02 Mood Disorders

Front 1

Term:

A description of one's internal emotional state

Back 1

Mood

Front 2

Term:

An abnormal range of moods associated with a loss of control over them

Back 2

Mood Disorder

Front 3

Term:

An assessment of how the patient's mood appears to the examiner

Back 3

Affect

Front 4

What dimensions are used to describe Affect?

Back 4

1. Quality

2. Motility

3. Appropriateness

Front 5

Term:

Depth/Range of Feeling

Back 5

Quality of Affect
--Flat (None)
--Blunted (Shallow)
--Constricted (Limited)
--Full (Average)
--Intense (More Than Normal)

Front 6

Term:

Speed at which a person shifts emotional states

Back 6

Motility of Affect
--Sluggish
--Supple
--Labile

Front 7

Term:

Whether affect is congruent with circumstances

Back 7

Appropriateness of Affect
--Appropriate (Mood Congruent)
--Inappropriate (Mood Incongruent)

Front 8

What gender and age group are most at risk for developing major depressive disorder (MDD)?

Back 8

Female to Male Ratio is 2:1

Highest Risk = Age 20-40

Front 9

What is the lifetime prevalence of MDD?

Back 9

15%

Front 10

What ethnicity and socioeconomic groups are most at risk for depression?

Back 10

None

All are equally affected!

Front 11

What is the concordance rate of depression in monozygotic and dizygotic twins?

Back 11

50-70% in Monozygotic Twins

20% in Dizygotic Twins

Front 12

What is the risk of completed suicide in major depression?

Back 12

15% over the course of a patient's lifetime

Front 13

Abnormal levels of what neurotransmitter are believed to contribute to depression?

Back 13

Serotonin

Front 14

Dysfunction of what neuroendocrine axis is thought to be involved in depression?

Back 14

Hypothalamic-Pituitary-Adrenal (HPA) Axis

Front 15

How does behavioral theory explain depression?

Back 15

"Learned Helplessness"

Depression results from repeated life experiences that lead to the belief that one can do little to improve his or her state of suffering or place in life

Front 16

How does cognitive theory explain depression?

Back 16

"Faulty Cognitive Frameworks"

Depression results from distorted, unrealistic, and unhelpful interpretations of one's environment

Front 17

How does psychodynamic theory explain depression?

Back 17

The inability to adequately recover from the loss of relationships or attachment to something valuable

Front 18

What medications are thought to trigger depressive symptoms?

Back 18

--Beta-Blockers
--Corticosteroids
--Benzodiazepines
--Interferon

Front 19

What are some common medical causes of depressive symptoms?

Back 19

1. Endocrine
--Hypothyroidism, Adrenal Dysfunction

2. Neurologic
--Parkinson Disease, Strokes, Dementia

3. Metabolic Disorders
--Vitamin B12 Deficiency

4. Cancer
--Pancreatic

5. Infectious
--HIV, Hepatitis

Front 20

DSM-IV Criteria for Major Depressive Disorder (MDD)

Back 20

1. Symptoms present for at least 2 weeks

2. Depressed Mood or Anhedonia

3. 5+ SIGECAPS Symptoms
--Sleep Changes
--Decreased Interest
--Guilt or Feelings of Worthlessness
--Low Energy
--Decreased Concentration or Indecisiveness
--Appetite Changes
--Psychomotor Retardation or Agitation
--Suicidality

4. Symptoms can NOT be due to substance use or medical conditions AND must cause social or occupational impairment

Front 21

Term:

Loss of interest in normally pleasurable activities

Back 21

Anhedonia

Front 22

How can depression present differently in the elderly population?

Back 22

Elderly patients may complain of anxiety, irritability, weakness, difficulty concentrating, memory problems, or multiple somatic complaints such as headache, backache, gastrointestinal complaints, dizziness, numbness, fatigue or lethargy.

