Transcript Mood

Mood Disorders
Compiled By
Salina Chan, R3
Asia Karakoc, R2
2013
Today We’ll Talk About…
 Major Depressive Disorder
 Treatments
 Bipolar
 Treatments
 Persistent depressive disorder (dysthymia)
 Cyclothymia
 Adjustment d/o
Major Depressive Disorder
Major Depression Stats
Public Health Agency of Canada/ Statistics Canada:
Lifetime prevalence of major depression: 12.2%, pastyear episodes: 4.8%
The peak annual prevalence occurred in the group aged
15 to 25 years.
Female to male ratio 2:1
Worldwide, major depression is the leading cause of
years lived with disability.
Major Depressive Disorder
M - SIGECAPS
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Mood
Sleep
Interest
Guilt
Energy
Concentration
Appetite
Psychomotor
Suicidal
ideation
Major Depressive Disorder
Criteria
 Depressed Mood; OR
 Markedly diminished
Interest/pleasure
 4 other symptoms (5/9
total)
 Most of the day, almost
every day
 2 weeks duration
Other Symptoms
 Weight or appetite changes
 Fatigue or loss of energy
 Feelings of worthlessness or
excessive or inappropriate guilt
 Diminished ability to
think/concentrate or
indecisiveness
 Insomnia or hypersomnia
 Psychomotor agitation or
retardation
 Recurrent thoughts of death,
recurrent SI, SA
Major Depressive Disorder
 Change from previous function
 Symptoms cause clinically significant distress or impairment
in social, occupation or other important area of functioning
 Episode not attributable to physiological effects of a
substance or to another medical condition
 Not better accounted for by SczA, Scz, delusional d/o or
other psychotic d/o
 Never been manic or hypomanic episode
Major Depressive Episode
Specifiers
Melancholic
 Loss of pleasure or lack of
mood reactivity + 3 of:
 Distinct depressed mood,
worse in morning
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early awakenings
psychomotor changes
weight loss
guilt
Atypical
 Mood Reactivity + 2 of:
 Chronic rejection
hypersensitivity
 leaden paralysis
 hypersomnia
 increased appetite
Major Depressive Episode
Specifiers
 Peri-Partum
 Onset of episode during pregnancy or within 4 weeks
postpartum
 With Seasonal Pattern
 Onset and offset at particular times of year
 MDE never in a different season in past 2 years
 With Psychotic Features
 Hallucinations or delusions
 With Anxious Distress
 Feeling 2 or more of keyed/tense, restless, difficulty conc b/c of
worries, fearing something awful may happen, feeling might lost
control
Major Depressive Episode
MSE
Appearance
 Normal to Poor
kempt/hygiene
 Psychomotor retardation or
agitation
 Objective or subjective
Mood & Affect
 May deny being sad but look it
 “depressed”, “down in
dumps”, “sad”, “hopeless”,
“discouraged”, “blah”, “have
no feelings”, “anxious”
 Irritability, down, depressed,
low, heavy, anxious, tense
 Lability, Range restriction
Major Depressive Episode
MSE
Speech & Thought
 Latency (may be long!)
