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

When would you hospitalize a pt in psychiatry?

When to Hospitalize

• If pt is too sick to care for themselves

• Threats to themselves or others

• Instability

Which of the following are not a mood disorder?
• Major depressive disorder

• Persistent depressive disorder

• Premenstrual dysphoric disorder

• Seasonal depressive disorder

• Bipolar I disorder

• Bipolar II disorder

• Cyclothymic disorder

None; All mood disorders

On a PHQ9 test what does It mean if the results are 10 or above?

>10 is 88% sensitive and specific for MDD

What are mood disorders often referred to as?

affective disorders

Disorders that virtually always result in impaired interpersonal, social, and occupational functioning are called?

Mood disorders

What does unipolar depression mean?

mood disorders are limited to depressive episodes. It refers to a type of depression without the presence of manic or hypomanic episodes.

What happens if you give antidepressants alone to a person with bipolar disorder?

It can trigger a manic episode in patients due to the absence of mood stabilizers.

What are the 6 classifications of unipolar depression disorders?

1. MDD

2. Persistent Depressive Disorder (Dysthymia)

3. Adjustment Disorder

4. PMDD

5. SAD

6. Postpartum Depression vs. Postpartum blues

What is the is the most powerful predictor for onset of depressive episode?

recent stressful event

What are the requirements (classifications) needed to diagnose the 6 unipolar depression disorders?

• MDD: ≥2 weeks, ≥5 symptoms (must include depressed mood or anhedonia)

• Persistent Depressive Disorder (Dysthymia): ≥2 years, mild, chronic

• Adjustment Disorder: onset within 3 months of stressor

• PMDD: luteal phase depression, resolves after menses

• Seasonal Affective Disorder (SAD): seasonal pattern

• Postpartum depression/blues

What is the etiology(causes) of depression?

• Neurotransmitters: ↓ serotonin, norepinephrine, GABA, glutamate

• ↑ Cortisol response, inflammation, brain structural changes

• Genetics: ↑ risk with FHx

• Stressful life events → strongest predictor

What is the most common psych mood disorder? And Is it more common in women or men?

Depression; Women

Which comorbid disorders are commonly increased in pts with depression?

ETOH abuse, Panic disorders, OCD, Social anxiety disorder

How does early treatment affect the outcomes of depression?

Early treatment is associated with better outcomes and prognosis

What mood disorder occurs without a history of mania or hypomania episodes?

Major Depressive Disorder (MDD).

How long must symptoms last to diagnose MDD?

At least 2 weeks, nearly every day.

What are examples of symptoms used to diagnose MDD? (SIGECAPS)

How many symptoms are required for an MDD diagnosis?

At least 5 symptoms, and one must be low mood (depressed mood) or anhedonia (loss of interest/pleasure).

Besides the symptoms, what else must be true to diagnose Major Depressive Disorder?

• Symptoms cause clinically significant distress or impairment.

• Symptoms are not due to substances, medical conditions, or other psychiatric disorders (e.g., bipolar, schizophrenia spectrum).

Inquiring about which of the following is the

best way to screen for past manic episodes?

• A) Excessive spending habits

• B) Sexual promiscuity

• C) Increased energy despite decreased sleep

• D) Concerned friends and family

• E) C and D

C) Increased energy despite decreased sleep

D) Concerned friends and family

How long can an untreated episode of Major Depressive Disorder last?

6–13 months

With treatment, how long may an episode of MDD last?

About 3 months

What are the atypical features of MDD?

• Hypersomnia

• Weight gain

• Mood reactivity (mood brightens in response to positive events)

What are the psychotic features of MDD?

Delusions or hallucinations.

How can MDD episodes occur?

As a single episode or as recurrent episodes.

What defines recurrent MDD?

At least 2 episodes, separated by 2 months without symptoms.

What endocrine disturbance must be ruled out when evaluating for Major Depressive Disorder?

Thyroid disturbance (e.g., hypothyroidism).

Besides thyroid, which other endocrine dysfunction can mimic depression? In other words, what other differential diagnoses can we put if it’s not MDD?

Adrenal dysfunction

Which medications can cause depressive symptoms and should be considered in the differential diagnosis?

