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Flashcards in 25 - Disorders of Mood Deck (38):

How common is major depressive disorder (MDD)?

- Second most common condition seen in primary care (after hypertension)
- 1/10 adult primary care outpatients have major depression or dysthymia


Describe the risk of relatives of patients with major depressive disorder (MDD) to develop MDD or other psychiatric diseases

- 1st degree relatives of individuals with MDD are 1.5-3 times more likely to also have the disorder than the general population
- 1st degree relatives also have elevated risk of alcohol dependence
- Children of individuals with MDD may have an increased risk of anxiety disorders and attention-deficit/hyperactivity disorder


What are the physical findings associated with MDD?

No laboratory findings have been identified that are diagnostic of MDD (although certain laboratory findings are more commonly abnormal among individuals currently experiencing a major depressive episode)


Describe the pathophysiology of MDD

- Dysregulation of several neurotransmitter systems
- Alterations of multiple neuropeptides
- Hormone disturbances may be present
- Alterations in cerebral blood flow may be present
- Not all individuals with MDD have these findings, and the findings are not specific to MDD

It is not as subjective as you might think - a lot of other systems are diagnosed pretty subjectively too


What are the DSM-V diagnostic criteria for a major depressive episode?

For at least two weeks, five or more of these symptoms, at least one of which is depressed mood or loss of interest/pleasure:
- Depressed mood most of the time, most days
- Loss of interest or pleasure in activities, most of the time, most days
- Significant change in appetite or weight
- Significant change in sleeping habits
- Psychomotor agitation or retardation
- Fatigue or loss of energy, most of the time, most days
- Feelings of worthlessness or excessive guilt
- Diminished ability to concentrate or make decisions
- Recurrent thoughts of death or suicide


Describe the gender differences in MDD

Women twice as likely to experience a depressive episode
- Lifetime risk for women is 10-25% in community samples
- Lifetime risk for men is 5-12% in community samples

Differential risk not evident in pre-pubertal children ***
- Just as common in adolescent male and female

Most other psychiatric diseases are the same across genders


Describe the course of MDD

- Average age of onset mid-20s, but may begin at any age
- Unlike with most anxiety disorders, course of MDD tends to be episodic
- Untreated episodes typically last at least four months, but will typically (60-75% of the time) eventually remit spontaneously


Describe the statistics on the outcome of MDD

- 40% of individuals with an MDE will still meet full criteria a year later
- 5-10% of individuals meet full criteria for an MDE lasting 2 years or more
- 20-30% of individuals will experience some symptom relief but have some symptoms persist for months or years that are still sufficient to cause clinically significant distress
- 40% of individuals who have a single MDE never have another one; risk of subsequent episodes rises with each additional MDE
- 5-10% of individuals with an MDE later have a manic episode
- 1st and 2nd episodes are more likely to be preceded by a psychosocial stressor


What is on the differential diagnosis list when diagnosing MDD?

- Normal sadness
- Grief
- Adjustment Disorder with Depressed Mood
- Persistent Depressive Disorder (Dysthymia)
- Manic episode with irritable mood or mixed features
- Dementia
- Mood Disorder Due to a General Medical Condition
- Substance-Induced Mood Disorder


What is the first line of treatment for MDD?

Psychopharmacology and psychotherapy are primary treatments

1st course of treatment only effective 40-60% of the time; multiple treatments may need to be tried.


What are the other treatment options for MDD?

- Complimentary and Alternative Medicine (CAM)
- Electroconvulsive therapy (ECT) is sometimes used in treatment-refractory depression
- Transcranial Magnetic Stimulation (TMS)
- Vagal Nerve Stimulation & Deep Brain Stimulation
- Exercise has been found to be of significant benefit in some studies
- Good sleep and nutritional habits can also be of significant benefit
- Encourage use of social support


What do you need to do before beginning treatment?

- Rule out medical causes for the mood disturbance
- Establish a diagnosis
- Assess substance use
- Assess for manic and psychotic symptoms
- Determine patient preference and past treatment outcomes
- Assess suicidality


What are the options for pharmacological anti-depressants?

- Monoamine oxidase inhibitors (MAOIs)
- Tricyclic antidepressants
- Selective serotonin reuptake inhibitors (SSRIs)
- Serotonin norepinephrine reuptake inhibitors (SNRIs)
- Others


Describe monoamine oxidase inhibitors (MAOIs)

Monoamine oxidase inhibiters (MAOIs)
- First effective treatment for depression, developed in 1950s
- Phenelzine (Nardil), selegiline (Emsam) are examples
- Not a first-line treatment due to significant risk with drug-food or drug-drug interactions.
- Foods containing tyramine (e.g. aged foods, wine, cheese) cause hypertensive crisis; also interacts with a variety of other drugs, including Demerol and pseudoephedrine


Describe tricyclic antidepressants

Tricyclic antidepressants
- Imipramine (Tofranil), amitriptyline (Elavil) are examples
- Side effects include dry mouth, constipation, weight gain, orthostatic hypotension, and sexual dysfunction
- Usual daily dose 25-300 mg, depending on specific drug
- Rarely used now for depression; too lethal in event of overdose (cardiac arrhythmias and seizures)
- Still used for other indications including chronic pain


Describe selective reuptake inhibitors (SSRIs)

Selective serotonin reuptake inhibitors (SSRIs)
- Most common first-line treatment for depression
- Citalopram (Celexa), escitalopram (Lexapro), fluoxetine (Prozac), fluvoxamine (Luvox), paroxetine (Paxil), and sertraline (Zoloft)
- Less sedating, less likely to cause weight gain than tricyclics but equally likely to cause sexual dysfunction; may cause GI upset, headaches, sleep disturbance, agitation.
- Most side effects (other than sexual) abate quickly
- Non-lethal in overdose
- Usual dose 20-200 mg, depending on medication; lower for escitalopram
- Require 2-7 weeks for patient to notice a response


Describe serotonin-norepinephrine reuptake inhibitors (SNRIs)

Serotonin-norepinephrine reuptake inhibitors (SNRIs)
- Also used as first-line treatment
- Venlafaxine (Effexor), desvenlafaxine (Pristiq), duloxetine (Cymbalta), levomilnacipran (Fetzima)
- Side effects: elevated blood pressure and heart rate (venlafaxine), weight gain, sexual dysfunction
- Usual daily dose 60-300 mg, depending on medication


What are the "other" pharmacological anti-depressants?

