A.
Major Depressive Disorder (MDD): Bipolar Disorder:
Essential features:
- symptoms of 2 weeks or more duration of:
- depressed mood or loss of interest or pleasure in nearly all activities
- changes in appetite or weight
- sleep changes
Sleep EEG abnormalities:
- prolonged sleep latency
- increased intermittent wakefulness
- early morning awakening
- reduced NREM stages 3 and 4 -decreased REM latency
- increased REM phasic activity
- increased duration of REM early in night
- changes in psychomotor activity
- decreased energy
- feelings of worthlessness or guilty
- difficulty thinking, concentrating or making decisions
- recurrent thoughts of death or suicide
- suicide plans or attempts
-significant distress or impairment in function
Single episode, or recurring
most striking symptoms
-depression
-elderly: mood changes, aggressive
Vegetative symptoms: sleep abnormalities usually insomia
subtypes have hypersomia
Anorexia, loss of libido, insomnia
subtypes can have reverse of things
Risk of suicide high in presence of
-psychosis
-previous attempts
-family history of suicide
-concurrent substance use
-co-morbid Panic Disorder
Other signs and symptoms:
-tearfulness
-irritability
-brooding
-obsessive rumination
-excessive worry over physical health
-somatic complaints
-delusions
-hallucinations
means: what other disorders will people have
dysthymic: double depression
-may improve from MDDE1 but not return to euthymia
2. Co-morbidity:
-Dysthymic Disorder
alcohol and substance abuse
-Substance-Related Disorders
-Panic Disorder
CVD: lots of liturature
-Obsessive-Compulsive Disorder
-commonality, both effect each other
-Anorexia Nervosa
-using antidepressents treats MIs
-Bulimia Nervosa
-SSRI are anticoagulants too
-Borderline Personality
-Disorder Diabetes
-Myocardial Infarction
Psychosis: delusions, feel like they did a crime
-Strong Relationship between CAD and MDD Carcinomas (Lung, Liver, Pancreas)
halucinaitons that are accusitory
-Stroke
These tumors can present with depressive episode
3. Medical complications:
-Patients over 55 years of age with MDD die 4X as often as general population.
-Patients with MDD admitted to nursing homes have markedly increased likelihood of death in
the first year.
-Patients with MDD in general medical settings have more pain and physical illness than
non-MDD patients.
somatic complaints can reach delusional proportions
4. Epidemiology:
Point prevalence = 4.3%
Life-time prevalence = 8%-20%
Women:Men = 2: 1
High Previlence
Lifetime over the course of illness, the cost $$$ of MDD is close
to CVD (very expensive bc its so prevalent)
5. Etiology:
A. Psychological
Dysthymic Disorder
-occurrence of one or more manic or mixed episodes in patient who is likely to have had one or
more major depressive episodes
Adolescence to patients at age 80
usually adolescence to middle ages
bread and butter of what psychiatrists treat
Essential features:
-chronically depressed mood -for most of the day
-more days than not
Manic episode:
-two years or more
Essential features: distinct period of abnormal, persistently elevated, expansive, or irritable mood
-poor appetite or overeating -insomnia or hypersomnia
-manic episode lasts at least a week
-low energy or fatigue
-grandiosity (inflated self-esteem)
-low self-esteem
dysthymic patients to not become psychotic
BPD: 2 pards
-decreased need for sleep
-poor concentration
-bipolar depressed looks like MDD
-pressured speech
-difficulty making decisions
Wash car at 3am
Smoldering depression
-bipolar
manic:
going
fast
-flight of ideas
-feelings of hopelessness
other people notice these people