 Circumstantial
 may be preoccupied with somatic complaints, death,
hopelessness, personal defects
 Ruminations about past failings
 Delusions of guilt
 guilt/responsibility not limited to being sick and not meeting
occupational/interpersonal responsibilities
MDD Video
 https://www.youtube.com/watch?v=4YhpWZCdiZc
MDD Differential
 Manic episode with irritable mood or mixed episodes
 Mood d/o due to another medical condition
 Substance/medication-induced depressive disorder
 ADHD
 Adjustment d/o with depressed mood
 Normal sadness
Bereavement
Bereavement
MDE
Primary feelings Emptiness/ loss
Depressed mood, loss of
pleasure
Timing
Waves of grief,
↓intensity
Persistent low mood
Thoughts
Preoccupation with
deceased
Self-critical, pessimistic
Self-esteem
Preserved
Worthlessness/self-loathing
Suicide
“joining deceased”
Worthless, hopeless, pain
Depressive Symptoms d/t…
Medical Conditions
Medications
 MS
 Anticonvulsants
 Stroke
 Beta blockers
 Hypothyroidism
 CCB
 Anemia
 Estrogen
 Opioids
MDD Treatment
 Lifestyle
 nutrition, exercise, socialize, Omega 3s
 Meds
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SSRIs
SNRIs
NDRI
Mirtazapine
Tricyclics, MAOIs
 Psychotherapy
 Cognitive-Behavioral Therapy, Interpersonal Therapy, Family
 ECT
Antidepressants: SSRIs
 SSRI – Selective Serotonin Reuptake inhibitor
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Fluoxetine (Prozac): 10 to 60 mg
Fluvoxamine (Luvox): 50 to 300 mg
Sertraline (Zoloft): 25 to 250 mg
Paroxetine (Paxil): 10 to 60 mg
Citalopram (Celexa): 10 to 60 mg
Escitalopram (Cipralex): 10 to 20 mg
 First line: any, escitalopram- some evidence for
superiority, or “select one based on patient’s
presentation & med SE profile”
Common SEs of SSRIs
 Headaches or dizziness
 Weight/appetite fluctuations
 Nausea, loss of appetite, diarrhea.
 Anxiety or irritability.
 Problems sleeping or drowsiness.
 Loss of sexual desire or ability.
Serotonin Syndrome
 Results from excess serotonergic activity centrally (5HT1a,
5HT2)
 Onset within 24 hours of initiating a serotonergic agent
 Signs and Symptoms
 Cognitive: agitation, delirium, hallucinations, coma
 Autonomic: shivering, diaphoresis, hyperthermia, hypertension,
tachycardia, diarrhea
 Neurologic: myoclonus, hyperreflexia, tremor
 Untreated or unrecognized may lead to rhabdomyolysis,
renal failure, seizures
Serotonin Syndrome
 Symptoms are self-limited with removal of offending
agent(s)
 Supportive treatment targeting specific symptoms or
medical consequences
 Cooling, hydration, antihypertensives, anticonvulsants,
 Benzodiazepines to manage agitation
 Serotonin receptor antagonists (cyproheptadine)
Other Antidepressants
 SNRI: Serotonin Norepinephrine Reuptake Inhibitor
 Venlafaxine (Effexor): 37.5mg to 450mg
 Desvenlafaxine (Pristiq): 50-400mg
 Duloxetine: (Cymbalta): 60 mg
 NDRI: Bupropion (Wellbutrin)
 Bupropion SR 100 mg to 450 mg
 Bupropion XL 150 mg to 400 mg
 NaSSA: Mirtazapine (Remeron)
 15mg to 60 mg
 Serotonin-2 antagonist/reuptake inhibitor: Trazadone: 50 to
400 mg
Common adverse effects of
antidepressants
Old Antidepressants
MAOIs
TCAs
 Not first line
 Not first line
 SE Hypertensive Crisis; if
 SE include: dizziness,
combined with foods containing
tyramine (unpasteurized
cheese, herring, unpasteurized
meats, some beers and wines)
 Phenelzine (Nardil): 15 mg BID
to TID
 Tranylcypromine (Parnate): 10
mg BID to TID
 Meclobemide (Mannerix) –
reversible MAOI
sedation, blurred vision,
urinary retention,
constipation, dry mouth
 Risk of cardiac
arrhythmias if OD
 Nortriptyline, Amitriptyline
 Desipramine, Imipramine
Starting Medications
 Start low, go mod-slow , aim for lowest efficacious
dose, hold & assess, go up if still symptomatic, don’t
go beyond usual highest dose
 Escitalopram: start at 5mg x 1-2 weeks, then increase to
10mg.
 Sertraline: start with 25mg and increase by 25mg every
week until 150-200mg
 Venlafaxine: start 37.5mg and increase by 37.5mg per
week till 150mg
Psychotherapy
 Details with Anxiety
lecture!
