Depressive Disorders; Bipolar and Related Disorders

27-year-old man accompanied by his girlfriend. In the office, he seems to be running from topic to topic without a clear message. His speech is pressured. The patient's girlfriend reports that he took steroids recently for a bad sinus infection, and since he started them, his behavior has been abnormal. After discontinuing the medication, he has still been having symptoms. He has not had a normal night of sleep for the past ten days, and he just bought a new sports car, though he has no need for one or the money to afford it. She also reports that she has caught him with multiple other women in the past few days, though they were in a committed relationship. The physical exam is benign and the patient's vital signs are within normal limits.

BPD1

overly high and/or irritable to sad and hopeless, then back again, often with periods of normal mood in between. severe changes in energy and behavior go along w these mood changes. this is chaarcteristic of what dz

BPD1

the periods of highs and lows are called

episodes of mania and depression

sx of a manic episode are

inc energy, activity, or restlessness, excessively high or really good euphoric mood, very irritable, racing thoughts and talks very fast, jumps from idea to idea. distracted, can’t concentrate, little sleep, unrealistic beliefs in one’s abilities and powers. bad judgement, spending sprees, lasting period of behavior that is diff that typical, inc sexual drive, abuse of drugs (cocaine, alc, sleeping pills). provocative, intrusive, or aggressive behavior, denial that anything is wrong, down sx, sometimes depressive sx include psychosis like hallucinations and delusions.

what is very common in pts with BPD1

suicide

what demographic of pts can also have BPD1

both kids and adolescents. more likely to affect kids of parents with BPD1

tx BPD1 depression

SSRIs CONTRAINDICATED

why are SSRIs contraindicated for tx BPD1

induces mania

tx BPD1

atypical antipsychotics or mood stabilizers

what atypical antipsychs tx BPD1

clozapine, olanzapine, risperidone, quetiapine, ziprasidone

what mood stabilizers tx BPD1

lithium, VPA (Depakote), gaba (neurontin), carba (tegretol), topiramate (topamax)

if a pt is on lithium what lab values do you need to check

TSH

bipolar I =

mania w or w/o depression

what involves a manic episode of BPD1

elevated, expansive, or irritable mood lasting at least a week w sx like grandiosity, dec need for sleep, pressured speech, flight of ideas, distracted, inc goal directed activity, and risky behaviors

do you need depression in order to be dx with BPD1

NO

sudden mood escalation, abnormally/persistently euphoric, expansive, or irritable

manic episodes

dx BPD1 according to DSM 5

at least one manic episode,

occurrence of manic and major depressive ep isn’t better explained bc of a schizoaffective d/o, schizophrenia, schizophreniform d/o, delusional disorder, or other specified or unspec schizophrenia spectrum and other psychotic disorder

criteria for a manic episode

a. distinct period of abnl and persistently hi expansive or irritable mood and abnl and persistently hi activity or energy. lasts 1 wk and is present most of the day, nearly every day

b. during time of mood changes 3 or more of the following sx are present

• inflated self esteem or grandiosity

• dec sleep need

• more talking

• flighty ideas/racing thoughts

• distracted easy

• inc in goal directed activity

• involved in risky activities that can have bad results

c. mood disturbance causes impaired social or work function or you need to be hospitalized to not harm people or urself

d. sx isn’t from a substance

what is the criteria for a hypomanic episode

a. distinct period of abnl persistently elevated or irritable mood and inc activity/energy lasting for 4 days straight and is present for most the day

b. during period of mood changes 3 or more sx is present

• inflated self esteem or grandiosity

• dec need for sleep

• more talkative than usual or pressure to cont

• flighty ideas or racing thoughts

• distracted easy

• inc goal directed activity

• risky behavior that can harm themself

c. change in fucntioning that’s uncharacteristic of pt when they don’t have sx

d. other people see that the pt has a change in mood and functioning

e. ep isn’t severe enough to cause big impairment in social ro job function to be hospitalzied

f. episode isn’t bc of a substance

what is the criteria for a major depressive episode

a. 5 or more of following that show for 2 weeks and are different from previous functioning

