers his feelings of inadequacy. His wife suggests that he seek help after finding him crying.

persistent depressive disorder