Mood disorders

Name the subtypes of mood disorders

(MAC, PAM, + SRP) With Melancholic Features With Atypical Features With Catatonia With Psychotic Features With Anxious Distress With Mixed Features With Seasonal Pattern With Rapid Cycling With Peripartum Onset

What are the risk factors for a mood disorder during pregnancy?

**History of psychiatric illness** Family history Younger age/ Low SES/ Less education/ Medicaid Insurance Unplanned pregnancy Maternal anxiety Smoking Lacking Social Support/ Single status/ Poor relationship/DV

T/F Anti-depressants are an effective treatment for bipolar disorder

*NO STOP IT WHAT ARE YOU THINKING FALSE* AD's Ineffective (step trial showed this) -accelerate cycle, induction of agitation or mania, inc. in suicidality, and 'poop out' phenom

Peripartum subtype: with what? symptoms? tmt?

*depression or mania* -if mood sx develop at any time during pregnancy up to four weeks post delivery. Note that 50% of postpartum MDE begins during pregnancy. -note: pregnancy NOT protective CHOOSE MEDICATION BASED ON SAFETY IN PREGNANCY AND LACATION

Mixed feature subtype: with what? symptoms? tmt?

*depression or mania* A mood episode that meets full criteria for either a depressive, manic or hypomanic episodes, but has at least three symptoms of the other pole disorder: For example, a manic individual who believes he is a prophet but feels guilty he has not saved the world, despairs of the future, feels he should be punished and is suicidal. OR a depressed individual who has grandiosity, talkative, and has racing thoughts. HIGHER RISK SUICIDE; CAUTION BIPOLAR; VALPROIC ACID MORE EFFECTIVE THAN LITHIUM

Catatonia: with what? symptoms? tmt?

*depression or mania* Types of catatonia: Stupor, catalepsy, waxy flexibiity, mutism, negativism, posturing, mannerism, stereotypy, agitation not influenced by external stimuli, grimacing, echolalia, echopraxia ECT, BENZODIAZEPENE

Seasonal pattern subtype: with what? symptoms? tmt?

*depression or mania* Usually depressed in winter, euthymic/manic in summer, but can be reverse. LIGHT THERAPY; CAUTION BIPOLAR; PREMEDICATE IN AUTUMN, STOP IN SPRING

Psychotic features subtype: with what? symptoms? tmt?

*depression or mania* hallucinations or delusions are present *during* depressive or manic episode -you *must* ask patient, it can be subtle ECT OR ADD ANTIPSYCHOTIC

Anxious distress subtype: with what? symptoms? tmt?

*depression or mania* keyed up, tense, difficulty concentrating bc of worry, fear that something awful will happen, feeling individual might lose control HIGHER RISK SUICIDE; TREAT ANXIETY

Atypical subtype: with what? symptoms? tmt?

*depression* Hypersomnolence and increased appetite, mood worse in pm, mood reactivity, history of interpersonal sensitivity (easily rejected, even when not depressed), leaden parralysis. MAO INHIBITOR (CAUTION BIPOLAR)

Rapid cycling subtype: with what? symptoms? tmt?

*mania/hypomania only* 4 or more mood episodes per year. ANTICONVULSANTS MAY BE MORE EFFECTIVE THAN LITHIUM

If patient has mood changes by reacting to a medical illness, we call it BLANK

-major depressive episode or adjustment disorder

Describe the spectrum of postpartum mood changes

1. "blues" Transient, nonpathologic -50-70%, inc. risk for depression 2. Postpartum depression -10%, 2/3 have onset by 6 wks postpartum 3. Postpartum Psychosis - .1%, 70% of whom are affective (Bipolar, Major Depression)

Diagnostic criteria for Disruptive Mood Dysregulation Disorder

1. *Applies only to children aged 6-18* 2. Persistently irritable kids who throw temper tantrums (3/week, for 12 month) 3. Most of these children will go on to develop MDE or anxiety disorder in adulthood *Irritability in adolescents is a manifestation of depression and should not be misconstrued as bipolar*

Non-ECT biological interventions for depression

1. Bright Light Therapy: for seasonal symptoms 2. Vagus Nerve Stimulation: requires surgery 3. Transcranial Magnetic Stimulation 4. Deep Brain Stimulation* 5. Psychosurgery* 6. Sleep deprivation 7. Aerobic exercise

