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141 Cards in this Set

  • Front
  • Back
% or people who get at least one mood disorder episode
20% at some point during lifetime
Characteristics of endogenous depression
(vs. Reactive)
NO recent stressors
Prominent vegetative symptoms
Characteristics of reactive depression
(vs. Endogenous)
Entails RECENT stressors
FEWER vegetative symptoms
MILDER depression
Number of episodes to constitute Major Depressive Disorder
One or more
Number of weeks to qualify as Major Depressive Episode
2 week period or longer
A Major Depressive episode must include at least one of these two
Depressed mood
Number of symptoms from list to qualify as Major Depressive Episode
FIVE or more
Time period to qualify as Adjustment Disorder
Within 3 MONTHS of stressor(s)

NOT beyond 6 MONTHS after stressor(s) removed
"Psychotic" Depression vs. "Neurotic" Depression
Psychotic -- more acute, more severe

Neurotic -- more chronic, more characterologic

Influence distinction between Major Depression (P) and Dysthymic Disorder (N)
Time period for Dysthymic Disorder
At least 2 years (NOTE: 1 yr. in children)

Never been w/o symptoms for more than 2 MONTHS at a time
Number of symptoms from list needed for Dysthymic Disorder
TWO or more
Diseases within category of UNIPOLAR disorders (3)
Major Depressive Disorder
Dysthymic Disorder
Depressive Disorder Not Otherwise Specified
Diseases within category of BIPOLAR disorders (3)
Bipolar TYPE I
Bipolar TYPE II
Cyclothymic Disorder
Cyclothymic Disorder
At least TWO YEARS of hypomanic AND dysthymic symptoms
Bipolar TYPE I
One or more MANIC OR MIXED episodes
Bipolar TYPE II
One of more Major Depressive Episodes
AT LEAST ONE HYPOmanic episode

NEVER a full-blown manic or mixed episode
Time period for Manic Episode
At least ONE WEEK

OR, any duration IF hospitalization necessary
Characteristics of a Manic Episode
THREE or more:

Grandiosity; Decreased sleep; Racing thoughts
Distractibility; Increased goal-directed activity
Excessive pleasurable, but potentially dangerous, activities
Characteristics of a HYPOmanic episode
Same as manic

BUT, NOT severe enough to cause marked impairment
Does NOT necessitate hospitalization
NO psychotic features
Characteristics of a MIXED episode
Meets criteria for BOTH Major Depressive AND Manic Episode

Every day for at least ONE WEEK

Causes marked impairment, or necessitates hospitalization
MAY entail psychotic features
In catatonic stupor:
A general absence of motor activity
Mutism, negativism, grimacing

In catatonic excitement:
Violent, hyperactive behavior with no visible purpose
Stereotypies, echo-praxia/lalia, verbigeration
Characteristics of ATYPICAL Depression (4)
LEADEN paralysis
Heightened rejection sensitivity
Preserved mood reactivity

2-3x more common in women
Treatment for ATYPICAL Depression
May respond best to MAO-Is

BUT, SSRIs are most commonly used
Differences between SAD and Atypical Depression (3)
SAD has less rejection sensitivity
SAD is increased in winter
SAD has greater prevalence in higher latitude areas
Treatment for SAD
May respond to Bright Light Therapy
"Double Depression"
Major Depressive Episode superimposed on Dysthymic Disorder
More refractive to therapy:

Dysthymic Disorder or Major Depression?
Dysthymic Disorder

Often requires higher doses of meds, and several combos
Who is more likely to be "widowed"

Over the age of 65, 50% of them are
Only 14% of men at that age
Med usually wrongfully given to those suffering depression after loss

Subtherapeutic doses w/ poor follow-up
Characteristics that distinguish Depression from "normal" grieving (6)
Decreased self-attitude or guilt
Severe functional impairment
Autonomous/Pervasive sadness
Persistent sadness after several months
Personal or family history
Risk factors for Depression in context of loss
Age; Past/Family History; Health

Years married; Sex; Social support; Religion
"Quality" of relationship; "Sudden" death
"Subsyndromal" Depression in Grief
LESS severe sadness and anxiety

Broken sleep, anhedonia, but WITHOUT:
Retardation; weight loss; awakenings
Difference in presentation of Depression in elderly
More anxiety and somatic complaints
Less guilt or lowered self-attitude
More likely psychotic

