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Lecture 12: Mood Disorders Part 2 COPY Flashcards

1
Q

What is adjustment disorder with depressed mood?

A

A depressed mood in response to a IDENTIFIABLE psychosocial stressor.

NOT a true depressive disorder.

Generally for conditions that do not meet criteria for a more specific depressive disorder.

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2
Q

How does adjustment disorder with depressed mood present?

A

Low mood, tearfulness, or feelings of hopelessness in response to a stressor (usually within 3 mo of onset)

Significant distress exceeding expected.
Impaired functioning.

Does not meet criteria for a different disorder.
Not an exacerbation of an existing disorder.
NOT BEREAVEMENT
Should resolve within 6 months.

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3
Q

What is seasonal affective disorder?

A

Recurrent major depressive symptoms that occur CONSISTENTLY at particular times of year.

Usually fall onset (winter depression).
Rarely spring onset (summer depression).

NOT A SEPARATE MOOD DISORDER.

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4
Q

What is seasonal affective disorder in the DSM-5?

A

MDD with seasonal pattern.

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5
Q

What is the etiology of SAD?

A

Lack of daylight triggers depressive symptoms in predisposed individuals.
Possible genetic contribution, linked to abnormal serotonin levels.

Prevalence of 10%.

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6
Q

Where is SAD most prevalent?

A

Places with high latitudes that lack daylight in winter months (Alaska)

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7
Q

What does fall onset SAD look like?

A

Increased sleep
Increased appetite (Carb craving)
Increased weight
Irritability
Interpersonal difficulties (Rejection sensitivity)
Leaden paralysis (Arms feel heavy)

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8
Q

What does spring onset SAD look like?

A

Decreased sleep
Decreased appetite
Decreased weight
Dysphoria (general negativity)

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9
Q

How is Fall onset SAD treated?

A

Light therapy
SSRIs, psychotherapy

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10
Q

What is light therapy?

A

10,000 lux DAILY therapy at the same time of day for at least 30 minutes.
Takes 4-6 weeks.

SE: usually few and reversible.
Photophobia, HA, fatigue, irritability, insomnia, hypomania.

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11
Q

How is bipolar disorder different from MDD?

A

It is a major depressie episode PLUS a manic episode.

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12
Q

What is the criteria for a Major depressive episode?

A

2+ weeks with 5+ of symptoms nearly all the time:

Depressed mood
Anhedonia
Weight/appetite change
Sleep changes
Activity changes
Fatigue
Guilt/worthlessness
Diminished thinking
Recurrent SI

AND must cause distress and not be due to other causes.

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13
Q

What is the criteria for a manic episode?

A

1+ week of abnormally expansive, elevated or irritable mood + abnormal increased activity or energy.

Disturbed mood and energy/activity + 3+ of the following:
Grandiosity
Less need for sleep
Pressured speech
Flight of ideas
Distractibility
Goal-direct activity or psychomotor agitation
High risk taking behavior

DIG FAST (Distractability, Impulsivity, Grandiosity, Flight of Ideas, Activity increase, Sleep Deficit, Talkativeness)

AND must cause distress and not be due to other causes.

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14
Q

What is the criteria for a hypomanic episode?

A

only 4+ days.
Same symptom set as manic episode and at least 3 as well.

Must be a change from baseline mood/behavior.
DOES NOT have to cause functional impairment.

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15
Q

How do I differentiate manic from hypomanic episodes?

A

Manic episodes are longer (7 days)
Manic episodes involve functional impairment.
Manic episodes are generally more severe.

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16
Q

What are the differences between bipolar 1 and 2 disorder?

A

Bipolar 1 is 1+ MANIC episodes. They also have hypomania and major depressive episodes.

Bipolar 2 is 1+ HYPOMANIC episodes (NO MANIC EPISODES)

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17
Q

What is cyclothymia?

A

Periods of HYPOmanic symptoms (that do NOT meet hypomanic criteria)

Periods of depressive symptoms (that do NOT meet MDD criteria)

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18
Q

How prevalent is Bipolar disorder?

A

1% for both BP1 and BP2.

83% of cases are severe.

Most likely due to underreporting since there is no push for a BP pt to seek treatment.

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19
Q

What is the MC demographic for BP disorder?

A

Equal race and gender.
Higher incidence in higher socioeconomic status.

18-20 is most common.

Younger pts are at higher risk for getting their 1st episode.
Older pts are at higher risk for getting frequent episodes.