Describe the Neuroendocrine model of depression

1. CRH--->ACTH--->Cortisol secretion, and Hypersecretion of cortisol found in 50% of depressed patients, b/c dysfunction of feedback loop 2. Abnormal dexamethasone suppression test 3. Early life adversity leads to methylation of the GR gene -> less receptors in hippocampus/hypothalamus -> blunted feedback (includes mothers who had depression during pregnancy ) 4. Cortisol/stress may also dec. BDNF, neurogenesis Problem: also found in anorexia, dementia, substance abuse

Diagnostic criteria for Cyclothymia

1. Fluctuations between hypomanic and depressive symptoms for over two years, never abate for more than 2 months 2. Depressive and hypomanic symptoms have met some, but not all, criteria for major depressive episode and hypomania 3. Never a full blown MDE or manic/hypomanic episode

Name the classic mood disorders

1. Major depressive disorder 2. Bipolar disorder I 3. Bioplar disorder II 4. Cyclothymia 5. Persistent Depressive Disorder (dysthymia)

DSM-5 Criteria for Hypomanic Episode

1. Period of abnormally elevated, expansive, or irritable mood, AND increased energy lasting at least FOUR DAYS 2. +3 of DIGFAST, but +4 if irritable (review: distractibility, insomnia, grandiosity, flight of ideas, activities, speech, thoughtlessness) 3. no psychotic symptoms, social/occupational impairment, or hospitalization

Diagnostic criteria for Persistent Depressive Disorder

1. Persistent for at least 2 years, no break for 2 months, with at least 2 of the following: A - Appetite changes C - Concentration difficulties H - Hopelessness E - Energy (low) W -Worthlessness  S - Sleep disturbances

DSM-5 Criteria for Manic Episode

1. abnormally elevated, expansive, or irritable mood AND persistent increase in energy, lasting at least ONE week 2. 3+ of DIGFAST Distractability Insomnia - decreased NEED for sleep *Grandiosity - inflated self-esteem* Flight of ideas Activities: increased goal-oriented, psychomotor agitation Speech: pressured, talkative Thoughtlessness - "risk taking"

Describe psychodynamic therapy

1. address early childhood attachment, primary relationships, unmet needs to address self-image, current relationships b/c depression is the "solution" to these problems 2. Explore relationships, childhood to develop insight ("explanatory model"), to create narrative of illness 3. Use transference as a laboratory

How do the demographics of bipolar differ from depression? SES link?

1. age of onset is 10 yrs younger (>50% before 20) 2. gender: male=female for 1, but 2:3 for spectrum 3. SES: inc. in spectrum, lower in bipolar 1 probably because 1 will decrease your functionality in manic state

Descrive Electroconvulsive therapy (ECT)

1. barbituates+succinylcholine+ induced 30 s seizure 2. 70-80% response rate, changes in days 3. bilateral or unilateral, aimed at frontal lobe risks: forming/maintaining memory during treatment period (anterograde amnesia)

Bipolar is hard to diagnose. What are the risks of misdiagnosis?

1. high recurrence in untreated, inc. severity and tmt resistance (kindling) 2. high risk of sub abuse, incarceration and suicide if untreated 3. anti-depressant misadventures If falsely diagnosed -> toxic drugs and stigma

Name 5 pathophys theories for depression

1. monoamine 2. synaptic remodeling 3. BDNF 4. Neuroendocrine 5. Inflammatory

DSM-5 Criteria for Major Depressive Episode

1. one of these: Depressed mood or anhedonia (Markedly diminished interest or pleasure) 2. + 4 of SIGECAPS -Sleep -Interest -Guilt -Energy -Concentration -Appetite (inc. or dec., weight change) -Psychomotor (agit or retard) -Suicidal ideation 3. rule out other condition/substance, clinically significant impairment, persisted most of every day for 2 weeks

"Bob is a 22 yr old U of C senior " -> describe how psychodynamic therapy was effective in this case

1. relationship with narcissitic dad was unknowingly transferred to classmate, teachers, and his psychiatrist 2. envy of Abe related to Abe's relationship with his own father 3. School failure, tmt adherence problem related to tension between wanting to surpass father and wanting his affection 4. Becomes social "mute" to avoid competition, self-sabotages to gain father's affection, transfers feelings to surrogates

Diagnostic criteria for Premenstrual Dysphoria and tmt

1. w/in 1 week start menses, improves w/in few days 2. treat with *phasic* SSRI, BZD, OCT that works immediately 3. *not an exacerbation of another disorder, but usually has 5 of SIGECAPS or other symptoms*

What is the prevalence of depression, and what is the risk of recurrence?

