Mood disorders - MH

Question 1

Mood is

Answer 1

• a sustained emotional tone

- perceived on a continuum

Question 2

Mood disorders are

Answer 2

• characterized by abnormal depression or euphoria
• categorized into: depressive and bipolar
• can have psychotic features

Question 3

Mood Disorders

Answer 3

Depressive Disorders

• “Depression”- in general
• Major Depressive Disorder
• Dysthymic Disorder
• Mania
• Hypomania
• Bipolar Disorders
• Adjustment Disorder

Question 4

Depression

Answer 4

• A mood state- irritable, empty, sad…
• A syndrome- “constellation of symptoms”
• A specific disorder: a “clinical condition”
• Ie… Major Depressive Disorder (MDD)

Question 5

Depressive Disorders stats

Answer 5

• Considered a major public health problem
• Economic consequence 83B. US & 118 B. UK
• Life time incidence: F- 20% and M- 10% (2:1)
• Precipitating event in 25% cases
• Diurnal variation- mornings worse
• Median age of onset is 40- but occur anytime
• *Most adults are not seen by mental health
• *FM- misses ½ of depressed patients they see

Question 6

Depression- pathophysiology

Answer 6

-Neurochemical- decreased serotonin, norepinephrine, dopamine

Hormonal- HPA axis is hyperactive in depression- leads to:

• increased cortisol secretion
• blunted release of TSH, decreased GH, -decreased FSH, LH and testosterone
• decreased immune functions
• Sleep- abnormalities 60-65% of mood dxs
• Genetic- “runs in families” – not like bipolar

Question 7

Depressive Conditions

Answer 7

Major depressive disorder (MDD)

• With Psychotic features
• Depression with melancholic or catatonic features
• Chronic
• With seasonal pattern(seasonal affective disorder)
• With postpartum onset (PPD)
• Atypical features
• Pseudodementia
• Depression in children
• Double depression

Dysthymic Disorder

• rated as mild, moderate, or severe.
• occur with or without psychotic symptoms
• can be mood congruent or incongruent.
• can be determined to be in full or partial remission. Usually resolved after tx in 6 mo
• should be diagnosed as chronic when an episode lasts longer than 2 consecutive years.

Question 8

Major Depressive Disorder Dx

Answer 8

• Diagnostic criteria: DSM-IV
• A major depressive episode is defined as a syndrome in which at least 5 of the 9 cardinal symptoms of depression have been present during the same 2-week period.
• The additional criteria are satisfied.

Question 9

Cardinal Symptoms of depression

Answer 9

• Sleep- insomnia or hyposomnia
• Interest –loss of interest or pleasure in activities
• Guilt- feelings of worthlessness or guilt
• Energy- low
• Concentration- poor
• Appetite- “change in” up or down or weight changes
• Psychomotor- (inability to think, concentrate, decide)
• Suicide- thoughts of death or suicidal ideation

*Depressed Mood

Question 10

Dysthymic Disorder

Answer 10

-Depressed mood for at least two years.
-Depression is present most of the day
…. For more days than not.

• Symptom free times may not exceed two months.
• A Major depressive episode does not occur in first 2 years.

Question 11

Dysthmic disorder criteria

Answer 11

Accompanied by two symptoms:

• Decreased or increased appetite
• Insomnia or hypersomnia
• Low energy
• Poor concentration
• Hopelessness

Question 12

History and Mental Status Exam

Answer 12

• Most important part of the evaluation
• Obtain from patient and often involves information from family or treatment providers.
• Consider patient confidentiality and consent

Question 13

History Goal: Psychiatric Sxs/ MSE

Answer 13

• Establish the presence or absence of each of the nine cardinal symptoms of depression.
• Determine the chronology of the symptoms
• Determine the impact of the episode on functional status
• Elicit alleviating or aggravating factors, stressful life events, social or occupational circumstances
• Include MSE and- supplements to history-

Question 14

Depression: The Patient’s story

Answer 14

• Anhedonia- loss of pleasure and interest; previous passion
• Withdrawal from family and friends
• No motivation- low frustration-

Vegetative signs

• Loss of libido
• Weight loss and anorexia
• Weight gain or hyperphasia,
• Low energy level, fatigability
• Abnormal menses
• Early morning awakening (terminal insomnia approximately 75% of depressed patients have sleep issues
• Diurnal variation
• Constipation, dry mouth, headache

Question 15

MSE- what you will notice:

Answer 15

• General Appearance- poor eye contact, tearful, inattentive to personal appearance, agitation or psychomotor retardation, downcast
• Affect- constricted, intense
• Mood- depressed, irritable, frustrated, sad
• Speech- monosyllabic, long pauses, soft, low, monotone, little or no spontaneity
• Thought content- pervasive feelings of hopelessness, worthlessness and guilt, obsessive rumination, suicidal ideation* 60%/15%, somatic preoccupations, indecisiveness, poverty of content, mood congruent hallucinations or delusions, little spontaneity
• Sensorium- distractibility, difficulty concentration, complaints of poor memory, apparent disorientation, abstract thought impairment.
• Insight/judgment- impaired due to cognitive distortions of personal worthlessness

Question 16

Associated Features

Answer 16

-Somatic complaints can mask depression
Cardiac, GI, GU, low back pain and orthopedic c/o

Content of delusions/hallucinations

• Mood congruent- (guilt, poverty, nihilism, deserved persecution,)
• Mood incongruent- thought insertion, broadcasting, control or persecutory delusions unrelated to depressive themes.

