CAM- mood disorders part 1

patient with mood disorder

1. abnormal range of moods

2. lose some control over mood

3. distress may be caused by severity

4. impairment in social and occupational function

mood

what patient states in quotes

affect

your observation

major depressive disorders can occur in:

1. major depressive disorder

2. persistent depressive disorder

3. bipolar 1 and 2 disorders

4. schizoaffective disorder

some mood disorders have ________________ features

psychotic

diseases that are commonly associated with depressive symptoms

1. chronic pain

2. cancer

3. cardiovascular disease

4. neurologic issues

5. diabetes

medications that are commonly associated with depressive symptoms

1. hormonal agents- steroids, tamoxifen

2. antivirals

3. immunologic agents

4. retinoic acid derivatives- isotretinoin

5. opioids

depressive disorders common features

1. sad, empty, or irritable mood

2. changes significantly affect capacity to function

3. what differs between them is issues of duration, timing, and etiology

screening for depressive disorders

1. PHQ-2

2. PHQ-9

3. Beck Depression Inventory for primary care

what is PHQ-9 used for?

1. monitor response to therapy

2. not accurate enough to definitively diagnose

Beck Depression Inventory for primary care is only available by...

license

what is the first step tool to screen for depression?

PHQ-2

what is the next step if PHQ-2 is positive?

PHQ-9

PHQ-9 scores >10

88% sensitivity and specificity for MDD

disruptive mood dysregulation disorder

1. common in children

2. likely greater in males

common comorbid conditions associated with disruptive mood dysregulation disorder

1. ADHD

2. MDD

3. SUD

patients with disruptive mood dysregulation disorder should not have symptoms that meet criteria for-

bipolar disorder

possible co-occurring symptoms for disruptive mood dysregulation disorder

may meet criteria for ODD or IED

if symptoms of disruptive mood dysregulation disorder meet criteria for ODD or IED and DMDD...

only diagnosis of DMDD should be given

key feature of disruptive mood dysregulation disorder

chronic, severe, persistent irritability occurring in childhood and adolescence

DSM-5 criteria for disruptive mood dysregulation disorder

1. severe recurrent temper outbursts that manifest verbally and/or behaviorally- out of proportion in intensity or duration

2. inconsistent with developmental level

3. ≥3 times per week

4. between outbursts, they are irritable or angry

5. present for 12 or more months

6. 2 of 3 settings- home, school, with peers

7. age of onset is before 10 years old

what age groups should not be diagnosed for the first time with disruptive mood dysregulation disorder?

before age 6 or after 18

functional consequences of disruptive mood dysregulation disorder

severe disruption in family relationships, peer relationships, school performance

children with disruptive mood dysregulation disorder are at increased risk to develop:

unipolar depression and/or anxiety in adulthood

risk factors for disruptive mood dysregulation disorder

1. associated with disrupted family life

2. genetic factors- family history of depression may be a risk factor

first line treatment for disruptive mood dysregulation disorder

1. usually psychotherapy for pt and family

2. parent training

what medications have been used to treat primary symptoms of disruptive mood dysregulation disorder?

1. stimulants

2. SSRIs

3. mood stabilizers

4. second gen antipsychotics

when does MDD peak?

in 20s

who has the highest prevalence for MDD?

patients aged 18-25

what is the second leading cause of death in patients aged 18-25?

depression-related suicide

biological etiology of MDD

likely due to neurotransmitter abnormalities in brain, electrical activity impacted

psychosocial/life events that may contribute to MDD

1. multiples ACE's

2. loss of parent before age 11

genetic risk factor for MDD

1. first degree relatives at 2-4x more lilely

diagnosis of MDD

1. depressed mood/anhedonia along with 5+ symptoms for most days for ≥2 weeks

2. sleep- insomnia or hypersomnia

3. interest in activities- decreased

4. guilt

5. energy- decreased

6. mood- decreased

7. concentration- decreased

8. appetite and weight change- increased or decreased

9. psychomotor- agitation or retardation

10. suicidal ideation

symptoms of MDD must not be attributed to-

substance abuse, medical issues, or bereavement

key points for MDD diagnosis

1. symptoms must cause distress/impairment in daily functioning

2. absence of mania or hypomania

anhedonia

inability to experience pleasure

apathy

inability to feel interested or motivated

MDD DSM-5 diagnosis

five or more of classic symptoms present during same 2 week period and represent change from previous functioning; at least one symptom is either depressed mood or loss of interest or pleasure

how can MDD present in children and adolescents?

irritability

most common types of sleep disturbance associated with MDD?

1. difficulty falling asleep (initial insomnia)

2. early morning awakenings (terminal insomnia)

MDD with anxious distress

feeling tense, difficulty concentrating, restless, fear of something bad happening, feeling like they lost control

MDD with atypical features

hypersomnia, hyperphagia, reactive mood, leaden paralysis, hypersensitivity to interpersonal rejection

MDD with psychotic features

1. delusions or hallucinations

2. present in many hospitalized patients and older patients with MDD

MDD with peripartum onset

onset occurring during pregnancy or 4 weeks following delivery

MDD with seasonal pattern

1. usually winter but can be any season

2. pts with fall onset often respond to light therapy

MDD with mixed features

can have manic/hypomanic symptoms

MDD with melancholic features

1. more likely in severely ill inpatients

2. psychotic features

3. anhedonia, early morning waking, depression worse in morning, psychomotor disturbance, excessive guilt, anorexia

