Mood disorders- Part 2 Flashcards by Johannah Crumpton

____ is persistent depressive disorder. What are the DSM criteria?

Dysthymia

Patients with ongoing depressive symptoms for two years or longer
Do not have to be in full major depressive episode for all of the two-year span PLUS 2 more of the following:

Appetite changes (poor appetite or overeating)

Sleep changes (insomnia or hypersomnia)

Fatigue or loss of energy

Diminished ability - thinking, concentration or decision-making

Low self-esteem

Feelings of hopelessness

aka more times than not in a depressed mood

How well did you know this?

Not at all

Perfectly

T/F: Dysthymia patients sometimes will have manic episodes.

FALSE! Cannot have manic symptoms or secondary cause

How well did you know this?

Not at all

Perfectly

What is the treatment for Dysthymia?

1st: SSRIs with therapy

2nd: TCAs and MAOIs have shown success in studies

How well did you know this?

Not at all

Perfectly

____ is a depressed mood in response to an identifiable psychosocial stressor

Adjustment Disorder with Depressed Mood

How well did you know this?

Not at all

Perfectly

T/F: Adjustment Disorder with Depressed Mood is classified as a true depressive disorder. Why or why not?

FALSE! NOT classified as a true depressive disorder

Significant depressive symptoms, in response to a stressor, that do not meet criteria for a more specific depressive disorder

How well did you know this?

Not at all

Perfectly

What is the DSM for Adjustment Disorder with Depressed Mood?

Low mood, tearfulness, or feelings of hopelessness in response to a stressor within 3 months of onset

Symptoms are significant, as evidenced by one or both of the following:
Significant distress exceeding what would be expected given the nature of the stressor
Impaired functioning (social or occupational)

Syndrome is not bereavement¹

Syndrome resolves within 6 months after stressor and its consequences have ended

How well did you know this?

Not at all

Perfectly

Recurrent major depressive symptoms occurring consistently at particular times of year is _____. Is it considered a separate mood disorder?

Seasonal Affective Disorder

NO, In conjunction with MDD or Bipolar I/II

How well did you know this?

Not at all

Perfectly

For seasonal affective disorder ____ onset is considered a “winter depression”. _____ is considered a “Summer depression”

Begins late fall-early winter; remits in summer

Begins in late spring; remits in winter

How well did you know this?

Not at all

Perfectly

Seasonal affective disorder is believed to be linked to ??? What types of areas is it worse?

abnormal serotonergic activity

more prevalent in higher latitudes

How well did you know this?

Not at all

Perfectly

**What are some s/s of fall onset seasonal affective disorder?

Increased sleep
Increased appetite
Carbohydrate craving
Increased weight
Irritability
Interpersonal difficulties
Rejection sensitivity
Leaden paralysis (extreme heaviness in the arms and legs)

How well did you know this?

Not at all

Perfectly

**What are some s/s of spring onset seasonal affective disorder?

Decreased sleep
Decreased appetite
Decreased weight
Dysphoria

How well did you know this?

Not at all

Perfectly

What is the treatment for SAD? When will you see a response?

light therapy for non-psychotic, non-suicidal patients

4-6 weeks to see a response

SSRIs, psychotherapy

How well did you know this?

Not at all

Perfectly

What are some SE of phototherapy?

Photophobia, HA, fatigue, irritability, insomnia, hypomania

How well did you know this?

Not at all

Perfectly

What is the basic bipolar requirments?

major depressive episode with manic episode

How well did you know this?

Not at all

Perfectly

What is the criteria for a major depressive episode?

2+ weeks with five or more of the following symptoms nearly all the time/nearly every day:

Depressed mood
Anhedonia

Significant change in weight or appetite
Sleep changes (insomnia or hypersomnia)
Activity changes (psychomotor agitation or retardation)
Fatigue or loss of energy
Feelings of worthlessness or guilt (excessive, inappropriate)
Diminished ability - thinking, concentration, or decision making
Recurrent thoughts about death or suicide

and must cause distress or functional impairment and must NOT be due to other cause (substances or medication)

How well did you know this?

Not at all

Perfectly

What is the criteria for a manic episode? **What is the big key here that is underlined and starred in the PP?

