MDD and Mood Disorders

There are several rating scales that assess severity of and change in depressive symptoms in the adult population? What are the 3 rating scales?

1. Hamilton Depression Rating Scale (HDRS): clinician administers; monitors severity of depression over time o Also known as the HAM-D = most widely used clinician administered depression assessment scale assess 17 items 2. Beck Depression Inventory (21 item self-reported) o scale 1-10= normal 11-16= mild mood disturbance , etc. over 40= extreme depression 3. PHQ-9(self-administered): often used in primary care to screen for mental health issues

There are subtypes of MDD, what are they ?

1. Melancholic 2.Atypical 3. Peripartum Depression 4. Seasonal Pattern Depression

What is cyclothymic disorder?

A distinct period of abnormally and persistently elevated, expansive, or irritable mood and abnormally and persistently increased activity or energy lasting at least 4 consecutive days and present most of the day, nearly every day • Common in men and women, but more seen in women • Duration of 2 or more years (1yr in children and adolescents)- (at least 4 days of symp like Bipolar 2) • Numerous episodes that resemble hypomania or depression but do not fully meet the criteria • Never symptom-free for more than 2 months and symptoms occur at least half the time These symptoms cause the individual distress and/or impairment in work or social functioning

What is Serotonin Syndrome?

A potentially life threatening syndrome dt inreased serotonergic activity in the CNS, marked by autonomic instability, hyperthermia, and seizures, can be life-threatening May occur from any SSRI's or combination of MAO-Is with SSRI's or SNRI's

Assessment of Bipolar patient

A. Evaluation • Thorough history • Include family history of bipolar • Medications B. Exam • Mental Status Exam • Physical Exam C. Lab tests • TSH, LFTs • CBC, BMP • drug/tox screen **It is very important to obtain collateral information- talk with family members, former treatment providers, therapists

In cyclothymic disorder are the manic episodes hypo or hypermanic?

***unlike mania, hypomanic episodes are not severe enough to cause marked impairment or to necessitate hospitalization

PMDD is like PMS but must have 5 of the 11 following symptoms (at least 1 being in first 4)

- Depressed mood, anxiety, labile mood, irritability - decreased interest in usual activities, difficulties concentrating, lethargy, change in appetite, changes in sleep, sense of being out of control or overwhelmed and other physical symptoms including joint pain/bloating Must beat least 2 cycles

-For women with ____-level symptoms present during non-premenstrual intervals, suggest _____ treatment throughout the menstrual cycle -For women with ________ menstrual cycles, ______ treatment is best since the onset of symptoms may be unpredictable. -For women with _______ symptoms that endure for > 1 week before the onset of menses, suggest a luteal phase regimen (Day 14 to menses)

- For women with low-level symptoms present during non-premenstrual intervals, suggest daily treatment throughout the menstrual cycle - For women with irregular menstrual cycles, continuous treatment is best since the onset of symptoms may be unpredictable. -For women with unpredictable symptoms that endure for > 1 week before the onset of menses, suggest a luteal phase regimen (Day 14 to menses)

What is General info for PDD (dysthymia)?

General • Lifetime prevalence 3 to 6%. Usually before 45yo • More common if primary relative with MDD • Female: male 3:1 • Early onset is often associated with a history of childhood loss or abuse (onset before 21). Increased risk with certain personalities: Histrionic, dependent, obsessive compulsive, avoidant, borderline, narcissistic.

How Does Bipolar Disorder Develop?

Genetics • twin and adoption studies demonstrate that inherited factors are involved in the pathogenesis of bipolar {genetic susceptibility is the interaction of many genes, not a single gene} Psychosocial factors: • stressful life events, child abuse, sleep deprivation, illicit drug experimentation Neurobiology: brain structure and function are altered in bipolar disorder & inflammation/ immune system dysregulation

Jim has been receiving treatment for his bipolar disorder and has been getting psychotherapy and Lithium. He was recently diagnosed with HTN and was prescribed Lisinipril. His wife reports that he has been slurring his speech and had developed a tremor. What is going on with your pt? How do you treat?

He has Lithium toxicity! Lithium Levels: increased by... • NSAIDs • Tetracyclines (Abx- Doxycycline) • Metronidazole • ACE inhibitors (Lisinipril) • Diuretics (HCTZ- thiazide or Furosemide- Loop) Management: • mild toxicity- manage electrolyte disturbances with IV hydration • severe {serum levels > 3mmol/L) need to do hemodialysis

The acute phase/stage of treatment focuses upon managing the patient's safety and the presenting symptoms. Patients in the acute phase may be suicidal, psychotic, and display such poor judgment as to pose an imminent risk to themselves. ___________________ until the severity of symptoms lessens.

Hospitalization is often necessary

Your pt has refractory depression And you have decided to start the pt on an MAOI, what should you advise the pt to avoid when taking these meds?

Hypertensive crisis is potentially lethal Risk elevates when MAO-I's are taken with tyramine-rich food {some wines, cheese, chicken liver, fava beans, cured meats}

A hypomanic episode is *similar to mania, but less severe and psychotic, what makes up a hypomanic episode?

