MH & W TEST 1 Mood disorders

how much time needs to pass of pervasive low mood, low self esteem, and anhedonia in order to be classified as having major depressive disorder?

two weeks

major depressive disorder is more common in what sex and age

females 25-44 yrs old

what are some biological theories for MDD

mood is affected by monoamines (norepi, serotonin, dopamine), or it is caused by neurotransmitter deficiency.

What is the hypothalamic-pituitary-adrenal (HPA) axis

inc cortisol that returns to nl when depression is gone. not all pts have this. Some drugs (ketoconazole) can have an antidepressant effect

what is the hypothalamic-pituitary-thyroid (HPT) axis

effect of thyroid hormones on brain development, maturation, and connectivity. hypothyroid pts have psych sx like depression and cognitive decline. replacement T3 can make antidepressant effect greater.

what is the cardinal feature of MDD and what other sx need to be present to diagnose

depressed mood or anhedonia for 2 weeks at least. at least 4 of the other following sx: appetite change, sleep changes, slowness in body activity or anxiety causing inability to sit still, loss of energy, feelings of worthlessness/guilt, indecisiveness, suicidal ideation

what is the melancholic subtype of MDD

pt has loss of pleasure in everything and 3 or more of the following: depressed mood, depression worse in am, early morning awake, psychomotor agitation/slow, anorexia, guilt

what is atypical depression MDD

MDD with mood reactivity to + event and 2 or more of: big weight gain, hypersomnia, leaden paralysis, sensitive to rejection

what is seasonal affective disorder

pts have depressive episodes at certain times of the year, usually colder.

what can occur before MDD

dysthymic disorder

average age for MDD

mid teens to late 20s

how long does it take for the sx of MDD to appear

days to weeks, where pre existing conditions like GAD or panic attacks were already present.

How to describe the remission of MDD

episodes can remit completely a bit or not at all. Pts go to premorbid level between episodes, some never fully return to normal state. relapse is common esp when you stop meds

what are the 3 exclusion criteria that have to be met to be able to diagnose depression

the illness is not due to a substance/med, the illness is not part of a mixed episode (like bipolar), and the sx are not considered bereavement but more than that.

how do pts typically present as a CC to their PCP when they have MDD

that they can’t sleep or have no energy. not typically a psych complaint until you ask further.

how is bereavement different than depression

bereavement is grief of a loved one, but you can eventually return to a life of normalcy. depression is when you fell into a continual functional impairment

how would you go about treating someone with MDD

talk to the pt and the family about their illness/causes, make them aware of signs and sx of an impending episode. Prescribe anti-depressants.

should you prescribe anti-depressants to adolescents

yes even tho there is some record of failure and inc risk of self harm. overall risk of suicide in children is still reduced with tx

do you give anti-depressants to elderly

yes but lower the dose

how should you start tx of MDD using anti-depressants

start them at a low dose and inc the dose over 7-10 days to achieve target dose. after 3-4 wk, evaluate effects. if therapeutic effect is shown, continue med for 6 months. some pts need long term tx. in this case you can slowly taper off the med after 5 yrs of tx if pt has no sx. or lifetime tx to prevent return of depression

what were the first class of antidepressants developed and what are their side effects

Monoamine oxidase inhibitors (MAOIs). can cause acute hypertensive crisis

how do MAOIs cause HTNsive Crisis

bc they block the breakdown of certain AAs like tyramine. neurotransmitter availability inc which causes the crisis.

pt comes in with clinical depression. they are complaining of pounding headache, flushing of the face, have blood vessel distention. they are taking MAOIs. what do they have and what should they be tx with

acute HTNsive crisis. tx with alpha blocker phentolamine.