Levodopa, clonidine, corticosteroids, and digitalis.

When diagnosing depression, what other psychiatric disorder must be ruled out first?

Bipolar disorder

How do we screen for bipolar disorder when evaluating for depression (what 2 key questions)?

Ask about:

1. 🌙⚡Periods of increased energy despite little sleep

2. 😃😡🤔Unusual changes in mood or behavior observed by others

For mild to moderate depression, what treatment options are considered equally effective?

Psychotherapy and medications; exercise is also helpful.

For moderate to severe depression, what is the first-line treatment?

Medications (antidepressants); psychotherapy can be added.

After starting treatment for depression, how long should therapy be maintained?

At least 6 months Why? minimum time needed to “lock in” recovery and reduce relapse risk.

How is adjustment disorder with depressed mood typically managed?

With social support, brief therapy, or a short course of medications.

How should depression due to substance use be treated?

By treating the substance disorder first, and considering therapy and/or medications.

What is the most important complication of Major Depressive Disorder?

Suicide (66% contemplate and 10-15% commit suicide)

What is the immediate goal when assessing a patient with MDD regarding suicide risk?

determine if hospitalization or outpatient management is needed

Which demographic group has the highest risk of suicide?

Elderly white men.

Besides elderly white men, which groups are also at higher suicide risk?

Females and adolescents.

What is the strongest single predictor of future suicide attempts?

Prior suicide attempt.

Which substance-related factor increases suicide risk?

Alcohol or drug abuse.

Name at least three psychiatric/medical factors that increase suicide risk.

Severe depression, schizophrenia, history of trauma/abuse, family history of suicide

What must always be documented in a psychiatric assessment regarding suicide/homicide?

SI/HI (suicidal ideation/homicidal ideation).

What is the immediate goal when assessing suicide risk in a patient?

determine if hospitalization or outpatient treatment is appropriate.

What should you ask about when evaluating suicide risk?

Intent, plan, means, and suicide-inhibiting factors ( family support, cultural beliefs, dependents, fear of death)

What is a “5150” in psychiatry?

A 72-hour psychiatric hold for patients at risk of harming themselves or others.

What is the name of the standardized tool used to screen for suicide risk?

ASQ – Ask Suicide-Screening Questions.

According to ASQ, what are example screening questions?

• “In the past few weeks, have you wished you were dead?”

• “In the past few weeks, have you felt that you or your family would be better off if you were dead?”

• “In the past week, have you been having thoughts about killing yourself?”

• “Have you ever tried to kill yourself?”

• (If yes to any: “Are you having thoughts of killing yourself right now?”)

How long must a depressed mood be present to diagnose Dysthymia (Persistent Depressive Disorder)?

Most of the day, nearly every day, for at least 2 years.

While depressed, how many additional symptoms are required for diagnosis of dysthymia?

At least 2 symptoms.

What are the possible additional symptoms of dysthymia?

• Poor appetite or overeating

• Insomnia or hypersomnia

• Low energy or fatigue

• Low self-esteem

• Poor concentration or difficulty making decisions

• Feelings of hopelessness

During the 2-year period, how long can a patient be without symptoms and still meet criteria for dysthymia?

No more than 2 months at a time.

Can criteria for Major Depressive Disorder be continuously present during dysthymia?

Yes — MDD criteria may be continuously present for 2 years.

What disorders must not be present for a diagnosis of dysthymia?

There must be no history of manic or hypomanic episodes, and criteria for cyclothymic disorder must not be met

How does dysthymia differ from major depressive disorder (MDD)?

Symptoms are milder, more chronic, and tend to be more subjective (feelings) than objective signs.

What do patients with dysthymia often complain about?

That they have “always been depressed.”

What are common characteristics of patients with dysthymia?

Habitual gloom, brooding, lack of joy, and preoccupation with feelings of inadequacy.

Which groups are more likely to develop dysthymia?

Women, unmarried individuals, and people of low socioeconomic status.

What medical condition should always be checked in suspected dysthymia?

Thyroid function.

What is the treatment approach for dysthymia?

Treatment is similar to MDD (psychotherapy, pharmacotherapy, lifestyle support).