Hypomanic Episode 3 or more of the following/ 4 if mood irritable: • grandiosity • decreased sleep • pressured sleep • flight of ideas • distractable • goal-directed activities • impulsivity *similar to mania, but less severe and psychotic

What are baby blues?

a mild form of sadness that occurs in about 50% of postpartum women (lasts about 2-3days after delivery)

What is a mood disorder?

a mood disorder that is characterized by episodes of mania, hypomania, and major depression

The _______________ lasts months to years after recovery from the mood episode, and aims to prevent recurrence of a new mood episode. Long-term or lifetime maintenance is recommended for patients who have suffered one manic episode

maintenance phase/stage of treatment

When would you decided to use ECT (electroconvulsive therapy)?

used in treatment-resistant cases; safe and can be used alone or combo with pharmacotherapy Approx. 8-10 Tx; uses small electric current to produce generalized seizure- can cause retrograde amnesia

How would you treat serotonin syndrome?

• The treatment for serotonin syndrome is Cyproheptadine (anti-histamine) AND discontinuation of offending agent o H1 blocking antihistamine + serotonin receptor blocking activity; Acts to block 5-HT1A and 5-HT2A receptors which are receptors responsible for symptoms of serotonin syndrome

What is Bipolar Disorder NOS?

• When distinction between Type 1 vs Type 2 cannot be made • When the possibility of an underlying causes (ex. Substance or GMC) has not yet been eliminated Emergency setting

What is melancholic depression?

• extreme anhedonia (inability to feel pleasure) • lack of mood reactivity (NO change in mood with positive occurrences) • worse in the morning; often has early morning awakenings (Bad in AM) • marked psychomotor agitation OR a slowing of thoughts with a reduction in movement • significant anorexia or weight loss excessive guilt

General info on bipolar disorder

• individuals <50y are at a higher risk of 1st episode; male/female ratio is equal • noted more in individuals of higher socioeconomic class • There is a strong genetic component in individuals c 1st degree relative with bipolar or unipolar disorders

What is Atypical depression?

• mood reactivity (improved mood when something good happens) • significant weight gain or increased appetite • hypersomnia (sleeping alot) • leaden paralysis (arms and legs feel heavy) • interpersonal rejection Notes: feel better to positive response MDD with Psychotic features: associated with hallucinations or delusions - usually severe episodes

What is hypomania?

• symptoms last at least 4 days (vs a whole week for regular, full-blown mania) • mood is elevated, expansive, or irritable • change in functioning from baseline, observable by others BUT NOT: psychotic, dangerous (require hospitalization) or markedly impaired not related to consumption of substance (meds/drugs)

A 38-year-old woman comes to the office because she is having difficulty coping with her 4-week-old son and is concerned that she is not bonding with him. She also reports increased irritability, lack of sleep, decreased appetite, low mood, and poor concentration. Medical history includes an episode of major depression in her early twenties, but is otherwise non-contributory. Examination shows a disheveled appearing woman, who answers questions in a quiet voice and avoids eye contact. Which of the following treatments should most likely be avoided? Selective serotonin reuptake inhibitors Anti-psychotics Counseling Serotonin/norepinephrine reuptake inhibitors Tricyclic antidepressants

Anti-psychotics Postpartum depression (PPD) affects approximately 10% of women. It is characterized by changes in sleep, energy level, appetite, weight, and concentration. Additionally, mothers with PPD may feel overwhelmed and unable to care for the baby, or feel that they are not bonding with their baby. Main explanation Anti-psychotics are not indicated for postpartum depression, and therefore should be avoided. They may be used in the treatment of postpartum psychosis, which is characterized by onset within two weeks of childbirth of a combination of psychotic symptoms (e.g. hallucinations and delusions) and symptoms of a mood disorder. Women with postpartum psychosis are at increased risk of harming their baby. Hospitalization may be appropriate and be considered on a case-by-case basis. Postpartum depression (PPD) affects approximately 10% of women. A history of depression either prior to, or during pregnancy is the primary risk factor. PPD is characterized by changes in sleep, energy level, appetite, weight, and concentration. Additionally, mothers with PPD may feel overwhelmed and unable to care for the baby, or feel that they are not bonding with their baby. Recommended treatment for PPD includes psychotherapyand pharmacotherapy with selective serotonin reuptake inhibitors.

What are some pharm treatments that help treat MDD?

Antidepressants (Medications take about 4-8 weeks to work): A. Selective serotonin reuptake inhibitors o (SSRIs) Sertraline (MC prescribed in pregnancy/Breast Feeding), Fluoxetine, Paroxetine o Bupropion [Wellbutrin]: less sexual side effects but may be less efficacious B. Serotonin and norepinephrine reuptake inhibitors (SNRIs) o Venlafaxine, Duloxetine, Desvenlafaxine C. Tricyclics antidepressants (TCAs) D. Monoamine oxidase inhibitors (MAO-Is) Adjunctive Meds: • stimulants (helpful- elderly/terminally ill) Antipsychotics: • especially for psychotic features Other: • treatment for other medical conditions (thyroid treatment)

What are atypical antidepressants?

Atypical Antidepressants: • Bupropion [Wellbutrin]: increases noradrenaline and dopamine leading to a stimulant effect o commonly used to aid in smoking cessation, + advantage= no sexual side effects • Mirtazapine [Remeron]: alpha 2 antagonist, causes weight gain (a lot!) and sedation o useful in treatment of refractory depression in patients who need to gain weight • Trazodone: inhibits serotonin reuptake, causes significant sedation

A 45-year-old woman comes to the clinic because of a depressed mood ever since her college daughter moved out of the house for school last month. She states that she briefly cheers up when her daughter visits her. The patient admits to significant weight gain recently. She sleeps for 13 hours a night, but still wakes up tired. Which of the following is the most likely diagnosis? Atypical depression Major depressive disorder Major depressive disorder with seasonal pattern (seasonal affective disorder) Melancholic depression Persistent depressive disorder (dysthymia)