1. depressed mood most of day, observed by others

2. dec interest or pleasure for all things

3. weight loss when not dieting or weight gain, or dec/inc in appetite daily

4. insomnia

5. agitation or retardation

6. fatigue or loss or energy

7. worthlessness or big guilt feelings

8. can’t focus or inc indecisiveness

b. recurrent thoughts of death or suicidal ideation w or w/o plan or attempt

C. Sx cause big distress and impairs social and job functioning

D. not bc of a substance

lithium can cause what AE

hypothyroidism, chronic autoimmune thyroiditis, goiter

how often do you monitor thyroid levels in pt taking lithium

1-2x in first 6 mo then 6-12 mo after

how often do you monitor renal function in pt on lithium

Every 3 to 6 months, then every 6 to 12 months

How often do you monitor electrolytes (sodium and calcium) in pt on lithium

Every 6 to 12 months

How often do you check weight and bmi in pt on lithium

Regularly bc of potential weight gain

How often do you review meds in pt on lithium

Regularly to avoid interactions that affect lithium levels (NSAIDs, ACE inhibitors, diuretics)

19-year-old male who has had bouts of sadness for a course of 1 year, in which he says that often he cannot even get out of bed, so he tells his parents he is ill. He states that he recently felt so energized that he could not keep his thoughts straight and jumped from one idea to another. During this energized state, he became irritable, and others noted that he was louder than usual, wondering if he had taken something that increased his energy. During the week of high energy, he maxed out two of his credit cards and is unsure how he will pay them off before he attends school in the fall. It was only a week later that he became so depressed that he did not find any pleasure in anything he did, was so tired he did not want to get out of bed, which has continued to be a struggle today.

BPD2

Key points on how to dx bipolar 2

At least one hypomanic episode and one major depressive episode. There has never been a manic episode

What are hypomanic sx

Similar but doesn’t lead to marked impairment. No psych sx, impulsivity is present

DSM 5 dx criteria for BPD2

A. At least one hypomanic episode and at least one major depressive episode

B. Never had a manic episode

C. Sx aren’t better explained by other disorders

Tx BPD2

Same meds used for BPD 1

Lithium first line mood stabilizer, benzos for agitation, antiepileptics (VPA, atypical antipsychotics risperidone, quetiapine, olanzapine), lamotrigine, haloperidol,

CBT, psychoeducation, and psychotherapy

If pt is on lithium what levels need to be monitored

Creatinine before initiating therapy

What dz inc likelihood for lithium tox

Renal failure, hyponatremia, dehydration

What dz can lithium cause

Hypothyroidism and Epstein anomaly in pregnant pts

when are benzos initiated in BPD2 pt

Acute sedation if pt is agitated

VPA is a good drug for BPD2 pts with what other comorbidity

Renal dysfxn who can’t take lithium

When is antidepressant therapy indicated for BPD2 pts

Only after starting a mood stabilizer

What drug is used to tx pregnant pts and acute mania in pts with severe sx with BPD2

Haloperidol

Atypical antipsychotics have an AE of what and are therefore avoided by obease pts

Weight gain

This drug induces mania in pts with BPD

SSRIs

28-year-old female presents to the clinic with concerns about her mood swings, which have been ongoing for more than two years. She describes periods of several days to weeks where she feels overly energetic, creative, and has a decreased need for sleep, followed by periods of low mood, fatigue, and disinterest in activities. These mood swings are not severe enough to cause significant impairment in her social or occupational functioning but are noticeable and distressing to her. She denies any history of major depressive or manic episodes. On examination, she appears well-groomed and is in no acute distress. She is diagnosed with Cyclothymic Disorder based on her chronic pattern of fluctuating moods. Psychoeducation is provided about the nature of the disorder, and regular follow-up appointments are scheduled. The importance of monitoring her mood and behavior is emphasized, and the option of starting psychotherapy, such as cognitive-behavioral therapy (CBT), to help manage her symptoms is discussed. The patient is also informed about the potential future risk of developing bipolar disorder and the importance of early intervention if her symptoms intensify.

cyclothymic d/o

chronic mood d/o characterized by eps of depression and hypomania for at least 2 yrs. less intense but longer lasting version of BPD, they have high and low moods, but never as severe as mania or major depression

cyclothymic d/o

DSM 5 criteria for cyclothymic d/o

at least 2 yrs criteria met for major depressive, manic, or hypomanic episode have NEVER been met, sx aren’t bc of other d/o. impairs social and job function

tx cyclothymic d/o

lithium if mood swings similar to bipolar, anticonvulsants like VPA and carbamazepine, psychotherapy

33-year-old woman complaining of fatigue and decreased interest in "the things that used to make me happy."  She is sleeping less and eating less, and she says that she is forcing herself to eat "because I know I have to eat something." She finds herself spending less time with her kids and husband as she retreats to her room. She feels guilty that she lacks the energy and enthusiasm she once had.