MDD with catatonia

immobility, purposeless movement, extreme negativism, staring, mutism, bizarre postures, echolalia

treatment for catatonia

1. lorazepam

2. especially responsive to ECT

most depressive episodes are self limiting and will resolve after ___________ if untreated

6-12 months

atypical symptoms of seasonal affective disorder

hypersomnia, increased appetite (carbs), weight gain

associated features of seasonal affective disorder

1. women > men

2. young adults

3. high latitudes

MDD gold standard treatment

combined use of antidepressant and psychotherapy

when to hospitalize MDD patients

1. unable to care for themselves

2. at risk for suicide

3. at risk for homicide

persistent depressive disorder (PDD)

chronic depression most of the time, and they may have discrete major depressive episodes

epidemiology of PDD

1. women 1.5-2x more likely

2. onset often in childhood, adolescence, early adulthood

course and prognosis of PDD

1. chronic and early insidious onset

2. depressive sx less likely to resolve than in MDD

treatment for PDD

recommended combo treatment with psychotherapy and antidepressant

MDD duration

symptoms last for at least 2 weeks

duration of PDD

symptoms last for at least 2 years or 1 year for children/adolescents

are symptoms of PDD more or less severe than MDD?

less severe

symptoms of PDD

1. two or more of the following

2. poor appetite or overeating

3. insomnia or hypersomnia

4. low energy or fatigue

5. low self-esteem

6. poor concentration or difficulty making decisions

7. feeling hopeless

8. never been without symptoms for more than 2 months at a time

diagnosis key points for PDD

1. no manic or hypomanic epsidoes

2. causes psychosocial impairment or distress

3. never asymptomatic > 2 months

4. no MDD episodes in first 2 years

premenstrual dysphoric disorder (PMDD)

1. onset is anytime after menarche

2. ceases after menopause but symptoms may worsen prior to menopause

risk factors for PMDD

smoking, obesity, stress, genetic predisposition

first line treatment for PMDD

1. SSRIs

2. daily therapy or luteal only treatment (starting on cycle day 14 and stop upon menses or shortly after)

other medication options for PMDD

1. OCPs

2. GnRH agonists

symptoms or PMDD resolve with...

B/L oophorectomy with hysterectomy

gold standard PMDD assessment scale

1. daily record of severity of problems

2. DRSP is most comprehensive scale available, but may be difficult for patients to adhere

3. rated 1 to 6

DSM-5 criteria for PMDD

1. ≥5 symptoms in final week before onset of menses, start to improve a few days after onset of menses, and become minimal or absent in week post menses

2. marked affective lability (mood swings)

3. marked irritability or anger or increased interpersonal conflicts

4. marked depressed mood, feeling hopeless, self-deprecating thoughts

5. marked anxiety, tension, and/or feelings of being on edge

6. changes in interest of activities, concentration, easily tired, appetite, sleep, feeling out of control

what physical symptoms associated with PMDD

1. breast tenderness or swelling

2. joint or muscle pain

3. sensation of bloating or weight gain

psychotherapy for MDD

CBT and interpersonal psychotherapy most studied

choosing antidepressant

1. patient response to previous antidepressant

2. patient preference

3. age

4. FHx of response to certain antidepressant

5. cost

6. comorbid conditions- anxiety, ADHD

following remission of single depressive episode, how long should they continue their antidepressant?

1 year

antidepressant in children

fluoxetine best evidence (also has long half life)

antidepressants for adults

escitalopram and sertraline preferred due to fewer drug-drug interactions, usually first line for depression with anxious distress

antidepressant if pregnant or breastfeeding

sertraline

SSRIs are considered first line for-

treating depression and anxiety

side effects of SSRIs

1. risk for hyponatremia

2. impaired platelet functioning

3. possible modest weight gain with long term use

4. sexual dysfunction

5. GI distress- nausea, diarrhea

6. headache

7. fatigue

serotonin modulator and stimulator (SMS)

1. FDA approved for MDD

2. compared to SSRI

SMS is less likely to cause which side effects?

1. weight gain

2. sexual dysfunction

which SSRI is associated with QT prolongation if >40 mg?

citalopram

what is the max dose of citalopram if >65 y/o?

20 mg

what is the max dose of escitalopram if >65 y/o?

10 mg

in what patients are bupropion contraindicated?

1. seizure disorders- risk at high doses

2. eating disorders

bupropion is good for use in patients who..

do not want sexual side effects

SNRI

may cause increase in BP due to noradrenergic activity, this is dose dependent

which antidepressant is better for pain and less likely to cause weight gain with long term use?

SNRI

which SNRI is approved for several pain conditions?

duloxetine

mirtazepine use

useful adjunct for insomnia

side effects of mirtazepine

1. increased appetite

2. sedation- take at night

trazodone

useful adjunct in treating insomnia

side effect of trazodone

priapism

TCAs

1. mainstay of treatment before SSRIs

2. now rarely used for depression

low dose TCAs used for:

1. insomnia

2. neuropathic pain

3. postherpetic neuralgia

4. fibromyalgia

5. migraines

common TCA side effects

1. anticholinergic effects

2. orthostatic hypotension

3. sedation

4. weight gain

5. confusion

6. lower seizure threshold

7. cardiotoxic complications

in who should you avoid using TCAs?

1. patients with increased fall risk, preexisting conduction abnormalities, recent MI

2. NOT good in elderly

TCA overdose

1. can be serious

2. treat with IV sodium bicarbonate

MAOIs

1. rarely used because of diet restriction and drug-drug interactions

2. phenelzine, tranylcypromine, isocarboxazid