1+ week (7+ days) of abnormally expansive, elevated, or irritable mood and abnormally increased activity or energy

Along with disturbed mood and energy/activity, 3+ of the following are present (4+ if the mood is only irritable):
Inflated self-esteem or grandiosity
Decreased need for sleep
More talkative than usual / pressured speech
Racing thoughts or flight of ideas
Distractibility
Increase in goal-directed activity or psychomotor agitation
Excessive involvement in activities with high potential for bad consequences / “risky” behavior

and must cause distress or functional impairment and must NOT be due to other causes

How well did you know this?

Not at all

Perfectly

What is the criteria for a hypomanic epidose?

4+ days of abnormally expansive, elevated, or irritable mood and abnormally increased activity or energy

Along with disturbed mood and energy/activity, 3+ of the following are present (4+ if the mood is only irritable):

Inflated self-esteem or grandiosity (less delusional than mania)
Decreased need for sleep
More talkative than usual / pressured speech
Racing thoughts or flight of ideas
Distractibility
Increase in goal-directed activity or psychomotor agitation
Excessive involvement in activities with high potential for bad consequences
Spending sprees, sexual indiscretions, foolish business investments

Must be a change from baseline mood/behavior that is observable by others

Must not cause functional impairment or require hospitalization

Must not be due to other causes (substances, medication)

How well did you know this?

Not at all

Perfectly

What is the difference between hypomania and mania?

Hypomania: is 4+ days and generally not as severe as mania

mania is 7+ days and more severe

How well did you know this?

Not at all

Perfectly

Bipolar ____ is more extreme than bipolar ____

Bipolar I is MORE severe than Bipolar II

How well did you know this?

Not at all

Perfectly

What is the criteria for bipolar I? Bipolar II?

Bipolar I:
1 or more manic episodes
Nearly always also have hypomanic and major depressive episodes

Bipolar II:
1 or more hypomanic episodes
1 or more major depressive episodes
No manic episodes

How well did you know this?

Not at all

Perfectly

What is cyclothymia? What is the criteria?

s/s of both mania and depression but not enough criteria for a dx of either

Periods of hypomanic symptoms - fall short of criteria for a hypomanic episode with

Periods of depressive symptoms - fall short of criteria for a major depressive episode

How well did you know this?

Not at all

Perfectly

Bipolar disorder has a higher incidence in those with ____ socioeconomic status

higher

How well did you know this?

Not at all

Perfectly

What some risk factors for bipolar?

-Expression and sensitivity to neurotransmitters

Response to psych drugs

(+) Family history of BPD in ⅔ of patients

Increased paternal age

How well did you know this?

Not at all

Perfectly

What are some bipolar disorder subtypes?

anxiety
catatonic
mixed
psychotic
atypical
melancholic
peripartum
seasonal

How well did you know this?

Not at all

Perfectly

How does the atypical subtype present?

reactivity to pleasurable stimuli, hyperphagia (always hungry, can never be satisfied) hypersomnia

Manic and hypomanic episodes develop over a ____ → Manic - resolves over _____ → Hypomanic - resolves over _____

few days 15-20 weeks 4-8 weeks

Depressive episodes develop ???? → Major depressive episode - resolves over ____. When is the highest risk of recurrent depressive episodes?

more slowly, days to weeks 20 weeks months following the resolution

What is the criteria for rapid-cycling BPD? The majority of these patients are ____. How would you describe their bipolar?

4+ mood episodes a year women: 80-95% Longer and more refractory course of illness

_____ : especially common in women with rapid-cycling BPD

Hypothyroidism

MDQ screens for symptoms of _____ or ____

mania or hypomania

What does the PHQ-2 test for?

quick initial screening for a depressive episode

What does the PHQ-9 test for?

Further evaluates presence and severity of depression Can be used for initial screening or follow-up evaluation

**What is the Zung self-rated scale used for?

Depression, more in-depth rating of current depressive episodes

Treatment of Bipolar I/II varies depending on if the patient is in an _____ or ______

acute mood episode needing maintenance therapy

What are the goals of bipolar treatment?

Control acute mood symptoms Induce remission of mood symptoms Reduce or prevent recurrence of mood episodes

What are the criteria for severe mania that they would need to be treated inpatient?

