Week 5 & 6: Mood Disorders

Mood

relating to a single pole-manic OR depressed

Bipolar

an episode of manic symptoms not meeting criteria for a manic episode

Milder form of bipolar: 2 years of hypomanic & depressive periods w/o fulfilling full criteria

Milder form of MDD: persistent depressive disorder that lasts 2 years or more but does not meet MDD criteria

Condition lasting 1 year or more and requires ongoing medical attention, limits ADLs, or both

Symptoms have a rapid onset and is accompanied by distinct symptoms that require urgent or short-term care, and get better with treatment

Most mental illness is chronic and expect times of relapse and remission

Get pt to the highest level of function and maintain

The longer that the patient is in a relapse phase, the more damage that is being done and can hinder the ability to reach the same level of maximum function from previous baseline.

Under-excitement

Structural changes, membrane changes, neurotransmitter alterations, and hormones

Serotonin

Norepinephrin & Serotonin

Norepinephrine and Dopamine

Norepinephrine

Multiple neurotransmitters all at once which can cause the vast number of side effects associated with these medications

GABA

Glutamate

Psychosis

Neuronal alterations or neuronal death. It may also lead to reduced volume of the cerebral cortex

The brain is pruning frequently to rid itself of unnecessary connections and stress often results in pruning that is damaging

Elevated HPA activity induced by high levels of stress

Immune dysfunction can lead to depression through inflammation and other disease processes. There are changes in the lymphocytes responsible for neuromodulation

Depressed pts have less slow wave sleep, more awakenings, less total sleep, increased phasic REM sleep, and an increased body temperature

Decreased anterior brain metabolism, subcortical hyperintensities (areas of the brain that are dysfunctional due to atrophy), hemispheric reductions in activity, & reduced cerebral blood flow. It is difficult to know if the depression caused the changes in the brain or if the changes in the brain led to the depression.

Goal setting and activities to attain goals

Integration of attention & emotion

Emotional learning and fear conditioning

Processing novel emotional stimuli

Hippocampus

It is where emotions are processed

A normal thyroid panel may still be contributing to the depressive symptoms

Lithium and propranolol

levothyroxine (take 1st thing in AM on empty stomach about 20-30 minutes ac)

liothyroxine sodium (take 1st thing in AM on empty stomach about 20-30 minutes ac)

liotrix (take 1st thing in AM on empty stomach about 20-30 minutes ac)

400mcg/day

Vitamin D

Vegetarians, dx of IBD (not IBS), malnutrition, & MTHFR mutations

Builds neurological tissue & reduction of inflammation

Serotonin

Norepinephrine & dopamine

Protein is a precurser to neurotransmitters and can mainfest as neurological or mental health disorders

Anemia

Major depressive disorder

Disruptive mood dysregulation disorder

Persistent depressive disorder/dysthymia

Premenstrual dysphoric disorder

5

2 weeks and represent a change from previous baseline functioning

1) depressed mood
2)) loss of interest or pleasure

A minimum of 5 of the following are required to diagnose and one of them must include a depressed mood and/or loss of interest or pleasure.
-significant wt loss outside of dieting or weight gain (>5%); change in appetite nearly every day
-insomnia or hypersomnia nearly every day
-psychomotor agitation or retardation nearly every day
-fatigue or loss of energy nearly every day
-feelings of worthlessness or excessive/inappropriate guilt nearly every day
-diminished ability to think/concentrate or indecisiveness nearly every day
-recurrent thoughts of death, recurrent suicidal ideation w/o a specific plan, or a suicide attempt or specific plan to do so

5 or more of the MDD criteria are reported or observed by others
Symptoms cause significant distress or impairment in social, occupational, or other areas of functioning
The episode is not attributable to effects from a substance or other medical condition

Need to assess for previous episode of mania or hypomania to fully meet the criteria for MDD

-berevement
-financial ruin
-losses from a natural disaster
-a serious medical illness or disability

Severity (mild, moderate, severe, psychotic features absent or present)
Remission status (partial remission or full remission)
Single episode or recurrent episode
Features (anxious distress, mixed, melancholic, atypical, mood-congruent, mood-incongruent, catatonia, peripartum, seasonal)

At least 2 of the following:
-feeling keyed up or tense
-feeling unusually restless
-difficulty concentrating because of worry
-fear that something awful may happen
-feeling that the individual might lose control
(mild=2; moderate=3; moderate-severe=4-5; severe=4-5 w/ motor agitation)

