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Psychiatry > Depressive and Bipolar > Flashcards

Depressive and Bipolar Flashcards

1
Q

What is the lifetime prevalence of depressive disorders for females and males?

A

Females - 20 to 25%

Males - 10 to 15%

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2
Q

What genetic factors are associated with depressive disorders?

A

First degree relatives have a 2-5x increased risk of developing depression

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3
Q

Describe the NE hypothesis for depression.
What 2 explanations support it?
What makes this hypothesis problematic?

A

Reserpine was known to decrease NE and caused depression.

Amphetamines and MAOIs increase the level of NE and have anti-depressant effects.

Problems:

  1. only 15% on reserpine got depression
  2. other drugs that decrease NE don’t cause depression
  3. amphetamine/MAOIs increase NE in hours/days, but antidepressant effects take weeks
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4
Q

What is the Serotonin hypothesis for depression?

What is problematic with this hypothesis?

A
  1. initial studies showed decreased serotonin/metabolites in depression
  2. most antidepressants were thought to work by increasing 5HT
  3. substances known to deplete 5HT led to depression symptoms

Problems:
Subsequent studies showed conflicting results with increased, decreased or unchanged CNS 5HT in depressed people

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5
Q

Describe the stress, HPA, Hippocampus hypothesis for depressive disorders.

A

Stress–> cortisol secretion via HPA axis.

Glucocorticoids are essential for acute stress, but sustained excessive HPA activation can lead to mood disorders because:

Hypercortisolemia –> damages hippocampal neurons by:

  1. decreasing dendritic arborization [branching]
  2. inhibiting neurogenesis
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6
Q

What fraction of patients with depression have been observed to have an excessively active HPA axis and hypercortisolemia?

A

1/2

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7
Q

What is the effect of dexamethasone on depressed individuals with overactive HPA axis?

A

it does NOT lead to suppression of plasma cortisol.

[it should normally suppress the axis, but in depressed patients it does not]

In depressed people, the HPA axis and hypercortisolemia can be corrected with antidepressants.

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8
Q

What is the kindling hypothesis for depressive disorders?

What clinical evidence supports this?

A

Repeated exposure to stress leads to sensitization of certain areas of the brain [limbic system] so that subsequent stressors –> permanent physiologic changes.

Evidence:

  1. early life trauma–> later depression
  2. recurrent depression - stress threshold is lower for later episodes
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9
Q

What is the neurotrophic hypothesis for depression?

A

Deficiency in neurotrophic support contributes to hippocampal pathology of depression

BDNF [brain derived neurotrophic factor] is decreased in the hippocampus in depression, but can be increased with the administration of anti-depressants which also repairs some stress-induced damage to hippocampal neurons

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10
Q

How does the neurotrophic hypothesis help explain why anti-depressant response may be delayed?

A

Anti-depressants upregulate BDNF which helps:

  1. repair stress-induced hippocampus damage
  2. protect vulnerable neurons from further damage

It takes sufficient tome for levels of BDNF to gradually rise and exert neurotrophic effects.

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11
Q

What is the mechanism and effect of ketamine on depressive disorders?

A

Ketamine blocks glutamate at the NMDA-receptors.

In the hippocampus, this has been shown to:

  1. increase the number of dendritic spines [in mice that had prior had decreased arborization]
  2. reverse depressive behaviors

Unlike traditional antidepressants, ketamine works within hours, not weeks. [however, the effect lasts only about a week]

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12
Q

What are the 7 “depressive disorders” outlined in DSM5?

A
  1. disruptive mood dysregulation disorder [DMDD]
  2. major depressive disorder [MDD]
  3. persistent depressive disorder [PDD- dysthymia]
  4. premenstrual dysphoric disorder
  5. other specified depressive disorder [Depression NOS]
  6. due to Medical condition
  7. due to substance/medication
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13
Q

What are the 2 main criteria for major depressive disorder?

A
  1. one or more major depressive episode

2. no history of mania or hypomanic episodes

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14
Q

A major depressive episode is classified by how many symptoms occurring for what period of time?

A

At least 2 weeks of at least 5 of the following [one of which must be an asterisk]

    1. depressed mood for most of the day
    1. loss of pleasure and interest in life
      1. appetite increase or decrease
      2. sleep increase or decrease
      3. psychomotor retardation or agitation
      4. decreased energy/fatigue
      5. Guilt or worthlessness
      6. impaired concentration
      7. thoughts of death or suicide

[ SIGECAPS - sleep, interests, guilt, energy, conc, appetite, psychomotor, suicide]

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15
Q

What are the 4 other symptoms commonly seen with major depressive episodes, but not included in the DSM5?