Suicidal/homicidal ideation or behavior with specific plan or intent Psychosis Catatonia Impaired judgement that puts patient/others at risk for harm Grossly impaired functioning affecting ability to care for self

Which drug classes are considered antimanic?

lithium anticonvulsants: carbamazepine (Tegretol), valproate/valproic acid (Depakene), divalproex sodium (Depakote) Lamotrigine (Lamictal) Antipsychotics: quetiapine (Seroquel), lurasidone (Latuda)

**______ prevents mania, but does not treat an acute manic episode?

Lamotrigine

What do you do for a severe acute manic/hypomanic episode?

antipsychotic + lithium or valproate

What do you do for a mild/moderate acute manic/hypomanic episode?

Antipsychotics - risperidone (Risperdal), olanzapine (Zyprexa), others Lithium (5-10 day latency) Anticonvulsants: carbamazepine (Tegretol) valproate (Depakene) divalproex (Depakote)

What things would you want to consider to "add on" for an acute manic/hypomanic episode?

benzodiazepines (for acute agitation), psychotherapy (adjunct) ECT (refractory)

**In a bipolar patient, what do you want to avoid for their acute depressive symptoms? Why?

Recommended to avoid antidepressant monotherapy (especially TCAs) because they have a risk of triggering manic symptoms

What are the medication options for an acute depressive symptom in a bipolar patient?

Anticonvulsants - carbamazepine (Tegretol), valproate (Depakene), lamotrigine (Lamictal) Lithium (few weeks latency) Antipsychotics - lurasidone (Latuda), quetiapine (Seroquel), olanzapine (Zyprexa), others

What are first line meds for bipolar maintenance therapy? 2nd line?

Lithium, valproate (Depakene), quetiapine (Seroquel) Lithium (if not already tried), or quetiapine (Seroquel), valproate (Depakene), lamotrigine (Lamictal)

What bipolar medications are anticonvulsants used as mood stabilizers?

Valproate (Depakene) / Divalproex (Depakote) Lamotrigine (Lamictal) Carbamazepine (Tegretol)

_____ mainly for acute mania/hypomania, or maintenance. How long does it take the antidepressant take effect? Has an (increased/decreased) risk of suicide?

Lithium several weeks to onset decreased risk of suicide

**When do you need to check levels on a pt taking lithium?

Check levels 5 days after dose change, 12 hrs after last dose (trough)¹

What are the pt education points for lithium?

Taken on a daily basis with food, not PRN

What are the CI for lithium?

Severe CKD, dehydration, sodium depletion, Severe cardiovascular disease - can cause dysrhythmias Pregnancy

**What are the DDI with lithium?

Diuretics, NSAIDs, ACEIs, tetracyclines, metronidazole, theophylline

What are some side effects of lithium? What lab do you want to check?

L - leukocytosis I - insipidus (nephrogenic diabetes insipidus) T - tremor / teratogenesis H - hypothyroidism P - parathyroid A - arrhythmia (dysrhythmia) thyroid panels

What is Ebstein's anomaly? What drug is it associated with?

congenital heart defect resulting in an abnormal, leaking tricuspid valve and ASD (atrial septal defect) Lithium

What baselines labs do you need to get before starting a patient on lithium?

Labs - Renal function (BUN/Cr), Calcium, Urinalysis (UA), Thyroid function Pregnancy test - if female of childbearing age ECG - if at risk for cardiac disease

What is the serum lithium levels testing schedule?

5 days after start and after each dose change Periodically once stabilized on a given dose q. 1-2 weeks until serum at desired level q. 2-3 months for first 6 months

Lithium has a very (narrow/wide) therapeutic index. What is the target range? What is toxic? Is lithium toxicity dangerous?

narrow therapeutic index Target - 0.6-1.2 mEq/L Toxicity - 1.5 mEq/L toxicity can be fatal if not recongized and treated

Early - GI upset (N/V/D) Late - tremor, ataxia, confusion, encephalopathy, seizures What am I? What is the treatment?

Lithium toxicity supportive care: ABC, IV hydration, benzos for seizures Hemodialysis if severe

What are the CI to valproic acid?

Allergy to drug; liver disease; mitochondrial disease; pregnancy Need to get pregnancy test!

______ is an anticonvulsant that increases GABA levels and effectiveness. What is the target serum level?

Valproic acid 50-125mg/dL

What are the common SE of valproic acid? What labs do you need to monitor?

