BH E1- Mood disorders

*not done

What classifies all mental disorders, specifying diagnostic criteria and describing manifestations of the disorder but rarely explains the causes or origins?

DSM (5-TR is current version)

What is a syndrome characterized by clinically significant disturbance in cognition, emotion regulation, or behavior that reflects a dysfunction in the psychological, biological, or developmental processes underlying mental functioning?

Mental disorder

Does a culturally approved / expectable response to a common stressor or loss (ie death of a loved one) count as a mental disorder?

No

What are the 3 domains of mental health indicators?

Emotional well being, psychological well being, social well being

Does the DSM include treatment options or theoretical concepts of mental disorders?

No - purely a diagnostic tool

What is the 2nd leading cause of death in youth and young adults?

Suicide

What mental disorder is most associated with people who have attempted suicide?

MDD

What are half of suicide attempts related to?

Firearms

What are the risk factors for suicide?

Sex (F more likely to attempt, M more likely to commit)

Age (bimodal- teens & elderly)

Depression

Previous attempt!

Etoh abuse

Rational thinking loss

Social support lacking

Organized plan

No spouse

Sickness / chronic illness

What is considered a protective factor against suicide?

Having responsibility to others (ie spouse)

What scale assesses suicide risk?

Columbia suicide severity rating scale (C-SSRS)

What 3 criteria must be met to have a patient involuntarily committed (IVC) / backer act?

-Presence of mental illness

-Refused voluntary examination OR unable to consent to exam

-Poses risk to self or others w/o tx AND it is not apparent that such harm may be avoided through help of other services

What rule governs the duty to warn individuals who are being threatened & use reasonable care to protect intended victim against such danger?

Tarasoff rule

What is a period of time when a patient feels abnormally happy or sad (ie major depressive, manic, hypomanic)?

Mood episode

The following diagnostic criteria is for what condition?

• ≥5 sx from SIGECAPS must be present during 2 week period, and atleast 1 must be depressed mood or anhedonia

• sx cause impairment in functioning & not caused by other condition

Major depressive episode (MDE)

What is anhedonia?

loss of interest/pleasure

What are the symptoms in the SIGECAPS mnemonic for major depressive epidoses (MDE)?

Sleep disturbances

Interest lost (Anhedonia)

Guilt / worthlessness

Energy dec (Fatigue)

Concentration issues

Appetite disturbances

Psychomotor changes

Suicidal ideation (SI)

The following DSM5 criteria is for what condition?

• abnormally & persistent elevated or irritably mood & inc energy, lasting atleast 1 week and present most of the day nearly every day

• ≥3 sx (or ≥4 if mood is only irritable)

  • distractibility

  • dec need for sleep

  • inc self esteem, grandiosity

  • flight of ideas / racing thoughts

  • inc goal directed activity or psychomotor agitation

  • activities w/ high potential for painful consequences

• marked impairment in functioning or necessitates hospitalization, or psychotic features are present

• not caused by other condition / substance

Manic episode

The following criteria is for what condition?

• feelings of persistent irritability & elation

• ≥3 DIGFAST sx for atleast 4 days

  • distractibility

  • insomnia

  • grandiosity

  • flight of ideas

  • inc activity

  • speech

  • thoughtlessness

• *does not cause significant impairment, hospitalization, or psychosis

Hypomanic episode

What mnemonic for symptoms of a manic/hypomanic episode?

Distractibility

Insomnia (dec need for sleep)

Grandiosity (inc self esteem)

Flight of ideas/racing thoughts

Activity / energy increased or psychomotor agitation

Speech (pressured or talkative)

Thoughtlessness (risky behavior)

Manic or Hypomanic episode?

• lasts at least 7 days

• causes severe impairment socially or occupationally

• may warrant hospitalization/baker act to prevent harm to self or others

• psychotic features

Manic episode

Manic or hypomanic episode?