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20
Q

What is the mnemonic for memorizing male vs female first episode type in BP?

A

Men are manic (1st episode)
Damsels in distress are depressed (1st episode)

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21
Q

What are the risk factors for BP disorder?

A

Sensitivity to NTs.
Response to psych drugs.
FMHx of BP disorder (2/3 of pts)
Increased PATERNAL AGE (Father AGE)

Stressful life events.

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22
Q

How do SSRIs and SNRIs reveal BPD?

A

Pts who are thought to be depressive have their mania revealed by the usage of serotonergic medications.

This will require additional medications like mood stabilizers.

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23
Q

What are the episode subtypes of BPD?

A

Same 8 as MDD.

Anxiety
Catatonic
Mixed
Psychotic
Atypical
Melancholic
Peripartum
Seasonal

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24
Q

How do BPD2 patients commonly present?

A

Initial Dx of MDD
OR
present with hypomanic or MD episode.

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25
How do BPD1 patients commonly present?
Initial Dx of MDD OR present with manic, hypomanic, or MD episode.
26
When do manic episodes resolve?
15-20 weeks.
27
When do hypomanic episodes resolve?
4-8 weeks.
28
What are mixed episodes?
Symptomatic periods in which they meet the full criteria from both ends of the spectrum. Full criteria for one episode + 3+ symptoms of opposite.
29
What is Rapid-cycling BPD?
4+ mood episodes/yr. 10-15% of pts. 80-95% are women. Indicative of a longer and more refractory course of illness.
30
What is rapid-cycling BPD often associated with?
92% have a secondary psychiatric disorder. Also increased rates of cardiac/pulm/GI/endocrine disorders.
31
What medical condition is most common in women with rapid-cycling BPD?
Hypothyroidism.
32
What is the most common FIRST episode type in BPD?
54% are MD. 22% are manic/hypomanic. 24% are mixed.
33
What are common DDx for BPD?
Other mood disorders Other psych disorders (Schizo, schizo affective, borderline personality disorder, ADHD) Substance use Med SE General medical disorders
34
What are some screening tests we can use for BPD?
Mood Disorder Questionnaire (MDQ) PHQ-2 PHQ-9 Zung Self Rated Depression Scale
35
What does the MDQ screen for?
Mania or hypomania
36
What do PHQ-2, PHQ-9, and Zung screen for?
Depression
37
What are the goals of BPD therapy?
Control acute mood symptoms. Induce remission of mood symptoms. Reduce or prevent recurrence of mood episodes.
38
What does treatment of BPD therapy depend on?
Whether they are in an acute manic episode or just need maintenance therapy.
39
Who is a good candidate for OP BPD treatment?
NO SI/HI Able to perform ADLs No psychosis Intact judgement.
40
How would we see if a BPD patient has intact judgement?
Are they aware of their situation? Are they aware they need treatment and are willing?
41
What drug classes treat BPD?
Lithium Anticonvulsants Antipsychotics
42
What anticonvulsants treat BPD?
Carbamazepine (Tegretol) Valproate/valproic acid/Depakene Divalproex sodium/Depakote Lamotrigine/Lamictal can prevent mania but CANNOT TREAT ACUTE MANIC episode. Lamaintenance drug
43
What antipsychotics treat BPD?
Main: Quetiapine (Seroquel) Lurasidone (Latuda) Less: Abilify Vraylar Risperdal Geodon Zyprexa
44
What is the first step in treating acute manic or hypomanic symptoms?
Evaluate SI/HI, psychosis, poor insight/judgement, or aggression.
45
What is the 2nd step in treating acute manic or hypomanic symptoms?
Severe => antipsychotics + lithium or valproate.
46
What is the 3rd step in treating acute manic or hypomanic symptoms?
Mild-moderate = monotherapy using antimanic drug. Options: Antipsychotics: Risperidone, zyprexa Lithium: (5-10 day latency) Anticonvulsants: Tegretol, depakene, depakote, lamictal
47
What is the last step in treating acute manic or hypomanic symptoms?
Consider other therapy: BZDs (acute) Psychotherapy (adjunct) ECT (refractory)
48
What should you keep in mind when treating BPD that began as MDD?
Keep them on their antidepressant until they are stable on a BPD drug as well. Only then can you consider tapering off their antidepressant.
49
What is the 1st step in treating acute depressive symptoms in a BPD pt?