Atypical depression Major takeaway Atypical depression is characterized by mood reactivity(improved mood when something good happens) and at least two of the following: significant weight gain or increased appetite, hypersomnia, leaden paralysis,or excessive sensitivity to rejection. This patient reports hypersomnia, weight gain, and describes mood reactivitywhen her daughter is around. Main explanation Atypical depression can be a specifier for either major depression or persistent depressive disorder (dysthymia). People with atypical depression have often experienced depression first at an early age, during their teenage years. A person with classic major depression has at least five of the following nine symptoms: - Sadness or depressed mood most of the day or almost every day - Loss of enjoyment in things that were once pleasurable - Major change in weight (gain or loss of more than 5% of weight within a month) or appetite - Insomnia or excessive sleep almost every day - A state of physical restlessness or being rundown that is noticeable by others - Fatigue or loss of energy almost every day - Feelings of hopelessness or worthlessness or excessive guilt almost every day - Problems with concentration or making decisions almost every day - Recurring thoughts of death or suicide, suicide plan, or suicide attempt Persistent depressive disorder (dysthymia) is a condition involving the presence of a depressed mood more days than not for at least a two year period in adults (one year in children and adolescents) plus at least two of the above associated symptoms, but fewer than the five symptoms which define a major depressive episode.

Bipolar Depression: Antipsychotics What are some Atypical: "Second generation antipsychotic"meds?

Atypical: "Second generation antipsychotic" • Risperidone (Risperdal) • Quetiapine (Seroquel) • Aripiprazole (Abilify) * may also use Benzodiazepines in ACUTE mania

What personality disorder does the following describe: • manic episodes begin relatively quickly with rapid escalation • depressive episode immediately before or after manic • somatic features: too much or too little sleep • behavioral features: social, outgoing, self-confident, talkative • cognitive: easily distracted, thought processes difficult to follow • risk of suicide: substantial risk o factors: previous attempts, h/o rapid-cycling, co-morbid substance abuse, current depressive episode need low stress job, scheduled lifestyle

Bipolar 1

What is Bipolar 1?

Bipolar 1 - episodes of mania cycling with depressive episodes • defined by at least one manic episode and often accompanied by depressed periods Mean age of onset for Bipolar I is 18yo

What personality disorder does the following describe: • recurrent episodes of major depression and hypomania (at least 4 days) • pt with rapid-cycling experience >/=4 episodes/year • often individuals will experience 1st episode in their early 20s, but sometimes starts in adolescents or after 40yo

Bipolar 2

What is Bipolar 2?

Bipolar 2- episodes of hypomania cycling with depressive episodes • marked by at least one hypomanic episode, at least one major depressive episode, and the absence of manic episodes Mean age of onset bipolar II is 20yo

What is the first line medication to treat bipolar disorder during pregnancy?

Bipolar depression: • Lamotrigine (anticonvulsant) is first line treatment in pregnancy ECT is considered to be safe and efficacious for pregnant pts Remember Lithium is teratogenic-->can cause Ebstein's anomaly

*You can treat sexual side effects from SSRI's with?

Bupropion or Mirtazapine (Atypicals)

What phamacotherapy used to treat MDD is rarely used 1st line?why?

Clinical Pearl: TCA's (tricyclic antidepressants) are rarely first line agents for depression due to potential for toxicity and lethality of cardiac arrhythmia in overdose --> Start on low dose and go very slow; extra cautious in elderly, do NOT prescribe if cardiac history

What is cyclothymia?

Cyclothymia - hypomania and less severe episodes of depression Notes:Hypomania= mania JR

What are is the diagnostic criteria for Major Depressive disorder (MDD)?

Diagnosis - KNOW THIS: Manifests with 5 or more of the following s/s, present for most of the day nearly every day over the course of 2 consecutive weeks (at least one of the symptoms is either depressed mood/loss of interest/pleasure) • Depressed mood most of the day nearly every day • Loss of interest or pleasure in most or all activities • Insomnia or hypersomnia • Change in appetite or weight • Restlessness or slowed behavior • Low energy • Poor concentration • Thoughts of worthlessness or guilt • Recurrent thoughts about death/suicide * To be considered a true MDD episode it MUST impact day-to-day activities *These symptoms can NOT be due to medications or a medical condition

A 24-year-old woman presents to the psychiatry department with concerns over her mood. Her boyfriend convinced her to speak to someone about her unstable emotional states. However, she does not report any significant impairment on her daily functioning. She was a victim of sexual assault years ago, and has been diagnosed with cyclothymic disorder. Which of the following symptoms is most commonly characterized by patients with this disorder? Episodes of hypomania and depression occurring for at least two years Insomnia for a week Psychosis Severe mood swings Suicidal thoughts

Episodes of hypomania and depression occurring for at least two years Major takeaway Cyclothymic disorder is a mild form of bipolar disorder in which a person has mood swings over a period of at least 2 years that go from mild depression to emotional highs. Main explanation Cyclothymic disorder is a mild form of bipolar disorder in which a person has mood swings over a period of years that go from mild depression to emotional highs. Mood swings are relatively less severe than in bipolar disorder or major depression. According to DSM-V, cyclothymic disorder is characterized by episodes of hypomania and mild depression for at least 2 years. An episode of hypomania is like a manic episode, except not severe enough to cause significant impairment on daily functioning. Hypomanic episodes last at least 4 consecutive days. Conversely, a manic episode is a distinct period of elevated or irritable mood and high energy lasting at least a week.