-usually psychotic, not in touch with rea;ity
-distractibility
-low interest -self-criticism
-psychomotor agitation or acceleration
-feelings of inadequacy
-involvement in dangerous or potentially financially ruinous activity
-loss of interest or pleasure in general
-marked impairment in function or psychotic features (often requiring hospitalization)
-social withdrawal
-guilt feelings
-irritability or excessive anger
Bipolar sexual psychotic
Other signs and symptoms:
-decreased activity, effectiveness, or productivity
much more noticable, can be aggressive an assultive
-little insight, denial
-symptom-free periods last no longer than 2 months
feel inflative self esteem and grandiosity
-impulsivity
-after 2 years of disorder patient may have superimposed MDD ("double depression")
feel like they know more than the doctor
-lack of inhibitions (e.g. sexual)
-unethical behavior (uncharacteristic)
Co-morbidity
Bipolar people at their peak dont want treatment
-poor judgment
MDD
he has seen of 2 cases of post-partum mania
Substance dependence
10. Depressive episode: see MDD
Various personality disorders
erratic an unusual behavior
11. Complications:
EX: tearful patient explaining how awesome he is
-completed suicide (10-15%) -child abuse
-spouse abuse
-job loss
-divorce
-criminal activity
-excessive activity may be dangerous for patients with cardiac conditions
Epidemiology:
Lifetime prevalence = 6%
Point prevalence = 3%
12. Co-Morbidity:
-Anorexia nervosa
-Bulimia nervosa
Anxiety disorders
-ADD
-Panic Disorder
-Social phobia Substance-related disorders
Treatment:
Psychodynamic psychotherapy
Cognitive psychotherapy
Antidepressant agents
13. Epidemiology:
-Lifetime prevalence = .5-1 %
-Women: Men = 3: 2
Genetics: more common among first degree relatives with MDD
Differential Diagnosis: see MDD
rare, harder to treat
strong genetic correlations
14. Genetics:
-First degree relatives of patients have mostly Bipolar Disorder but also MDD.
-Twin and adoption studies suggest strong genetic component
-X chromosome linkage reported
15. Neurobiology:
-increased number of high signal intensity regions (NM)
anticonvulsants
-SPECT switched from
anti psychotics
-high glucose utilization during mania
lithium
-low glucose utilization during depression
-Increased central dopaminergic activity
DA and GABA too in addition to
NE, 5HT
16. Subtypes:
classic
1) Bipolar I
-manic episode
-major depressive episode
-mixed episode
MOOD DISORDERS
Overall Goal: recognize, evaluate, and state the treatments for patients with mood disorders.
Specific Objectives:
Students will be able to:
hypomanic + MDD
2) Bipolar II
-hypomanic episode
-major depressive episode
Why do people have MDD??
1. Discuss evidence for neurobiological, genetic, psychological, and environmental etiologies of mood disorders;
Psychological theory simply
-retroflexed anger turned inward
B. Genetics
3) With seasonal pattern
2. State the epidemiologic features, prevalent rates, and lifetime risks of mood disorders in clinical and non-clinical populations;
-instead
of
externalizing,
internalizing
-more MDD seen in families of patients with MDD than Bipolar Disorder.
With rapid cycling many episodes over the year
-thinking aobut death of parent, caused death
-monozygotic to dizygotic ration = 4: 1
3. Compare and contrast the epidemiologic and clinical features of major depression and bipolar disorder;
-feel guilty about death, internalized
-1.5 - 3 X more common among first degree relatives of MDD patients than the general population.
17. Differential Diagnosis:
-increased risk of alcohol dependence among first degree relatives of MDD patients.