How do MAOIs cause acute toxicity

bc it interferes with metabolic clearance of other drugs.

how do MAOIs cause serotonin syndrome

when also administered with SSRIs or I-tryptophan

what is serotonin syndrome

caused by MAOIs + SSRIs/I-tryptophan. sx of hyperreflexia, myoclonus, acute mental status change, restlessness, diaphoresis, tremors, diarrhea, seizures with the potential of falling into a coma or death

what are TCAs

tx depression. safer than MAOIs but not as good as SSRIs/SNRIs. Good option for pts who failed other antidepressants

what are adverse events of TCAs to tx depression

antimuscarinic properties like blurry vision, dec GI motility, constipation, urinary retention. pt can become tolerant to adverse events. drug also behaves like class 1A antiarrhythmic drugs that stop VF, dec contractility, inc collateral circulation to ischemic heart muscle. these anti-arrhythmic properties have a risk of death when used long term

what are SSRIs

most widely prescribed antidepressant. limit reabsorption of serotonin

adverse events of SSRIs

N/V/D, anorexia, anxiety, headache, insomnia, sexual dysfunction

pt presents to their pcp with cc of n/v/d, anorexia, anxiety, HA, trouble sleeping, and sexual dysfunction. they were previously diagnosed with clinical depression. what drug is causing this adverse effect?

SSRIs

how well to pts with MDD respond to antidepressants

majority respond well but 1/3 actually recover. Tx failure happens when pt doesn’t have right dose, length of tx, bad side effects, non-adherence and incorrect diagnosis

when is ECT used to tx MDD and how does it work

for severely depressed pts or when pt doesn’t have good liver/renal function. avg is 6-12 tx given 3x/week. should be continued 6-12 mo after remission

how does interpersonal psychotherapy help with MDD

recognizes and explores depressive pts who went thru loss, social isolation, or social deficits. focuses on interpersonal problems and deemphasizes childhood antecedents.

what is cognitive behavioral therapy and how does it help MDD

helps pts recognize their irrational beliefs and releives distress. reduces dperessive sx in acute MD and has a lasting effect that protects against other relapse

what is a positive progrnosis indicator for MDD

no psychotic sx, short hospitalization/depression duration, good family.

what is a poor prognostic indicator for MDD

also having psych disorder, substance use, early age onset, long duration of first episode, hospitalization

what sex demographic of people have more severe bipolar disorder

females

when are depressive episodes more common in BPD

spring and fall

when are mania episodes more common in BPD

summertime

what are some theories for why people get BPD

environmental conditions, kindling model (tx early episodes before they get worse)

pt presents to pcp with mom explaining that pt was having trouble performing daily tasks and getting out of bed and was feeling sad last week. they now present with irritible mood with grandiose statements and the pt cannot sit still. the pt thinks they are unstoppable.

bipolar I disorder

pt presents to pcp by mom saying that pt was severely dperessed and sad last week and had been sleeping for 10-13 hours a day. in the past 5 days the pt has been feeling more energetic and has been able to get all of her work done while only sleeping for 3 hours. pt is constantly inturrupting others and talks erratically fast. pt sees nothing wrong with themselves

bipolar II

4 or more affective episodes a year. women make up majority of the pts with this condition.

rapid cycling bipolar disorder

how do you tx a pt with BPD

tx doesn’t prevent future episodes. lithium + anticonvulsants maintain stable mood

how do you determine if a pt has BPD

make sure that sx are not coming from drug use or another medical condition.

primary tx for acute depressive episode in BPD

SSRI, Bupropion

secondary tx for acute depressive episode in BPD

ECT, MAOIs, TCAs

primary tx of acute manic episode in BPD

lithium, VPA/carbamazepine w/ antipsychotic like Haldol or benzo like clonazepam

secondary tx of acute manic episode in BPD

Verapamil, ECT

primary tx to maintain BPD

lithium, divalproex, lamotrigine, atypical antipsychotics, VPA or carbamazepine, in difficult cases lithium ± VPA or carbamazepine.

secondary tx to maintain BPD

educational and structural psychosocial support

what is the risk of giving SSRIs to a pt with BPD

it increases their energy which can put them at a risk of suicide

What are atypical antipsychotics and how do they help tx BPD

acute anti-manic effects. effective as maintenance tx. Quetiapine

how do you manage acute manic episodes of BPD

lithium, divalproex, or atypical antipsychotic can all be taken. delusional sx + agitation = give atypical antipsychotics or benzodiazepines on top of original tx

what are some other tx that can be helpful for BPD

mood charting to figure out frequency and severity of sx. Benzodiazepines help w insomnia and agitation. family education and cognitive therapy can reduce relapse and help adhere to meds

how does ECT affect BPD

useful for manic pts who don’t respond to meds and for those in mixed states at hi risk of suicide

how to describe dysthymic disorder

lower intensity depression but sx last longer. women more affected than men 2:1, onset prior to 45 yrs old. inordinate interpersonal dependency happens where pts self esteem relies on approval and attention of others, so much that when the attention goes away you become depressed.