• lasts atleast 4 days

• no marked impairment

• does NOT require hospitlization

• NO psychotic features

Hypomanic episode

What is the DSM-5 criteria for major depressive disorder (MDD)?

≥1 MDE (SIGECAPS) + NO history of mania/hypomania

What are key features of MDD?

Sadness, irritability, suicidal ideation (SI)

Who is MDD more common in?

F > M, peaks ~20 y/o; sudden or gradual onset

In what MDD patients would mortality be increased?

Comorbidities (DM, stroke, CV dz)

The following etiology is for what condition?

• dec NE, 5HT, DA

• abnormal B receptor regulation

• thyroid disorders, dysregulation of brain pathology

• fhx 1st degree relative (2-4x inc risk)

• disturbance in infant/mother relationship (freud)

• poor stability of family structure & social functiong

MDD

How often should primary care screen adults for depression?

annually (more often if risk factors)

How often should primary care screen a patient for depression with chronic controlled HTN on a BB?

screen every visit

How long can untreated MDD episodes last?

6-13 mos

What clinical signs are present with MDD?

Sleep complaints, appetite changes, energy/fatigue complaints, GI complaints, physical pain (ex- HAs)

When would you hospitalize a patient w/ MDD?

SI, HI, unable to care for self

What is the preferred treatment for MDD?

Combo pharmacotherapy + psychotherapy

What type of therapy often includes education, relaxation exercises, coping skills training, stress management or assertiveness training?

Cognitive behavioral therapy (CBT)

What kind of therapy focuses on individuals interpersonal life in 4 problem areas- grief over loss, interpersonal disputes, role transitions, and interpersonal skill deficits?

Interpersonal therapy (IPT)

What type of psychotherapy?

• develops self insight by exploring how past experiences influence current behaviors, emotions & relationships

• uncover unconscious patterns in interpersonal relationships, conflicts & desires

• methods to enhance self awareness

Psychodynamic psychotherapy

What type of psychotherapy helps individuals cope & deal with illness, crisis or transient problem as well as maintain optimism and hope (offers guidance, advice, praise, etc)?

Supportive therapy

What type of psychotherapy attempts to correct distorted communications & impaired relationships by helping partner/entire family as well as the patient?

Family and couples therapy

What type of psychotherapy offers supportive networks for people who have similar difficulties?

Group therapy

What type of psychotherapy tackles specific life problems that contribute to emotional distress?

Problem solving therapy

What is integrated care?

Availability of mental health specialty care in context of primary care

What is the general approach to treatment in MDD?

Try 2 SSRIs & 1 SNRI first (only 1 at a time) for 3-4 weeks minimum

If first SSRI fails → switch to another SSRI → if fails again, try SNRI

What qualifies as treatment resistant depression (TRD)?

2-3 medication failures

What are treatment options for treatment resistant depression (TRD)?

augment w/ SGA (ex abilify), esp if psychotic features

augment with Wellbutrin or mood stabilizer (Lithium if SI)

TMS, esketamine, ECT

How long can it take for antidepressants to work?

3-4 weeks

What SSRIs are used for MDD?

Citalopram (Celexa)

Escitalopram (Lexapro)

Paroxetine (Paxil)

Sertraline (Zoloft)

Fluoxetine (Prozac)

What SNRIs are used for MDD?

Venlafaxine (Effexor), Duloxetine (Cymbalta)

What anti-psychotics that can be used as adjunct in MDD treatment?

Quetiapine (Seroquel)

Lurasidone (Latuda)

Olanzapine/fluoxetine (Symbyax)

What MAOI can be used to treat MDD?

Phenelzine

What is the first line treatment for MDD?

SSRIs >> SNRIs

What SEs are seen with SSRIs?

HA, GI disturbance, sexual dysfunction, rebound anxiety

*safer & generally better tolerated

What is the 2nd line treatment for MDD?