What are the treatment options for mild depression?

Psychotherapy and alternative therapies.

What is considered the first-line pharmacologic treatment for Major Depressive Disorder (MDD)?

SSRIs, SNRIs, NDRI (bupropion), and other atypical antidepressants.

Which medication classes are considered second- or third-line for MDD?

Tricyclic antidepressants (TCAs) and Monoamine oxidase inhibitors (MAOIs).

Besides antidepressants, which other pharmacologic agents may sometimes be used in MDD?

Stimulants.

What procedural treatments are available for depression?

Electroconvulsive therapy (ECT) and repetitive transcranial magnetic stimulation (rTMS).

What types of therapy are effective in depression management?

A6. Psychotherapy, social therapy, and behavioral therapy.

Name the first-line SSRIs used for depression. "Effective For Sadness, Panic, & Compulsions"

Citalopram, Escitalopram, Fluoxetine, Fluvoxamine, Paroxetine, Sertraline.

Name the first-line SNRIs used for depression.

Desvenlafaxine, Duloxetine, Levomilnacipran, Milnacipran, Venlafaxine XR.

Which atypical antidepressants are considered first-line or commonly used?

Bupropion (SR, XL), Mirtazapine, Trazodone, Nefazodone, Vilazodone, Vortioxetine.

Name at least 3 TCAs used in depression.

Amitriptyline, Nortriptyline, Imipramine, Desipramine, Doxepin, Clomipramine, Trimipramine, Amoxapine, Maprotiline, Protriptyline.

Which medications are MAOIs?

Phenelzine, Selegiline (patch), Tranylcypromine.

Which SSRI has the lowest drug interactions?

Sertraline.

Which SSRI is FDA-approved for adolescents?

Escitalopram.

Which atypical antidepressant is also used for smoking cessation?

Bupropion.

Which antidepressant is most sedating and often used for sleep?

Trazodone (also Mirtazapine).

Which class of antidepressants has the highest risk of anticholinergic and cardiac side effects?

TCAs.

Which antidepressants require dietary restrictions due to risk of hypertensive crisis with tyramine?

MAOIs.

Name 5 common SSRIs.

Fluoxetine, Sertraline, Paroxetine, Escitalopram, Fluvoxamine.

Which SSRI has the longest half-life?

Fluoxetine (Prozac).

Which SSRI has the lowest drug interactions?

Sertraline (Zoloft).

Which SSRI is highly anticholinergic and has the shortest half-life?

Paroxetine (Paxil).

Which SSRI is FDA-approved for adolescents?

Escitalopram (Lexapro).

Which SSRI has more drug drug interactions than others?

Fluvoxamine.

What are SSRIs indicated for besides depression?

Panic disorder, generalized anxiety disorder (GAD), OCD, PTSD.

What time of day are SSRIs usually given?

In the morning (AM).

What are common side effects of SSRIs?

Headache, tinnitus, nausea/diarrhea, insomnia, nervousness, erectile dysfunction.

Which SSRIs are safest to use with warfarin?

Sertraline and citalopram.

What are two important warnings associated with SSRIs?

Black box warning: increased risk of suicide in adolescents. Caution: risk of serotonin syndrome.

SSRIs are commonly indicated to treat which disorders?

Depression

◦ Panic Disorder

◦ GAD

◦ OCD

◦ PTSD

Which SNRI is associated with arrhythmias and hypertension side effects?

Venlafaxine (Effexor)

What additional benefit do SNRIs have that SSRIs do not?

They provide benefit for pain conditions such as fibromyalgia and neuropathy (FDA approved).

What are the main indications for SNRIs?

Same as SSRIs: depression, GAD, panic disorder, OCD, PTSD.

How well are SNRIs tolerated and what is their onset of action?

They are well tolerated but have a delayed onset of action.

What is the side effect profile of SNRIs compared to SSRIs?

Same as SSRIs

Which medication (SNRI) is approved for depression (off-label) and fibromyalgia treatment?

Milnacipran (Savella)

Which SNRI treats depression and pain (neuropathic, fibromyalgia, chronic pain)

Duloxetine (Cymbalta)