>risk of suicide, longer duration of illness, > likelihood of treatment failure

At least 3 of the following:
-elevated, expansive mood
-inflated self-esteem or grandiosity
-more talkative than usual or pressure to keep talking
-flight of ideas or racing thoughts (subjective)
-increase in energy or goal-directed activity
-increased or excessive involvement in activities that have a high potential for harmful consequences
-decreased need for sleep

>risk factor for the development of bipolar 1 or bipolar II

At least 1 of the following:
-loss of pleasure in almost all activities
-lack of reactivity to usually pleasurable stimuli
At least 3 of the following:
-depressed mood characterized by "emptiness" or "despair"
-depression that is worse in the AM
-early morning awakenings
-psychomotor agitation or retardation
-anorexia or weight loss
-excessive or inappropriate guilt

Mood reactivity (mood brightens in response to positive events)
At lease 2 of the following:
-weight gain or increased appetite
-hypersomnia
-leaden paralysis (extremities feel heavy)
-pattern of interpersonal rejection sensitivity that results in social or occupational impairment

-delusions or hallucinations are present at any time during the episode
note if congruent or incongruent
-congruent: content is consistent w/ typical depressive themes of inadequacy, guilt, disease, death, nihilism (negativity), or deserved punishment
-incongruent: content is not consistent or is mixed

catatonic featrures are present
-stupor
-cataplexy
-waxy flexibility
-mutism
-negativism
-posturing
-mannerism
-stereotypy
-agitation
-grimacing
-echolalia
-echopraxia

Stupor

Cataplexy

Waxy flexibility

Mutism

Negativism

Posturing

Mannerism

Stereotypy

Echolalia

Echopraxia

Mood symptoms occur during or within the 4 weeks of delivery

Regular pattern established between the onset of various episodes and a particular time of the year and subsides once the season changes
-happens at least the last 2 years

Recurrent

Full: during the last 2 months no significant s/s are present
Partial: during the last 2 months there have been no significant symptoms present but may still have some symptoms of the last episode present

-Severe recurrent temper outbursts through verbal rages or physical aggression that are out of proportion in intensity or duration to the situation or provocation
-Tantrums are inconsistent w/ developmental level
-Outbursts occur 3+ times/week
-Mood in between is irritable or angry most of the day and nearly every day (observable by caregiver)
-Present in at least 2 of 3 settings (home, school, or w/ peers)
-Present for at least 12 months and not observable for <3 months at a time
**do not make diagnosis before age 6 or after age 18

2

2 years (adults) & 1 year (children & adolescents)

A depressed mood for most of the day, for most days. For children & adolescents mood may be irritable.

-poor appetite or overeating
-insomnia or hypersomnia
-low energy or fatigue
-low self-esteem
-poor concentration or difficulty making decisions
-feelings of hopelessness

During the 2 year period (or 1 year for child/adolescents), the individual has never been without the symptoms for more than 2 months at a time
No evidence of a manic or hypomanic episode
Can co-occur with a major depressive episode (assign both diagnoses)

5

Present during most cycles that occurred in the preceding year

In the majority of cycles, symptoms are present in the final week before onset of menses, start to improve within a few days after it begins, and become minimal or absent in the week postmenses

-Marked affective lability (mood swings, sadness or tearful, or increased sensitivity to rejection)
-Marked irritability/anger or increased interpersonal conflicts
-Marked depressed mood, feelings of hopelessness, or self-deprecating thoughts
-Marked anxiety, tension, and/or feelings of being keyed up or on edge
Additionally at least 1 of the following:
-decreased interest in usual activities
-difficulty concentrating
-lethargy, easily fatigued, or lack of energy
-change in appetite (> or specific food cravings)
-hypersomnia or insomnia
-feeling overwhelmed or out of control
-physical symptoms: breast tenderness, joint or muscle pain, bloating, weight gain

-bipolar
-ODD
-ADD
-MDD
-anxiety
-autism
-intermittent explosive disorder

-mania
-medical condition
-SUD
-ADD
-adjustment disorder
-sadness

-MDD
-psychotic disorder
-medical condition
-SUD

-PMS
-dysmenorrhea
-bipolar
-MDD
-persistent depression
-hormones

Mild depression

Moderate depression

Severe depression

Mild depression

Moderate depression

Severe depression

-citalopram (Celexa)
-escitalopram (Lexapro)
-fluoxetine (Prozac)
-sertraline (Zoloft)
-fluvoxamine (Luvox)
-paroxetine (Paxil)

-desvenalfaxine (Pristiq)
-venlafaxine (Effexor)
-levomilnacipran
-milnacipran
-duloxetine (Cymbalta)

-bupropion

-vilazodone (Viibryd)
-vortioxetine (Trintelix)

-nefazodone
-trazodone

mirtazapine (Remeron)

-amtriptyline (Elavil)
-doxepin
-nortriptyline
-clomipramine

MAOIs (low tyramine diet)

Celexa and Lexapro

Celexa & Lexapro

Luvox & Paxil

Check interactions between all of the pt's medications and OTC meds including vitamins and herbal supplements.

