Lecture 9: Mood/Affective Disorders: Depressive and Bipolar Disorder

mental health notes Lecture 9: 2/19 Mood/AiectvDe Bvsorders: BepressvDe and Evpolar Bvsorder Mood Bvsorder -haractervstvcs The Mood Spectrum Mood/AiectvDe Bvsorders Mood variations are normal when they don't interfere with a person's life/functioning Pervasive/extreme alterations in emotion Feeling low, sad, blue from time to time Symptoms interfere with life and impair ability to function Manifested by depression, mania/hypomania, or both Typically, low periods last a few days Particularly r/t self-esteem, relationships, and work/school On the opposite end of the mood spectrum: feelings of elation or euphoria Long-term sadness, agitation, or elation Not attributable to physiological eUects of substance use or another medical condition Typically, recede within a few days with return to euthymic mood Dnipolar jepressive jisorders Euthymic: Stable, average mood state Ma(or depressive disorder Persistent depressive disorder )dysrhythmic disorderB Prolonged grief disorder gtvoloy& C gpvdemvoloy& Ripolar and Helated jisorders Etiology Bipolar I: Mania qighly biological connection with strong genetic ties )more so in bipolar disorderB Bipolar II: qypomania Cyclothymia: FreAuent mood swings between hypomania and ma(or depression Possibly inIammation-mediated r/t autoimmunity NT alterations and hormonal dysregulation Environmental factors Epidemiology 2s per the N0Mq in .8.8: Prevalence of depression in the D4S4 is %417 for adults and 367 for adolescents Typically begins in early adolescence Females aUected more commonly by depression Leading cause of disability in the D4S4 qigh comorbidity w/ psychiatric/physical illnesses BvasthesvsbStress Model -ontrvFutvny jactors qigher Culnerability/Probability to Mental jisorder Riological Qenetic predisposition Qenetic Whildhood trauma Neurobiological 0nability to cope with excessive stressful circumstances 0nIammatory process Lower Culnerability/Probability of Mental jisorder Physical health Psychological Minimal stressful circumstances BP-1: 8-.417, BP-2: 845-14%7, hypomania: .4V-64%7, cyclothymia: 84G-V457 Stressful life experiences, trauma Environmental qousing, weather 2ir Auality, pollutants BepressvDe Bvsorders Ma(or BepressvDe Bvsorder U)nvpolar5 jiet, lifestyle MBB BSMbP -rvterva Episodes last at least . weeks with depressed mood or anhedonia Five or more symptoms must be present during the same .-week time period that represents changes in functioning Meet 1 of the % criteria: 2t least one is either depressed mood or loss of interest Sleep dysregulation MBB SpecvGers Episodic Single vs4 recurrent Symptoms Partial vs4 full remission 0nterest de;cit jepressed mood most of the day, nearly every day zuality/Severity Quilt Mild Energy de;cit Markedly diminished interest/pleasure in all/almost all activities most of the day and nearly every day Woncentration de;cit Signi;cant weight loss when not dieting or weight gain Severe: &ith/without psychotic features 2ppetite and weight loss/gain 0nsomnia or hypersomnia nearly every day Psychomotor retardation/agitation Fatigue or loss of energy nearly every day Suicidality Feelings of worthlessness or excessive, inappropriate guilt jiminished ability to concentrate or indecisiveness nearly every day Moderate Seasonal AiectvDe Bvsorder USAB5 Episodes of depression following seasonal pattern Hecurrent thoughts of death Most common pattern of low mood during fall and winter fersvstent BepressvDe Bvsorder UBSM5 Formerly known as dysthymic disorder jepressed mood for most of the day, for more days that not Symptoms frolonyed Orvez Bvsorder Persists at least two years" never without symptoms for more than two months Poor appetite or over-eating qypersomnia or insomnia WharacteriZed by intense and persistent grief that causes functional impairment 0ncreased appetite and carbohydrate cravings Loss of loved one must have occurred at least a year ago for adults or at least six months ago for WJ2 0nterpersonal conIict 0rriability The grieving individual must have experienced at least three of the following symptoms nearly every day for at least the last month prior to the diagnosis Low energy or fatigue Low self-esteem Poor concentration, indecisiveness 0ncreased sleep qeaviness in Extremities jiminished energy Symptoms Feelings of hopelessness Must be associated with clinically significant distress or impairment in normal level of daily functioning 2bsence of manic/hypomanic episode or psychotic episode Wannot be accounted for by a medical condition or substance use 0dentity disruption Marked sense of disbelief about the death 2voidance of reminders that the person is dead 0ntense emotional pain related to the death ji culty with reintegration, intense loneliness Emotional numbness, feeling that life is meaningless fremenstrual B&sphorvc Bvsorder UfMBB5 Severe form of premenstrual syndrome )PMSB Fluctuation in hormones along with altered G-qT 0mpacts 5-%7 of premenopausal women Potential dysfunction in social activities or occupation r/t symptoms Symptoms Mood lability, irritability Wther BepressvDe Bvsorders fostpartum Bepressvon jiUerent from baby blues, which includes mild, predictable mood disturbances occurring during ;rst several days after delivery Symptoms typically subside without tx Onset often within .