Front 23

What is the differential diagnosis of major depression? (9)

Back 23

1. Mood Disorder due to a General Medical Condition
2. Substance-Induced Mood Disorder
3. Dysthymic Disorder
4. Bipolar Disorder (BD)
5. Dementia
6. Adjustment Disorder with Depressed Mood
7. Schizoaffective Disorder
8. Other Psychotic Disorders
9. Bereavement

Front 24

What sleep disturbances are seen in depression?

Back 24

1. Deep Sleep (Delta Sleep, Stages 3, 4) is decreased

2. Time spent in Rapid Eye Movement (REM) Sleep is increased and the onset of REM in the sleep cycle is earlier (decreased Latency to REM)

Some people report intermittent and early morning awakenings

Front 25

What is the typical course of a depressive episode?

Back 25

Depressive episodes last about 6-9 months if left untreated.

50% of individuals who develop a single depressive episode will have additional episodes.

The majority of those who suffer from a second episode will subsequently have a third.

Front 26

What subtypes of depression exist?

Back 26

1. Melancholic

2. Atypical

3. Catatonic

4. Psychotic

These subtypes can be used to describe a patient's diagnosis, for example, "MDD with psychotic features"

Front 27

Subtype of Depression:

Anhedonia, early morning awakenings, psychomotor disturbance, excessive guilt, and anorexia

Back 27

Melancholic Depression

40-60% of hospitalized patients with depression

Front 28

Subtype of Depression:

Hypersomnia, hyperphagia, reactive mood, leaden paralysis and hypersensitivity to interpersonal rejection

Back 28

Atypical Depression

Front 29

Subtype of Depression:

Purposeless motor activity, extreme negativism or mutism, bizarre postures, and echolalia

Back 29

Catatonic Depression

--Can also be applied to Bipolar Disorder

Front 30

Subtype of Depression:

Presence of hallucinations or delusions

Back 30

Psychotic Depression

10-25% of hospitalized patients with depression

Front 31

What is Seasonal Affective Disorder (SAD)?

Back 31

Subtype of depression that only occurs during winter months

Patients respond to treatment with Light Therapy

Front 32

What are the main classes of antidepressant used to treat depression? (5)

Back 32

1. Selective Serotonin Reuptake Inhibitors (SSRIs)

2. Tricyclic Antidepressants (TCAs)

3. Monoamine Oxidase Inhibitors (MAOIs)

4. Selective Noradrenaline Reuptake Inhibitors (SNRIs)

5. Dopamine Reuptake inhibitors

Front 33

What are the different types of psychotherapy used to treat depression? (4)

Back 33

1. Cognitive-Behavioral

2. Supportive

3. Brief Interpersonal

4. Psychodynamic

Have the most data to support their efficacy in treating depression

Front 34

What are the indications for using Electroconvulsive Therapy (ECT)? (6)

Back 34

1. Depression refractory to antidepressants
2. Contraindications to antidepressant medications
3. Immediate risk for suicide
4. History of good response to ECT
5. Depression with psychotic features
6. Pregnancy (may be safer than alternate treatments)

Front 35

What are contraindications to using ECT?

Back 35

1. Recent cardiovascular event (eg, MI within the last 6 months)

2. Space-occupying brain lesions

3. Increased intracranial pressure (ICP)

Front 36

How is ECT performed?

Back 36

ECT is performed under general anesthesia with the aid of muscle relaxants. A seizure is induced by passing an electric current through the brain. The seizure lasts <1 minute.

Approximately 8 treatments are administered over a 2-3 week period, with significant improvement typically seen after the first week.

Front 37

What are the major side effects associated with ECT

Back 37

1. Transient Cognitive Side Effects
--including confusion

2. Anterograde Amnesia
--occurring during the course of ECT, disappearing days to weeks after completion of treatment
--most common amnesia seen in ECT

3. Retrograde Amnesia
--usually disappears after 6 months

Front 38

How can the side effects from ECT be minimized?