May be "subsyndromal"
Typical age of onset of Bipolar Disorder
Early 20s
Bipolar disorder is often misdiagnosed as these
Conduct Disorder
This treatment can actually trigger a manic episode
Average age of onset of Major Depressive Disorder
Late 20s

50% of cases are > 40 y.o.
Average time between first two Bipolar episodes
5 years
Characteristics of "Rapidly cycling" Bipolar
4 or more episodes per year

Poorer prognosis
Kindling model
"Episodes beget episodes"

With more recurrences, episodes come cloer together
Ultimately, become independent of life circumstances
Average number of episodes in Bipolar pts.
9 episodes

40% of pts. have > 10
Breakdown of long-term outcome of Bipolar disorder
15% euthymic
45% euthymic, BUT multiple relapses
30% partial remission
10% chronically ill
Average number of episodes in Depressed pts.
5-6 episodes over 20 years
When does prevalence of Depression amongst females increase
After puberty

Becomes twice that in men
Who has higher prevalence of Bipolar disorder?

Men or Women
Both have the SAME prevalence
Effect of marriage as a risk factor for mood disorder in men/women
Married men have LOWER rate
Married women have HIGHER rate
Problems with psychoanalytic view (2)
Doesn't explain mania well
Doesn't explain pts. who DO express anger
Picking up attitudes through "osmosis"

Most frequent example: picking up parents' attitudes
Emotions are displaced from one person to another
Feelings towards others usually displaced onto therapist

Used in psychoanalytic therapy
Free association
Verbalization of whatever comes to mind

Used in psychoanalytic therapy
Discouraged in SHORT-TERM as can lead to regression
Goal of psychodynamic therapy
"Corrective" emotional experience
Four most common obstacles from INTERPERSONAL view
Unresolved grief
Interpersonal disputes
Role transitions
Interpersonal deficits
Therapy in which homework may be involved
Cognitive behavioral therapy
Emphasis of cognitive behavioral therapy
Automatic thoughts that accompany depressed mood state
Family risks for Bipolar Disorder
If one parent has, 25% offspring will have
If two parents have, 50-75% offspring will have

1st degree relatives @ 4-18x normal risk for Bipolar
1st degree relatives @ 2-10x normal risk for Depression
Twin studies for Bipolar and Depression
Monozygotic twins -- 60% concordance
Dizygotic twins -- 12% concordance
Chromosomes potentially involved in Mood disorders
Effects of reserpine
Anti-hypertensive / antipsychotic

Depletes biogenic amines

CAUSES depression in 15% of pts.
Monoamine Hypothesis
Depression is the result of a monoamine deficiency

Research has failed to fully validate this
Problems w/ neuroreceptor hypothesis (4)
ECT -- causes upregulation of 5-HT2A receptor
Buproprion -- NO effect on NE or 5-HT systems
Thyroid hormone -- augments beta-adrenergic function

Propranolol -- may even cause depression in some
These 2 illnesses assoc. w/ loss of hippocampal volume
Major Depressive Disorder
Post-Traumatic Stress Disorder
The brain's major excitatory neurotransmitter
Function of cAMP response-element binding protein (CREB)
Among other things, activates genes for BDNF

Hippocampal CREB levels increase in response to chronic anti-depressants
Endocrine abnormalities assoc. w/ Major Depression
Dysregulation of:

Hypothalamic-Pituitary-Adrenal Axis
Hypothalamus-Pituitary-Thyroid Axis
Hypothalamic-Growth Hormone Axis
Depression correlates with DECREASED metabolic acitivity here
(part of brain)
DORSOLATERAL prefrontal cortex
Depression shows increased metabolic activity here
(part of brain)
VENTRAL prefrontal cortex
Abnormalities of circadian rhythms in Depression
Decreased REM latency
Shifting REM into first half of night
Increased density of eye movements

Decrease REM latency correlates with severity
Most common stroke locations assoc. w/ Depression (2)
Left frontal lobe and left basal ganglia
Most common stroke locations assoc. w/ Mania (2)
RIGHT limbic-cortical circuit, or basal ganglia

Note: mania is much more rare in stroke pts.
Stress Diathesis Model
Certain individuals are more susceptible
Combination of temperament and stress lead to dysfunction
Time for clinical effects of mood disorder medications to be seen
2-3 weeks
Full response generally requires 6-8 weeks
% of pts. who are non-responders to anti-depressant meds

Note: same % as placebo responders
Side effects of TCA Histamine receptor blockade (4)
Weight gain

Side effects of TCA ACh muscarinic receptor blockade (6)
Dry mouth/eyes
Blurred vision