10% prevalence, 17% lifetime risk, higher for women 50% recurrence risk, which increases after each episode

First degree relative with MDD: BLANK more likely to have MDD Monozygotic twins: concordance rate of MDD = BLANK

2-3x, 50% -stronger genetic risk in bipolar vs. unipolar in twin study, with genetic overlap of each

What percentage of patients respond to anti-depressants?

2/3rds

Avg. age of first episode depression

20-25 median, but 20-40

What percentage of patients experience remission?

35%, and relapse rates get worse with successive therapies

Bipolar rate of recurrance

; >90% with manic episode will develop recurrent mood episodes

Diagnostic criteria of Bipolar

At least one hypomanic episode AND one major depressive episode -clues: family history, AD misadventures, abrupt course, and atypical presentation

Diagnostic criteria of Bipolar I

At least one manic episode (with or without major depressive episode) -clues: family history, AD misadventures, abrupt course, and atypical presentation

Melancholic: with what? symptoms? tmt?

Basically a really bad *depression* Complete anhedonia, lack of mood reactivity, early am awakening, mood worse in am, anorexia and wt loss, marked psychomotor retardation/agitation, excessive or inappropriate guilt. TRICYCLIC ANTIDEPRESSANT

Lifetime prevalence of bipolar disorders

Basically: 1%, increased for cyclothymia Bipolar I: 1% Bipolar II: 1.1% Cyclothymia: 2.4% Range in different studies: 2.6-7.8%

Which mood disorder has highest suicide rate?

Bipolar; 15-19% suicide rate (highest among psychiatric disorders) due to impulsivity of manic state -this is not saying most prevalence, but highest risk -also leads to social, sexual and financial problems -61% comorbidity with substance abuse (highest of Axis I disorders)

Which of the following are not considered diagnostic criteria for MDE? Crying spells Appetite (inc. or dec., weight change) Helplessness/Hopelessness Irritability/aggressiveness Lack of Energy Anxiety Somatic symptoms (e.g. pain) Difficulty sleeping/oversleeping Sexual dysfunction Self neglect Suicidality Hallucinations or delusions

Crying spells Helplessness/Hopelessness Irritability/aggressiveness Anxiety Somatic symptoms (e.g. pain) Sexual dysfunction Self neglect Hallucinations or delusions

Pathophys: relationship between depression and sleep

Depressed patients have circadian dysregulation -decrease in growth hormones during sleep, dec. in melatonin -Stage IV defects, with *decreased REM-latency* and increased REM intensity -changes can be seen during euthymic episodes

Most common diagnosis with suicide

Depression

When Does Mood Disturbance Become Pathological?

Disproportionate to precipitant Prolonged duration Unresponsive to feedback Pervasive and unrelenting Impairment in judgment and behavior

Tmt for bipolar

Drugs 1. Anticonvulsants (Valproic Acid, Carbamazepine, Lamotrigine) 2. Lithium (*decrease suicide, in depression too*) 3. Antipsychotics 4. Benzodiazepenes Non-drug -ECT equally effective against manic and depressive states -psychotherapy effective *as an adjunct*

Pathophys of mania

Drugs that treat mania work by stabilizing neuronal membranes (via voltage-gated ion channels), lessening excessive inhibition and excitation -AD's, cocaine, amphetamines can induce mania

T/F Patients always progress through each stage of Mania

False

T/F Pregnancy is protective for a mood disorder

False. 50% of postpartum MDE begins during pregnancy

T/F Risk of depression increases to 10% for women during the postpartum period

False. Depression during the postpartum period affects approximately 10% of patients, which is not greater than the risk for depression at other time points in a woman's life

T/F Offspring of bipolar patients have increased risk of bipolar disorder specifically

False: mood disorders to not breed true! Bipolar first-degree relative: 10X more likely to be bipolar, but 50% bipolars have at least one parent with a *mood disorder* One bipolar parent: 25% chance of child with mood disorder

Examples of Other Specified or Unspecified Disorders

Full Hypomanic episodes and mild depressive episodes Manic periods never last more than a week Meets criteria for depression but no anhedonia or sadness

What are the risks to the mother of a mood disorder during pregnancy?

General: Impaired functioning Bad choices: Abnormal BMI, Use of tobacco, ETOH, illicit drugs, medications Bad care: Missed PNC visits, termination of wanted pregnancy Mental ill: Postpartum depression/ psychosis, also Suicide

Where in brain, specifically, if BDNF most found? How does this place change in depression?

Hippocampus -Cornu Ammonis area 3 and Dentate Gyrus -hippocampus volume decreases in depression, possibly a result of downregulation of BDNF -reccurent stress/MDE's injure, reduce hippocampus

STAR*D-Child study showed what?

