Mood Disorders

What is the overall state of emotion at a given time that is influenced by internal and external factors ? Internal condition is visible through external behaviors.

mood

What is a condition that affects a person's everyday emotional state/mood that affects nearly 1 in 5 adults >18 years old? It can be primary or secondary.

mood disorder (affective disorders)

What neurotransmitters in the brain regulate mood?

serotonin, norepinephrine, dopamine

What are the keys for diagnosing psychiatric conditions that are the most widely recognized systems used for psychiatric diagnosis, billing and coding?

DSM and ICD

What are the 3 DSM criteria conditions for all psychiatric conditions?

1. The condition is not caused by the direct effects of any drug or external exposure

2. The psychiatric disorder is not caused by effects of a medical condition

3. There is significant impairment of social functioning, occupational functioning, or both.

In what population is Major Depressive Disorder (MDD) more common?

1. younger population (30 years old)

2. women

3. low socioeconomic status

In what racial group is MDD most common?

Native Americans

In what racial group is MDD least common?

Asians/Pacific Islanders / African Americans

What are genetic/biologic factors of MDD?

-Neurotransmitter expression / sensitivity (Serotonin, norepinephrine, glutamate, GABA, dopamine)

-Response to antidepressant drugs

-FH of depression or alcoholism

What are life event factors of MDD?

-Adversity or loss of loved one, job, or relationship

-Early childhood trauma

-Postpartum period

What are medications that can induce MDD?

Glucocorticoids, Interferons

What are some neurotransmitters that can play a role in MDD?

melatonin, histamine

What are some hormones that can play a role in MDD?

thyroid, adrenal

What are some neuropeptides that can play a role in MDD?

endorphins, vasopressin

What are some personality risk factors of MDD?

-Low self-esteem

-Sensitive to stressors

-Insecure or worried

-Dependent or unassertive

-Introverted

What are some social risk factors of MDD?

-Lack of close relationships

-Close individuals with depression

-Maladaptive learned behaviors from close individuals

What are some medical condition risk factors of MDD?

Neurologic, Infectious, Cardiac, Endocrine (adrenal/thyroid), Cancer, Inflammatory

What is the first step of diagnosing MDD?

A depressed mood and/or anhedonia (loss of interest in activities) for ≥ 2 weeks

What is the second step of diagnosing MDD?

AND ≥ 4 of the following:

-sleep changes

-feelings of worthlessness

-fatigue

-decreased concentration

-significant appetite or weight change

-activity changes (psychomotor agitation)

-recurrent thoughts about death or suicide

somatic complaints make it harder

What is the pneumonic for MDD criteria?

S- sleep disturbances

I- interest decreased

G- guilt/feelings of worthlessness

E- energy decreased

C- concentration problems

A- appetite/weight changes

P- psychomotor agitation or retardation

S- suicidal ideation

What is a MDD subtype that includes high levels of accompanying anxiety?

anxiety

What is a MDD subtype that includes major psychomotor disturbances?

catatonic

What is a MDD subtype that includes symptoms of mania?

mixed

What is a MDD subtype that includes accompanying psychosis?

psychotic

What is a MDD subtype that includes reactivity pleasurable stimuli, hyperphagia, and hypersomnia?

atypical

What is a MDD subtype that includes anhedonia, psychomotor changes, insomnia, and decreased appetite?

melancholic

What is a MDD subtype is seen during pregnancy or within 4 weeks of birth?

peripartum

What is a MDD subtype is associated with a particular season?

seasonal

To have MDD, what must a patient have?

at least one major depressive episode

What is the average time to resolution of an MDD episode?

20 weeks

When is there a high risk of recurrence of a MDD episode?

within the first few months following episode's resolution

What is the rate of episode recurrence of MDD?

1-year=40%

lifetime=85%

What is a quick, initial screening for depression that asks about the two key symptoms of a depressive episode (depressed mood and anhedonia)? This is not a stand-alone test and needs follow-up if positive.

two-question screen (PHQ-2)

What further evaluates presence and severity of depression and can be used for initial screening or follow-up evaluation?

patient health questionnaire-9 (PHQ-9)

What evaluation allows a more in-depth rating of current depressive symptoms?