 *Cognitive Behaviour
Therapy
 Family Therapy
 Supportive Therapy
 *Interpersonal therapy
 Dialectic Behavior Therapy
 Psychodynamic Therapy
ECT
 Gold Standard treatment for depression
 Most efficacious with least side effects
 Main side effects: memory loss
 1st line for acute catatonia/psychosis/
suicidality/patient’s preference
 Also used for refractory cases
 May take up to 15 sessions before effect seen
BIPOLAR
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Bipolar Disorder Criteria
 Abnormally elevated, expansive or irritable mood
and
 Persistently increased goal-directed activity or energy
 Plus 3 (4 if mood = irritable) of possible associated
symptoms
GST PAID by Bipolar Buyer
Bipolar Disorder
GST PAID
 Grandiosity (inflated self esteem)
 Sleep (less)
 Talkative (Pressured speech or talking more)
 Pleasurable activities with painful consequences
 spending, sex, speed, substances, foolish investments, gambling
 Activity increased (Goal-directed or psychomotor agitation)
 Ideas, Flight of (or racing thoughts)
 Distractable
Bipolar Disorder
Manic
 >7 days
 marked impairment in
social/occupational
functioning OR
hospitalization
 Possible psychotic features
Hypomanic
 >4 days
 Not severe enough to cause
marked
impairment/psychosis
 No hospitalization needed
 No psychotic features
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Bipolar Disorders
 Bipolar Type I
 At least one manic episode
 Bipolar Type II
 At least one Major Depressive Episode and one
Hypomanic Episode
Q: What is a Mixed Episode?
 No longer a Dx
 Now a mixed features specifier for MDD or Bioplar
 MDD
 > 3 manic/hypomanic symptoms that don’t overlap with
symptoms of major depression
 Hypomania/Mania
 the presence of at least three symptoms of depression in
concert with the episode of mania/hypomania
Bipolar disorder stats
 Bipolar I disorder: 12mo prev 0.6%, mean age 18
 Bipolar II disorder: 0.8%, early 20s
 Male: female ratio 1.1:1 (BPI)
 Females: more rapid cycling, mixed episodes,
depressive symptoms
 12% of originally diagnosed MDE  bipolar
 5-15% of bipolar II  bipolar I
Bipolar MSE
Appearance
 Flamboyant, better hygiene
than normal
 Psychomotor activity:
exaggerated hand gestures,
getting up from chair
frequently
 Intense eye contact
Mood & Affect
 “anxious”, “happy”, “angry”
 Elevated, ecstatic, euphoric,
irritable, worried
 Quick liability between
extremes
Bipolar MSE
Speech & Thought Form
Thought Content
 Pressured speech
 Grandiosity
 Flight of ideas
 Paranoia
 Distractibility
 Religious preoccupation
 Tangential
Bipolar Video
 https://www.youtube.com/watch?v=zA-fqvC02oM
Bipolar Disorder Differential
Bipolar I
Bipolar II
 MDD
 MDD
 Anxiety d/o
 Cyclothymic disorder
 Substance/Medication-
 Scz spectrum & oter related d/o
induced
 Anxiety d/o
 ADHD
 Substance-use d/o
 Personality d/o
 ADHD
 Disorders with prominent
 Personality d/o
irritability
 Biopolar II
 Bipolar I
Bipolar Disorder Treatment
 Lifestyle
 eat well, exercise, socialize, SLEEP!!!
 Meds
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Mood Stabilizers
Antipsychotics
Lamotrigine – for depression only
+ SSRIs (usually with a mood stabilizer or anti-psychotic)
 Psychotherapy
 Case Management, Mental Health Teams
 ECT
Mood Stabilizers
 Lithium, Valproic Acid, Carbamazepine
 Drugs of choice for bipolar disorder, schizoaffective
disorder and cyclothymia
 Acute mania and prophylaxis of mania and depression
in bipolar disorders
 Less effective for bipolar disorder depression
 Sometimes used for impulse control disorders,
aggressive behaviour and mood management in
personality d/o
Lithium
 Used in Bipolar mania, but also popular as an
antidepressant augmenter (especially resistant)
 Forms: regular, slow release, liquid
 300-1200mg total daily dose (OD or BID dosing)
 Start with 300mg OD/BID
 Dose increased over 7 to 10 days until plasma level
 0.8 to 1.2 mEq/L (0.8 to 1.2 mMol/L) for acute mania
 Lower in elderly (0.4 –1.0)
 0.6 to 0.8 mEq/L for maintenance
 Usual dose range: 900 mg/day to 2100 mg/day
 Make sure to measure levels 12 hrs after the preceding dose
Lithium
 Baseline Labs: BUN, Creat, lytes, FBG, TSH, fT4,
ECG>40yrs or cardiac disease
 Effects: 2 weeks, need 4-8 weeks for trial (7-14 days
for acute mania)
 Levels: drawn on day 5, usually weekly for first 1-2
month, then q2-4wks.