Evaluate SI/HI, psychosis, poor insight or judgement, or aggression.
50
What is the 2nd step in treating acute depressive symptoms in a BPD pt?
CAUTION Many antidepressants have a risk of triggering manic symptoms, so it is recommended to AVOID monotherapy with antidepressants.
51
What is the 3rd step in treating acute depressive symptoms in a BPD pt?
Anticonvulsants: Tegretol, depakene, lamictal. Lithium Antipsychotics: Lutuda, seroquel, Zyprexa
52
What is the last step in treating acute depressive symptoms in a BPD pt?
Antidepressants (adjunct) Therapy (Adjunct) ECT (refractory)
53
What is the maintenance treatment for BPD?
Preferred is psycho + pharmacotherapy. First-line: The same med that managed the acute episode. (Lithium, depakene, seroquel) Second-line: Lithium, seroquel, lamotrigine Third-line: other antipsychotics, combination therapy Potentially problematic: antidepressants, BZDs (can still use as adjuncts)
54
What are the main anticonvulsants used as mood stabilizers?
Depakene Depakote Lamictal Tegretol
55
What are the main indications for Lithium?
Acute mania/hypomania DECREASED RISK OF SI Decreased risk of relapses and severity. Antidepressants effects as well.
56
How do you dose lithium?
300mg start, slow titration up to eventual 900-1800mg/day. T1/2 = 1 day, 4-5 days to get to steady state.
57
How do you monitor lithium dosing?
Checks levels 5 days after dose change. 12 hours after last dose (TROUGH LEVEL)
58
How is lithium dosed?
Daily with food to lower GI upset.
59
What are the main CIs for lithium?
CKD!!! (can cause dehydration and sodium depletion) SEVERE CVD PREGNANCY not absolute but... can cause ebstein's anomaly)
60
What conditions are worsened by lithium?
Myasthenia gravis Psoriasis
61
What drugs does lithium interact with?
Diuretics NSAIDs ACEIs Tetracyclines Metronidazole Theophylline DAM TNT
62
What are the main acute SEs of lithium?
GI upset, thirst and polyuria, weight gain, loose stools.
63
What are the long term SEs of lithium?
Renal, thyroid, parathyroid, leukocytosis, dysrhythmias, nephrogenic DI. We generally avoid keeping pts on lithium long-term.
64
What is the lithium mnemonic?
LITH-PA Leukocytosis Insipidus (nephrogenic DI) Tremor/teratogenic Hypothyroidism Parathyroidism Arrhythmia (dysrhythmia)
65
How do we monitor lithium before giving it?
Baseline BMP, UA, Thyroid. EKG Pregnancy
66
What are the maintenance lab tests for lithium monitoring?
UA Renal function Calcium Thyroid Serum lithium levels (5 days after start and after each dose change.) 1-2 weeks until stable. 2-3 months for first 6 months after stable.
67
How narrow is lithium's TI?
Target is 0.6-1.2 Toxicity is 1.5
68
How do we treat lithium toxicity?
Supportive. ABC IV hydration BZDs if seizing Hemodialysis if severe.
69
What are the late symptoms of lithium toxicity?
Tremor Ataxia Confusion Encephalopathy Seizures
70
What anticonvulsants are mood stabilizers?
Depakene/Depakote Lamictal Tegretol
71
What is the difference between depakene and depakote?
Depakote is the enteric coated version.
72
What is the MOA of valproate?
Increasing GABA levels and effectiveness.
73
What are the main CIs of valproate?
Allergy LIVER Mitochrondrial disease Pregnancy
74
What are the main DDIs of valproate?
TCAs, other anticonvulsants
75
What are the main SE of valproate?
N/V HA Hair loss Bruising Weight gain Tremor Dizziness
76
How do we monitor valproate?
Serum drug levels LFTs
77
What is lamictal indicated for?
Prevention of manic episodes. NOT FOR ACUTE MANIA.
78
What is the MOA of lamictal?
Inhibits release of glutamate. AKA inhibits an excitatory NT
79
How often can we increase lamictal dosing?
Must wait 2 weeks minimum before increasing dose.
80
What is the CI of lamictal?
Allergy Safer in pregnancy than lithium or others.
81
What are the DDIs of lamictal?
MANY
82
What are the SEs of lamictal?
Nausea, rash, pruiritis. Rare includes SJS or toxic epidermal necrolysis or multiorgan reactions.
83
How do we monitor lamictal?
Serum drug levels LFTs Renal function
84
What is the MOA of tegretol?
Anticonvulsant Anticholinergic Antimania Antidepressant Antidiuretic Antineuralgic Similar to TCAs molecularly
85
What are the CIs of tegretol?
Allergy to drug OR TCAs BM suppression Use within 2 weeks of a MAOI Not recommended in pregnancy
