Depressive Disorders, Bipolar and Related Disorders

Question 1

What is a manic episode?

Answer 1

• Abnormally persistently elevated, expansive, or irritable mood AND ↑ activity or energy lasting ≥ 1 week (any duration if hospitalized)
• ≥ 3 sx (4 if mood is only irritable)
• significant impairment or requires hospitalization or +psychotic features

Question 2

What is a hypomanic episode?

Answer 2

• Abnormally persistently elevated, expansive, or irritable mood AND ↑ activity or energy lasting ≥ 4 days
• ≥ 3 sx (4 if mood is only irritable)
• No psychotic features
• No significant impairment or hospitalization

Question 3

What is a mixed episode?

Answer 3

≥ 3 manic/hypomanic symptoms + depression

Question 4

What is DIGFAST and what does it stand for?

Answer 4

Symptoms of mania/hypomania
* Distractibility
* Impulsivity
* Grandiosity
* Flight of ideas
* Activity/agitation
* Sleep (↓ need)
* Talkativeness

Question 5

What is the strongest RF for bipolar disorders?

Answer 5

Family history

Question 6

What is biolar I?

Answer 6

1+ manic episode +/- MDD

Question 7

What is bipolar II?

Answer 7

1+ major depressive episode PLUS 1+ hypomanic episode

Question 8

What is cyclothymic bipolar disorder?

Answer 8

hypomanic sxs + periods of depression for ≥ 2 yrs (≥ 1 yr in children)

Question 9

What is the first line treatment for bipolar disorders?

Answer 9

Lithium
* Valproic acid or Carbamazepine for rapid cycling (≥ 4 mood episodes w/in 12 months) or mixed features

Question 10

What is 2nd line treatment for bipolar disorders?

Answer 10

2nd generation (atypical) antipsychotics
* Risperidone, Quetiapine, Olanzapine, Ziprasidone
* Effective as monotherapy or w/ mood stabilizer (most effective)

Question 11

What medications can be used for bipolar depression?

Answer 11

Lurasidone, Cariprazine, Quetiapine, Olanzapine-Fluoxetine

Question 12

What are side effects of lithium?

Answer 12

• GI upset
• Tremors
• Polyuria
• Weight gain
• Leukocytosis
• Hyper: PTH, Ca, Mg
• Hypothyroidism
• Diabeties incipidus

Question 13

What is the BBW for lithium?

Answer 13

toxicity
* Pre-lithium workup: CBC, T4, TSH, BUN, serum creatinine & electrolytes, UA, ECG
* Therapeutic range: 0.8-1.2 mEq/L
* Toxicity > 2 mEq/L
* Monitoring: q4-5 days & after changes in dose → q1-2 months → q6-12 months if stable

Question 14

What is SIGECAPS?

Answer 14

Sxs of depression
* Sleep
* Interest
* Guilt
* Energy
* Concentration
* Appetite
* Psychomotor agitation/retardation
* Suicide

Question 15

What is the diagnostic criteria for MDD?

Answer 15

≥ 5 sxs for ≥ 2 wks (must include depressive mood or anhedonia)
* Cause significant functional distress or impairment

Question 16

How is MDD treated?

Answer 16

CBT + SSRIs

Question 17

What is the diagnostic criteria for persistent depressive disorder?

Answer 17

chronic depressive mood for ≥ 2 yrs PLUS ≥ 2 sxs (≥ 1 yr in children)
* Has not been symptom-free for > 2 months

Question 18

How is persistent depressive disorder treated?

Answer 18

CBT + SSRI

Question 19

What is the diagnostic criteria for premenstural dysphoric disorder?

Answer 19

≥ 5 sxs during luteal phase for ≥ 1 year a/w significant distress & interfere w/ usual activities

Question 20

How is PMDD treated?

Answer 20

exercise + diet modification
* Depression/anger/anxiety: SSRIs (Fluoxetine, sertraline)
* Severe or unable to take SSRIs: OCPs w/ drospierenone
* Bloating/fluid retention/breast tenderness: spironolactone

Question 21

What is the diagnostic criteria for disruptive mood dysregulation disorder?

Answer 21

recurrent temper outbursts inconsistent w/ developmental level ≥ 3/week for ≥ 12 months in 2 settings and ≥ 6 y/o
* Btwn outbursts, pt has persistently irritable or angry mood
* Has not been without sxs for ≥ 3 months
* Symptom onset before age 10 → cannot be diagnosed before age 6 or after age 18
* Settings: home, school, w/ peers

Question 22

How is disruptive mood dysregulation disorder treated?

Answer 22

psychotherapy (parent management training) +/- medications for sxs/comorbid conditions

Question 23

What are symptoms of persistent complex bereavement disorder?

Answer 23

• identity disruption (feeling as if part of oneself has died)
• sense of disbelief about the death
• avoidance of reminders of deceased, intense emotional pain (anger, bitterness, sorrow)
• difficulty reintegrating into relationships/activities
• emotional numbness
• feeling that life is meaningless
• intense loneliness

Question 24

What is the diagnostic criteria for persistent complex bereavement disorder?

Answer 24

≥ 1 month of intense yearning/longing or preoccupation w/ thoughts/memories of the deceased after a death ≥ 12 months PLUS ≥3 sxs
* Death ≥12 months ago (≥6mo for children/adolescents)

Question 25

How is persistent complex bereavement disorder treated?

Answer 25

CBT, support groups

Question 26

What screening tool can be used for postpartum depression?

Answer 26

Edinburgh Postnatal Depression Scale (EPDS) **AND** consider hypothyroidism!!

Question 27

What is the diagnostic criteria for postpartum depression?

Answer 27

≥2 weeks of feeling depressed or hopeless w/in 1 month to 1 year of birth PLUS ≥ 5 sxs (must include depressive mood or anhedonia)

Question 28

How is postpartum depression treated?

Answer 28

**Psychotherapy + SSRI/SNRIs** * No Paroxetine in 1st trimester → risk congenital heart defect!

Question 29

What SSRI is most likely to cause discontinuation syndrome?

Answer 29

Paroxetine

Question 30

What SSRI is least likely to cause discontuination syndrome?

Answer 30

Fluoxetine

Question 31

What are symptoms of discontinuation syndrome?

Answer 31

dizziness, paresthesias, dysphoric mood, agitation, flu-like sxs w/in 24-48 hrs of discontinuation

Question 32

How is discontinuation syndrome treated?

Answer 32

resume medication at prescribed dose & taper over weeks-months * OR substitute the SSRI w/ 1-2 doses of fluoxetine

Question 33

What is serotonin syndrome?

Answer 33

Can occur with overdose or combination of ≥ 2 serotonergic agents * SSRIs, SNRIs, TCAs, MAOi, bupropion, St. Johns wort

Question 34

What are symptoms of serotonin syndrome?

Answer 34

**TRIAD → autonomic dysfxn + neuromuscular dysfxn + mental status changes** * Hyperthermia & labile BP + clonus & hyperreflexia + agitation & delirium

Question 35

How is serotonin syndrome treated?

Answer 35

stop offending agent, IVF, **BZDs (Lorazepam)** * If sxs fail to improve: **cyproheptadine**