MDD

person develops affective or behavioral sx in response to an identifiable stressor so bad they can’t work or study.

adjustment d/o

what type of stressors occur in pts with adjustment d/o

natural disasters, retirement, divorce, abuse.

how long does adjustment d/o last

less than 6 months after the stressor ends

if adjustment d/o sx last more than 6 mo then it is considered

depression

tx adjustment d/o

psychoterapy

what neurotransmitter is active in dperession

serotonin and norepi and dopamine (females>males)

pt has diminished interest or pleasure, significant weight loss or pleasure, insomnia or hypersomnia, psychomotor agitation or retardation, fatigue or loss of energy, feelings of worthlessness, diminished ability to think or concentrate/indecisiveness. recurrent thoughts of death, suicidal ideation, suicidal ideation, attempt, or plan

depression

how long do sx persist in order to be dx with MDD

2 mo or longer

what do you need to r/o when you wanna dx a pt with MDD

r/o thyroid involvement w TSH, r/o addison’s, cushing’s

1st line tx MDD

SSRIs like fluoxetine, paroxetine, sertraline, fluvox, citaloplam, escitalopram

how do you dose SSRIs

inc dosage q3-4 wk until sx are in remission

when do you want to see pt when they start an SSRI

within 2-4 wks of starting meds and meet every 2 wks until improvements, when monthly to monitor med changes

SNRIs to tx MDD

venlafaxine, duloxetine

atypical antidepressants to tx MDD

bupropion, nefazodone, mirtazapine, trazodone

TCAs to tx MDD

amitriptyline, nortriptyline, desipramine, clomipramine, doxepin, protriptyline, trimipramine, imipramine

what MAOIs are used to tx MDD

phenelzine, tranylcypromine

how long are MDD pts treated for

1 yr and have to note a change by 2-6 wks therapy

SIGECAPS sx to dx MDD

5 or more for at least 2 wks felt qd

Sleep disturbances, Interest loss, Guilt or worthlessness, Energy loss or tired, Concentration hard, Appetite changes, Psychomotor agitation, Suicidal thoughts

what are the different hypotheses for MDD

monoamine, neurotrophic, neuroendocrine

this form of depression is characterized by paranoia and delusions, it’s more commonly seen in pts over 50. high suspicions or hallucinations

psychotic major depression

this form of depression is characterized by fatigue, hypersomnia, excessive eating and reactive mood

major depression w atypical features

this form of depression is not characterized by reactive mood although lack of interest and vegetative sx are severe

melancholic major depression

this form of depression occurs seasonally mostly in fall and winter, characterized by lethargy, excessive carb cravings, hypersomnia and excessive eating

major depression with seasonal onset

this form of depression is in preg women, occurs b/w 2 wk to 6 mo PP.

PP depression

DSM 5 criteria to dx MDD

a. 5 or more sx seen in the following 2 wks

depressed mood, dec interest or pleasure, weight loss more than 5% in a mo/dec appetite, insomnia/hypersomnia daily, agitation or retardation, fatigue, worthlessness/guilty, dec ability to concentrate, recurrent thoughts of death w or w/o intent

b. sx cause distress and impairment in social and job

c. not bc of a substance

d. not bc of another dx

e. NEVER been a manic episode or hypomanic episode

30-year-old married male who has felt down most of the time for the past three years. He experiences frequent, intrusive thoughts that he is not good enough, despite personal and professional successes. He tries to overcompensate for his thoughts by taking on more than he can handle, which leads to failure and furthers his feelings of inadequacy. His wife suggests that he seek help after finding him crying.