-5 weeks of delivery qopelessness Substance- or medication-induced depressive disorder ji culty concentrating jepressive disorder due to another medication condition 2ltered sleep 0ncreased appetite Other speci;ed and unspeci;ed depressive disorder Symptoms Labile mood and aUect Wrying spells, sadness Evpolar Bvsorder C SchvHoaiectvDe Bvsorder Whanges in appetite 0nsomnia 2nxiety Postpartum Psychosis 2cute onset within days of delivery Progression to delusions and hallucinations is a medical emergency Evpolar Bvsorder C SchvHoaiectvDe Bvsorder Screenvny zor Manva: B OjAST Screenvny zor Evpolar Bepressvon: IR fLASRgB jistractability &ired/worse on antidepressants 0ndiscretion: Excessive involvement in pleasurable activities qypomania Qrandiosity: 0nIated self-esteem Psychomotor retardation Flight of ideas Loaded family history 2ctivity increase 2brupt onset or ending of depressive symptoms Sleep de;cit )decreased need for sleepB Seasonal or postpartum )S2j or hypomanic in springB Talkativeness: Pressured speech qyperphagia and hypersomnia )atypical featuresB 0rritability Early age at depression onset jelusions or other psychotic features Evpolar Bvsorder To be considered mania, the elevated, expansive, or irritable mood must last for at least one week Re present most of the day, nearly every day juring this period, three or more of the symptoms must be present and represent a signi;cant change from usual behavior Symptoms/Writeria Qrandiosity jecreased need for sleep 0ncreased talkativeness Hacing thoughts jistracted easily 0ncrease in goal-directed activity or psychomotor agitation Evpolar Bvsorder To be considered hypomania, the mood must last at least four consecutive days Present most of the day, almost every day jiagnosis reAuires at least one hypomanic and at least one ma(or depressive episode qypomania Milder version of mania with increased activity and energy Experienced as euphoria and often increases functionality and productivity Patients may not seek treatment due to liking this burst of energy -&cloth&mvc Bvsorder Those who experience mood cycling over a two-year period but do not meet the criteria for RP-3, RP-., or Mjj Six criterion with one speci;er Symptoms/Writeria For at least two years, there have been episodes of hypomanic and depressive experiences, which do not meet the full jSM The above criteria have been present for at least half the time during the two years, with not more than two months of symptom remission No history of diagnoses for manic, hypomanic, or a depressive episode Engaging in activities that hold the potential for painful conseAuences )ex4 unrestrained shoppingB May still experience signi;cant depressive symptoms following hypomanic episode" may increase risk for suicidal behaviors Hecurrent thoughts of death, recurrent S0 without a speci;c plan, or a suicide attempt qypomanic symptoms may also represent a progression from depression to bipolar Symptoms cannot be accounted for by substance use or a medical condition Not combined with psychotic symptoms Symptoms cause distress or signi;cant impairment in social/occupational functioning joes not reAuire hospitaliZation Symptoms cannot be accounted for by a psychotic disorder SchvHoaiectvDe Bvsorder 2n uninterrupted period of illness during which there is a ma(or episode )depressive or manicB concurrent with criterion 2 of schiZophrenia )depressed moodB Symptoms/Writeria jelusions or hallucinations for . or more weeks in the absence of a ma(or mood episode )depressive or manicB during the lifetime duration of illness Symptoms that meet criteria for a ma(or mood episode are present for the ma(ority of total duration of the active/residual portions of illness Manic type: This subtype applies is a manic episode is part of the presentation Evpolarb elated -onsvderatvons Bvierentvatvny the Bvsorders 0f psychotic symptoms are present only during a mood episode, it is likely Mjj with psychotic features, current episode manic, with mood-congruent psychotic features Wurrent severity: Evaluated by provider on 8-1 scale, based on most severe occurrences over last 6 days Nearly eAual incidence in males and females: Manic episodes more in men jepressive episodes more in women &omen are more likely to be rapid cyclers 0ncludes delusions or hallucinations 0f mood symptoms are more rare but the psychotic symptoms are more continuous