Question 17

Age Specific Considerations

Answer 17

Prepubertal
-Somatic complaints; agitation; single voice auditory hallucination; anxiety disorders; phobias

Adolescent
-Substance abuse/antisocial behavior; restlessness; truancy; school issues; promiscuity; increased sensitivity to rejection, poor hygiene

Elderly
-Cognitive deficits (memory loss, disorientation, confusion; Pseudodementia or dementia syndrome of depression; apathy; distractibility

Question 18

Medical History

Answer 18

Many general medical conditions throughout all organ systems and drugs to cause or contribute to depressive episodes

Evaluate

• Current and Past medical history
• Medication use
• Review of symptoms
• • ASSESS SUICIDE RISK- A MUST!

Question 19

Comorbid psychiatric disorders & FHx

Answer 19

• Anxiety symptoms
• Alcohol and other substance use
• Cognitive symptoms and functioning
• Prior history of hypomania, manic or psychotic episodes.
• Family history of mood or other psychiatric disorders

Question 20

Comorbid medical conditions-

Answer 20

• Severe new onset depression including melancholia and psychotic depression
• New- onset depression in an older adult
• New –onset or recurrent depression that is not understood in the context of psychosocial stressors
• Depression that has not responded to treatment
• Depression with sufficient coexisting cognitive impairment, anxiety, substance abuse or comorbid psychopathology

Question 21

Lab Assessment

Answer 21

-Complete blood count
-Electrolytes and glucose
-BUN and creatinine
-Hepatocellular enzymes
-TSH
-RPR
-Serum B12 and folate
-Urinalysis
+/< EKG

Question 22

MDD: Course and Prognosis

Answer 22

• 15% of depressed patients eventually commit suicide
• An untreated, averaged depressed episode lasts 10 months
• At least 75% patients have a second episode, usually within the first 6 months of the initial
• Patients with depression have an average of 5 episodes in a lifetime

Prognosis- with treatment

• 50% usually recover
• 30% partially recover
• 20% have a chronic course

Question 23

Treatment- overview

Answer 23

-MDD- treatable in 70-80% of a patients

DELICATE BALANCE-
-Psychotherapy in conjunction with antidepressants is more effective than either treatment alone

Question 24

Therapy- The Basics

Answer 24

• Sleep
• Exercise
• Adequate fluid intake
• Eating Healthy
• Spirituality or Centering

Question 25

Treatment pharmacologic

Answer 25

-Almost always in MDD and often dysthymia - If a family history of a positive response to a particular drug- try it first - If not, begin with SSRI- monitor for 2-3 weeks - Response in usually 4-6 weeks (75% positively) - If not, increase dose/add adjuvant/ if s.a.- change - Maintenance for 6 months helps prevent relapse

Question 26

Mania- the Patient’s story

Answer 26

Erratic and uninhibited behavior - Excessive spending of money, gambling - hypersexuality, promiscuity - Overextended in activities and responsibilities - Low frustration tolerance Vegetative signs - Increased libido - Weight loss/anorexia - Insomnia- or expressed as “no need to sleep” - Excessive energy

Question 27

Manic MSE

Answer 27

- General Appearance- agitation, seductive, colorful clothes, excessive makeup, inattentive to personal appearance or bizarre combinations, intrusive, entertaining, hyperexcited - Affect- labile, intense - Mood- euphoric, expansive, irritable, demanding, flirtatious - Speech- pressured, loud, dramatic, exaggerated, incoherent - Thought content- high elevated self-esteem, grandiosity, delusions, egocentric, hallucinations (that are mood-congruent in self-worth and power, grandiose- not often paranoid) - Thought process- flight of ideas, racing thoughts neologisms, clang associations, circumstantiality, tangentiality - Sensorium- highly distractible, difficult with concentration, abstract thinking generally is intact, memory usually ok - Insight and judgment- extremely impaired, often total denial, inability to make organized thoughts or rational decisions.

Question 28

Bipolar Disorders- E/E

Answer 28

- 30 mean age of onset - Genetic disposition- greater than in depression - 50% of patients have a parent with a mood disorder - 20-25% risk if patient has first degree relative - M and F ratio equal

Question 29

Bipolar Psychotic symptoms

Answer 29

Grandiose delusions: - of exceptional talent - of assistance, of reference and persecution - of exceptional mental and physical fitness - of wealth, aristocratic ancestry or other grandiose identity Fleeting auditory or visual hallucinations:

Question 30

Bipolar treatment

Answer 30

- Pharmocotherapy- Lithium is toc for bipolar I (80% effective) and cyclothymic disorders - In acute tx- add antipsychotic- (Haldol) - Lithium trial should last 4 weeks before dc - If MDD occurs during- add antidepressant or increase dose of lithium * Pre-clinical work up prior to starting lithium - As in depression- psychotherapy in conjunction with antimanic drugs is more effective than either alone - Psychotherapy is NOT indicated when a patient is experiencing a manic episode. - Calming is necessary- pharmacological and physical steps must be taken to protect and calm the patient.

Question 31

Bipolar Course and Prognosis

Answer 31

-About 1/3 of dysthymic patients develop Bipolar II -45% of manic episodes recur. -Untreated manic episodes last 3-6 months 80-90% of manic patients eventually experience a full depressive episode Prognosis is fair - 15% recover - 50-60% partially recover - 30% have chronic symptoms with social deterioration

Question 32

Adjustment Disorder

Answer 32

- Pathological behavioral response to a psychosocial stressor resulting in impaired social or vocational functioning - Stressors are in the range of normal- marriage, job loss, divorce, illness, birth of a baby, leaving home, going to college - Most symptoms diminish over time without treatment, especially if stressor removed - Subgroup- maintains chronic course- co-dxs

Question 33

Adjustment Disorder - etiology

Answer 33

-Most frequent in adolescents, but at any age Etiology: - Genetic- high anxiety temperament, prone to overreacting to stressful events - Biologic- greater vulnerability with history of illness or disability - Psychosocial- greater vulnerability with a person who lost a parent or who had poor mother experiences