A
  1. crying
  2. low libido
  3. hopeless, helpless
  4. low self-esteem
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16
Q

By definition, what 2 things are required to make something a true “psychiatric disorder”?

A
  1. causes impairment or distress

2. NOT substance, medication, other medical condition, or other mental disorder [usual rule-outs]

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17
Q

What is the criteria for persistent depressive disorder [Dysthymia]?

A

Depressed mood [same criteria as major depressive episode, only slightly more mild] that lasts at least 2 years.

  • decreased/increased appetite
  • decreased/increased sleep
  • decreased energy
  • low self-esteem
  • problems concentrating
  • hopeless

Essentially, it is chronic depression

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18
Q

What criteria classifies a disorder as premenstrual dysphoric disorder?

A
  1. begins in the week before menses, improves with onset of menses, minimal/absent in the weeks after menses
  2. at least 5 of the following:
    - affective lability*
    - depression*
    - irritability *
    - anxiety *
    - decreased interests and concentration
    - decreased energy
    - increased appetite/food cravings
    - sleep disturbances
    * ** overwhelmed/out of control
    * **     physical symptoms
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19
Q

What depressive disorder should a patient be diagnosed with if they have recurrent brief depression [less than 2 weeks], or disorders that do not meet full criteria for premenstrual dysphoric disorder, persistent depressive disorder or major depressive disorder?

A

Other specified depressive disorder

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20
Q

A person experiences depressive symptoms as a result of a break-up. The symptoms are thought to be directly related to the stressor.
What is this called and what is treatment if it lasts less than 2 weeks or has less than 5 criteria?
What is it called if it lasts for at least 2 weeks and has 5 criteria? What is treatment?

A

Less than 2 weeks:

  1. adjustment disorder with depressed mood
  2. time and support NOT antidepressants

Over 2 weeks:

  1. major depressive episode
  2. antidepressants
21
Q

A patient presents with major depressive disorder. She also experiences feelings of tension and restlessness. Worrying has been causing problems with concentration. She feels like she is losing control.
What modifier goes with this?

A

MDD with anxious distress

22
Q

A patient presents with MDD and SOME criteria [but not full criteria] for mania or hypomania. How is this disorder classified?

A

MDD with mixed features

23
Q

A patient presents with MDD with despondency and despair. He has terminal insomnia and reports waking at 330a every morning. He has developed anorexia. He says when his daughter was born, he knew he should be happy but couldn’t feel his mood change.
It is worse in the mornings.
What is the classification and implications of this?

A

MDD with melancholic features

*indication for hospitalization and possibly shock therapy

24
Q

A patient fits the criteria of MDD and has hallucination and delusions that are mood congruent.
What is the classification?

A

MDD with mood-congruent psychotic features

25
Q

What are the features associated with depressive disorder with atypical features?

A
  1. hypersomnia
  2. hyperphagia
  3. leaden paralysis [heavy arms and legs]
  4. mood reactivity
  5. easily gets feelings hurt

**less responsive to TCAs

26
Q

Which specifier for depressive disorders is less responsive to TCAs?

A

atypical features

27
Q

What is the time frame for something to be considered MDD with peripartum onset?

A

if the depression begins during pregnancy or the 4 weeks after

28
Q

What is the lifetime prevalence of bipolar disorders?

Are they more prevalent in males or females?

A

1% with males and females being equal

29
Q

First degree relatives of a person with bipolar disorder have what risk of developing bipolar disorder? What are they also at increased risk for?

A

24x as likely to get bipolar disorder, but also at increased risk for major depressive disorder.

80% concordance between monozygotic twins

30
Q

What are the 4 DSM5 classified bipolar disorders?

A
  1. bipolar 1
  2. bipolar 2
  3. cyclothymic disorder
  4. other specified bipolar disorders
31
Q

What are the qualifications to determine something is a manic episode?

A

Elevated, expansive, irritable or labile mood that:

  1. lasts 1 week OR requires hospitalization
  2. has at least 3 of the following symptoms:
    - grandiosity
    - decreased need for sleep
    - pressured speech
    - flight of ideas
    - distractibility
    - increased goal-directed activity and psychomotor agitation
    - excessive involvement in high risk activities
32
Q

How does lack of sleep differ for a manic episode and major depressive disorder?