TCAs: Amitriptyline, Clomipramine, Nortriptyline

What SEs are seen with TCAs?

Sedation, orthostatic hypotension, anti-cholinergic SEs, long QT syndrome

lethal in overdose

What SEs are seen with anti-psychotics?

EPS (dystonia, akathisia), Tardive dyskinesia (involuntary movements)

What are indictions for ECT treatment in MDD?

Non responding, non tolerating to anti-depressants (pregnancy)

Rapid recovery required

Can use in conjunction with rx or alone; ~ 8 tx over 2-3 wks

What is the process of ECT?

premedicate w/ atropine, general anesthesia, muscle relaxants, & induce generalized seizure

What is a possible SE of electro-convulsive therapy (ECT)?

Temporary retrograde amnesia ~6 mos

What is the diagnostic triad for serotonin syndrome?

Autonomic instability, hyperthermia, seizures

What is the diagnostic criteria for Dysthymia (persistent depressive disorder)?

Depressed mood ≥2 years + never asymptomatic for >2 mos + no manic/hypomanic sx + ≥ 2 CHASES sx

The following DSM5 criteria is for what condition?

• depressed mood for atleast 2 years (1 yr in kids)

• ≥ 2 of the following (CHASES)

  • poor concentration/focus, hopelessness, appetite changes, sleep changes, fatigue/low energy, low self esteem

• *criteria for MDD continuously present for 2 yrs

Dysthymia / Persistent depressive disorder

What are the CHASES symptoms associated with Dysthymia?

Concentration decreased

Hopelessness

Appetite change

Sleep change

Energy decreased

Self esteem decreased

Who is dysthymia / persistent depressive disorder MC in?

F > M, onset before mid 20s, insidious onset & chronic course

What treatment regimen provides the best results / most efficacious for dysthymia?

Pharmacotherapy + psychotherapy

What is the treatment for dysthymia?

1st line: SSRI / SNRI

2nd line: MAOI, TCA

+CBT, IPT, insight oriented psychotherapy

What tools can be used for screening/assessment of MDD & Dysthymia?

MMSE, HAM-D, PHQ-9

What assessment tool administered by a clinician monitors progress of depressive disorders by serially measuring severity of symptoms (detailed & time consuming)?

Hamilton rating scale for depression (HAM-D)

What are setbacks to the PHQ-9 depression questionnaire?

illiteracy, physical impairment, impaired cognitive functioning

What is the PHQ-9 depression quesitonnaire?

self report measurement, monitors response tx, not accurate enough to definitively dx

What labs should be considered when evaluating depressive disorders?

CBC, CMP, U/A, HCG, TSH, EKG, urine toxicology, vit B12, folate

What is the etiology associated with PPD?

Genetics, dec estrogen & progesterone, TSH

What are risk factors for depression w/ peripartum onset (postpartum depression)?

Hx perinatal or nonperinatal depression, stressful life events, poor social/financial support, Fhx PPD/psychiatric illness, <25 y/o, & multiparity

“Baby blues” or postpartum depression?

• MC

• 3-5 days after delivery, lasts days-weeks

• some sleep disturbance

• rare thoughts of harming baby

• absent/rare feelings of guilt

• no associated stressors, hx mood disorder, SI

Baby blues

“Baby blues” or postpartum depression?

• 3-6 mos after delivery, lasts months-years (untx)

• assoc w/ stressors & hx mood disorder

• sleep disturbances always present

• SI, feelings of guilt & inadequacy

• persistent thoughts of harming baby

Postpartum depression

What are reflags for postpartum depression?

anxiety about baby’s health / ability to care for baby, negative perception of infant temper/behavior, lack of interest in infant, lack of response to support/reassurance, alcohol / drug use

What is the first line treatment for postpartum depression in breast feeding patients?

Paroxetine (Paxil) or Sertraline (Zoloft)

*secretes less into breast milk than other SSRIs

What can also be used for treatment of postpartum depression with severe anxiety or agitation?