A 25-year-old man comes to the psychiatry clinic for a follow up after being diagnosed with unipolar depression. Various trials of selective serotonin reuptake inhibitors and serotonin-norepinephrine reuptake inhibitors have shown to be ineffective. Psychiatric evaluation shows various atypical features to his depressive episodes. Which of the following features would most likely be present during one of this patient's depressive episodes? Emotional detachment, muteness, depersonalization Hurried speech, delusions, hallucinations Improved mood in reaction to positive events, hyperphagia, sleeping at least two hours more when depressed Inability to focus, need for control, excessive worrying Social or occupational conflicts, talkativity, risky behaviors

Improved mood in reaction to positive events, hyperphagia, sleeping at least two hours more when depressed Major takeaway Central features of atypical depression include mood reactivity, hypersomnia, and hyperphagia. Treatment of choice is selective serotonin reuptake inhibitors. Main explanation The Diagnostic and Statistical Manual of Mental Disorders, 5th edition, lists a variety of atypical features, three of which must be present during the depressive episode in a patient with major depressive disorder for a diagnosis of depression with atypical features. One of these features must be improved mood in response to good news (i.e. mood reactivity to pleasurable stimuli). The other features include:Increased appetite or weight gainHypersomniaHeavy or leaden feeling in limbsLong-standing pattern of interpersonal rejection sensitivity, which is not limited to mood episodes, and which causes social or occupational conflicts.Only the answer containing "Improved mood in reaction to positive events" meets the criteria of "mood reactivity to pleasurable stimuli."The drug of choice of atypical depression is a selective serotonin reuptake inhibitor, not a monoamine oxidase inhibitor. Monoamine oxidase inhibitors are often reserved as a last line of treatment due to their potentially lethal dietary and drug interactions.

• The goal of INITIAL treatment for depression is symptom remission and restoring baseline functioning. Relapse appeared to occur less frequently in patients who remitted, compared with patients who responded but did not remit. How would you treat MDD?

Labs and Psychologic Testing: • Lab work is performed in order to r/o any suspected underlying medical condition (or meds) Randomized trials indicate that the combination of pharmacotherapy and psychotherapy (eg, cognitive-behavioral therapy or interpersonal psychotherapy) is more efficacious than either pharmacotherapy alone or psychotherapy alone.

It has been observed on psychological testing that patients have increased neuroticism and introversion. In about 25 to 50% of pts with Persistent Depressive Disorder, you will see that there is an EEG abnormality of?

Labs and psychological testing: • On EEG abnormalities seen in 25 to 50% of patients o Reduced slow wave sleep with impaired sleep continuity.

What are some non-pharm treatments in MDD?

Lifestyle modifications: resets the brain function (help with sleep / brain function) • exercise, relaxation techniques, positive activities, light therapy for seasonal affective disorder Hospitalization: indicated if patient is at risk for self-harm, hurting others, or cannot meet their basic needs (SI/HI) Psychotherapy: behavioral, cognitive, supportive, family *most useful in combo with medications* ECT: electroconvulsive therapy- used in treatment-resistant cases; safe and can be used alone or combo with pharmacotherapy Approx. 8-10 Tx; uses small electric current to produce generalized seizure- can cause retrograde amnesia Pharmacotherapy: antidepressants, stimulants, antipsychotics, mood stabilizers and anxiolytics

Lithium is used to treat bipolar d/o but some SE include weight gain, GI upset, fatigue, arrhythmias, seizures, metallic taste, diabetes insipidus. It is important to recognize lithium toxicity, how does it present? How would you treat Lithium toxicity?

Lithium toxicity: presents as a tremor, ataxia, and slurred speech; can eventually lead to stupor/ coma/ delirium/ seizures/ death Managing Lithium toxicity: • mild toxicity- manage electrolyte disturbances with IV hydration • severe {serum levels > 3mmol/L) need to do hemodialysis

What medication would you use for refractory depression or atypical depression? is this a good first line med to use, why or why not?

MAOI's are very effective for refractory depression - NOT first-line for depression because of increased safety and tolerability of other agents - Hypertensive crisis is potentially lethal Risk elevates when MAO-I's are taken with tyramine-rich food {some wines, cheese, chicken liver, fava beans, cured meats} Side effects: hypertensive crisis, CNS stimulation**

MDD vs PDD (dysthymia)

MDD vs PDD (dysthymia): MDD: vegetative symptoms such as insomnia, loss of appetite, loss of libido, weight loss, and psychomotor symptoms are common PDD (dysthymia): chronic, less severe depressive symptoms that can persist for 2 or more years, vegetative symptoms are less common

Tricyclic Antidepressants (TCA's) in MDD

MOA: blocks reuptake of norepinephrine/serotonin Drug examples: • imipramine • amitriptyline (used in Migraine/tension) • clomipramine • nortriptyline (Pamelor), • desipramine Used in:Major depressive disorders, enuresis, OCD, fibromyalgia (DM neuropathy)Side effects:tachycardia, urinary retention, sedation, lowers seizure threshold Toxicity:can be fatal {3 C's: convulsions, coma, cardiotoxicity} prolong QT !

SSRI selective serotonin reuptake inhibitors MOA?

MOA: decreases serotonin reuptake pump in neurons thereby increasing synaptic serotoninDrug examples: - citalopram (Celexa); escitlaopram (Lexapro)- fluoxetine (Prozac); fluvoxamine (Luvox)- paroxetine (Paxil);sertraline (Zoloft)

SNRI's serotonin and norepinephrine reuptake inhibitors MOA?