 Watch TSH and Creat q6months
 For side effects relief always think sustained release or
spreading the dose around
 For tremor consider beta blocker
Predictors of Lithium Response
 Previous or family history of response
 Few previous manic episodes
 “Classic mania” (not mixed)
 Lack of rapid cycling
 Less effective than Valproic Acid in rapid cycling
Lithium: SEs
Acute SE
Long-term SE
 GI (nausea, diarrhea)
 Hypothyroidism (20%)
 Neuro (drowsiness, cognitive
 GU: impaired concentration
dulling, fine hand tremor)
 Metabolic (wt gain)
 Derm (rash, worsening of
psoriasis, acne)
 GU (polydipsia/polyuria, DI)
 Hematologic (mild
leukocytosis common)
of urine, DI, renal
parenchymal changes, rare
kidney failure
Lithium: Toxicity/Overdose
Symptoms:
Causes:
Mental status changes
Nausea/Vomiting
Incontinence
Course hand tremor
Dysarthria
Gait ataxia
Cardiac: depressed ST
Dehydration, NSAIDs, ACEi,
diuretics can increase Li levels
segments, T wave inversions,
arrhythmias
CAN BE FATAL
Management:
 Stop lithium
 Supportive medical care
 Draw lithium levels
 Dialysis if serum level > 4 or
if clinically indicated
Valproic Acid
 Effective for bipolar disorder, schizoaffective disorder,
cyclothymia
 More effective than lithium for rapid cycling and mixed
state episode bipolar disorder
 Can also be used for impulse control disorders,
aggression and Cluster B personality disorders
 May take up to 14 days to see antimanic effect
 Trial of 4 to 6 weeks should be completed
Valproic Acid - Dosing
 Starting dose: 20 mcg/kg for rapid stabilization of mania
 Approx: 500 mg TID or 750 mg BID
 Titrate up to serum level of 50 to 125mg/mL (350 –
700) = Avg maintenance dose: 1500 to 3000mg/day
 Available in once daily or divided doses
 Elderly require approximately half that of younger
adults
Valproic Acid
Labs
 Baseline: CBC, LFTs
 Serum levels, CBC, platelet
count, and PT/PTT should be
done weekly during first
month
 Serum levels, CBC, LFTs
Q3-6months
SEs
 Favourable SE profile and
lower toxicity compared to
Lithium
 Nausea, diarrhea, headache,
sedation, fine tremor, weight
gain, alopecia, leukopenia,
neutropenia,
thrombocytopenia, elevated
LFT’s – in rare cases liver
failure and/or pancreatitis
Lamotrigine
 Anticonvulsant
 Indicated for bipolar depression
 More effective in the treatment of bipolar
depression compared to other mood stabilizers
 Also used in treatment resistant unipolar
depression
 Used as monotherapy or adjuncive tx to other
mood stabilizers and/or antidepressants
Lamotrigine – Dosing
 Initial dose: 25 mg OD, increased weekly by 25
mg/week until you reach 200 mg/day
 Up to 400 mg may be required to treat depression
 Once or twice daily dosing usually qhs
 Therapeutic effect may be seen in 2 to 4 weeks
Lamotrigine
Labs
 Baseline: renal and hepatic
fx (both involved in excretion)
 Serum levels not useful as
therapeutic window not yet
determined
SEs
 Very well tolerated by most
patients
 HA, somnolence, nausea,
diarrhea, dizziness, ataxia,
diplopia, blurred vision
 RASH (10%): limbs
 Steven – Johnson (0.3%): chest,
neck, face, oral mucosa
 If rash of any sort advise pt to DC
and see MD immediately
Carbamazepine
 Anticonvulsant
 Used in pts who do not respond to lithium
 Starting dose: 200 mg BID
 Maintenance dose: 800 to 1600 mg/day
 Divided BID or TID to minimize SE
 Serum level 25 to 60 mM