persistent depressive disorder (dysthymic d/o)

duration to dx dysthymic disorder

at least 2 yrs in adults and 1 yr in children/teens

depressed mood, irritable mood in kids, most of the day, more days than not, accompanied by sx of poor appetite/overeating, insomnia/hypersomnia, low energy or fatigue, low self esteem, poor conc and/or hard making decisions, hopelessness

dysthymic d/o

what si the difference bw MDD and dysthymic

dysthymic persists for 2 yrs or more, less acute and severe than MDD

if a pt has dysthymic d/o the chance of their family having depression is 50

50%

SSRIs to tx dysthymic d/o

fluoxetine, paroxetine, sertraline, fluvoxamine

depressive sx for >2 yrs. pt has never been w/o a depressive sx for more than 2 mo at a time. no manic episode or hypomanic episode

dysthymic d/o

DSM 5 criteria for chronic MDD and dysthymic d/o

a. depressed mood for at least 2 yrs

b. 2 or more

poor appetite or overeating, insomnia or hypersomnia, low energy or fatigue, low self esteem, poor concentration/can’t make decision, feeling hopeless

c. during 2 yrs pt had sx for at least 2 mo

d. pt has MDD for 2 yrs

e. no manic episode or hypomania

f. cause distress/impairment in social or occupational areas of functioning

first line tx of persistent depressive d/o (dysthymic)

psychotherapy (CBT) and antidepressants (SSRIs or SNRIs). follow-up and support. continue meds for at least 2 yrs after sx subside

26-year-old patient is complaining of depression and anxiety just prior to her menses. The symptoms have been going on for more than 1 year, but are now starting to interfere with her relationships and her productivity at work. One week prior to menses each month, she experiences a depressed mood, a feeling of being on edge, increased irritability, difficulty sleeping, a feeling of being overwhelmed, and is easily fatigued. She charted her symptoms daily in a log and returned to the office two cycles later. The log is consistent with the history. Her physical examination and general laboratory profile showed no abnormalities.

PMDD

during what phase of the menstrual cycle do sx of PMDD manifest

luteal phase and resolve with menstruation

repeated episodes of significant depression and related sx week before menstruation

PMDD

DSM 5 criteria for dx PMDD

at least 5 sx have to be present the week before menses start and have to improve/go away after menses start

• mood swings/tearfulness

• irritable or inc interpersonal conflict

• depressed mood, hopelessness

• anxiety

• dec interest in usual activities

• cant concentrate

• appetite changes

• insomnia/hypersomnia

• overwhelmed

• physical sx (breast tender, joint/muscle pain, bloating)

these sx interfere with work or school

tx PMDD

SSRIs fluoxetine or sertraline qd or when pt has sx. can also give it during luteal phase or at time of ovulation and stop the meds when period starts.

SNRI venlafaxine is also effective in pts with psych sx mostly

benzos as add ons and TCA clomipramine

OCPs, low dose estrogen, diuretics also decent tx

GnRH leuprolide for refractory cases

long term GnRH therapy is associated with

accelerated bone loss and vasomotor symptoms

what nutritional supplements are commonly used for sx reduction in PMDD

vit B6 vit E calcium carbonate, magnesium

what surgery can be used to tx PMDD as last last case scenario

ovariectomy

17-year-old male brought in by his mother after she found a goodbye note. He recently broke up with his girlfriend, has been giving away his belongings, and made an overdose attempt last year. He admits to daily thoughts of ending his life and says there is a firearm in the home. Asked directly about plan and intent, he describes both. He is hospitalized for safety, the family secures the firearm out of the home, a safety plan is built with him before discharge, and his underlying depression is treated with close follow-up.

suicidal behaviors

what is the strongest single predictor of a future suicide

a prior suicide attempt

does asking about suicide increase risk

no

what pop of people attempt suicide more, but what but dies more

women, men

red flags for suicidal behaviors

giving away things, saying goodbye, calm after depression, access to lethal means, recent psychiatric discharge

how to assess if a pt has suicidal behaviors

ask about ideation → plan → intent → means → past attempts

tools to assess suidicality

columbia C-SSRS, PHQ 9, ASQ in adolescents

RF for suicidality

male sex, age extremes, depression, prior attempt, substance use, rational thinking dec, social isolation, organized plan, no spouse, sickness/chronic pain, access to firearms

protective factors for suicidality

connectedness, responsibility for kids, engaged tx, religious objections

tx pt with suicidal behaviors

hospitalize, lethal means restriction (lock firearms and secure meds), safety planning (warning signs→ coping steps→ contacts→ means restriction). tx underlying disorder w lithium (mood d/o) and clozapine (schizo)