MOA: increases serotonin, norepinephrine, and dopamine Used in: depression, fibromyalgia, generalized anxiety Toxicity/side effects: • Hypertension; Sedation; Nausea Examples: • Venlafaxine (Effexor) and Duloxetine (Cymbalta) Withdrawal from SNRI's:potential withdrawal symptoms from SNRI's are seenafter 1-3 missed doses(flulike symptoms)

____________lasts weeks to months, during which remission of symptoms and restoration of functioning is preserved with ongoing treatment. The goal is to prevent relapse of the mood episode.

The continuation phase/stage

A 42-year-old woman comes to the emergency department because she has been very tired and has gained weight during the past month. She says she has been struggling with depression for a long time, but it has gotten worse since she found out her husband was diagnosed with cancer. She also says that she previously had an episode of decreased need for sleep, irritability, increased goal-directed activity, but it never significantly impaired her work or home life. Her temperature is 37.1C, pulse is 80 /min, respiratory rate is 12/min, and blood pressure is 110/75 mmHg. Physical examination is normal. She says that she has been compliant with her antidepressant therapy. Which of the following is the most likely diagnosis? Bipolar II Cyclothymic disorder Schizoaffective disorder Seasonal affective disorder Bipolar I

Major takeaway Bipolar II disorder is characterized by one or more hypomanic episodes and one or more major depressive episode. Hypomanic episodes do not go to the full extremes of mania. Bipolar II disorder is characterized by at least one or more hypomanic episodes and one or more major depressive episode. Hypomanic episodes do not go to the full extremes of mania (i.e., do not usually cause severe social or occupational impairment, and are without psychosis), and this can make bipolar II more difficult to diagnose, since the hypomanic episodes may simply appear as a period of successful high productivity and is reported less frequently than a distressing, crippling depression. The diagnosis of bipolar II disorder requires that the individual never experienced a full manic episode. The most common treatment of bipolar disorder requires the administration of mood stabilizers such as lithium.

A 28-year-old woman is brought to the emergency department by her sister because of erratic behavior. The sister claims that while driving the patient said "let's close our eyes" while crossing red-traffic lights, and then laughed frenetically. The patient works as a stockbroker and over the past 2 months she has joined multiple organizations as a consultant. She claims to sleep with different men after closing business deals because she feels empowered. When asked about her personal information, she talks very rapidly, claims to feel better than ever, while assuring that there is no need to keep her in the hospital. Her medical history is relevant for being diagnosed with major depressive disorder a year ago, and anorexia nervosa when she was 15-years-old. Physical examination is noncontributory. Her temperature is 36.1°C (96.9°F), pulse is 94/min, respirations are 29/min, and blood pressure is 125/60 mm Hg. Which of the following is the most likely diagnosis? Bipolar disorder type 1 Bipolar disorder type 2 Borderline personality disorder Brief psychotic disorder Histrionic personality disorder

Major takeaway Bipolar disorder type 1 is a mood disorder characterized by at least one episode of mania with or without a hypomanic or depressive episode. The patient must experience inflated self-esteem, decreased need for sleep, increased rate of speech, flight of ideas, increased libido, goal-directed activity/psychomotor agitation, and erratic behavior. Main explanation This patient's presentation with manic symptoms, such as excessive involvement in activities (i.e. joined multiple organizations), increased libido, erratic behavior, increased self-esteem and pressured speech, in addition to, history of major depressive disorder is suggestive of bipolar disorder type 1. Bipolar disorder type 1 is a mood disorder characterized by at least one episode of mania with or without a hypomanic or depressive episode. The hallmark sign in these patients is the presence of a manic episode, which is characterized by a distinct period of abnormally and persistently elevated, expansive, or irritable mood, lasting at ≥7 days. There are no psychoticfeatures related to bipolar type 1 disorder. Keep in mind, that hospitalization is needed when maniac symptoms are very severe. The pathogenesis of bipolar disorder is characterized by increased norepinephrine and increased serotonin. In addition to understanding the neurochemical changes, is important to know that bipolar disorder is the most genetic disorder of all psychiatric disorders. Treatment for patients with bipolar disorder includes mood stabilizers, such as lithium, valproic acid, and carbamazepine. If patients with bipolar disorder are misdiagnosed, prescription of antidepressants may trigger a manic episode.

A 35-years-old man comes to the clinic because of a one-month history of fatigue and insomnia. He explains that he cannot concentrate like before and that he is always tired. The patient says that he has gone through a recent divorce and that he only sees his kids on Saturdays. He has also lost most of his savings investing in a pyramid scheme. Physical examination shows poor posture, unkempt hair, and that his shirt is dirty. He states that other patients with real diseases should be examined before him. He then tells the nurse that she looks like a character from his favorite medical television series, but that he doesn't enjoy watching it anymore. He has poor eye contact. His family medical history is notable for his father's suicide when the patient was 14. Which of the following is the most likely diagnosis? Borderline personality disorder Dysthymia Generalized anxiety disorder Major depressive disorder (MDD) Post-traumatic stress disorder

Major takeaway Common symptoms of major depressive disorder include persistent low mood, anhedonia, sleep and appetite changes, and reduced concentration and energy. Family history, recent stress, or illness are risk factors for depression. Main explanation This patient has symptoms of major depressive disorder (MDD). A major depressive episode is defined as a syndrome in which at least 5 of the following symptoms have been present for at least 2 weeks: •Depressed mood (for children andadolescents, this can also be an irritable mood) Diminished interest or loss ofpleasure in almost all activities (anhedonia) •Significant weight change orappetite disturbance (for children, this can be failure to achieveexpected weight gain) •Sleep disturbance(insomnia orhypersomnia) •Psychomotor agitation or retardation •Fatigue or loss of energy •Feelings of worthlessness •Diminished ability to think or concentrate; indecisiveness •Recurrent thoughts of death,suicidal ideation •A pattern of long-standing interpersonal rejection ideation, suicide attempt, or specific plan for suicide From the symptoms listed above, the patient suffers from depressed mood,anhedonia, sleep disturbances, fatigue, diminished ability to concentrate, and feelings of worthlessness. From the ten symptoms listed above, the patient suffered from six for about one month. A family history of depression is also very important since major depressive disorder appears to be a multifactorial and heterogeneous group of disorders involving both genetic and environmental factors.