A

Manic episode - the patient has a decreased need for sleep and can go days w/o sleep and still feel energetic

MDD- the person wants to go to sleep and tries but they just can’t and are tired/drained

33
Q

A patient is brought to you claiming that she is a princess. She keeps talking even when you attempt to interrupt for questions. When she is talking she changes ideas so fast it is difficult for you to make connections with what she is saying. She is easily distracted and must be redirected in conversation. Her husband says she has not slept in days, but is very energetic. He complains that yesterday she went to the mall and bought 20 pairs of shoes for the balls she will attend as a princess. She wants to write a book about her like as a princess.

What is it likely that she is having?

A

A manic episode

34
Q

What criteria classify something as a hypomanic episode?

A

persistently elevated, expansive or irritable/labile mood lasting 4 days with 3 of the following:

  1. grandiosity
  2. decreased need for sleep
  3. excessive talkativeness [maybe pressured]
  4. flights of ideas
  5. distractibility
  6. goal-directed activity/psychomotor agitation
  7. excessive involvement in high risk activity
35
Q

What are the 3 main differences between a manic episode and a hypomanic episode?

A
  1. hypomanic is LESS severe - ex. excessive talking/racing thoughts vs. pressured speech/flight of ideas
    - 3. hypomanic causes SOME impairment but usually does not require hospitalization, or elicit psychotic symptoms
36
Q

What criteria classify something as bipolar 1 disorder?

What specifier is commonly given?

A

One or more manic episodes.
- history of depressive disorder is NOT necessary to make diagnosis

Specifier:
Bipolar 1 disorder with current/most recent episode:
-manic
-hypomanic
-depressive
-unspecified
37
Q

What criteria classify something as bipolar 2 disorder?

A
  1. at least 1 MDD episode

2. at least 1 hypomanic episode [w/o full criteria for manic]

38
Q

What is cyclothymic disorder?

A
  1. numerous hypomanic periods and mild depressive periods that last for 2 years or more.
    * *persistent rapid-cycling of mild bipolar disorder
  2. NO major depressive episodes or manic episodes during the first 2 years
39
Q

What is the only specifier specific to to bipolar I and II disorders?

A

With rapid cycling - this means that they have 4 distinct mood episodes [mania, hypomania, depression] in the past 12 months.

  • 4 manic
  • 3 hypomanic, 1 manic
  • 2 depressive, 2 hypomanic

etc etc

40
Q

What is bipolar disorder with mixed features?

A

When bipolar disorders meet the full criteria for manic or hypomanic episodes but DO NOT meet the full criteria for depressive episode

41
Q

What is depressive or bipolar disorder due to another medical condition?

A

When the psychological disorder is related to the PHYSIOLOGICAL effects of a medical illness NOT the emotional reaction to the diagnosis

42
Q

What endocrine disorders are associated with the development of depressive and/or bipolar disorder?

A
  1. Cushings
  2. Addison’s
  3. hypothyroidism
  4. hypocalcemia OR hypercalcemia
43
Q

What malignancies are associated with depressive and bipolar disorders?

A
  1. brain tumors
  2. lymphomas
  3. pancreatic carcinoma [often depression is 1st manifestation]
44
Q

What infections are associated with depressive and bipolar disorders?

A
  1. hepatitis
  2. encephalitis
  3. mononucleosis
  4. HIV
45
Q

What neurological disorders are associated with depression and bipolar disorder?

A
  1. Parkinson’s
  2. Huntington’s
  3. stroke
46
Q

What 9 drugs have associations with medication-induced depressive or bipolar disorders?

A
  1. steriods
  2. methyl-DOPA
  3. reserpine [decreases NE]
  4. propanolol
  5. carbonic anhydrase inhibitor
  6. stimulants
  7. sedative-hypnotics
  8. narcotics
  9. anti-depressants [can flip to mania]
47
Q

How do you select which anti-depressant to use for your patient?

A

All anti-depressant are EQUALLY effective, so differentiate based on:

  1. what has worked for the patient in the past
  2. if they have never been on an antidepressant, see if any family member has, provided no contraindications
  3. consider side effect profile, safety and drug-drug interactions, ease of dosing/cost
48
Q

What is the course of treatment with anti-depressants?

A
  1. get patient up to therapeutic dose which can take 4-6 weeks [DO NOT switch anti-depressants w/in first 4-6 weeks]
  2. get depression into remission NOT just “better” because this leads to increased lifetime risk of recurrence
  3. continue the medication for minimum of 6 months to avoid relapse [usually 9-12 months] and then slowly taper the drug
49
Q

What is CBT? IPT?

A

CBT - cognitive behavioral therapy where there is a time-limited therapy focused on examining thoughts in order to change feelings.

IPT- interpersonal therapy where the patient examines one’s relationships and life role transitions

COMBO of these is most effective

Psychiatry (18 decks)

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