Zung Self-Rated Depression Scale

What are the non-pharm treatment options for MDD?

-Psychotherapy

-Electroconvulsive Therapy (ECT)

-Vagal Nerve Stimulation

-Transcranial Magnetic Stimulation (TMS)

What are the pharm treatment options for MDD?

-Supplements

-Herbals

-Antidepressants

What is the preferred approach of MDD treatment?

*****combination of pharmacotherapy AND psychotherapy*****

What treatment for MDD is "counseling" that commonly includes CBT or interpersonal psychotherapy? Family or couples therapy can also be useful.

psychotherapy

What are some relaxation techniques for MDD?

meditation and muscle relaxation

What are some behavioral activation for MDD?

Restarting positive activities that ceased due to depression

What are some exercise suggestions for MDD?

Aerobic or resistance training

What MDD treatment is an outpatient procedure using a small electric current to induce a cerebral seizure while patient is under general anesthesia?

electroconvulsive therapy (ECT)

What treatment is first line for severe suicidality, severe psychosis, catatonia, and malnutrition d/t food refusal secondary to depressive illness that cannot tolerate other therapies?

electroconvulsive therapy (ECT)

What is the most efficient treatment for MDD?

electroconvulsive therapy (ECT)

What are the contraindication of electroconvulsive therapy (ECT)?

none! use caution with cardiopulmonary disease, neurologic disease, or those on anticoagulants

What are the most common adverse events of electroconvulsive therapy (ECT)?

cardiopulmonary, HA, nausea, transient cognitive impairment, muscle aches

What MDD treatment includes a device being implanted in the chest wall and connected to one (left) vagus nerve that is used primarily for refractory epilepsy?

vagal nerve stimulation

What MDD treatment is a metal coil with magnetic field that is placed against scalp to induce depolarization of neurons in a focal area? It is performed outpatient without sedation.

transcranial magnetic stimulation (TMS)

What are the indications for TMS?

treatment-refractory depression

What are the contraindications for TMS?

-High seizure risk, incompatible

-Implants (metallic, electrical, cochlear)

What are the side effects of TMS?

Seizures, HA, scalp pain, transient hearing loss

What MDD supplement naturally occurs in the body that may raise dopamine levels?

S-Adenosylmethionine (SAMe)

What MDD supplement can be used as an adjunctive option for mild to moderate depression in pregnant patients?

S-Adenosylmethionine (SAMe)

What may S-Adenosylmethionine (SAMe) trigger?

manic episodes

What MDD supplements is natural precursor to serotonin?

5-Hydroxytryptophan (5-HTP)

What is a risk when using 5-Hydroxytryptophan (5-HTP)?

GI upset, serotonin syndrome, eosinophilic myalgia syndrome

What MDD supplement may work better if combined with antidepressants and may increase risk of bleeding?

Omega-3 Fatty Acids

What MDD herbal increases serotonin, and possibly norepinephrine and dopamine levels?

St John's Wort

What are the risks of St John's Wort?

GI upset, serotonin syndrome, photosensitivity

What is something to be aware of with St John's Wort?

numerous drug-drug interactions

What MDD herbal may help with depression with risk of GI upset, mania, bleeding and can be fatal at high doses?

saffron

What MDD herbal may improve mood in pts being treated for memory loss? It may increase sensitivity to serotonin>

Ginkgo biloba

What are the general guidelines for antidepressant use (MDD)?

-start low and go slow! (titrate dose over 7-10 days)

-trial of at least 4 weeks (may take 4-6 weeks!!)

How long should an antidepressant prescription be continued?

6+ months

What is recommended when discontinuing antidepressants?

gradual down titration

What are the efficient SSRIs for MDD?

paroxetine, escitalopram

What is the efficient SNRI for MDD?

venlafaxine

What are the efficient serotonin modulators for MDD?

mirtazapine, vortioxetine

What is the efficient TCAs for MDD?

amitriptyline

What is included in first generation (old school-not used) antidepressant classes?