86
Why is tegretol not commonly used?
MANY DDIs
87
What are the SEs of tegretol?
N/V, HA, rash, pruritis, hyponatremia Rare: BM suppression, aplastic anemia, agranulocytosis SJS and toxic epidermal necrolysis
88
How do we monitor tegretol?
Serum drug levels LFTs CBC Sodium
89
What are the two antipsychotics?
Seroquel Latuda
90
What are the main SEs of antipsychotics?
Tardive dyskinesia (face makes weird involuntary mvmts) Dyslipidemia Hyperglycemia HA Sedation Quetiapine/Seroquel: HTN Latuda: akathisia (restlessness)
91
When are antipsychotics indicated?
Mainly for schizo. Used as adjunctive therapy for depression. Can be used initially or as addon for BPD. Increasingly used as initial therapy in BPD.
92
What do we use to assess tardive dyskinesia?
AIMS score (Abnormal involuntary movement scale) Goal is 0-1. Higher amounts of involuntary movements = more likely.
93
What is the main risk factor for cyclothymia?
FMHX of BPD. (1/3 of pts)
94
What is cyclothymia?
Persistently fluctuating mood beyond the normal range of mood symptoms.
95
What is the criteria for cyclothymia?
2+ years of numerous periods of hypomanic symptoms and number periods of depressive symptoms. Usually: Symptoms present at least 50% of the time. No more than 2 consecutive months free Patient does not meet full criteria for a mood episode Symptoms cause distress Symptoms not due to substance use Symptoms not described better by another psych disorder
96
What is disruptive mood dysregulation disorder?
DMDD is persistent abnormal mood with severe, frequent temper tantrums that interfere with ability to function at school or at home. Considered part of the spectrum for DEPRESSIVE mood disorders.
97
How is DMDD treated?
Not well-treated. Lithium used but not shown to be effective.
98
What qualifies as DMDD?
1+ year of abnormal mood-related symptoms, including: 3+ temper tantrum outbursts per WEEK: Must be out of proportion. Not consistent with developmental level. Moodly nearly every day
99
What are the age requirements for DMDD?
> 6yo and Dx must have manifested prior to 10. Symptoms must affect functioning in more than ONE PLACE. Not accounted for by another psych Dx.
100
What cause of death # is suicide?
It is the #12 cause of death.
101
What age groups have more successful suicide rates?
It is the #2 cause of death in 10-34. It is the #4 cause of death in 35-54.
102
What gender is more likely to have SI and attempt suicide?
Women 3x more likely to attempt suicide. Attempts are mainly via poisoning or OD.
103
What gender is more likely to successfully commit suicide?
Males. 4x more likely to succeed in committing suicide. Generally via firearms.
104
How common is death by suicide in mood disorders?
15% in MDD. 10-15% in BPD.
105
What demographic has the overall highest suicide rate?
Elderly white men
106
What are the risk factors for SI?
Positive family history Elderly white males Present/anticipated poor health Access to firearms => method in half of all suicides. Inability to accept help Living alone Lack of support
107
What are the biggest risk factors for SI?
Specific, detailed plans. Lack of protective factors (AKA what is keeping a patient from doing it) Psychiatric illnesses.
108
What are protective factors?
Social support Family connectedness Pregnancy Parenthood Religious beliefs
109
What assessment tools are used to screen for SI?
PHQ-2/PHQ-9 Columbia Suicide Severity Rating Scale
110
How is SI managed?
Patients that have attempted or are at moderate-severe SI with a specific plan are hospitalized. Ensure patient safety, transport to IP facility via ambulance. Inpt treatment via lithium or ECT. Generally, we are treating for their comorbid psychiatric disorders.
111
How do we determine a patient to not be at imminent risk for suicide?
Protective factors Lack of access to firearms Family and friends are supportive
112
How do we managed OP SI?
Urgent psychiatric consult Disable access to firearms and other means of self-harm. Increase frequency of patient contact. Aggressive treatment of psychiatric disorders. No harm contracts are NOT SHOWN TO BE BENEFICIAL.
113
What is the suicide crisis lifeline?
988
114
What is the national suicide prevention hotline?
1-800-273-8255 (TALK)

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