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Flashcards in Section 3: Mood Disorders Deck (39)
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1

Major Depressive Disorder

This disorder is characterized by depressed mood or anhedonia and depressive symptoms lasting at least 2 weeks.

List the symptoms of depression

Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kaplan Medical Usmle Master the Boards Step 3) (Kindle Locations 15469-15478). Kaplan Publishing. Kindle Edition.

Sleep disturbance

Loss of interest/apathy

Feeling of guilt or worthlessness

Lack of energy

Lack of concentration

Loss of apetite

Psychomotor agitation

Suicidal ideation

Use the mnemonic: "SIG E CAPS"

 

2

In the management of depression, it is important to look for other causes of depression where the first step in management is different.

List these differential and the tests to do

  1. Hypothyroidism: – Check TSH – First step in management is thyroxine
  2. Parkinson’s disease: – Treat with anti-Parkinson medications
  3. Medications: – Corticosteroids, ß-blockers, antipsychotics (especially in the elderly), and reserpine – Treat by discontinuing medication and switching to an alternative
  4. Substance Abuse disorders: – Alcohol (ask CAGE questionnaire), amphetamines – Treat with detoxification and antidepressants

 

Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kaplan Medical Usmle Master the Boards Step 3) (Kindle Locations 15473-15491). Kaplan Publishing. Kindle Edition.

3

Rx of MDD

Admit the patient if there is suicidal/ homicidal ideation or paranoia.

Begin antidepressant medications (SSRI is first drug of choice).

Give benzodiazepines if agitated.

Electroconvulsive therapy (ECT) is the best choice if the patient is acutely suicidal (works quicker than antidepressants) or for patients worried about side effects from medications.

Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kaplan Medical Usmle Master the Boards Step 3) (Kindle Locations 15505-15509). Kaplan Publishing. Kindle Edition.

4

Diagnosis:

  • Low level depression symptoms
  • Present on most days for at least 2 years

 

Rx of above condition

Dysthermic disorder

Rx

  • Long term individual, insight-oriented psychotherapy
  • SSRIs if above fails

5

Diagnosis

  • Depressive symptoms in the winter mood
  • No depressive symptoms in the summer

 

Rx

Seasonal Affective Disorder

Phototherapy or Sleep deprivation

 

6

Diagnosis:

Bipolar patient with > 4 episodes of mania

Rapid cycling bipolar

7

List the symptoms of mania

  • Grandiosity
  • Less need for sleep
  • Excessive talking or pressured speech
  • Racing thoughts or flight of ideas
  • Distractibility
  • Goal-focused activity at home or at work
  • Sexual promiscuity

 

Use the mnemonic "DIGS FAR"

CCS Tip: If the history suggests drug use, first get a drug screen to rule out amphetamine use as a cause of mania. If the history gives elevated blood pressure or low TSH, consider medical conditions, such as pheochromocytoma and hyperthyroidism.

Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kaplan Medical Usmle Master the Boards Step 3) (Kindle Locations 15529-15534). Kaplan Publishing. Kindle Edition.

8

Outline the steps in the management of acute mania

  1. Hospitalize
  2. Mood stabilizers are used to induce remission. Lithium is the drug of choice (takes 1 week for effect)
  3. Antipsychotics are used until acute mania is controlled. Drug of choice is risperidone
  4. Give IM depot phenothiazine in noncompliant, severely manic patients.
  5. Give antidepressants only when there’s a history of recurrent episodes of depression and only together with mood stabilizers (to prevent inducing manic episode)

 

Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kaplan Medical Usmle Master the Boards Step 3) (Kindle Locations 15533-15549). Kaplan Publishing. Kindle Edition.

9

  1. What is the most common cause of progression to rapid cycling bipolar?
  2. How should you manage rapid cycling bipolar?
  3. What other medical conditions predispose a patient to rapid cycling bipolar?
  4. What drug has been shown to prevent suicidal ideation in bipolar disorder?
  5. A 32 year-old known bipolar patient who is undergoing maintenance therapy with lithium presents with a positive pregnancy test

 

Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kaplan Medical Usmle Master the Boards Step 3) (Kindle Locations 15546-15564). Kaplan Publishing. Kindle Edition.