Urinary retention

Decreased memory
Resting tachycardia
Side effects of TCA alpha-1 receptor blockade (3)
Orthostatic hypotension
Reflex tachycardia

Potentiation of anti-hypertensive effect of Prazosin
Side effects of TCA alpha-2 receptor blockade (1)
Blocks effects of clonidine
Side effects of TCA 5-HT2 receptor binding (4)
Ejaculatory dysfunction
Side effects of 5-HT3 receptor binding (3)
Side effects of MAO-Is (9)
Weight gain

"Cheese reaction"
Serotonin Syndrome

Daytime somnolence
Orthostatic hypotension
Avoid combining MAO-Is and... (2)
Opiates (esp. MEPERIDINE)
Uses of MAO-Is (4)
Dysthymic Disorder
"Atypical" Depression

Possibly, Bipolar Depression
Selective MAO-B inhibition

Could be a way around "Cheese reaction"
BUT, requires high dose for AD effect
Loses selectivity @ high doses
Transdermal form of selective MAO-B inhibitor

No dietary restrictions at lowest doses
Foods to avoid on MAO-Is (7)
Matured or aged cheese
Fermented/dry sausage
Improperly stored meat
Broad bean pods
Banana peels
All tap beers
Soy condiments
Tertiary amine TCAs act more on which receptor
Secondary amine TCAs act more on what receptor?

Ex. Desipramine
TCA w/ least amount of orthostatic hypotension
TCAs w/ least anti-cholinergic effect (2)
Shape of dose response curve for TCAs
Only TCA that has a "therapeutic window"

Has a curvilinear relationship
What do TCAs inhibit?
Uptake of BOTH 5-HT and NE
Why are TCAs prescribed one week @ a time?
Lethal in OD of even a 10 day supply
Troubling side effects of SSRIs (5)
SEXUAL dysfunction

GI distress
Drugs that may help w/ SSRI induced sexual dysfunction (3)
Venlafaxine (Effexor) key points
Combined selective serotonin-NE reuptake inhibitor(SNRI)
More noradrenergic effects as dose increases
@ highest doses, some DA reuptake inhibition

Side effects resemble SSRIs
Safe in OD

NOTE: Has greater rate of full remission of symptoms
Duloxetine (Cymbalta) key points
Actions on 5-HT and NE more equally balanced across dosage range
Safe in OD

LOW rate of sexual side effects

Of benefit in chronic pain
Buproprion key points
Inhibits NE and DA (weakly)

May be helpful in Bipolar disorder and ADHD
Helps stop smoking

Safe in OD (not cardiotoxic)

Side effects resemble SSRIs:
BUT, MINIMAL sexual side effects

NOTE: Higher risk of SEIZURES
Doses 450-600 mg/day increases risk 10-fold
Buspirone key points
Approved only for Generalized Anxiety Disorder

Anti-anxiety effects at low doses
Anti-depressant effects at high doses

PARTIAL AGONIST @ 5-HT1A receptors
Trazodone key points
Weak 5-HT uptake inhibitor, Direct 5-HT2 ANTagonist
Also acts to block alpha-1 receptor

Useful in agitated demented patients
Used as HYPNOTIC in combo w/ SSRIs
Safe in OD

Can cause orthostatic hypotenstion, SEDATION, and priapism
Side effects attributed to increased serotonin (4)
Nervousness (anxiety)
GI distress
Sexual problems
Nefazodone key points
Similar to Trazodone
Modified to DECREASE alpha-1 blockade

Safe in OD
Side effects similar to TCAs, but MUCH LESS
Does NOT interfere with sleep architecture

NOTE: higher rate of liver failure
Drug pulled from market (2004)
Mirtazapine key points
5-HT2 and 5-HT3 antagonist
Also INCREASES NE and 5-HT release via alpha-2 blockade
Also, significant histaminergic blockade (sedation, weight gain)

Safe in OD
LOWER rate of sexual side effects

Despite sedtaion, does NOT interfere w/ sleep ARCHITECTURE
Stimulants key points
Used to combat APATHY assoc. w/ SSRIs
Used as anti-depressant AUGMENTING agents

INCREASE release of DA, 5-HT, and NE


Short half-life -- several doses per day

Side effects include:
Appetite suppression; Nervousness; Insomnia
@ higher doses -- possible psychosis
Characteristic that distinguishes stimulants from other meds
Clinical effect is RAPID
Atomoxetine (Strattera) key points
Used for treatment of ADHD