Improvement in child's psychiatric symptoms; faster remission -> less symptom counts for children

Pathophys: relationship between depression and inflammation

Increases in CRP, IL-1, IL-6 and TNF-alpha, interferon causes depression in 50% of pt's Pro-infl cytokines -> express IDO in brain over TDO in liver -> TRP converted to quinolinic acid (QUIN), a toxic metabolite -> astrocyte apoptosis, shunt away monoamines

Which medications can induce a mood disorder?

Isotretinoin (Accutane); Montelukast (Singulair); Varenicline (Chantix); Oseltamivir (Tamiflu) Oral contraceptives *Steroids* Interferon Antihypertensives (e.g. reserpine (VMAT inhibitor), clonidine, beta-blockers) Any drug that acts on CNS, including psychotropics!

*important:* 4 factors that increase risk for suicide in depressed patients

MAPS M: hx of mania/hypomania A: etoh/drug abuse P: Psychotic symptoms S: prior suicide attempt

How distinguish manic episode from schizophrenia?

Manic episodes -> can develop psychotic; is it cyclic (bipolar) or chronic (schizophrenia)?

What are the risks to the pregnancy of a mother with a mood disorder during pregnancy?

Miscarriage Maternal vasoconstriction Gestational HTN, diabetes, pre-eclampsia Preterm/ Operative delivery Low birth weight and APGAR scores Infant admission to a SCN Lack of self-care b/c of depression might explain some findings

What is mood? How does it differ from affect?

Mood - Patient's stated mood in "quotes" AND/OR inferred mood as it appears to examiner; sustained emotion felt inwardly Affect - Describes range, intensity, appropriateness to content, congruence to stated mood

Diagnostic criteria for Substance Induced Mood Disorder

Not classic intoxication or withdrawl of, for example, cocaine (mania) or alcohol (depression) This diagnosis is reserved for those cases in which: 1. the mood symptoms are so severe that they warrant independent clinical attention 2. last longer or are in excess of what is expected from intoxication or withdrawal (*so etoh -> depression-> persists when NOT drunk/withdrawl*) *note: If a full hypomanic or manic episode emerges and persists after treatment with an antidepressant, the patient is considered bipolar*

What would the difference be between a primary mood disorder and a primary substance abuse disorder (in terms of substance-induced mood disorder)

Patient medicating him/herself with the substance (Primary Mood Disorder) Substance causing the depressive symptoms? (Primary Substance Use Disorder) Or patient has a DUAL diagnosis?

Which of the following are NOT diagnostic criteria for manic episode? Sensual Acuity Insomnia Mood lability Poor insight Thoughtlessness Impulsivity Pressured talking Aggressiveness Hallucinations or Delusions Flight of ideas

Sensual Acuity Mood lability Poor insight Impulsivity Aggressiveness Hallucinations or Delusions

What were the results of the STAR*D trial

Sequenced Treatment Alternatives to Relieve Depression -not a randomized controlled study -showed 67% remission rate after 4 treatments, but decreasing efficacy with successive treatments -relapsed decreased if remission decreased

Describe the monoamine hypothesis of depression

Simple: lack of DA (think: buprion), 5HT, NE (think: reserpine) from any step in pathway

What is an adjustment disorder?

Some people feel overwhelmed and develop symptoms of depression, anxiety, or both to the point where functioning is impaired in relation to stressful situations, usually within 3 months and resolve within 6 *note: they do NOT meet the criteria for a major depressive episode*

What are the 3 stages of Mania

Stage I: "1", "A", "G", "T" Increased psychomotor activity, labile affect, expansiveness, grandiosity, sexually preoccupied, *still in control* Stage II: "S", "F", "G" More pressured speech, psychomotor activation, open hostility, flight of ideas, grandiose delusions Stage III: Desperate, panic stricken, bizarre behavior, incoherence, hallucinations

Important side effects of anti-depressants

Stomach upset - Insomnia Agitation - Sedation *Sexual Dysfunction* - Discontinuation *Weight Gain* - Mania or Suicide

Impact of non-treatment on infant of mother with mood disorder during pregnancy?

