Clinical Medicine- Lecture 1- Mood Disorders (part 2)

An 62-year-old female with a recent history of hypertensive emergency is being started on an antidepressant. Which of the following medications should be avoided?
• A) Sertraline • B) Mirtazapine • C) Fluoxetine • D) Desvenlafaxine • E) Fluvoxamine

D;Because SNRIs (venlafaxine, desvenlafaxine, etc.) can raise blood pressure, they should be avoided in patients with a history of hypertensive crisis/emergency.

An 18-year-old male with MDD reports forgetting to take his antidepressant 2-3 times per week. Which of the following medication would be best to minimize withdrawal and maintain more stable blood levels? • A) Paroxetine • B) Mirtazapine • C) Fluoxetine • D) Sertraline • E) Aripiprazole

✅ Correct Answer: C) Fluoxetine

Because of its long half-life, fluoxetine is least likely to cause withdrawal symptoms if doses are missed and helps maintain more stable drug levels.

When should you consider stopping antidepressant treatment?

When the patient has been in remission for \sim1 year and has a low risk of recurrence or severe depression.

When should you consider switching antidepressants?

If the patient has intolerance OR no clinically significant response (at least partial) after >6 weeks at a therapeutic dose.

When should you consider augmenting antidepressant therapy?

If the patient has only a partial response, or if they have treatment-resistant or refractory depression.

What does ECT use to treat depression?

Electrical current to induce a seizure in the sedated patient’s brain.

What is ECT the most effective treatment for?

Severe depression.

When is ECT especially indicated?

Poor response to medications, severe depression with suicidality, mania, and in pregnancy.

What are the main side effects of ECT?

Headache and memory disturbances.

What does TMS use to treat depression?

Magnetic fields to stimulate nerve cells in mood-control brain regions.

What conditions is TMS FDA-approved for?

Depression (poor response to meds), migraines, and OCD.

What are the main side effects of TMS?

Headache and lightheadedness.

Name at least three supplements that may support mood in depression.

Omega-3 fatty acids, magnesium, vitamin B12, folate.

Which herbal supplement is widely used for mild to moderate depression but has drug–drug interaction risks?

St. John’s Wort.

Which compound, also known as SAMe, has been studied as a mood support supplement?

S-adenosyl-L-methionine (SAMe).

According to DSM-5, how many symptoms must be present to diagnose PMDD?

Five or more symptoms during the week prior to menses, resolving within a few days after menses begins.

Can PMDD symptoms be attributed to another psychiatric illness?

No — they must not be explained by another disorder.

What are recommended treatments for mild PMDD symptoms?

Exercise, relaxation techniques, chasteberry, primrose oil, vitamin B6, vitamin E, magnesium.

What is the treatment of choice for moderate PMDD symptoms?

SSRIs (e.g., sertraline, citalopram).

How can SSRIs be administered for PMDD treatment?

Either continuous therapy or intermittent therapy (day 14 or luteal phase only)

How is bipolar characterized?

severe mood swings btw depression and elation → remission—> reoccurrence

What are the types of bipolar disorders?

1. Bioloar 1 (mania)

2. Bipolar 2 (hypomania)

3. Cyclothymia

Which neurotransmitter systems are dysregulated in bipolar disorder?

Dopamine and serotonin systems.

What is the average age of onset for bipolar disorder?

25 years.

How does childhood-onset bipolar affect prognosis?

It has a poorer prognosis.

What symptom does bipolar most often start with?

Depression.

What percentage of patients with a single manic episode are likely to have another?

90%.

What defines rapid cycling in bipolar disorder?

Four or more episodes per year.

Which substance can mimic bipolar symptoms?

Cocaine.

What is the first priority in treating Bipolar I disorder?

Patient safety (because the most common complication is suicide).

When should a patient with Bipolar I be hospitalized?

• At risk for suicide or homicide

• In need of diagnostic procedures

• If symptoms are rapidly progressing

What is the overall treatment goal in Bipolar I?

To get the patient to maintenance therapy (euthymic/stable phase). Stabilization IS important in Bipolar I b/c It decreases cycling and relapses, which are linked to poorer outcomes.

How long must manic symptoms last to diagnose bipolar I?

At least one week.