Selective NE reuptake inibitor

Allows once-daily dosing
One of these two is usually employed during Lithium "lag period"
Predictors of poor response (40%) to Lithium (3)
Mixed states
Rapid Cycling
Substance abuse

NOTE: such cases may respond better to ANTI-CONVULSANTS
Uses of Lithium (5)
Effective for 70-80% of patients with BIPOLAR DISORDER
Helps BOTH manic and depressive episodes

Augmenting agent in Depression
Schizoaffective disorder
Aggression and Impulse control problems
Dose related side effects of Lithium (6)
Weight gain
Diabetes Insipidus

ECG changes reflecting HYPOkalemia
Cognitive problems
Birth defects
Idiosyncratic side effects of Lithium (3)
Facial rash
Aggravation of Psoriasis
Characteristics of mild to moderate Li intoxication
1.5 - 2.0 mEq/L

Worsened TREMOR
GI effects
Characteristics of moderate to severe Li intoxication
2.0 - 2.5 mEq/L

Delirium --> Stupor --> Coma
Ataxia w/ fasciculations
Characteristics of severe Li intoxication
> 2.5 mEq/L

Renal Failure
% of pts. who fail to respond to or can't tolerate Li
30 - 50%
Use of these may contribute to Li refractoriness (1)
Anti-depressants, particularly TCAs
Carbamazepine is more effective than Li for these
Mixed states
Dysphoric manic states
Rapid cycling

NOTE: it is as effective as Li for euphoric states
Uses of carbamazepine
Seizures (simple P, complex P, generalize T-C)
Neuropathic PAIN
Dose-related side effects of carbamazepine (3)
CNS effects
GI effects

When used w/ Li or anti-psychotics --> INCREASED neurotoxicity

NOTE: NOT safe in OD -- cardiac toxicity like TCAs (but less)
IDIOSYNCRATIC side-effects of carbamazepine (5)
BM -- leukopenia (10%) & aplastic anemia

Skin -- rash (from mild to life threatening (rare))
--- NOTE: watch for mucus membrane involvement ---

Liver -- elevated LFTs, signs of cholestasis

Increased metabolism of oral contraceptives
Valproic Acid key points
Same uses as Carbamazepine PLUS MANIA
Useful in both acute mania and maintenance

Similar range of efficacy to carbamazepine

Side effects include sedation, N&V, diarrhea, weight gain, TREMOR

RARELY: Fatal hepatotoxicity, Hemorrhagic pancreatitis, Agranulocytosis
Major RFs for Valproic Acid's deadly side effects (3)
Being under age of 2 (no fatalities > 10 y.o.)
Administration w/ other anti-convulsants
Presence of other medical problems
Lamotigrine key points
1st approved maintenance therapy for BIPOLAR since Li
Delays mood episodes in Bipolar I

Side effects mainly benign
BUT, serious concern is risk of SERIOUS RASH

Effect of VPA on blood level of Lamotigrine
Doubles it
Effect of CBZ on blood level of Lamotigrine
Halves it
Atypical anti-psychotic that has been approved for mania
Most effective in ACUTE mania

NOTE: anti-psychotics are typically used as augmenting strategy
Most effective current treatment for mood disorder
Treatment of choice for catatonia
ECT is NOT very effective for (2)
Used for muscle relaxation in ECT procedure
Conditions of "greater concern" with regards to ECT (4)
Increased ICP
Space-occupying lesions
Recent MI or stroke
Large aneurysm
ECTs effects on memory
Anterograde amnesia up to an hour after treatment

Retrograde amnesia going back several days

Persistent memory complaints are very rare
Seemingly paradoxical mechanisms of ECT
Increases sensitivity of DA receptor (despite anti-psychosis)

Decreases GABA synthesis and release (despite anti-convulsant)
Major Depressive children are LESS likely to present w/ (3)
Sleep disturbance
Weight loss
Major Depressive children are MORE likely to present w/ (#3)
Prominent somatic complaints
Social withdrawal
Bipolar Disorder in children is more often...

(w/ regards to pattern)
Continuous (no episodic pattern)
Most common comorbid anxiety disorder in adults
Generalized Anxiety Disorder
Most common comorbid anxiety disorder in children
Separation Anxiety Disorder
Average length of depressive episode in children
9 months
Therapy type that appears to be most effective in the short term
Cognitive therapy

Note: may not be feasible in many young children
Only AD approved for treating MDD in pediatric pts.
Drugs approved for OCD in pediatric pts. (4)