and chronic, it is likely schiZophrenia Mean age of onset is 3% y/o Most onset in late adolescence/early adulthood )ages 3G-.GB Negative symptoms may be less severe and persistent than those seen in schiZophrenia Ma(or depressive episodes may also occur jepressive type: This subtype applies if only ma(or depressive episodes are part of the presentation Lifetime suicide risk: 38-58x general population Male onset earlier than female SelzbAssessment flannvny jepressed Patients 2cute Phase Potential to feel what the pt is feeling Prevent in(ury Strive for empathy, not sympathy Medical stabiliZation Engage in self-care Maintaining safety Seek guidance and support as needed Self-care needs StabiliZation Phase Manic Patients Manipulative Antvdepressants Prevent relapse jemanding Selective Serotonin Heuptake 0nhibitors )SSH0sB Maintain medication adherence 2mbivalent Psychoeducational teaching" referrals qigh energy can be exhausting for staU Fluoxetine )ProZacB, sertraline ) oloftB, citalopram )WelexaB, escitalopram )LexaproB First-line therapy" indicated for depressive disorders Maintenance Phase StaU member actions: Limit severity/duration of future episodes FreAuent staU meetings to deal with patient behavior and staU response 2dverse eUects include sexual dysfunction, mild nausea, tremors, and risk for suicidal ideation May take weeks for a response to develop Potential toxic eUects: Serotonin syndrome 2typical 2ntidepressants DtiliZed when a patient has an inadeAuate response or 2jHs from SSH0s SNH0s: Cenlafaxine )EUexorB: Monitor RP" risk for discontinuation syndrome )Iu-like symptomsB jesvenlafaxine )PristiAB: Metabolite of venlafaxine juloxetine )WymbaltaB: qelps address depression and nerve pain Others: Rupropion )&ellbutrinB: NjH0, avoid with history of seiZures or eating disorders due to decreased seiZure threshold MirtaZapine )HemeronB: Low dose for promoting sleep and increasing appetite s/t depression and anxiety Tricyclic 2ntidepressants 2mitriptyline )ElavilB, nortriptyline )PamelorB, imipramine )TofranilB Neurotransmitter eUects Wardiovascular eUects: Sinus tachycardia, prolonged PH/zHS/zT, ST/T-wave changes, heart block, vasodilation, hypotension, cardiogenic shock, v-;b/v-tach, asystole WNS eUects: jrowsiness, coma, convulsions, EPS, rigidity, delirium, respiratory depression, ophthalmoplegia 2nticholinergic eUects: jry mouth, blurred vision, mydriasis, urinary retention, hypoactive bowel sounds, pyrexia, myoclonic twitching Monoamine Oxidase 0nhibitors )M2O0sB Set limits consistently fharmacoloyvcal Treatment zor Evpolar Mood StabiliZers Lithium: Qold standard treatment HeAuires freAuent monitoring of therapeutic/toxic serum levels Wther Bepressvon Treatments Electroconvulsive therapy )EWTB 0npatient treatment Therapeutic: 84V-34. mEA/L May cause mild confusion, q2, and sometimes chronic short-term memory loss Maintenance: 841-345 mEA/L Toxic: 34G mEA/L and above Transcranial magnetic stimulation )TMSB 2void high doses with renal impairment Hisk for electrolyte imbalance Outpatient treatment Cagus nerve stimulation Symptoms of lithium toxicity: Mild: N/C, lethargy, tremor, fatigue 2pproved for treatment-resistant depression jeep brain stimulation 34G-.48 mEA/L Moderate: Wonfusion, agitation, delerium, tachycardia, hypertonia .48-.4G mEA/L Severe: Woma, seiZures, hyperthermia, hypotension 2bove .4G mEA/L Not currently Fj2 approved Light therapy and vitamin j supplementation St4 ohn's &orth )OTWB May cause serotonin syndrome in addition to other antidepressants Lifestyle changes )ex4 sleep, dietB 2nticonvulsants Lamotrigine )LamictalB for bipolar depression Wther Evpolar Treatments Calproate )jepakoteB in acute episodes Electroconvulsive therapy )EWTB WarbamaZepines )TegretolB Teamwork and safety Second-Qeneration/2typical 2ntipsychotics OlanZapine ) yprexaB Hisperidone )HisperidalB Support groups qealth teaching and health promotion Non-Pharmacological 2ripipraZole )2bilifyB 0ndividual psychotherapy )WRTB zuetiapine )SeroAuelB Setting good circadian patterns: Less risk for EPS but more for metabolic symptoms/exacerbation )jM, obesity, qLjB Sleep hygiene and sleep promotion jark/light therapy Second or third line in depressive disorders PhenelZine )NardilB, isocarboxaZid )MarplanB, selegiline transdermal patch )EmsamB Foods to avoid include produce, dairy, meats, bread, soy/;sh sauce, beers, wines Tyramine may lead to hypertensive crisis 0nteracts with antihistamines, opioids, sedatives, antihypertensives, and other drugs that raise RP fs&chotherap& 2 combination of medication and psychotherapy is considered the most eUective treatment for depressive disorders 0nterpersonal therapy: Focus on relationship di culties and roles Rehavioral therapy: Seeks to change maladaptive behaviors Wognitive therapy: Dse of cognitive reframing to change distorted thinking patterns