Back 38

1. Reducing the frequency of treatment from 3 to 2 times/week

2. Use of brief pulse rather than sine wave ECT machines

3. Unilateral or bifrontal positions of the electrodes instead of bitemporal

Unfortunately, these techniques are also associated with less effective treatment of depression

Front 39

How effective are the various treatment modalities for depression?

Back 39

1. Antidepressant alone achieve remission in 30-50% of patients with up to 70% showing improvement

2. Combined with treatment with psychotherapy and antidepressants achieves remission in 60-70% of patients

3. ECT achieves remission in >75% of patients

Front 40

What is the pharmacologic treatment regimen for major depressive episode?

Back 40

Antidepressants should be continued for at least 6 months and more often 8-12 months before a taper in initiated, during which time patients must be observed for signs of relapse.

Patients may need to remain on antidepressants for longer if they have experienced several depressive episodes in the past or if they have a strong family history of depression

Front 41

What is the lifetime prevalence of Bipolar I Disorder (BD I)?

Back 41

1%

Front 42

Are there any gender disparities in the incidence of BD I?

Back 42

No

Men and women are equally affected

Front 43

What is the typical age of onset of BD?

Back 43

15-30 years

Front 44

Is there a difference in age of onset of BD by gender?

Back 44

Recent data suggest a 3-5 year earlier age of onset for men

Front 45

Is there a genetic predisposition to BD?

Back 45

Yes

40% concordance among monozygotic twins

First-degree relatives of BD patients have a 25% risk of any mood disorder

Front 46

What is the mortality rate in BD?

Back 46

10-15% mortality by suicide

Front 47

Risk Factors for Suicide Completion

Back 47

"SAD PERSONS"
--Sex (male)
--Age (elderly or adolescent)
--Depression
--Previous suicide attempts (#1)
--Ethanol abuse
--Rational thinking loss (psychosis)
--Social support lacking
--Organized plan to commit suicide
--No spouse (divorced > widowed > single)
--Sickness (physical illness)

Front 48

What are the diagnostic features of BD I?

Back 48

The occurrence of one manic or mixed episode

Between manic episodes, there may be euthymia, MDD, or hypomania, but none of these are required for diagnosis

Front 49

What is a Bipolar Mixed Episode (aka, mixed mania or dysphoric mania)?

Back 49

1. Criteria are met for both mania and major depression nearly every day during at least a 1 week period

2. Increased energy and some form of anger, from irritability to full blown rage, are the most common symptoms

3. Symptoms may also include auditory hallucinations, confusion, insomnia, persecutory delusions, racing thoughts, restlessness and suicidal ideation

Front 50

DSM Criteria for Manic Episode

Back 50

1. Period of abnormally and persistently elevated, expansive or irritable mood lasting at least 1 week

2. At least 3 DIG FAST
--Distractibility
--Insomnia (decreased need for sleep)
--Grandiosity (inflated self-esteem)
--Flight of Ideas or Racing Thoughts
--Agitation or increased goal-directed activity socially, at work or sexually
--Speech (pressured)
--Thoughtlessness: excessive involvement in pleasurable activities (shopping sprees, high-risk sexual activity)

3. Symptoms cannot be due to substance use or medical conditions

4. Symptoms must cause social or occupational impairment

Front 51

What distinguishes mania from hypomania?

Back 51

Duration and Severity

Mania
--abnormal mood for at least 1 week unless hospitalization is required
--symptoms severe enough to impair social or occupational functioning or presence of psychotic symptoms

Hypomania
--abnormal mood for at least 4 days
--symptoms do not significantly impair ability to function (ie, milder symptoms)

Front 52

What is the differential diagnosis of BD?

Back 52

1. Other Mood Disorders

2. Psychotic Disorders with Mood Symptoms

3. Mood Disorder due to a General Medical Condition

4. Substance-Induced Mood Disorder

Front 53

What are some common medical causes of manic symptoms?