what are some reasons that a person can get dysthymic disorder

their primary relatives have similar mood disorders, shortened REM latency.

pt presents to pcp explaining that they don’t feel confident in themselves and feel inadequate, they have lost interest in the things they once loved, are not talking to their friends or family, are constantly tired. they get excessively angry and irritated over trivial things and they are less productive at work because they have trouble concentrating.

dysthymic disorder

what is some psych testing that can be done to diagnose dysthymic disorder

maudsley personality inventory shows inc score for neuroticism (experience - emotions like sadness and anxiety) and introversion (focusing on internal thoughts and feelings instead of external environment)

what are the five big personality traits

openness to experience (inventive/curious vs consistent/cautious), conscientiousness (efficient/organized vs extravagant/careless), extraversion (outgoing/energetic vs solitary/reserved), agreeableness (friendly/compassionate vs critical/rational), neuroticism (sensitive/nervous vs resilient/confident)

what are some lab findings that correspond with dysthymic disorder

EEG abnormalities similar to MDD (reduced REM latency, inc REM density, impaired sleep continuity). pts with this usually have fam hx of MDD

how is DD different than MDD

MDD = 1 or more episodes of depression that impair usual functioning. sx of insomnia, no appetite, loss of libido, weight loss. DD is chronic less severe depressive sx persisting for 2 or more years. still able to function as a citizen

how to tx dysthymic disorder

primary is SSRIs, secondary TCAs, and MAOIs all effective. also interpersonal psychotherapy, CBT

when drug tx of dysthymic disorder isn’t effective what is the second route of tx

psychotherapy addresses delays in social and occupational functioning, pessimism and hopelessness and lack of assertiveness. interpersonal psychotherapy and CBT are used to tx MD bc it allows for interaction b/w individual and psychosocial environment. goal is to reduce depressive sx and develop effective strategies for coping with relationships

how does CBT help DD

altering your negative thoughts with diff strategies. help pt see negative cognitions and replace with an alternative more flexible schema (pattern of thought)

complications of DD

if you just have DD you can get MDD.

development of DD over time

early onset in childhood, adolescence or adult life. if you have DD before MDD you are less likely to recover in between episodes and you’re more likely to have major depressive episodes

how to describe cyclothymic disorder

mild BPD, going between mild depression and hypomania (elevated mood). starts early in life and is equally common in men and women, but clinically seen more in women.

pt presents to their pcp with cc of being unhappy and depressed for a couple days. pt now says that they’ve been feeling much happier but has been told that the things they say are unhinged. they explain that they can feel really happy and sad all in one day. they have moved multiple times throughout their life, participate in a religious extremist group, and have trouble keeping a job.

cyclothymic disorder

what is the course of illness of cyclothymic disorder

triggered by interpersonal stressors or losses. their problems are usually related to interpersonal and behavioral crises like romantic failures caused by hypomanic episodes. their unpredictable mood changes can cause stress and pts usually say their mood is out of control. they are less productive after they go through an episode

how to diagnose cyclothymic disorder

if the mood disorder is due to a medical condition that needs to be associated. if substances like stimulants are used to cause mood disorder that should also be specified. The mood states do not reach the criteria of BPD I or II. usually confused with borderline personality disorder or ADHD, but the mood swings are worse with cyclothymic.

how to tx cyclothymic disorder

lithium used to suppress hypomanic cycles. some pts shift to acute manic states or rapid cycling if given TCAs. insight oriented psychotherapy tx temperamental features, psychoeducational and interpersonal strats can also be used for affective instability

what are some complications of cyclothymic disorder

other mood disorders like MDD or BPD II can follow onset of cyclothymic disorder. can also get personality disorder, impulse control disorder, sleep disorder, and substance related disorder. this disorder makes way for other mood disorders to be present.