-Multiple Sclerosis
4. mood disorders
Depression is biologically driven
-Stroke
rule out physical things
signs and symptoms
C. Neurobiology:
-Brain tumor
drugs are high, cocaine
differential diagnosis (including general medical and substance induced disorders)
Definitely runs in families, and stronge genetic
[Catecholamine hypothesis + Functional deficit of serotonin] >>> Biogenic Amine Hypothesis
-Epilepsy
course of illness
connection,
EX
2
parent
famliy,
both
with
MDD
-Dysregulation in acetylcholine, dopamine and GABA system
-Head trauma
Antidepressents, contraversial if they CAUSE mania
comorbidity
-5 childen 4 girls (2 twins)
-Areas of decreased metabolic activity or perfusion in left frontal region (PET)
-HIV
prognosis
-he has treated all the girls
-Increased number of focal signal hyper intensities in white matter (MRI)
-Neurosyphilis
complications
-one depressed
-Cushing's Disease
-one schizoaffective disorder + SLE
Neuroendocrine abnormalities:
-Lupus (SEE)
5. elderly patients with major depression
-one bipolar disorder
-increased blood cortisol level
-ADD
special characteristics of the clinical presentation in
-one was suicidal
-blunted growth hormone response to insulin challenge -blunted TSH response to TRH
-Schizophrenic Disorder
the complications of the illness
-male: medical student, broke down some doors -Drug induced:
unique precautions necessary in treating this population;
-treated with Li, he has been stable for 25yrs
Structural Abnormalities
-amphetamines
-still on Li maintainence
-decrease in hippocampal size
-cocaine
6. Discuss the increased prevalence of major depression in patients with general medical/surgical illness
-low levels of BDNFC brain derived Neurotrophic factor
-methylphenidate
(e.g. myocardial infarction, CVA, hip fracture)
Most work these days is on the biogenic amine hypothesis
-corticosteroids
the impact of depression on morbidity and mortality from their illness
originally: treatment with some anti-hypertensives became depressed
6. Subtypes of MDD
-ACTU
-reserpine depletes biogenig amines
-Single Episode
-cyclosporine
7. Outline the recommended acute and maintenance treatments for dysthymic disorder, major depression, and bipolar disorder.
he said the electioconvolsive did it once
INH
for
Tb,
sometimes
saw
a
elevation
in
mood,
it
is
an
analogue
to
a
MAOi
-Recurrent
-levodopa
after 8 ECTs hes seen it happen
Biogenic Amine Hypothesis: need proper regulation of brain 5HT, NE,
-Chronic (continuous for 2 years or more)
-antidepressant agents
we treat MDD by elevating 5HT and NE, or both
(to a lesser extent DA, GABA, ACh)
-With psychotic features (delusions, hallucinations)
Other induced:
-Mood-congruent
-electroconvulsive treatment
there
is
neuroendocrine
changes
-Mood-incongruent
-light therapy
psychotherapy doesnt work bc they are psychotic
low BDNF
deceased hippocampal size
With melancholic features
often need hospitalization
-Loss of pleasure in all activities or lack of reactivity to pleasurable stimuli
18. Treatment:
Subtypes: MDDE1, MDDR, Chronic (tough to treat)
-Worse in the morning
depecote: valproate
Chronic = treatment resistant depression
-Early morning awakening
-Manic episode:
tegretal: carbamazapine
-Marked psychomotor retardation or agitation
-hospitalization
antipsycotics = neuroleptics for schizophrenia
MDD can have psychotic features
-Significant anorexia or weight loss
-mood stabilizers
(treat rapidly with haloperidole (potent)
Mood congruent: delusions are in line with depression
-Excessive or inappropriate guilt
1. lithium carbonate
get them on a lithium and off of haloperidol
-mood is depressed, delussions are depressed
2. anti-consultants
often
BPD patients are on more than on drug
Mood incongruent: depressed but think they are the king
With seasonal pattern
3. neuroleptics
(usually is a different disorder
-adjunctive agents
Exam Question: patient w BPD comes in with a depressive episode
psychotic MDD is bad for prognosis
7. Course of MDD:
-electro convulsive therapy
-take lithium, gave it up, 4 months later he is suicidal
-50-60% of those who have an episode will have a second episode.
-dont give an antidepressant bc it will induce manic episode
Involutional Period: biological factors
-70% of those experiencing two episodes will have a third.
-Major depressive episode:
-increase the mood stabilizer
-menopause, old age, diurnal variation = worse in morning
-90% of those having three will have a fourth episode.
-increase dose of mood stabilizer or
-or can give mood stablizer + antidepressant (he tends to keep it like this)
-diurinal variation is common in MDD
-5-10% of first episode patients will have a subsequent manic episode.