A 30-year-old woman comes to the emergency department after exhibiting unusual behavior. According to her mother, she has not slept for more than a week, appears to be extremely agitated, and is unable to concentrate. Her mother says she has seen her like this in the past and it is usually followed by an episode of severe depression. She is admitted for psychiatric evaluation and treatment is initiated. Three weeks after she is discharged from the hospital, she begins complaining of polyuria and intense thirst. Urinalysis reveals a specific gravity of 1.001 and an osmolality of 190 mOsm/kg. After one hour of water restriction, urine osmolality is 210 mOsm/kg. Which of the following is the most likely medication that could cause these symptoms? Carbamazepine Demeclocycline Lamotrigine Lithium Valproic acid

Major takeaway In patients undergoing pharmacotherapy for bipolar disorder and later present with thirst and polydipsia, primary polydipsia and nephrogenic diabetes insipidus secondary to lithium may be the cause. If urine osmolality does not improve with water restriction, the most likely diagnosis is diabetes insipidus. Main explanation Bipolar disorder is defined by the presence of at least one manic (type 1) or hypomanic (type 2) episode followed eventually by symptoms of depression. The patient presented with decreased need for sleep, psychomotor agitation, and distractibility, suggesting she was experiencing a manic episode. Lithium is the first-line mood stabilizer used to prevent relapse and acute manicevents in bipolar disorder. Adverse effects of lithium include tremor, edema, heart block, hypothyroidism, teratogenesis, and nephrogenic diabetes insipidus. It is diagnosed by a lack of urine osmolality change with water deprivation. The normal response to dehydration is to concentrate urine, causing urine osmolality to increase and stabilize above 280 mOsm/kg. Patients with diabetes insipidus will have an increase in osmolality of less than 30 mOsm/kg per hour for at least 3 hours. Nephrogenic diabetes insipidus can occur in patients who take lithium, because lithium works as an antidiuretic hormone antagonist. This prevents fluid reabsorption, leading to significant fluid wasting. It presents clinically with intense thirst, polyuria, hypernatremia and extremely dilute urine.

A 26-year-old woman comes to the office because she has felt increasingly sad and tired for a week. She gave birth to a healthy baby boy one month ago via an uncomplicated spontaneous vaginal delivery. She really enjoyed taking care of her son for the first week after he was born, but feels things have become increasingly difficult since then. She also says that she keeps starting tasks around the house, but constantly forgets what she is doing, or loses interest in the project at hand and that she hasn't slept in days. Examination shows she appears disheveled and is slightly malodorous. Her affect is flat, and she is slow to answer questions, but does reply appropriately. Which of the following is the most likely diagnosis? Birth-related post-traumatic stress disorder Normal post childbirth mood changes Postpartum blues Postpartum depression Postpartum psychosis

Major takeaway Postpartum depression affects approximately 10% of postpartum women. It is characterized by severe depressive symptoms that last and worsen for more than two weeks after delivery. Main explanation Postpartum depression(PPD) affects approximately 10% of women. A history of depression either prior to, or during pregnancy is the primary risk factor. PPD is characterized by changes in sleep, energy level, appetite, weight, and concentration. Additionally, mothers with PPD may feel overwhelmed and unable to care for the baby or feel that they are not bonding with their baby. Recommended treatment for PPD includes psychotherapyand pharmacotherapy with selective serotonin reuptake inhibitors.

A pt is exhibiting signs of a manic episode, if one of those signs is irritability, how many of the following must be met?

Manic Episode 3 or more of the following: (if irritability, must meet 4) • grandiosity/inflated self-worth • decreased need for sleep • hyperverbal or pressured speech • flight of ideas or racing thoughts • increased distractibility • increased goal directed activity or agitation (can be very productive!) •increased impulsivity/hedonism/risk-taking

What are manic episodes?

Manic episodes include: • at least 1 week during which mood is elevated, expansive, or irritable o can be mania if it is less than a week BUT hospitalization is required • the symptoms must impact work, relationships with others, require hospitalization to prevent harm to the individual or to others, or have psychotic features • cannot be caused by medication or a medical issue

What is the mnemonic to help dx MDD?

Mnemonic to help: SIG E CAPS • Sleep • Interest • Guilt • Energy • Concentration • Appetite • Psychomotor • Suicide

Ruben's dad recently passed away a month ago, he has been feeling down and fatigued for several days, has insomnia, decreased appetite. Would you dx this pt with MDD?

No, pt is in bereavement! When symptoms of depression develop or persist beyond 2 months past the death of a loved one, a diagnosis of normal bereavement gives way to major depression

What other mood stabilizers can be used to treat bipolar disorder?