Celexa & Lexapro

Prozac

Both approved for much younger ages

Luvox

Paxil

No use in pregnancy
Withdrawal symptoms when run out or stop
Weight gain

Luvox & Paxil

Celexa, Lexapro, Prozac & Zoloft

Prozac & Zoloft (1-2 lbs/year)

Those that had poor response to a SSRI because it hits both serotonin and norepinephrine

Pain control and >energy level

> heart rate and BP

Seizure disorder

Bupropion

vilazodone (Viibryd)

vilazodone (Viibryd)

vortioxetine (Trintelix)

trazodone

At low doses can be used PRN anxiety
Helps w/ sleep
Used for anxiety and depression (max is 600mg/day but typically not pushed beyond 400mg)

Helps with sleep at lower doses
Works well for depression
Stabilizes appetite

mirtazapine

"California Rocket Fuel" beneficial combination for depression

Treatment of OCD

Amitriptiline and Doxepin

Helps with neuropathy, sleep, anxiety & depression

Weight gain
Avoid if pt has arrhythmias
Overdose w/ these medications can be lethal with just a month supply

Need to be weaned off slowly and be off the MAOI for at least 2 weeks before initiation of the new medication

Try not to prescribe from the same "family" (Ex. Sertraline + mirtazapine + bupropion is appropriate)

True.

Almost all cause prolongation. Try to avoid combining several that cause prolongation. (Ex. Geodon + Effexor + hydroxizine) All have the potential to impact the QT interval

>450

>470

Fainting, palpitations, seizures, fatigue, dizziness, irregular heart beat, and may result in cardiac arrest

Refer to a cardiologist

Head (headache/poor concentration) or stomach (nausea, diarrhea) This is r/t location of serotonin receptors.
Some sexual side effects (poor organsm, <libido, erectile dysfunction)

Wellbutrin or buspirone
Viagra for men w/ ED

SSRI

4-7 days

Have pt take at bedtime instead if they notice this effect with AM administration

-buspirone (Buspar)
-aripiprazole (Abilify)
-brexpiprazole (Rexulti)
-olanzapine (Zyprexa)
-quetiapine (Seroquel)
-lamotrigine
-lithium
-ketamine
-Spravato

In office over a 30 minute infusion and improvement is often evident over 2-7 days

TD, chronic tachycardia, weight gain, metabolic changes, & hyperglycemia

olanzapine & quetiapine

May be over stimulating (may lead to panic attacks)

r/t dopamine levels being affected

olanzapine (can be given for a short course to break the deep depressive cycle)

Seroquel

Rexulti

Good option for mood stabilization, bipolar depression, and depression.

25mg daily for 2 weeks
50mg dialy for 2 weeks
Then up to 100mg daily after that
*most therapeutic between 100-200mg

Rash w/ risk of Steven Johnson syndrome. Pt should call to report all rash symptoms to assess if it will be stopped or slower titration is needed.
Most of the time the rash is the result of too much medication too fast and requires a slower titration in some individuals.

check for interactions or reference the prescribers guide.

Treatment resistant depression

Lithium

Stay hydrated, avoid NSAIDs, and need to monitor thyroid and kidney function so frequent labs will be required.

Must be administered in the clinic
Pt must wait in the office after administration

Dissociation
Hypertension

Outcomes can be achieved with psychotherapy alone or in conjunction with pharmacotherapy

Cognitive distortions and the ability to develop alternative, flexible, positive thinking

Discrete behaviors are addressed in the context of their effect on relationships

Address maladaptive behaviors that may have resulted in inadequate positive feedback

Change personality structure

Utilize if disorder jeopardizes the family unit.

Compliance of taking the medication

The neurotransmitter receptors are sensitive to any changes in neurotransmitter levels and it takes 4-8 weeks to see full benefit and any lapses in treatment can cause a decline fairly quickly.

1 year after achieving maintenance level. If symptoms resurface, restart medication at the same level they ended as long as not much time has elapsed.