N/V, HA, hair loss, bruising, weight gain, tremor, dizziness serum drug levels, liver function tests (LFTs)

_____ anticonvulsant; inhibits release of glutamate

Lamotrigine

**What is the titration schedule for lamotrigine?

25 mg QD initially, titrated up every 2 weeks

_____ is safer in pregnancy than lithium or other anticonvulsants

lamotrigine

Nausea, rash, pruritus, drowsiness, dizziness Rare - multiorgan hypersensitivity reaction, derm reaction Stevens-Johnson Syndrome and Toxic Epidermal Necrolysis These are CI to _____

Lamotrigine

______ anticonvulsant; anticholinergic; antimanic; antidepressant; antidiuretic; antineuralgic and is chemicall related to TCAs

Carbamazepine

allergy to drug or TCAs; bone marrow suppression; use within 14 days of MAOI. Not recommended in pregnancy. These are the CI to _____

Carbamazepine

**Which psych med has numerous DDI?

Carbamazepine

N/V/D, HA, rash, pruritus, hyponatremia, fluid retention, leukopenia Rare - bone marrow suppression, aplastic anemia, agranulocytosis Stevens-Johnson Syndrome and Toxic Epidermal Necrolysis These are SE of _____

Carbamazepine

If you miss 2-3 days of _____ you need to start over at 25mg

Lamotrigine

________ were initially developed for psychotic d/o, schizophrenia Used as adjunct therapy for other psych d/o, such as depression May be used as initial or add-on therapy for bipolar disorder

Antipsychotics

____ MOA works on serotonin and dopamine antagonists. List them

Antipsychotics quetiapine (Seroquel), lurasidone (Latuda)

tardive dyskinesia, GI, dyslipidemia, hyperglycemia, headache, sedation These are the SE of _____

Antipsychotics

** What is the specific SE of Quetiapine? Lurasidone?

HTN Akathisia (no feelings or emotions)

**Patients taking an antipsychotic (typical or atypical) are at risk of developing _____. If a patient is taking an antipsychotic, you should be assessing their ______ score regularly.

tardive dyskinesia AIMS (Abnormal Involuntary Movement Scale)

Persistently fluctuating mood beyond the normal range of mood symptoms is _____

cyclothymia

What is the presentation of Cyclothymia?

2+ years with numerous periods of hypomanic symptoms and numerous periods of depressive symptoms Symptoms are present at least half of the time No more than 2 consecutive months free of symptoms Patient does not meet full criteria for a mood episode _______ Symptoms cause distress or functional impairment Symptoms are not due to substance use Symptoms are not better accounted for by another psych disorder

What is the treatment for cyclothymia?

meds and therapy may try mood stabilizer such as lithium If frequent or refractory depressive s/s, may use low-dose antidepressant in conjunction

What is Disruptive Mood Dsyregulation Disorder? What will they go on to develop as adults?

Persistently abnormal mood (irritable, sad or angry) with severe, frequent temper tantrums that interfere with ability to function at school or at home depression

What is the Disruptive Mood Dsyregulation Disorder presentation? What is the important point?

1+ year of abnormal mood-related symptoms, including: 3+ severe temper outbursts per week Reaction is out-of-proportion for the stressor **Reaction is not consistent with developmental level** Sad, irritable, or angry mood nearly every day Child must be at least 6 years old at time of diagnosis AND Symptoms must have manifested before age 10 must happen in more than 1 place not another psych dz

Suicide is the ___ cause of death in the US for all ages

#12

____ are more likely to have suicidal thoughts Attempt suicide 3x as often Preferred method - poisoning/overdose

Females

____ 4x as likely to successfully commit suicide Preferred method - firearms

Males

What ethnicities commit suicide most often?

American Indian, Alaska Native, White

What are suicide risk factors?

Elderly white men (young pts more likely to attempt) family hx present or anticipated poor health access to firearms inability to accept help living alone: **never married**, widowed, divorced or separated lack of support psych illness

What are to major red flags for suicide?

if they have specific detailed plan lack of protective factors

_____ scale is given to patients who have a plan to harm themselves to determine in pt vs out pt

Columbia suicide severity rating scale

When do you want to hospitalize a pt for suicide?

Patients who have actually made a suicide attempt Patients with moderate-severe suicidal ideation: Stated intent, specific plan

What is the protocol to ensure a suicidal patient's safety?

Have staff member present Limit access to objects that could cause harm Transport to inpatient facility via ambulance

____ and ____ are often used as an inpatient treatment of comorbid disorders

lithium and ECT