Back 53

1. Endocrine (hyperthyroidism)
2. Neurologic (seizures, strokes)
3. Systemic Disorders (HIV, Vitamin B12 Deficiency)

Front 54

What medications/drugs tend to produce manic symptoms?

Back 54

1. Stimulants
--Methylphenidate, Dextroamphetamine
2. Steroids
3. Sympathomimetics
4. Antidepressants
5. Recreational Drugs
--Cocaine, Amphetamines, Alcohol
6. Withdrawal from Alcohol or other Central Nervous System (CNS) Depressants such as Barbiturates and Benzodiazepines can produce manic symptoms

Front 55

What is the typical course of a manic episode?

Back 55

Mania develops over days and lasts about 3 months if untreated

More than 90% of patients will have a recurrence of their manic symptoms

Episodes may occur more frequently as the disease progresses

Front 56

What is meant by "rapid-cycling" BD?

Back 56

4 or more mood disturbances in 1 year

--MDD, Mania or Mixed

Front 57

What are some known precipitants of manic episodes? (4)

Back 57

1. Changes in Sleep-Wake Cycle

2. Antidepressant Treatment

3. Stressful Life Events

4. Postpartum Period

Front 58

What are the medications used to treat mania?

Back 58

1. Lithium
2. Anticonvulsants
--Valproate (Depacon)
--Carbamazepine (Tegretol)
3. Antipsychotics
--Olanzapine (Zyprexa)
--Risperidone (Risperdal)
--Quetiapine (Seroquel)
--Ziprasidone (Geodon)
--Aripiprazole (Abilify)
4. Benzodiazepines can be used adjunctively in acute mania for sedation

In severe cases, more than one class of medication (eg, Lithium combined with an atypical antipsychotic and a benzodiazepine) may be used

Front 59

What are the medications commonly used to treat depressive phase of Bipolar I Disorder?

Back 59

1. Lithium
2. Symbax (Olanzapine + Fluoxetine)
3. Quetiapine (Seroquel)
4. Lamotrigine (Lamictal)

Given their potential to induce mania, antidepressants should be used with caution

Front 60

What medications are most often used to prevent recurrence of mood episodes (ie, Maintenance Therapy)?

Back 60

1. Lithium

2. Valproate (Depakote)

3. Atypical Antipsychotics
--Aripiprazole (Abilify)
--Olanzapine (Zyprexa)
--Lamotrigine (Lamictal)

Front 61

What medication is thought to be the most effective in treating rapid-cycling bipolar disorder?

Back 61

There is some evidence that Valproate (Depakote) may be most effective

Front 62

What adjunct therapies can be useful for patients with Bipolar Disorder

Back 62

1. Supportive Psychotherapy

2. Family Therapy

3. Group Therapy

Front 63

What nonpharmacologic treatment can be sued for acute mania?

Back 63

ECT

Front 64

What is the lifetime prevalence of Bipolar II Disorder (BD II)?

Back 64

0.5%

Front 65

Are there any gender disparities in the incidence of BD II?

Back 65

More common in women

Front 66

What are the diagnostic features of BD II?

Back 66

History of one or more major depressive episodes and at least one hypomanic episode

Front 67

In relation to depressive episodes, when do hypomanic episodes tend to occur?

Back 67

Just prior to or following a depressive episode

Front 68

What is the course of Bipolar II Disorder?

Back 68

Similar to BD I

Tends to be chronic, requiring long-term treatment

Front 69

What are the treatment goals and methods for BD II?

Back 69

Same as BD I

Front 70

What disorder is often different to distinguish from BD II?

Back 70

Borderline Personality Disorder (BPD)

Both BPD and BD II involve "mood swings"

Front 71

How does one distinguish between BD II and BPD?

Back 71

In BD II, mood episodes (hypomania and depression) generally last weeks or months

In BPD, there is marked mood lability ("emotional dysregulation") in response to external stressors, causing changes in moods lasting seconds, hours or days

Front 72

What is Dysthymic Disorder?