- Vilazodone (Viibryd) and Vortioxetine (Brintellix)
- Bupropion (Wellbutrin)
- Mirtazapine (Remeron)
- Trazodone (Desyrel)


Describe the use of Vilazodone (Viibryd) and Vortioxetine (Brintellix)

Add on drug to SSRIs


Describe the use of Bupropion (Wellbutrin)

- Norepinephrine and dopamine reuptake inhibitor
- Activating, increases energy; does not help with anxiety, unlike SSRIs and SNRIs
- Does not cause sexual dysfunction or weight gain; may cause dizziness, dry mouth, or agitation; can cause seizures at high dosages (but rarely)
- Marketed as Zyban for smoking cessation
- Usual daily dose: 300-400 mg


Describe the use of Mirtazapine (Remeron)

- Significant sedating and weight gain effects; useful in patients where insomnia and loss of appetite are prominent
- Usual daily dose: 15-60 mg


Describe the use of Trazodone (Desyrel)

Too sedating to be useful at dosages effective for depression; commonly prescribed as a non-habit-forming sleep aid


Describe bipolar disorder

- Equally common in men and women
- Lifetime prevalence from 0.4-1.6%
- Recurrent course: 90% of individuals with a full-blown manic episode will have another manic episode in the future
- 1st degree relatives have elevated risk of Bipolar I, Bipolar II, and Major Depressive Disorder
- Diagnosis requires the presence of a manic or mixed episode; no depressive episode is required
- Significantly elevated risk of suicide as compared with general population (rate of completed suicide is up to 12-20%)


What is mania?

- Mania typically requires hospitalization
- Unlike in a depressive episode, individuals having a manic episode often do not believe anything is wrong and do not want treatment
- Untreated, typically lasts a few weeks to several months
- May end abruptly with the onset of a depressive episode
- Mean age of onset is early twenties, but standard deviation is large
- Psychosocial stressors often precede the episode
- Postpartum psychosis is thought to typically be a manic episode


What is the DSM-V criteria for a manic episode?

Distinct period of abnormally elevated, expansive, or irritable mood and abnormally and persistently increased goal-directed activity or energy lasting at least one week (any duration if hospitalized), and...

At least three of the following symptoms (four if only irritable mood):
- Inflated self-esteem or grandiosity
- Decreased need for sleep
- Increased talkativity or pressure to talk
- Flight of ideas or racing thoughts
- Distractibility
- Increase in goal-directed activity
- Excessive pleasurable activities that are likely to have negative consequences (e.g. sex, spending)

May involve psychotic features


What are the other types of mood episodes?

- Hypomanic episode
- Substance/Medication induced (mood disorder)
- Due to another medical condition
- Other specified and unspecified (mood disorder)
- Mild, moderate, severe
- With anxious features, rapid cycling, psychotic features, catatonia, peripartum onset, seasonal pattern
- With mixed features


Describe hypomanic episodes

- Same symptoms as manic episode, but less severe, 4 days or more
- Symptoms are a definite change from baseline, but do not markedly impair functioning


Describe mood episodes with "mixed features"

Criteria are met for both a depressive episode and a manic episode simultaneously for at least a week


Describe the treatment of bipolar disorders

- Pharmacologic treatment is typically the treatment of choice
- Anti-depressants alone can trigger a manic episode in an individual with underlying bipolar
- Mood stabilizers
- An antidepressant plus an antipsychotic medication may also be used
- Psychotherapy is useful as an adjunct for coping with symptoms and improving quality of life
- Regular sleep habits are particularly important


What are the mood stabilizers we use in the treatment of bipolar disorders?

- Lithium
- Some anti-convulsants


Describe the use of lithium

- Highly effective but difficult to tolerate
- Narrow therapeutic window, can cause a variety of toxicities; requires ongoing close monitoring


What anti-convulsants can be used?

Some anti-convulsants (e.g. lamotrigine (Lamictal), divalproex (Depakote))

Can also cause serious adverse events and require careful monitoring


What are the mood disorders you will be differentiating between?

- Major Depressive Disorder
- Persistent Depressive Disorder (MDD-Chronic & Dysthymia)
- Premenstrual Dysphoric Disorder
- Bipolar I Disorder
- Bipolar II Disorder
- Cyclothymia


Describe Major Depressive Disorder

One or more major depressive episodes without any manic, hypomanic, or mixed episodes


Describe Persistent Depressive Disorder (MDD-Chronic & Dysthymia)

Chronic, low-level depressed mood most days for at least 2 years


Describe Bipolar I Disorder

- One or more manic or mixed episodes (no MDE required)
- Hypomanic and depressive episodes may also be present


Describe Bipolar II Disorder

At least one hypomanic and at least one depressive episode without any manic or mixed episodes


Describe Cyclothymia

2 years of fluctuating periods of hypomanic and depressive symptoms that don’t meet full criteria for a hypomanic or major depressive episode (must include clinically significant distress or impairment and never symptom free for more than 2 months)