Carbamazepine – SEs
 Agranulocytosis and aplastic anemia (1 in 20 000)
 Induction of liver enzymes: effects most psych meds,
decreased effectiveness of OCP, auto–induction (half
life and serum level decrease with time)
 SJS reported (rare)
Second Generation
Antipsychotics:
 Evidence for efficacy as monotherapy and add-on
mood stabilizers for:
 Risperidone, Olanzapine, Quetiapine
 Same doses as treating psychotic d/o
 Risperidone 4-8mg/d
 Olanzapine 15-35mg/d
 Quetiapine 600-900mg/d
 More info about antipsychotics with Psychosis lecture
Other Treatments
 Psychotherapy
 Re: medication compliance
 ECT
 For prolonged or severe mania
 Bipolar depression
Persistent Depressive Disorder
(Dysthymia)
 Depressed Mood most of the day, for more
days than not, for > 2 yrs
 Children: mood can be irritable & > 1 year
 Not without symptoms for > 2 months at a time
 > 2 of 6 following (CHASES):
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Concentration, poor or difficulty making decisions
Hopelessness
Appetite, poor or increased
Sleep, decreased or increased
Energy low
Self-esteem low
The Dysthymia Dog CHASES its Tail
Cyclothymia
 Numerous periods of Hypomanic symptoms and
Numerous periods of depressive symptoms for 2 years.
 No full manic, hypomanic or major depressive episode
 Not symptom-free for > 2 months
Adjustment Disorder
 Emotional or behavioural symptoms in response to an
identifiable stressor
 Occurs within 3 months of onset of stressor
 Marked and excessive distress
 Sig impairment in important areas of functioning
 Symptoms don’t persist > 6 months after stressor or its
consequences have ended
Adjustment Disorder Specifiers
 With depressed mood
 With anxiety
 With mixed anxiety and depressed mood
 With disturbance of conduct*
 With mixed disturbance of emotions and conduct
 Unspecified
 *abnormal conduct violating the rights of others or going
against societal norms. Ie. truancy, vandalism, reckless
driving, fighting, or defaulting on legal responsibilities.
Summary
 Depression:
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Bereavement exclusion gone, but use clin judgement
MAOi/TCAs rarely used
Anti-depressants equally efficacious  S/E profile
Watch for serotonin syndrome
 Bipolar disorder:
 New criteria: mood PLUS energy/ goal-directed activity
 Watch for lithium toxicity
Thank-you!
QUESTIONS?
:):
Hypertensive Crisis: “the
cheese reaction”
 Tyramine causes a potent release of NE
 In the absence of an MAO-I, tyramine is broken down
by MAO-A in the gut, liver and any NE released is
broken down in the synaptic cleft
 Normally a person can ingest 400mg of tyramine with
no increase in BP (a high tyramine meal only has
40mg)
 Drug-drug interactions can also lead to hypertensive
crises (decongestants, stimulants, SNRIs)
TCA Overdose
 Most symptoms related to anticholinergic load:
delirium, tachycardia, dilated pupils, ileus
 Seizures and coma (mechanism poorly understood)
 Cardiotoxicity mediated via the Na channel blockade
 Arrhythmias
 ECG changes: QT prolongation, widening of the QRS, AV
blockade, V tach
 Severe hypotension (a-adrenergic blockade)
TCA Overdose Management
 Hospitalization, cardiac monitoring (continue for 24
hours after signs of toxicity have resolved)
 Charcoal
 IV fluid resuscitation
 Bicarb infusion to treat acidosis
 Psychiatric consult