  1. Use of antidepressants: Do not give antidepressants prophylactically unless the question describes previous severe depressive episodes. In that case, antidepressants are only given for a few weeks.
  2. Gradually stop all antidepressants, stimulants, caffeine, benzodiazepines, and alcohol.
  3. Hypothyroidism: Check TSH in any patient with rapid cycling bipolar and replace thyroid hormones if needed
  4. Lithium
  5. Discontinue lithium (to avoid heart abnormalities): Choose ECT therapy for first-trimester patients with manic episodes. Lamotrigine may be used in 2nd or 3rd trimester.

 

Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kaplan Medical Usmle Master the Boards Step 3) (Kindle Locations 15546-15564). Kaplan Publishing. Kindle Edition.

10

Diagnosis

  • History of recurrent episodes of depressed mood and hypomanic mood for at least 2 years,

Rx

Cyclothymia

It resembles a milder form of bipolar affective disorder

Psychotherapy is the first step in management. Many people function without medications and learn to manage their hypomanic dispositions (especially artists). Start divalproex when functioning is impaired. Divalproex is more effective in cyclothymia than lithium.

 

Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kaplan Medical Usmle Master the Boards Step 3) (Kindle Locations 15565-15593). Kaplan Publishing. Kindle Edition.

11

Compare grief and depression.

Sadness, tearfulness, decreased sleep, decreased appetite, decreased interest in the world are common to both

Symptoms wax and wane in GRIEF BUT symptoms are pervasive and unremitting in DEPRESSION

Shame and guilt are less common in GRIEF than in DEPRESSION

Suicidal ideation is less common in GRIEF than in DEPRESSION

Symptoms can last up to 1 year in GRIEF while symptoms continue for more than 1 year in DEPRESSION

Patient usually returns to baseline level of functioning within 2 months in GRIEF; Patient does not return to baseline functioning in DEPRESSION

Treatment includes supportive therapy in GRIEF; Treatment includes antidepressant medications in DEPRESSION

 

Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kaplan Medical Usmle Master the Boards Step 3) (Kindle Locations 15565-15593). Kaplan Publishing. Kindle Edition.

12

A 32-year-old woman who gave birth 4 months ago is brought in by her husband because of depressed mood. The husband reports that she has been depressed since the birth of her child, refuses to eat, has trouble sleeping, and is unable to concentrate. The woman reports that she has lost interest in everything and sometimes can’t even get out of bed. She reports that she’s recently had visions of seeing her deceased mother talking to her and criticizing her skills as a new mother. She also admits that she hears her voice talk to her constantly too. She denies homicidal or suicidal ideation. Which of the following is the best initial treatment?

a. Psychotherapy

b. Behavioral therapy

c. Sertraline

d. Risperidone

e. Phenelzine

Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kaplan Medical Usmle Master the Boards Step 3) (Kindle Locations 15594-15614). Kaplan Publishing. Kindle Edition.

D. Patients with both mood and psychotic symptoms respond to both antidepressants and antipsychotic medication. However, you must treat the worst symptom first. In this case, the antipsychotic would be most indicated to reduce her psychotic symptoms.

Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kaplan Medical Usmle Master the Boards Step 3) (Kindle Locations 15594-15614). Kaplan Publishing. Kindle Edition.

13

 A 45-year-old woman presents 2 months after the sudden loss of her son in a car accident. She reports “not being able to cope well.” She is constantly teary, has lost her appetite, and has decreased 2 dress sizes. She finds herself laying out a dinner plate every night for him. Recently, she believes she has heard his voice and every night she has nightmares about the car accident. She denies suicidal ideation. Which of the following is the most appropriate next step in management?

a. Group therapy

b. Amitriptyline

c. Fluoxetine

d. Zolpidem

e. Supportive therapy

Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kaplan Medical Usmle Master the Boards Step 3) (Kindle Locations 15594-15614). Kaplan Publishing. Kindle Edition.

 E. This patient is undergoing normal grief reaction. Auditory hallucinations without other psychotic symptoms are normal in grief reaction. Antidepressants are indicated when symptoms last longer than 6 months and the patient’s symptoms can be classified as major depression.

Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kaplan Medical Usmle Master the Boards Step 3) (Kindle Locations 15614-15646). Kaplan Publishing. Kindle Edition.

14

Compare Post-Partum Blues (PPB), PostPartum Depression (PPD) and PostPartum Psychosis (PPP)

Onset After any birth (PPB); Usually after 2nd birth (PPD) Usually after 1st birth (PPP)

Mother’s emotions toward baby Cares about baby (PPB); Many have thoughts about hurting the baby (PPD); Many have thoughts about hurting the baby (PPP)

Symptoms Mild depressive (PPB); Severe depressive (PPD); Look for psychotic symptoms along with severe depressive symptoms (PPP)

Treatment Self-limited; no treatment necessary (PPB); Antidepressants (PPD); Mood stabilizers or antipsychotics and antidepressants (PPP) TIP: Avoid medications if patient is breastfeeding; instead choose electroconvulsive therapy (ECT).

 

Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kaplan Medical Usmle Master the Boards Step 3) (Kindle Locations 15614-15646). Kaplan Publishing. Kindle Edition.

15

List the risk factors for suicide

  • History of suicide threats and attempts is the most important predictor of suicide
  • Family history of suicide
  • Perceived hopelessness (demoralization)
  • Schizophrenia/ borderline or antisocial PD
  • Drug use, especially alcohol
  • Males/ Age > 65
  • Socially isolated/ recently divorced or widowed
  • Chronic physical illness
  • Low job satisfaction or unemployment

 

Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kaplan Medical Usmle Master the Boards Step 3) (Kindle Locations 15651-15680). Kaplan Publishing. Kindle Edition.

16

Outline the emergency assessment of the suicide patient

  • Take all suicide threats seriously
  • Detain and hospitalize (usually a couple of weeks)
  • Never transport patient to emergency department without medically trained personnel accompanying patient
  • Do not identify with the patient
  • Do not leave patient unsupervised
  • Treatment of choice = psychotherapy + antidepressant medications (SSRIs are first choice)
  • For acute, severe risk of self-harm, treatment of choice is electroconvulsive therapy (ECT) 

 

Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kaplan Medical Usmle Master the Boards Step 3) (Kindle Locations 15651-15680). Kaplan Publishing. Kindle Edition.

17

List the indications for ECT

Major depressive episodes that are unresponsive to medications

High risk for immediate suicide

Contraindications to using antidepressant medications

Good response to ECT in the past

Caution: The biggest complication of ECT is transient memory loss, which worsens with prolonged therapy and resolves after several weeks. Use of ECT is cautined in patients with space occupying lesions (e.g., brain metastasis), as ECT induces transient intracranial pressure

Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kaplan Medical Usmle Master the Boards Step 3) (Kindle Locations 15651-15680). Kaplan Publishing. Kindle Edition.

18

SSRIs

SSRIs are first-line therapy for many conditions because of their therapeutic effect and low side effect profile.

List the indications for SSRIs

  • Major depressive disorder
  • Bipolar disorder
  • Anxiety disorders: Panic disorder, OCD, social phobia, generalized anxiety disorder
  • Bulimia nervosa

Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kaplan Medical Usmle Master the Boards Step 3) (Kindle Locations 15683-15694). Kaplan Publishing. Kindle Edition.

19

Guidelines for use of antidepressants

  • SSRIs are first-line therapy
  • TCAs are avoided because of risk of toxicity (think: TCA may be Toxic)
  • MAOIs are more helpful in atypical depressive disorders
  • Choose an antidepressant based on side effect profile
  • Switch to another antidepressant if patient does not respond after 8 weeks or if the patient does not tolerate the side effects
  • Treat patients for 6 months and attempt to discontinue after tapering
  • Consider long-term therapy for multiple episodes of depression
  • When the question describes a patient concerned about weight gain or sexual side effects, give bupropion (causes modest weight loss). Note: Bupropion is associated with seizures
  • When the question describes a patient who has poor appetite, loss of weight, or insomnia, give mirtazapine. Mirtazapine is associated with weight gain.
  • Amitriptyline is used to treat chronic pain (especially effective in neuropathic pain)
  • Imipramine is useful in enuresis.
  • Trazodone is strongly sedating and is often used to treat depressed patients who have severe insomnia
  • SSRIs and TCAs are safe in pregnancy except for paroxetine (Paxil)

 

Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kaplan Medical Usmle Master the Boards Step 3) (Kindle Locations 15694-15705). Kaplan Publishing. Kindle Edition.