Depression is often chronic and lifetime treatment is often necessary.

depressed mood
loss of interest or pleasure

Generalized psychomotor retardation

Hand wringing or hair pulling

Decreased rate and volume of speech
Limited details & delayed responses

Fatigue
Low energy
Inattention
Insomnia
Early morning awakening (terminal insomnia)
Poor appetite & weight loss
Decreased libido & sexual performance
Menstrual irregularities
Worse depression in the AM

Reduced energy
Difficulty finishing tasks
Decreased motivation to take on new tasks

Trouble sleeping
Early AM awakening (terminal insomnia)
Multiple awakenings throughout the night
Awakenings that lead to rumination about problems

Increased appetite & weight gain
Hypersomnia

Feelings described as sadness, depressed, blue, down, etc.

Lack of pleasure in activities that were once enjoyable

Feeling "ill" or "sick"

negative views
non-delusional ruminations of loss, guilt, suicide, and death
thought blocking
poverty of content

delusions or hallucinations are present

consistent w/ the depressed mood and may include: guilt, sinfulness, worthlessness, poverty,failure, persecution, & terminal somatic illnesses (ex. cancer)

not consistent w/ the depressed mood and may include: grandiose themes

Higher lifetime risk of successful suicide than those never hospitalized for these factors

A suicide that results as the pt begins to improve and regain the energy needed to plan & carry out suicide

Inability to concentrate
Impairments in thinking
Poor memory

Reviewing actions in the past and behavior during the interview

Symptoms
Past episodes

Impact on level of functioning

School phobia
Clinging
Poor academic performance
Substance abuse
Antisocial behavior
Sexual promiscuity
Truancy
Running away

Occurence of a least one episode of major depression with significant depressive symptoms that last for at least 2 weeks

Severe disease
Poor prognosis

the dark mood of depression
characterized by severe anhedonia, early morning awakening, weight loss, and profound guilt

2-3 symptoms; function is normal despite distress

4+ symptoms; difficulty w/ functioning

Several distressing symptoms
Loss of self-esteem
Feelings of worthlessness and guilt
Suicidal ideation/acts
Somatic symptoms of depression

stupor
blunted affect
extreme withdrawal
negativism
psychomotor retardation

Light therapy

presence of a depressed mood that lasts most of the day and is continuous
"always been depressed" or no periods of euthymic mood

With recurrent brief depressive disorder, the symptoms are present for <2 weeks

Pts meet the criteria for both major depressive disorder and dysthymia

Thyroid dysfunction
Adrenal dysfunction
Diabetes

Syphillis
Toxoplasmosis
Viral infections
AIDS

RA
Lupus

MS
PD
TBI
Seizures
OSA
Tumors (cerebral)
CVA

Early age at onset
Psychotic depression before age 25
Postpartum depression
Rapid onset and offset of depressive episodes of less than 3 mo
Recurrent depression (>5 episodes)
Depression w/ marked psychomotor retardation
Atypical features
Seasonality
Family h/o bipolar
Mood lability
Hypomania w/ antidepressant use
>3 failures of antidepressants after initial response
Depressve mixed states

BP-I=at least one lifetime manic episode
BP-II=at least one hypomanic episode but never mania

-Abnormal period of abnormally and persistently elevated, expansive, or irritable mood and abnormally and persistently increased activity or energy, lasting at least 1 week and present most of the day, nearly every day

3 or 4 if the mood is only irritable

-inflated self-esteem or grandiosity
-decreased need for sleep
-more talkative than usual or pressure to keep talking
-flight of ideas or subjective experience that thoughts are racing
-distractibility (reported or observed)
-increase in goal-directed activity or psychomotor agitation
-excessive involvement in activities that have a high potential for painful consequences

For hypomania, the "manic" symptoms are present at least 4 consecutive days and are present most of the day, nearly every day during that stretch; the primary difference is the impact on impairment & mania shows "marked" impairment; hypomania the symptoms are "not severe enough" to produce "marked" impairment

No but many pts with this diagnosis do experience a major depressive episode at some point in their lifetime

-current/past hypomanic episode (duration 4 days) and current/past major depressive episode (duration 2 weeks)

Unipolar depression (MDD)

Symptoms of hypomania

They may not find this "troubling" and may consider it "productive". However, others involved w/ the pt may detail irratic behavior coupled w/ increased impulsivity

-impacts quality of life
-treatments aimed at only treating depression may limit full treatment potential
-treatment for bipolar disorders is distinctly different than the treatment recommendations for unipolar depression

-never use antidepressants as monotherapy
-a mood stabilizer is needed
-only use antidepressants as a mood stabilizer

Immediately stop the antidepressant

2-4 months unless the pt has a h/o relapsing into a depressive state after discontinuation of the antidepressant

TCAs
Least likely w/ bupropion

-past h/o poor outcomes w/ antidepressant treatment
-past h/o polarity changes w/ initiation of antidepressnat treatment (became more suicidal or "up cleaning all night" after taking XZY)
-concurrent manic symptoms
-substance use disorders
-recent mania/hypomania w/in the past 2-3 months