What exception allows mania to be diagnosed without a full week of symptoms?

If hospitalization is necessary.

How many symptoms are required during a manic episode if mood is elevated/expansive?

Three symptoms.

How many symptoms are required if mood is irritable?

Four symptoms.

What are some DSM-5 symptoms of mania?

Inflated self-esteem, decreased need for sleep, pressured speech, flight of ideas, distractibility, increased activity, excessive risky behavior.

What must the mood disturbance cause to meet criteria?

Marked impairment in social or occupational functioning, or hospitalization.

How many lifetime manic episodes are required to diagnose bipolar I disorder?

At least one.

Which psychiatric disorder has the highest rate of suicide (15%)?

bipolar

What is DIGFAST?

An acronym for the symptoms of a manic episode, including Distractibility, Indiscretion/impulsivity, Grandiosity, Flight of ideas, Activity increase, Sleep deficit, and Talkativeness.

How long must hypomanic symptoms last to diagnose bipolar II?

At least 4 consecutive days, most of the day, nearly every day.

How many symptoms are required if the mood is elevated/expansive? How many symptoms are required if the mood is only irritable?

Three symptoms; Four symptoms

What type of change must the episode be associated with?

A clear change in functioning that is uncharacteristic of the individual.

**Is hypomania severe enough to cause marked impairment or hospitalization?

No. If psychotic features are present, the episode is considered manic instead.

What is the first-line mood stabilizer for Bipolar I? Why? Name an alternative.

Lithium carbonate (300–900 mg/day) b/c it protects against suicide.

Can use Carbamazepine as an alternative

What protective effect does lithium have?

It reduces suicide risk.

What labs must be monitored on lithium?

Thyroid (TSH/T4), kidney (CMP, UA), CBC, and EKG.

What are common side effects of lithium?

Hypothyroidism, tremor/shakiness, mild GI upset, polydipsia, parkinsonian effect, weight gain/diabetes, and drug-drug interactions, weight gain, DM.

What is valproic acid?

A mood stabilizer used to treat bipolar disorder.

What are side effects of valproic acid?What should you monitor?

GI upset, weight gain, teratogenic effects (harmful to baby)

Must monitor LFTs, CBC, glucose, weight.

What type of drugs are carbamazepine and oxcarbazepine?

Anticonvulsants that also act as mood stabilizers.

What dangerous side effects are linked with carbamazepine/oxcarbazepine?

Aplastic anemia and agranulocytosis

Do mood stabilizers pass through breast milk?

Yes — all of them do.

What supplements should be given to women of childbearing age who are taking valproic acid or carbamazepine? *hint black box warning

Folic acid (folate) supplementation.

Why is folate supplementation important in these patients?

Both valproic acid and carbamazepine are teratogenic and increase the risk of neural tube defects— folate helps reduce this risk.

What is the general rule for treating an acute bipolar episode?

Use the same regimen that successfully treated a prior acute bipolar episode.

What is the first-line pharmacologic treatment for an acute bipolar manic episode? Does the medication take effect right away?

Lithium or valproate + a 2nd generation antipsychotic. No; several days

What are the 2nd- gen antipsychotics?

Olanzapine, risperidone, aripiprazole

Which antipsychotics do you use for acute bipolar mania episode to control behavior?? *hint there is a first gen one

Olanzapine IM or haloperidol IM (1st gen) for behavior control

Name the antipsychotics that are serotonin and dopamine antagonists. 1^st Gen Antipsychotic (AKA typicals)

Note: Typical antipsychotics or 1st generation (block D2 receptors)

• Phenothiazine

• Chlorpromazine

• Haloperidol (Haldol) - comes in quick injectable form

• Perphenazine

What are the SEs of 1^st Gen Antipsychotic (AKA typicals)

dry mouth, muscle stiffness, tremors, weight gain,

extrapyramidal symptoms and tardive dyskinesia

What is the mechanism of action of atypical (2nd gen) antipsychotics? (Bipolar I – Atypical Antipsychotics)

dopamine partial agonists

Name at least three examples of atypical antipsychotics (2nd Gen) (Bipolar I – Atypical

• Clozapine (Clozaril)

• Risperidone (Risperdal) – comes in a depot (long acting) form

• Olanzapine (Zyprexa) –

• Quetiapine (Seroquel)

• Ziprasidone (Geodon)

What are common side effects of atypical antipsychotics?