20

A young male recently started on antidepressants develops prolonged erection. What is the antidepressant he was most likely taking?

Trazodone

21

An elderly patient presents with depression and agitation. What is the most appropriate medication?

Give an antidepressant with sedative effects (e.g., doxepin, trazodone). Amitriptyline is also sedating but has anticholinergic effects, which may be problematic in elderly.

Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kaplan Medical Usmle Master the Boards Step 3) (Kindle Locations 15707-15729). Kaplan Publishing. Kindle Edition.

22

A 25-year-old male with history of seizures is diagnosed with depression. Which medications should be avoided?

Seizures are common with TCAs and bupropion, and these medications should be avoided in patients with seizure disorders

 

Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kaplan Medical Usmle Master the Boards Step 3) (Kindle Locations 15707-15729). Kaplan Publishing. Kindle Edition.

23

 A middle-aged woman is brought into the ER with confusion and disorientation. An overdose of prescription medications is suspected. Blood pressure is 90/ 53 mm Hg, HR 111/ min. Pupils are dilated, mucous membranes are dry, and she has facial flushing.

What is the most likely cause of acute intoxication?

Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kaplan Medical Usmle Master the Boards Step 3) (Kindle Locations 15707-15729). Kaplan Publishing. Kindle Edition.

TCA

24

 A middle-aged woman is brought into the ER with confusion and disorientation. An overdose of prescription medications is suspected. Blood pressure is 90/ 53 mm Hg, HR 111/ min. Pupils are dilated, mucous membranes are dry, and she has facial flushing. 

What is the most important test to determine severity and prognosis in this patient?

a. EKG

b. EEG

c. Serum sodium

d. Serum tricyclic levels

e. Urinalysis

 

Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kaplan Medical Usmle Master the Boards Step 3) (Kindle Locations 15707-15729). Kaplan Publishing. Kindle Edition.

A. EKG

25

 A middle-aged woman is brought into the ER with confusion and disorientation. An overdose of prescription medications is suspected. Blood pressure is 90/ 53 mm Hg, HR 111/ min. Pupils are dilated, mucous membranes are dry, and she has facial flushing. EKG is performed and shows PR and QRS prolongation and sinus tachycardia. What is the most appropriate next step in management?

a. Calcium carbonate

b. Diazepam

c. Gastric lavage

d. Insulin and glucose

e. Sodium bicarbonate

Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kaplan Medical Usmle Master the Boards Step 3) (Kindle Locations 15707-15729). Kaplan Publishing. Kindle Edition.

E. Sodium bicarbonate

26

A 42-year old woman with a history of hypertension, diabetes, and depression presents to the clinic with dry eyes and dry mouth. hermedications include hydrochlorothiazide, metformin, and amityptyline. which of the following is the next step in management?

a. Discontinue amitriptyline and change to sertraline

b. Order antinuclear antibodies

c. Order SS-Ro and SS-La

d. Prescribe eye drops

e. Refer to ophthalmology

MTB3 Page 475

A. Discontinue amitriptyline and switch to another antidepressant medication with little or no anticholinergic effects. Anticholinergic effects are most severe with amitriptyline, but there are almost none with most SSRIs

27

Indications for lithium

  • Bipolar
  • Schizoaffective disorder
  • Rx and prophylaxis of mood episodes

28

Side effects of lithium

Acne and weight gain (most common problems)

Dose-related tremors, GI distress, and headaches (decreases the dose)

Hypothyroidism (5%)

Polyuria

Cardiac defects in pregnancy

29

Indications for divalproex

  • Rapid cycling bipolar disoder
  • Lithium is ineffective
  • Lithium is impractical or contraindicated

30

Rx when lithium and divalproex are contraindicated

Side effect of above medication

Carbamazepine

Agranulocytosis and sedation