-add anti-depressant agent
-discontinue ADA as soon as depressive symptoms lift
Seasonal: SAD, seasonal affective disorder
8. Differential Diagnosis:
-develop depression at this time of year
-Hypothyroidism (Myxedema)
-In general:
-less
light,
improves
with
spring
time
-Hyperthyroidism. (apathetic type)
-psycho education for patient and family
-increase antidepressenent in winter months
-Hyperthyroidism
-supportive psychotherapy
-Cushing's Disease
-psychodynamic psychotherapy (if needed) between episodes
Classic MDD: season independent
-Addison's Disease
-use sodium valproate for rapid cyclers (lithium may exacerbate Rapid cycling
-Multiple sclerosis
MDD clinical course
-Stroke
-50% of MDD1E have another
-Systemic lupus erythematosus
-if you have another you are likely to have many disorder
-Congestive heart failure
-can progess to mania, then we change the diagnosis
-Parkinsonism
Anything that affects the body
-most do not progess to BPD
-Huntington's Disease
affects the brain
-change the dx, bc Rx is different
-Infectious mononucleosis
-Infectious hepatitis
Rule out other psycological
-HIV infection
Rule out system by system
-Pancreatic carcinoma
hypothyroid can look like depression
-Bipolar Disorder
Malignancy: lung, liver, pancrease like MDD
-Schizophrenic Disorder
HIV, MONO, LYME
-Dementia ("pseudo dementia")
CVD, AI,
-Uncomplicated bereavement
Wilsons
-Dysthymic Disorder
-Adjustment Disorder with depressed mood
-Borderline Personality Disorder
BPD (Bipolar)
Type 1: Classic Manic Episodes and depressive episodes
Type 2: Hypomanic episodes
Manic Episode
Mood
-Drug induced:
0-sedatives, hypnotics, anxiolytics (e.g. barbiturates, benzodiazepines)
-anti-hypertensives (e.g. reserpine, alpha-methyldopa)
-oral contraceptives
-steroids (and withdrawal)
both illicit and non-illicit
-anti-psychotics
antihypertensives, sedatives (barbs)
-stimulant withdrawal (e.g. cocaine)
BZDs, steroids, etOH
-alcohol
9. Treatment:
A. Psychotherapy -supportive
-psychodynamic
-cognitive
-interpersonal
BPD type 1
BPD type 2
Time: days - years
more often psycho-supportive
some psycho-dynamic
Mild MDD can respond to psychotherapy alone
usually we go to MDD
B. Pharmacotherapy
-anti depressant
-Augmentation Drugs
C. Electro-convulsive Treatments
D. Trans cranial magnetic Stimulation (TCMS)
E. Magnetic Convulsive Therapy
F. Vagal nerve stimulation
G. Phototherapy
H. Deep Brain Stimulation
I. Suicide Prevention
Hypomanic Symptoms + Depressive
Euthymia
50% of patients
Anti-depressents: SSRI, SSNI, new 5HT agonist
MAOis with side effects
18 antidepressants on the market
Prozac paxil zoloft cimbalta, effexor
Aumentation drugs: back up to 18 antidepressents
-Li augmentation in some MDD (mood stabilizer)
-buprionone
2 antipsychotics approved aumentation for MDD
1) abillify
2) serequell
(not to keen on their use)
elector convulsive is good in older, and preggers
(alternative to drugs)
gets bad publicity from sientologists
transcranial magnetic stimulation
-can produce seizure
Vagal nerve stimulation: used in chronic (treatment resistant)
-never really caught on
Phototherapy: lights for SAD
-2 patients that use them, 1 says yes, 1 says no
DBS: probes, where do they go?
MDDR
MDD1E
MDD (Major Depressive Disorder aka Unipolar depression
1E = 1st Episode (over 50% have another episode)
R = Recurrent episode
Tx is directed towards index episodes
-maintainance Tx for Chronic MDD
Treatment at index episode = acute treatment
Prophylactic treatment = remission
BPD can present with depressive episode
if manic episodes are known, treatment is different
Dysthymia
-Waxes and Wanes
-not as severe as MDD