Low doses of Lorazepam

What benzodiazepines should be AVOIDED in PPD breastfeeding patients?

Clonazepam, Diazepam

What is another treatment option for refractory / psychotic postpartum depression (PPD)?

ECT

What condition is a severe form of PMS that can onset anytime after menarche, worsens prior to menopause, & stops after menopause?

Premenstrual dysphoric disorder (PMDD)

The following DSM5 criteria is associated with what condition?

• ≥5 sx must be present with at least 1 being from the first 4 (depressed mood, anxiety/tension, anger/irritability, mood swings)

PMDD

How do the symptoms occur in PMDD?

Sx present in final week before menses (last week of luteal phase; progesterone peaks)

Sx must improve w/in a few days after menses & are absent the week after menstruatrion

Confirmed by DRSP for at least 2 cycles

What is the first line treatment for PMDD?

SSRIs- Fluoxetine, Sertraline, Citalopram

Daily or luteal phase only treatment (start on day 14 of cycle and stop on menses onset)

What are other treatment options for PMDD?

OCPs, GNRH agonists, B/L oophorectomy w/ hysterectomy (severe)

Most psychiatric medications improve symptoms but are not disease modifying EXCEPT for which meds?

Lithium & mood stabilizers for bipolar disorder

Which SSRIs are the safest in pregnancy?

Sertraline and fluoxetine

Which SSRI has the lowest passage into breast milk?

Sertraline (Zoloft)

What is the most effective starting dose for Escitalopram (Lexapro)?

10 mg

What drug?

• MDD (12+ y/o), GAD

• avoid in OCD due to risk of long QT at high doses

Escitalopram (Zoloft)

What conditions can Sertraline (Zoloft) be used in?

MDD, OCD (6+ y/o), PMDD, panic disorder, PTSD, SAD

What SSRI is the most energizing and has the longest half-life & therefore lowest risk of withdrawal?

Fluoxetine (Prozac)

Which SSRI is the most antihistaminic (sedation & weight gain) and is pregnancy category D?

Paroxetine (Paxil)

What drug?

• inhibits its own metabolism (titrate slowly)

  • potent CYP2D6 inhibitor

• MDD, OCD, SAD, PTSD, GAD, PMDD, vasomotor sx, Panic disorder

Paroxetine (Paxil)

What drug?

• potent inhibitor of CYP1A2

• substrates: caffeine, xanax, rozerem

• tx OCD (8+ y/o), SAD, MDD

Fluvoxamine (Luvox)

What drug?

• newer SSRI and 5-HT1A receptor partial agonist

Vilazodone (Viibryd)

What drug?

• NOT an SSRI, multimodal serotonin modulator

• lower risk of sexual SEs compared to SSRIs

• pro cognitive- can improve attention and memory

Vortioxetine (Trintellix)

What is the MOA of Vortioxetine (Trintellix)?

inhibit serotonin reuptake and interact with/ multiple receptors (5-HTA1 agonist, 5-HT3 anatag)

*not an SSRI

What drug?

• NDRI- inc NE and DA levels

• less sexual SEs than SSRIs

• tx MDD, smoking cessation, & off label use in ADHD

• relatively safer in bipolar disorder

Wellbutrin (Bupropion)

What are CIs to Wellbutrin?

Hx of seizures or active anorexia/bulima (seizure risk)

*also monitor BP/HR at high doses (≥300mg)

What drug?

• SNRI- potent inhibitor of 5HT & NE reuptake

  • 5HT >> NE

• less sexual SEs than SNRIs,

• HTN/tachycardia at doses ≥225 mg, discontinuation syndrome (short half life)

• tx MDD, GAD, SAD, Panic disorder, off lane for OCD

Venlafaxine

What SNRI is notorious for discontinuation syndrome due to a short half life & needs to be tapered off slowly?

Venlafaxine (Effexor)