Back 72

A mild, chronic form of major depression

Front 73

What is the lifetime prevalence of Dysthymia?

Back 73

6%

Front 74

What is the point prevalence of Dysthymia?

Back 74

3%

Front 75

What age group is most at risk for developing Dysthymia?

Back 75

Patients younger than 25, although women aged 65 or younger are also at increased risk

Front 76

Are there any gender disparities in the incidence of Dysthymia?

Back 76

Yes

It is two or three times more common in women

Front 77

What percentage of patients with Dysthymia will develop BD or major depression?

Back 77

<5% will develop BD I

20% will develop MDD

Front 78

What is the endocrine disorder most commonly associated with depressive symptoms?

Back 78

Hypothyroidism

Front 79

What type of cancers can manifest with depressive symptoms?

Back 79

1. Pancreatic Cancer

2. Oropharyngeal Carcinomas

Front 80

What is Cyclothymic Disorder

Back 80

Chronic fluctuating episodes of mild depression and hypomania, lasting a variable amount of time

Front 81

What is the lifetime prevalence of Cyclothymia?

Back 81

<1%

Front 82

What age group is most at risk for Cyclothymia?

Back 82

Young Adults (15-25 yo)

Front 83

DSM-IV Criteria for Dysthymia

Back 83

1. Chronically depressed mood most of the time for a minimum of 2 years
2. 2+ CHASES Symptoms:
--poor Concentration
--Hopelessness
--change in Appetite
--change in Sleep
--low Energy or Fatigue
--low Self-esteem
3. No symptom-free period >2 months, no major depressive episode

"Rule of 2s": 2 years, 2+ Symptoms, no symptom-free period >2 months

Front 84

What is meant by the term "Double Depression"?

Back 84

Major Depressive Episodes occurring in conjunction with Dysthymia

Front 85

What is the differential diagnosis for Dysthymia?

Back 85

1. Major Depression

2. Mood Disorder due to a General Medical Condition

3. Substance-Induced Mood Disorder

Front 86

DSM-IV Criteria for Cyclothymic Disorder

Back 86

1. Numerous periods with hypomanic symptoms and periods with depressive symptoms for at least 2 years

2. No symptom-free period >2 months during those 2 years

3. No history of major depressive episode or manic episode

Front 87

What diagnostic criteria differentiate cyclothymic disorder from bipolar II disorder?

Back 87

Chronic course and lack of a major depressive episode

Front 88

A mood disorder with marked motor immobility, excessive and purposeless movement or mutism is generally classified as what type of depression?

Back 88

Catatonic Depression

Front 89

What is Postpartum Depression?

Back 89

Depression occurring within 4 weeks of delievery

Front 90

Diagnosis:

Depression with severe vegetative features and profound feelings of guilt or remorse

Back 90

Melancholic Depression

Front 91

Do all depressive episodes feature lack of sleep and weight loss?

Back 91

No

Patients with Atypical Depression may be hypersomnic, gain weight and have excessive mood lability

Front 92

How long after the onset of substance use do mood disorder symptoms appear in a substance-induced mood disorder?

Back 92

Within 1 month of substance intoxication or withdrawal

Front 93

What is the most effective treatment for Dysthymia?

Back 93

Therapy (Psychotherapy or Cognitive Therapy) in conjunction with antidepressant medications

Front 94

How is Cyclothymia usually treated?

Back 94

Antimanic Medications (eg, Lithium, Anticonvulsants and Antipsychotics) are generally used.

It must be noted that patients diagnosed with this disorder are less likely to seek medical attention than patients with traditional mania or MDD

Front 95

What is the treatment for patients with substance-induced mood disorders?

Back 95

Cessation of use of the drug or substance

Front 96

If symptoms of a substance-induced mood disorder do not resolve within a few weeks after cessation of the causative substance, what is the best approach to treatment?

Back 96

At this point, patients may benefit from an appropriately prescribed medication

It is important to treat the substance-abuse problems as well as the mood disorder