Suicide/infanticide Failure to thrive Poor maternal child bonding / attachment disorders Lower global IQ / poor language/ cognitive and social delay Developmental delay on Bayley Scale at 1 year Behavioral problems / emotional dysregulation Early onset of ADHD, mood, anxiety conduct disorders as well as tendency towards violence

4 basic types of psychotherapy

Supportive Therapy Cognitive Behavioral Therapy Interpersonal Therapy (solve relationship problems) Psychodynamic Therapy

Pathophys of depression: 5HT transport

The serotonin transporter gene transcription (5HTT) is modulated by a polymorphism (loss of fxn -> makes less protein, less inhibiiton of unwanted signals) in its upstream regulatory region, and may play a key role in the fine-tuning of serotonergic neurotransmission

Mood disorder caused by another illness (give examples)

Think: thyroid and pancreatic cancer Neuro -Brain tumor, MS, Huntington's Disease, CVA, Parkinson's disease, Sleep Apnea Endocrine-Metabolic -*Thyroid*, Cushings, Adrenal insuff, B12 def, Uremia, Cirrhosis, Hypercalcemia Infections -HIV, syphilis, TB Cancer (*pancreatic*) *note: Does NOT refer to the individual's emotional response to having the medical condition*

Treatment w/ antidepressants should continue after symptom resolution T/F

Treatment should continue for minimum of 6 months after symptom resolution, Long-term prophylactic tx if recurrent

T/F Medical patients are at higher risk for depression

True. 10% of in-patient, 4x prevalence in chronically ill, but also failure to remit increases risk for co-morbid complications (e.g. post-MI mortality increases)

T/F We are more proned to depression than euphoria

True. Because evolution. 16.6% lifetime prevalence major depressive disorder, 2.5% dysthymic, 3.9% bipolar

T/F Disruptive mood dyregulation disorder applies only to kids 6-18

True. Remember this diagnosis was created to limit kids getting bipolar disorder and taking heavy drugs

T/F signs and symptoms of depression during the postpartum period are essentially indistinguishable from MDD during other times in a woman's life

True. The diagnosis of postpartum depression is not distinct from a diagnosis of a major depressive episode at another time period

T/F Responses to a significant loss can constitute a MDE

True. The presence of an MDE should be carefully considered, but decision inevitably requires the exercise of clinical judgment.

Treatment for adjustment disorder?

Typically medication is not needed; exceptions may be benzodiazepines for sleep or anxiety control. Anti-depressants are typically not indicated Psychotherapy is the treatment of choice

How long can a depressive episode last?

Untreated episodes last 6-14 months, but can be chronic Treated episodes last 2-3 months Prognosis: after initial episode 1 year = 25% recurrence 10 years = 75% recurrence 15 years = 87% recurrence

Should pregnant women discontinue anti-depressents?

Women were 3x more likely to relapse if they discontinued medication, although in both groups relapse rate is very high

First episode of bipolar disorder usually occurs in BLANK, and is BLANK

adolescence, depressive episode

Bereavement is considered BLANK in DSM-5 if symptoms exceed what is considered 'normal' response to loss of loved one (intensity, duration)

an adjustment disorder -again, if it meets MDE criteria, it is MDE -distinguishing grief from MDE is tough, Low self esteem, worthlessness and guilt are often key signifiers that MDE is involved

How does Postpartum depression differ from Major Depressive Disorder?

are essentially indistinguishable from MDD, but includes -*obsessions* focused on infant (usually harming infant) -*compulsions* following obsessions to alleviate thought, often through avoidance (either avoiding baby or things one might use to harm baby)

Antidepressant induced mania is a risk particularly in those with BLANK

bipolar spectrum disorder, it can be diagnostic -it is important to rule out bipolar before prescribing anti-depressants

Describe the BDNF hypothesis

cAMP response element binding (CREB) transcriptio factor -upregulated in patients responsive to to anti-depressents, psychotherapy -may increase Brain derived neurotrophic factor (BDNF), by upregulating BDNF receptors TrkB, LNGFR -BDNF is concentrated in hippocampus and supports neurogenesis and plasticity -hypermethylation of BDNF in psychiatric illness, including mood disorders and schizophrenia

Kraeplin associated with first diagnosis of?

dementia preco (now schizophrenia) and "manic-depressive insanity" -gave his old patients to dr. Alzheimer

In bipolar disorder, atients cycle between depressive and manic/hypomanic episodes, but are mostly BLANK

depressed

Mood disorders involve diseases whose primary symptoms are characterized by BLANK or BLANK episodes, or BLANK

depressive or manic, or a combination of both

Diagnostic criteria of Major Depressive Disorder

one or more depressive episodes

2 features of an atypical depression

overeating and oversleeping -> puts bipolar higher on differential in your depressed patient

DSM-IV postpartum onset specifier for MDD2 is

within 4 weeks of delivery, however women develop symptoms more insidiously weeks or even months later

# suicides per year

~40,000, often goes underreported, over 1 million attempts