Significant Functional Impairment

Mood Disorders syndrome rather than medical condition
 MC MAJOR psychiatric disturbance

 Early recognition and intervention important in rapid onset
 No racial prevalence, however:
o Tend to under diagnose mood disorder, and over diagnose schizophrenia in backgrounds that differ from one’s own.
Depression: Significant functional impairment

1. Major depressive disorder
2. Persistent depressive disorder  Replaces “Dysthymia” (mild persistent depression)
3. Disruptive mood dysregulation disorder  Replaces “Childhood bipolar disorder”
4. Pre-Menstrual dysphoric disorder
Major Depression:
- 10-15% prevalence in primary care pts (25% women)
- 50% reoccurrence (within 6 mos) – can have 5-6 significant episodes in 20y period
o Between episodes pts function at their “normal”
o Frequency and length of episode increases with age
- 25% seek help; 75-80% pts are treatable
o If untreated: usually self-limiting and lasts 6-12 months
- 15% commit suicide
- Up to 50% unaware or deny depression
Dx:
- 5+ symptoms present in 2 week period
- May present with psychosis but delusions/hallucinations are uncommon
- At least one symptom must be present:
o Depressed mood OR loss of interest in pleasure
- Additional Criteria:
o Sleep disturbance: insomnia or hypersomnia
o Interest waning: or diminished pleasure
o Concentration: decreased focus or ability to think
o Psychomotor: agitation (excited) or retardation (slowed)
o Appetite: weight loss or gain (5% in a month)
o Guilt: or feeling of worthlessness
o Energy: loss of energy or fatigue
o Suicidal: ideation, recurrent thoughts of death, or attempt – risk may increase w/ treatment (↑ energy)
 ALWAYS ASK ABOUT SUICIDE
- Important Info:
o Family hx
o PMH
o Medical sxs
o Stressors
o Level of functioning
o Alcohol/drugs
- Ddx:
o Substance use (sedatives)/dependence or stimulant withdrawal
o Hypothyroidism
o Medications: reserpine, propanalol, methyldopa, steroids
o Malignancy/disease
- Associated conditions:
o Cancers: pancreatic cancer may initially present as depression
o Renal, cardio/pulm disorders, endocrine
o Infectious: HIV, pneumonia, influenza, mono
o Neurologic: Parkinson’s, MS, stokes (esp. frontal lobe)
o Psychiatric: anxiety, schizophrenia, eating disorders
Case:
- 40-yo woman lost interest in work and social life, has lack of energy, lack of motivation and appetite, admits to thoughts
of suicide, and feels hopeless/helpless most of the time. Feels between in the evening than in the morning (diurnal
variation in sxs)
Treatment: all take 3-6 weeks to take effect
- Heterocyclic antidepressants: (ACID)

o Major SEs: sedation, anticholinergic effects, CV effects (orthostatic hypotension), weight gain
 Amitriptyline (Elavil) 75-300 mg/day: depression w/ anxiety
 Clomipramine (Anafranil) 100-250 mg/day: OCD
 Imipramine (Tofranil) 75-300 mg/day: panic disorder with agoraphobia, enuresis, anorexia, and bulimia
 Desipramine (Norpramin) 75-300 mg/day: depression in the elderly, anorexia, bulimia
- SSRIs:
o OCD, premature ejaculation, and panic disorder
o Major SEs: activation & insomnia, sexual problems/delayed orgasm (men), anticholinergic, CV, minor weight gain
 Paroxetine (Paxil) 20-50 mg/day
 Fluoxetine (Prozac) 20-80 mg/day – MC (more tolerable SEs)
 Sertraline (Zoloft) 50-200 mg/day
- MAOIs: (TIP)
o Atypical depression, panic disorder, eating disorder, or pain disorder
o Major SEs: hypertensive crisis with tyramine rich foods (beer, wine, cheese)
 Tranylcypromine (Parnate) 20-60 mg/day
 Isocarboxazid (Marplan) 10-50 mg/day
 Phenelzine (Nardil) 30-90 mg/day
- Other antidepressants:
 Alprazolam (Xanax) 2-6 mg/day: anxiety w/ depression
 Amoxapine (Asendin) 75-400 mg/day: depression w/ psychosis
 Bupropion (Wellbutrin) 300-600 mg/day
 Nefazodone (Serzone) 300-600 mg/day: intolerant to other antidepressants
- Electro-convulsion therapy:
o Induces 25-60s long seizures
o Dose: 8 Treatments over 2-3 weeks
o Unilateral (non-dominant hemisphere) or bilateral
o Major SEs: amnesia (resolves within 6 mos)
o Indication:
 Refractory to antidepressants
 Rapid resolution of sxs – for high suicide risk
o Contraindicated: in increased cranial pressure
o Antidepressants or ECT 1-2x a month for maintenance
- Psychotherapy: (interpersonal or family)

o Most effective as adjunct w/ medication
- Hospitalization:
o Indications:
 High suicide risk
 Unable to care for themselves
 Poor support systems
 Decline in fxning
Disruptive Mood Dysregulation Disorders: (Replaces “Childhood Bipolar”)

- Dx: in children up to 18
- Sxs: persistent irritability, episodes of extreme/out-of-control behavior
Premenstrual Dysphoric Disorder:

- Dx: occurs in most menstrual cycles during the past year
- Sxs: improve within a few days of menses and are minimal/absent one week post menses
- Includes 5+ marked sxs during week before menses – w/ at least one of the first four sxs
o (1) Affective liability (mood swings; suddenly sad, tearful, or increased sensitivity to rejection)
o (2) Irritability or anger or increased interpersonal conflicts
o (3) Depressed mood, feelings of hopelessness, or self-deprecating thoughts
o (4) Anxiety, tension, feelings of being “keyed up” or “on edge”
o (5) Decreased interest in usual activities ( work, school, friends, hobbies)
o (6) Subjective sense of difficulty in concentration
o (7) Lethargy, easy fatigability, lack of energy
o (8) Change in appetite, overeating, or specific food cravings
o (9) Hypersomnia or insomnia
o (10) Subjective sense of being overwhelmed or out of control
o (11) Other physical symptoms: breast tenderness or swelling, joint/muscle pain, “bloating” or weight gain
Bipolar Disorder
Criteria:
 Distractibility and easy frustration
 Irresponsibly and erratic, uninhibited behavior
 Grandiosity
 Flight of ideas or manic, rapid thoughts
 Activity increased (w/ weight loss or increased libido)
 Sleep decreased
 Talkativeness
- Manic episode = elevated mood for 7 days or more w/ at least 3 sxs (4 if irritable)
- Hypomanic episode = elevated mood for 4 days or more w/ at least 3 of the sxs (4 if irritable)
o NO functional impairment (but change in fxn appreciated by others) – EXCEPT in BD II
- Rapid cycling of episodes (at least 4 episodes per year) – 10-20% pts
 More treatable
 2/3rd are women
Risks:
- 7% if one first degree relative; ~49% w/ two parents
- 1% if one second degree relative (aunt/uncle, grandparent)
Causes for exclusion: another medical cause or substance abuse/medication
Types:
- BD I: (more severe)
o F=M
o Prevalence: 0.4 -1.6%
o Onset: 18 yoa
o Criteria:
 1+ manic episodes
 Major depressive episode = not necessary
- BD II: (less severe)
o F>M
o Prevalence: 0.4-1.6%
o Onset: Mid 20s
o Criteria:
 1+ hypomanic episodes
 1+ major depressive episodes
- Cyclothymic: (steady state)
o F=M
o Prevalence: 0.4-1.0%
o Onset: adolescence/early adulthood
o Criteria: 2 years of subsyndromal depression + hypomania
Mixed Disorders:
- If either criteria is met, DX = manic w/ mixed features

o Dysphoric mania OR Activated depression
Treatment:
Old Standard = mood stabilizer + reuptake blocker
Lithium: more favorable in tx-naïve cases (1st course)

- C/I: NSAIDs
- Needs to check renal fxn
- Teratogenic: 1st trimester  Ebstein’s anomaly (defective
tricuspid valve)
Valproic acid (Depakote): better for mixed episodes

- Can cause PCOS in young women
- Teratogenic: neural tube defects
Other side effects:

- Chlorpromazine (Thorazine): auto-induction, agranulocytosis
- Lamotrigine (Lamictal): OCP interaction and can cause SJS;
interacts with VA
Adjuncts: combo drugs useful in acute stabilization

- Antipsychotics: required when psychotic episodes
- Benzos: sedative, relaxant
ECT: can be used

Manic: reuptake blockers or Lamictal (v. useful)
Other features of BD:

- 60% manic episodes immediately preceded by major depressive episode
- Major depressive episodes usually significantly outnumber hypomanic and manic episodes
- 35% suicidal  15% successful (15x greater risk than population) – BD II more lethal attempts
Consider other medical reasons: do baseline tests (CBC, chem, TSH, B12, tox screen, HCG, HIV/ELISA)
- Similar to depression
- Autoimmune: SLE
- #1 Substance induced depression = ALCOHOL
- Drugs: Steroid, B-blockers, antidepressants
Adjustment Disorder:
- Develops in response to a stressor (w/in 3 months)
- Terminates w/in 6 months of end of stressor
- Distress out of proportion to stressor
- May cause significant impairment
- Similar to acute stress (ASD) or PTSD but not as severe

Significant Functional Impairment

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Significant Functional Impairment

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What are the main types of mood disorders discussed in the document?

What are the main types of mood disorders discussed in the document?

What are some of the treatments discussed for depression?

What are some of the treatments discussed for depression?

Mood Disorders syndrome rather than medical condition

 MC MAJOR psychiatric disturbance

Depression: Significant functional impairment

- Heterocyclic antidepressants: (ACID)

- Psychotherapy: (interpersonal or family)

Disruptive Mood Dysregulation Disorders: (Replaces “Childhood Bipolar”)

Premenstrual Dysphoric Disorder:

Causes for exclusion: another medical cause or substance abuse/medication

- If either criteria is met, DX = manic w/ mixed features

Old Standard = mood stabilizer + reuptake blocker

Lithium: more favorable in tx-naïve cases (1st course)

Valproic acid (Depakote): better for mixed episodes

Other side effects:

Adjuncts: combo drugs useful in acute stabilization

ECT: can be used

Other features of BD:

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