Other Mood Stabilizers: Anticonvulsants - Valproic Acid (Valproate) - Carbamazepine - Lamotrigine (Lamictal) o anticonvulsant, FDA approved for Bipolar I o Black box: SJS (and other serious skin rashes) Valproic Acid and Carbamazipine may cause neural tube defects **pregnant women need to be concerned

A 25-year-old comes to the office because of general feelings of sadness. She has been feeling sad, run-down, and easily annoyed for the past three days. She gave birth to a healthy baby girl a week ago via spontaneous vaginal delivery. Right after her daughter was born, she was overjoyed. However, now, even when her daughter is asleep, she finds she is unable to concentrate on work or get any rest herself. These symptoms have not compromised the care of her daughter. Examination shows some elements of depression, but she answers questions appropriately and her hygiene is good. Which of the following is the most appropriate next step in management? Reassurance and support with a follow-up appointment in 1-2 weeks. Recommend emergency admission Recommend starting a selective serotonin reuptake inhibitor (SSRI). Recommend starting a tricyclic antidepressant (TCA). Refer to cognitive behavioral therapy.

Reassurance and support with a follow-up appointment in 1-2 weeks. Major takeaway Postpartum blues affects 70-80% of postpartum women, characterized by mild depressive symptoms that typically resolve within two weeks. Roughly 10% go on to develop the more severe and longstanding postpartum depression. Main explanation This patient has postpartum blues. This condition affects 70-80% of postpartum women. These women experience mild depressive symptoms such as sadness, insomnia, difficulty with concentration, and increased irritability. They are still able to care for their newborn and themselves. Typically, the postpartum blues begin 2-4 days after giving birth and resolve within two weeks. No treatment is necessary aside from reassurance and support. Approximately 10% of women will go on to develop postpartum depression. These women have more severe and longer lasting depressive symptoms that may interfere with their ability to care for their child. Postpartum depression can be treated with antidepressant medication and/or cognitive behavioral therapy. It is too early to recommend these therapies to this patient, but she should be closely followed to ensure that her symptoms resolve in the expected time period.

What are the goals of treatment for bipolar depression?

Remission defined as resolution of the mood symptoms or improvement to the point that only 1 or 2 symptoms of mild intensity persist • If there are psychotic features (delusions or hallucinations), you MUST treat the psychosis BEFORE remission is attainable • Some patients do NOT achieve remission. A reasonable goal in these patients is Response:stabilization of the patient's safety ands ubstantial improvement in the number, intensity and frequency of mood symptoms

What is the first line medication to treat major depression disorder during pregnancy?

SSRI's used most due to safety profile • Sertraline, Fluoxetine, Escitalopram • no proven teratogenic complications • Sertraline in BF women too ECT is considered to be safe and efficacious for pregnant pts

Jane a 30 yo F presents to the clinic stating that she feels tired all the time and has been sleeping excessively. She has being eatting more carbs that usually and she reports being easily irritable. She has been feeling the this for the past 2 years but states that it only occurs during the winter months. What is at the top of your differential? How would you treat?

Seasonal Pattern Depression Management: SSRIs, light therapy, bupropion (per PPP)

A pt presents to the ER comes into the clinic with AMS, confusion, agitation, hallucinations and hypomania. His past medical hx includes MDD, he was recently changed to another medication to treat his MDD, bit does not recall the name of the med. He is tachycardia, diaphoretic and hyperthermia. Admits to N/V/D. On PE you note increased DTR and tremor. You also note mydriasis. What is at the top of your differential dx? How would you treat?

Serotonin syndrome. Prompt discontinuation of the offending med. Supportive care: mainstay of therapy- supplemental oxygen, IV fluids, and Benzo (for agitation, to reduce hyperthermia, and to correct midl increases in HR and BP) • Give Cyproheptadine (anti-histamine) • Antipyretics should NOT be used for hyperthermia

What are the symptoms of Mania? (remember mnemonic)

Symptoms of Mania: "DIG FAST" D= distractibility I= insomnia G= grandiosity F= flight of ideas A= activity/agitation S= speech (pressured- fast) T= thoughtlessness (no concern for consequences) ** Manic episode is a MEDICAL EMERGENCY because an individual's judgment is severely impaired which can place them and others at risk; mania has high risk of suicide*

In Persistent Depressive Disorder, the depressed mood is accompanied by 2 or more of the what sx?

The depressed mood is accompanied by two or more of the following symptoms: • Decreased or increased appetite. • Insomnia or hypersomnia. • Low energy or fatigue. • Poor self-esteem. • Poor concentration. • Hopelessness. The individual could have never experienced a manic or hypomanic episode and does not meet the criteria for cyclothymic disorder, schizoaffective disorder, schizophrenia, delusional disorder or any other psychotic disorder.

A 28-year-old woman comes to the office because of difficulty coping with her 6-week-old baby and is concerned that she is not bonding properly with him. She also says she has a bad mood, irritability, poor sleep, decreased appetite, and poor concentration. She had an episode of major depression in her early twenties, but she has been feeling well for over 5 years. Which of the following statements best describes the situation? This is a normal reaction to childbirth and does not require further treatment or follow up This patient has childbirth-related post traumatic stress disorder and should seek out treatment This patient has postpartum blues, which should resolve on its own This patient has postpartum depression and should seek out treatment This patient has postpartum psychosis and should be hospitalized immediately

This patient has postpartum depression and should seek out treatment Major takeaway Postpartum depression is characterized by changes in sleep, energy level, appetite, weight, and concentration. It affects 10% of women, and a history of depression either prior to, or during pregnancy is the primary risk factor. Main explanation Postpartum depression (PPD) affects approximately 10% of women. A history of depression either prior to, or during pregnancy is the primary risk factor. PPD is characterized by changes in sleep, energy level, appetite, weight, and concentration. Additionally, mothers with PPD may feel overwhelmed and unable to care for the baby, or feel that they are not bonding with their baby. Recommended treatment for PPD includes psychotherapyand pharmacotherapy with selective serotonin reuptake inhibitors. Actress Brooke Shields spoke out about her battle with postpartum depression after the birth of her first child. She also wrote a book which chronicled her experiences and raised public awareness for postpartum depression.