Dry mouth, blurred vision, dizziness, insomnia, extreme tiredness, weakness, bloating.

Which newer atypical antipsychotic is commonly used in Bipolar I?

Aripiprazole (Abilify).

What are common side effects of aripiprazole?

Nausea, vomiting, dizziness, insomnia, restlessness.

What class of medications are clonazepam (Klonopin) and lorazepam (Ativan)?

High potency benzodiazepines.

Give two examples of high potency benzodiazepines.

Clonazepam (Klonopin) and Lorazepam (Ativan)

What are common side effects of high potency benzodiazepines?

Drowsiness, confusion, dizziness, vision problems, impaired coordination.

What are the first-line and second-line treatments for acute bipolar depression?

• First-line: Quetiapine, Lurasidone

• Second-line: Antidepressant + atypical antipsychotic (e.g., Olanzapine + Fluoxetine) — but use antidepressants cautiously

• Second-line monotherapy: Valproic acid

What are third-line options for treatment-resistant bipolar depression? Those who don’t respond to standard antidepressant

Lamotrigine, low-dose Ziprasidone, or Electroconvulsive Therapy (ECT).

Why lamotrigine?

has mood stabilizing and antidepressant properties, so

FDA approved for maintenance treatment of bipolar depression

What serious skin reaction can lamotrigine cause?

Stevens–Johnson syndrome or toxic epidermal necrolysis (>30% body involvement).

What are the early warning signs of Stevens–Johnson syndrome?

Flu-like symptoms (fever, malaise).

What happens a few days after Stevens–Johnson syndrome begins?

Skin starts to blister and peel. Can effect Mucous membranes, especially the mouth.

Why should lithium often be retained in the treatment regimen?

It has antisuicide and neuroprotective effects.

What dual focus must be maintained in the treatment of bipolar disorder?

Both acute short-term treatment and prophylaxis (long-term relapse prevention).

When treating bipolar which should you look out for as a medical emergency?

mania

BIPOLAR II: TREATMENT HYPOMANIA

Name the 2 classes: atypical antipsychotics and mood stabilizing agents.

How long do most medications for bipolar disorder take to determine efficacy?

• Atypical antipsychotics: Olanzapine, quetiapine, risperidone, aripiprazole, and ziprasidone

• Mood stabilizers: Lithium, carbamazepine, oxcarbazepine, valproate

About 2 weeks.

Why should all antidepressants be discontinued in bipolar II depression treatment?

To prevent triggering mania.

What are the first-line treatment options for bipolar II depression?

The same medications as bipolar I depression- Lithium or lamotrigine (Lamictal) also studied as 1st line

When can an antidepressant be added to treatment for bipolar II depression? Which antidepressants are preferred if added in bipolar II depression?

It can be added later, once mood stabilization is achieved.

Bupropion or paroxetine.SSRIs, SNRIs, or MAOIs.

How does DSM-5 define cyclothymic disorder?

As a chronic, fluctuating mood disturbance with many periods of hypomania and depression, lasting at least 2 yearswithout more than 2 months in remission.

Cyclothymic disorder is considered a mild form of which disorder? How is cyclothymic disorder differentiated from bipolar II disorder?

A mild form of bipolar II disorder.

By the presence of “minor” depressive symptoms and hypomanic episodes, rather than full major depressive episodes.

Which personality disorder frequently co-exists with cyclothymic disorder?

Borderline personality disorder.

What traits may characterize individuals with cyclothymic disorder as children?

They may have been described as sensitive, hyperactive, or moody.

In what decade of life does cyclothymic disorder often occur?

Most often in the 20s.

How does cyclothymic disorder impact functioning in school or social interactions?

It can hinder academic performance and make interaction with others difficult.

Despite challenges, how do many people with cyclothymic disorder manage long-term functioning?

They often develop adaptive strategies that allow them to hold long-term jobs.

What medications are considered first-line treatment for cyclothymic disorder?

Mood stabilizers and antipsychotics.

What are the goals of psychosocial therapy in cyclothymic disorder?

To increase awareness of the condition, develop coping mechanisms during mood swings, and provide family/support group therapy.