-Monoamine Oxidase Inhibitors (MAOIs)

-Tricyclic Antidepressants (TCAs)

-Tetracyclic Antidepressants (TeCAs)

What is included in second generation antidepressant classes?

-Selective Serotonin Reuptake Inhibitors (SSRIs)

-Serotonin-Norepinephrine Reuptake Inhibitors (SNRIs)

-Atypical antidepressants

-Serotonin modulators

-Ketamine/Esketamine

What is the most common class of antidepressants used for MDD?

second generation antidepressants

What is commonly used as first line for MDD?

SSRIs

What selectively decreases the action of 5-HT reuptake pump, leading to increased serotonin levels in the synapse?

SSRIs

What are the SSRIs?

-Sertraline

-Citalopram

-Escitalopram

-Fluoxetine

-Paroxetine

-Fluvoxamine

What are SSRIs metabolized by?

liver

What are the contraindications of SSRIs?

-Allergy to SSRI

-*****Use of MAOI within 2 weeks****

With what SSRIs must you wait 5 weeks before starting a MAOI?

fluoxetine

What are the side effects of SSRIs that are typical upon initiation and dose increase?

GI upset (ND anorexia), sleep change, neuro, sexual dysfunction (anorgasmia), psych (increased risk of suicide), serotonin syndrome, weight gain

What is caused by increased serotonergic activity that is most commonly associated with SSRIs? It typically occurs within 24 hrs (often w/in 6 hrs) of starting/changing medication or overdosing.

serotonin syndrome

What are the signs and symptoms of serotonin syndrome?

Diarrhea, increased bowel sounds, agitation, hyperreflexia, dry mucous membranes, autonomic instability, hyperthermia, HTN, tremor, clonus, seizure, death

How do you diagnose serotonin syndrome?

clinical

What is the treatment for serotonin syndrome?

-Supportive care

-D/C serotonergic medications

-Sedation with benzodiazepines

-Normalize vitals and hydration status

What is the dosing of SSRIs?

once a day in the morning

What SSRI has more GI upset than others in the class, esp. diarrhea, is less likely to cause prolonged QT, drowsiness, and has slightly higher chance of insomnia SE?

setraline

What SSRI is most associated with prolonged QT  with minimal SE profile? It has least inhibition of hepatic cytochrome enzymes.

citalopram/escitalopram

What SSRI has shortest half-life and frequently causes somnolence? It is a potent inhibitor of 2 cytochrome systems → potential for DDIs.

fluvoxamine

What SSRI was the 1st on the market and has the longest half-life? It has side effects of insomnia and anxiety.

fluoxetine

What SSRI should not be written with tamoxifen (breast cancer)?

fluoxetine

What SSRI causes anticholinergic side effects with a slightly higher risk of orthostatic hypotension, weight gain, & sexual dysfunction than other SSRIs?

paroxetine

What is a potential inhibitor of 2 cytochrome systems, so potential for DDIs and should not be written with tamoxifen?

paroxetine

What are often used as first-line therapy, or as second-line therapy for patients who cannot tolerate SSRIs? They are used for tx of other disorders, including anxiety disorders, fibromyalgia, neuropathy, menopausal s/s.

SNRIs

What blocks reuptake of 5-HT and norepinephrine (NE), increasing their levels in the synapse? Savella/Fetzima - greater effect on NE; others - greater effect on 5-HT

SNRIs

What are the drugs included in SNRIs?

-Venlafaxine

-Desvenlafaxine

-Duloxetine

-Milnacipran

-Levomilnacipran

How are SNRIs cleared?

kidneys and liver

What is the dosing of SNRIs?

QD

What are the contraindications of SNRIs?

-Allergy to SNRIs; use within 2 weeks of an MAOI

-other serotonergic drugs

-angle closure glaucoma

What are the side effects of SNRIs?

GI (NVD, constipation, dry mouth), sleep change, neuro, sexual dysfunction (anorgasmia), psych (increased risk of suicide), serotonin syndrome, diaphoresis

What SSRI has higher risk of side effects than other SSRIs that is most associated with elevated BP?

venlafaxine