How do you treat bipolar disorders?

Treating Bipolar Disorders (pharmacotherapy is NOT optional)*** A. Mood stabilizer= Lithium B. Mood stabilizer= Lamotrigine [Anticonvulsants ] C. depression management= Antipsychotics (typical-1st gen or atypical- 2nd gen) **ECT(electroconvulsive therapy) may be used in treatment-resistant bipolar depression • Lamotrigine [Lamictal] (anticonvulsant) may be effective • Olanzapine (atypical) shown to reduce depressive sypm, but should be included with an SSRI (Fluoxetine) • ECT if patient not responding to tx for manic state or presents a high risk of suicide • Psychotherapy Lifetime maintenance for those who have had >/=3 manic episodes or1 severe episode

How would you treat PDD (dysthymia)?

Treatment of PDD (dysthymia): a. Antidepressants: SSRIs, MAO-Is • Continued for at least 6 to 12 months. Preferably initiate treatment with SSRIs • Sometimes another drug or drugs need to be added. b. Psychotherapy: address impairments in social and occupational functioning, pessimism and hopelessness

How do you treat cyclothymic disorder?

Treatment: • Lithium • Bupropion (atypical), MAO-Is, and low dose SSRIs in conjunction with Lithium

How would you treat Premenstrual dysphoric disorder (PMDD)?

Treatment: • SSRIs including (first line) Fluoxetine, Sertraline, Paroxetine and Ctalopram • OCP's can be used as first line tx for PMDD or as adjuvant tx with SSRI's (especially if needs form of birth control as well) *combination **Yaz- FDA approved for treating PMDD)

How do you treat an acute manic episode?

Treatment: ACUTE MANIA • Assess for suicidal risk, aggressive or risk of violence toward others • Evaluate for substance abuse (NO ETOH/drugs etc) • Decrease alcohol, caffeine, & nicotine • Tx: Lithium, anticonvulsants, anti-psychotics, and Benzos are used to induce remission in mania or hypomania

Bipolar Depression: Antipsychotics What are some Typical neuroleptics: "First generation antipsychotic"?

Typical neuroleptics: "First generation antipsychotic" • Haloperidol (Haldol) • Chlorpromazine (Thorazine)

What is Seasonal Pattern Depression?

• A regular, temporal relationship between the onset of major depressive episodes and a particular time of year, for the past 2 years (same time each yr) • Remission also occurs at a specific time of year: episodes may begin in winter and remit in summer • Triad for seasonal affective disorder: o Irritability o increased consumption of carbs o hypersomnia (excess sleeping)

What is Persistent Depressive Disorder?

• Depressed mood for at least 2 years o In children this must have been at least one year and mood can be irritable • Depressed mood is present for most of the day, for most days than not • Never without symptoms for more than two months • Previously has been called Depressive Personality Disorder and Neurotic Depression or Dysthymia This is not related to medication or medical condition and causes distress or impairment for the individual

What is major depressive disorder?

• Episodic (occasionally chronic). The estimated rate of recurrence over 2 yrs is 40% after 2 episodes it increases to 75% • Lifetime prevalence: 12% Now 15% 2020 • Peak onset in the fourth decade of life à female:male 2:1 • Has an estimated cost of 83 billion dollars in the US, 118 billion euro in EU • Onset of age increasing in 18-29yo groups, now higher than other groups • No ethnic or socioeconomic differences • About 2/3 of all depressed patients contemplate suicide, and 10-15% attempt suicide • Only ½ of pts with a Major Depressive Disorder (MDD) ever receive treatment • Elderly patients with depression are twice as likely to commit suicide as the general population Depressive symptoms are present in 15% of nursing home residents

What is Mood Disorder Due to GMC (General Medical Condition)?

• Large number of conditions produce symptoms of depression, mania • Must rule out of GMC as cause before diagnosing a "primary: mood disorder •Can affect morbidity and mortality of a patient

What is Peripartum Depression?

• Onset of mood episodes during pregnancy or within 4 weeks of childbirth • Hormonally drive (unable to bond cbaby) • Incidence of major depression among • postpartum women is approx. 10-15% • Needs to be differentiated from the "baby blues" a mild form of sadness that occurs in about 50% of postpartum women (lasts about 2-3days after delivery)

What is Premenstrual dysphoric disorder?

• Premenstrual syndrome (PMS) The presence of both physical and behavioral symptoms that occur repetitively in the second half of the menstrual cycle (luteal phase) and interfere with the woman's life.

Many studies describe treatment outcome using the terms "response" and "remission," based upon the amount of improvement from baseline on a clinician administered depression rating scale. What is "response"? What is "Remission"?

• Response: Improvement ≥50% but less than the threshold for remission. o Ie feels better but does not meet normal range criteria • Remission: Depression rating scale score less than or equal to a specific cutoff that defines the normal range. As an example, studies using the 17 item Hamilton Rating Scale for Depression often define remission as a score ≤7

If a person has PDD they are at risk for developing ?

• Risk of developing MDD within a year.