-early onset of 1st depressive episode (<25 y/o)
-multiple prior episodes of depression
-positive family h/o bipolar
-h/o postpartum depression

Symbyax (combo of fluoxetine & olanzapine)
Seroquel
Latuda

6/25mg at HS

nausea
diarrhea
weight gain
sedation

300mg

It can be titrated up fairly quickly if needed

dry mouth
sedation
dizziness
constipation
weight gain

20mg q supper time (take w/ at least 350 calories of food)

akathisia
nausea

Lithium
Lamictal
Zyprexa
Abilify
Seroquel
Risperdal (long acting injection)
Geodon

Lithium

2400mg

Lab monitoring r/t narrow therapeutic window

onset of effect takes 6-8 weeks w/ limited prevention of relapses

tremor
weight gain
kidney dysfuntion
thyroid dysfunction

25mg daily for 2 weeks
50mg daily for 2 weeks
100mg daily from there on or if need to go up can do 150mg daily for 1 week
Max dose is 200mg

25mg every other day for 2 weeks
25mg daily for 2 weeks
50mg daily for 1 week

Tegretol
Dilantin
Phenobarbitol
Primidone
BC pill

Steven Johnson syndrome

Slow titration

Begin at baseline starting dose again (25mg or 50mg depending on other medications the pt is taking)

Depakote
Tegretol
Zyprexa

often has a powerful effect
can help reduce the number of depressive episodes (not manic/hypomania)
decreases relapse
improves functioning
enhances treatment adherence

CBT, interpersonal, & social rhythm therapy

Start mood stabilizer if not on one
Optimize mood stabilizer
If no response over 4-6 weeks, change medication
If only a partial response, augment from a different class
Try to limit to 3 different medications if possible
Include psychotherapy

ketamine
repetitive transcranial magnetic stimulation
ECT
DBS
stimulants

SIGECAPS: Sleep/Interest/Guilt (worthlessness)/Energy (> or <)/Concentration/Appetite/Psychomotor (agitation)/Safety (suicide/self-harm/homicide)

Lithium

200mg BID

150mg BID

0.5-1.5

diarrhea
vomiting
drowsiness/sluggish
incoordination/ataxia
muscular weakness
seizures
death

Weight gain
Acne
Tremor
Cognitive impairment
Diabetes inspipidus
Hypothyroidism
Renal impairment
Arrythmia (sick sinus)
Pseudotumor cerebri (rare)

Protective against suicidality

Thyroid
Heart
Kidneys

TSH, CMP, CBC, & EKG if >40 y/o or h/o CVD

No, considered category D r/t risk of congential defect (cardiac malformation Epstein's anomaly)

Need to stay well-hydrated
Need for frequent lab monitoring when 1st starting
Symptoms of toxicity
Avoid NSAIDs while taking Lithium

NSAIDs
Thiazide diuretics
ACE inhibitors
Prozac
Tetracycline
Alcohol

Tegretol
Depakote/Depakene
Trileptal
Lamictal

200mg BID

dizziness
somulence
ataxia
GI distress

Genetic test for HLA-B 1502 allele

CBC, CMP, and eye exam

CBC, CMP, Tegretol level, & eye exam (annual)

No, category D > risk of neural tube defects

4-12

Induces liver enzymes and may speed up the metabolism of other medications (even induces itself)

acetaminophen
benzos
coumadin
lamotrigine
valproate
topiramate
clozapine
oral birth control pills

250mg TID

25mg/kg/day

250mg TID

weight gain
sedation
dizziness
headache
polycystic ovaries
nausea
vomiting
hair loss
easy bruising/thrombocytopenia
tremor

Alphers Huttenlocher Syndrome

Liver

No category D > risk of neural tube defects; consider avoidance all together in women of child-bearing age

300mg BID

-better tolerated
-less side effects
-does not induce own metabolism

dizziness
GI distress
somulence
hyponatremia

Sodium and drug level

Steven Johnson Syndrome
Pancytopenia
Aplastic Anemia
A-V block/arrhythmias
Pancreatitis
Weight Gain
Hepatoxicity

Weight
Fasting lipid, cbc, cmp
Assess for EPS symptoms
EKG: QT prolongation

Not for use for dementia psychosis

Latuda & Clozaril

prolactin

Treatment resistant schizophrenia or suicide prevention associated with schizophrenia

Agranulocytosis: WBC<2000 or Absolute Neutraphil Ct <1000 need to d/c Rx