Mood Disorders
1
MOOD DISORDERS Overall Goal: recognize, evaluate, and state the treatments for patients with mood disorders. Specific Objectives: Students will be able to: 1. Discuss evidence for neurobiological, genetic, psychological, and environmental etiologies of mood disorders; 2. State the epidemiologic features, prevalent rates, and lifetime risks of mood disorders in clinical and non-clinical populations; 3. Compare and contrast the epidemiologic and clinical features of major depression and bipolar disorder; 4. mood disorders signs and symptoms differential diagnosis (including general medical and substance induced disorders) course of illness comorbidity prognosis complications 5. elderly patients with major depression special characteristics of the clinical presentation in the complications of the illness unique precautions necessary in treating this population; 6. Discuss the increased prevalence of major depression in patients with general medical/surgical illness (e.g. myocardial infarction, CVA, hip fracture) the impact of depression on morbidity and mortality from their illness 7. Outline the recommended acute and maintenance treatments for dysthymic disorder, major depression, and bipolar disorder. A. Major Depressive Disorder (MDD): 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 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 2. Co-morbidity: -Dysthymic Disorder -Substance-Related Disorders -Panic Disorder -Obsessive-Compulsive Disorder -Anorexia Nervosa -Bulimia Nervosa -Borderline Personality -Disorder Diabetes -Myocardial Infarction -Strong Relationship between CAD and MDD Carcinomas (Lung, Liver, Pancreas) -Stroke 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. 4. Epidemiology: Point prevalence = 4.3% Life-time prevalence = 8%-20% Women:Men = 2: 1 5. Etiology: A. Psychological B. Genetics -more MDD seen in families of patients with MDD than Bipolar Disorder. -monozygotic to dizygotic ration = 4: 1 -1.5 - 3 X more common among first degree relatives of MDD patients than the general population. -increased risk of alcohol dependence among first degree relatives of MDD patients. C. Neurobiology: [Catecholamine hypothesis + Functional deficit of serotonin] >>> Biogenic Amine Hypothesis -Dysregulation in acetylcholine, dopamine and GABA system -Areas of decreased metabolic activity or perfusion in left frontal region (PET) -Increased number of focal signal hyper intensities in white matter (MRI) Neuroendocrine abnormalities: -increased blood cortisol level -blunted growth hormone response to insulin challenge -blunted TSH response to TRH Structural Abnormalities -decrease in hippocampal size -low levels of BDNFC brain derived Neurotrophic factor 6. Subtypes of MDD -Single Episode -Recurrent -Chronic (continuous for 2 years or more) -With psychotic features (delusions, hallucinations) -Mood-congruent -Mood-incongruent With melancholic features -Loss of pleasure in all activities or lack of reactivity to pleasurable stimuli -Worse in the morning -Early morning awakening -Marked psychomotor retardation or agitation -Significant anorexia or weight loss -Excessive or inappropriate guilt With seasonal pattern 7. Course of MDD: -50-60% of those who have an episode will have a second episode. -70% of those experiencing two episodes will have a third. -90% of those having three will have a fourth episode. -5-10% of first episode patients will have a subsequent manic episode. 8. Differential Diagnosis: -Hypothyroidism (Myxedema) -Hyperthyroidism. (apathetic type) -Hyperthyroidism -Cushing's Disease -Addison's Disease -Multiple sclerosis -Stroke -Systemic lupus erythematosus -Congestive heart failure -Parkinsonism -Huntington's Disease -Infectious mononucleosis -Infectious hepatitis -HIV infection -Pancreatic carcinoma -Bipolar Disorder -Schizophrenic Disorder -Dementia ("pseudo dementia") -Uncomplicated bereavement -Dysthymic Disorder -Adjustment Disorder with depressed mood -Borderline Personality Disorder -Drug induced: 0-sedatives, hypnotics, anxiolytics (e.g. barbiturates, benzodiazepines) -anti-hypertensives (e.g. reserpine, alpha-methyldopa) -oral contraceptives -steroids (and withdrawal) -anti-psychotics -stimulant withdrawal (e.g. cocaine) -alcohol 9. Treatment: A. Psychotherapy -supportive -psychodynamic -cognitive -interpersonal 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 Bipolar Disorder: -occurrence of one or more manic or mixed episodes in patient who is likely to have had one or more major depressive episodes Manic episode: Essential features: distinct period of abnormal, persistently elevated, expansive, or irritable mood -manic episode lasts at least a week -grandiosity (inflated self-esteem) -decreased need for sleep -pressured speech -flight of ideas -distractibility -psychomotor agitation or acceleration -involvement in dangerous or potentially financially ruinous activity -marked impairment in function or psychotic features (often requiring hospitalization) Other signs and symptoms: -little insight, denial -impulsivity -lack of inhibitions (e.g. sexual) -unethical behavior (uncharacteristic) -poor judgment 10. Depressive episode: see MDD 11. Complications: -completed suicide (10-15%) -child abuse -spouse abuse -job loss -divorce -criminal activity -excessive activity may be dangerous for patients with cardiac conditions 12. Co-Morbidity: -Anorexia nervosa -Bulimia nervosa -ADD -Panic Disorder -Social phobia Substance-related disorders 13. Epidemiology: -Lifetime prevalence = .5-1 % -Women: Men = 3: 2 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) -SPECT switched from -high glucose utilization during mania -low glucose utilization during depression -Increased central dopaminergic activity 16. Subtypes: 1) Bipolar I -manic episode -major depressive episode -mixed episode 2) Bipolar II -hypomanic episode -major depressive episode 3) With seasonal pattern With rapid cycling 17. Differential Diagnosis: -Multiple Sclerosis -Stroke -Brain tumor -Epilepsy -Head trauma -HIV -Neurosyphilis -Cushing's Disease -Lupus (SEE) -ADD -Schizophrenic Disorder -Drug induced: -amphetamines -cocaine -methylphenidate -corticosteroids -ACTU -cyclosporine -levodopa -antidepressant agents Other induced: -electroconvulsive treatment -light therapy 18. Treatment: -Manic episode: -hospitalization -mood stabilizers 1. lithium carbonate 2. anti-consultants 3. neuroleptics -adjunctive agents -electro convulsive therapy -Major depressive episode: -increase dose of mood stabilizer or -add anti-depressant agent -discontinue ADA as soon as depressive symptoms lift -In general: -psycho education for patient and family -supportive psychotherapy -psychodynamic psychotherapy (if needed) between episodes -use sodium valproate for rapid cyclers (lithium may exacerbate Rapid cycling Dysthymic Disorder Essential features: -chronically depressed mood -for most of the day -more days than not -two years or more -poor appetite or overeating -insomnia or hypersomnia -low energy or fatigue -low self-esteem -poor concentration -difficulty making decisions -feelings of hopelessness -low interest -self-criticism -feelings of inadequacy -loss of interest or pleasure in general -social withdrawal -guilt feelings -irritability or excessive anger -decreased activity, effectiveness, or productivity -symptom-free periods last no longer than 2 months -after 2 years of disorder patient may have superimposed MDD ("double depression") Co-morbidity MDD Substance dependence Various personality disorders Epidemiology: Lifetime prevalence = 6% Point prevalence = 3% Genetics: more common among first degree relatives with MDD Differential Diagnosis: see MDD Treatment: Psychodynamic psychotherapy Cognitive psychotherapy Antidepressant agents BPD (Bipolar) Type 1: Classic Manic Episodes and depressive episodes Type 2: Hypomanic episodes 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 Dysthymia -Waxes and Wanes -not as severe as MDD MDDR MDD1E BPD type 1 BPD type 2 Mood Euthymia Hypomanic Symptoms + Depressive Time: days - years 50% of patients Treatment at index episode = acute treatment Prophylactic treatment = remission Manic Episode BPD can present with depressive episode if manic episodes are known, treatment is different 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 Psychosis: delusions, feel like they did a crime halucinaitons that are accusitory means: what other disorders will people have dysthymic: double depression -may improve from MDDE1 but not return to euthymia alcohol and substance abuse CVD: lots of liturature -commonality, both effect each other -using antidepressents treats MIs -SSRI are anticoagulants too These tumors can present with depressive episode somatic complaints can reach delusional proportions High Previlence Lifetime over the course of illness, the cost $$$ of MDD is close to CVD (very expensive bc its so prevalent) Adolescence to patients at age 80 usually adolescence to middle ages bread and butter of what psychiatrists treat Why do people have MDD?? Psychological theory simply -retroflexed anger turned inward -instead of externalizing, internalizing -thinking aobut death of parent, caused death -feel guilty about death, internalized Depression is biologically driven Definitely runs in families, and stronge genetic connection, EX 2 parent famliy, both with MDD -5 childen 4 girls (2 twins) -he has treated all the girls -one depressed -one schizoaffective disorder + SLE -one bipolar disorder -one was suicidal -male: medical student, broke down some doors -treated with Li, he has been stable for 25yrs -still on Li maintainence Most work these days is on the biogenic amine hypothesis originally: treatment with some anti-hypertensives became depressed -reserpine depletes biogenig amines INH for Tb, sometimes saw a elevation in mood, it is an analogue to a MAOi Biogenic Amine Hypothesis: need proper regulation of brain 5HT, NE, we treat MDD by elevating 5HT and NE, or both (to a lesser extent DA, GABA, ACh) there is neuroendocrine changes low BDNF deceased hippocampal size Subtypes: MDDE1, MDDR, Chronic (tough to treat) Chronic = treatment resistant depression MDD can have psychotic features Mood congruent: delusions are in line with depression -mood is depressed, delussions are depressed Mood incongruent: depressed but think they are the king (usually is a different disorder psychotic MDD is bad for prognosis Involutional Period: biological factors -menopause, old age, diurnal variation = worse in morning -diurinal variation is common in MDD Seasonal: SAD, seasonal affective disorder -develop depression at this time of year -less light, improves with spring time -increase antidepressenent in winter months Classic MDD: season independent MDD clinical course -50% of MDD1E have another -if you have another you are likely to have many disorder -can progess to mania, then we change the diagnosis -most do not progess to BPD -change the dx, bc Rx is different Anything that affects the body affects the brain Rule out other psycological Rule out system by system hypothyroid can look like depression Malignancy: lung, liver, pancrease like MDD HIV, MONO, LYME CVD, AI, Wilsons both illicit and non-illicit antihypertensives, sedatives (barbs) BZDs, steroids, etOH more often psycho-supportive some psycho-dynamic Mild MDD can respond to psychotherapy alone usually we go to MDD 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? BPD: 2 pards -bipolar depressed looks like MDD -bipolar manic: going fast -usually psychotic, not in touch with rea;ity Wash car at 3am other people notice these people Bipolar sexual psychotic much more noticable, can be aggressive an assultive feel inflative self esteem and grandiosity feel like they know more than the doctor Bipolar people at their peak don’t want treatment he has seen of 2 cases of post-partum mania erratic an unusual behavior EX: tearful patient explaining how awesome he is Anxiety disorders rare, harder to treat strong genetic correlations anticonvulsants anti psychotics lithium DA and GABA too in addition to NE, 5HT classic hypomanic + MDD many episodes over the year rule out physical things drugs are high, cocaine Antidepressents, contraversial if they CAUSE mania he said the electioconvolsive did it once after 8 ECTs hes seen it happen psychotherapy doesn’t work bc they are psychotic often need hospitalization depecote: valproate tegretal: carbamazapine antipsycotics = neuroleptics for schizophrenia (treat rapidly with haloperidole (potent) get them on a lithium and off of haloperidol often BPD patients are on more than on drug Exam Question: patient w BPD comes in with a depressive episode -take lithium, gave it up, 4 months later he is suicidal -dont give an antidepressant bc it will induce manic episode -increase the mood stabilizer -or can give mood stablizer + antidepressant (he tends to keep it like this) dysthymic patients to not become psychotic Smoldering depression
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Transcript of Mood Disorders
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MOOD DISORDERSOverall Goal: recognize, evaluate, and state the treatments for patients with mood disorders.
Specific Objectives:Students will be able to:
1. Discuss evidence for neurobiological, genetic, psychological, and environmental etiologies of mood disorders;
2. State the epidemiologic features, prevalent rates, and lifetime risks of mood disorders in clinical and non-clinical populations;
3. Compare and contrast the epidemiologic and clinical features of major depression and bipolar disorder;
4. mood disorders signs and symptoms differential diagnosis (including general medical and substance induced disorders) course of illness comorbidity prognosis complications 5. elderly patients with major depression special characteristics of the clinical presentation in the complications of the illness unique precautions necessary in treating this population; 6. Discuss the increased prevalence of major depression in patients with general medical/surgical illness (e.g. myocardial infarction, CVA, hip fracture) the impact of depression on morbidity and mortality from their illness 7. Outline the recommended acute and maintenance treatments for dysthymic disorder, major depression, and bipolar disorder.
A. Major Depressive Disorder (MDD):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
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
2. Co-morbidity: -Dysthymic Disorder -Substance-Related Disorders -Panic Disorder -Obsessive-Compulsive Disorder -Anorexia Nervosa -Bulimia Nervosa -Borderline Personality -Disorder Diabetes -Myocardial Infarction -Strong Relationship between CAD and MDD Carcinomas (Lung, Liver, Pancreas) -Stroke 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.
4. Epidemiology: Point prevalence = 4.3% Life-time prevalence = 8%-20% Women:Men = 2: 1
5. Etiology: A. Psychological B. Genetics -more MDD seen in families of patients with MDD than Bipolar Disorder. -monozygotic to dizygotic ration = 4: 1 -1.5 - 3 X more common among first degree relatives of MDD patients than the general population. -increased risk of alcohol dependence among first degree relatives of MDD patients. C. Neurobiology: [Catecholamine hypothesis + Functional deficit of serotonin] >>> Biogenic Amine Hypothesis -Dysregulation in acetylcholine, dopamine and GABA system -Areas of decreased metabolic activity or perfusion in left frontal region (PET) -Increased number of focal signal hyper intensities in white matter (MRI) Neuroendocrine abnormalities: -increased blood cortisol level -blunted growth hormone response to insulin challenge -blunted TSH response to TRH
Structural Abnormalities -decrease in hippocampal size -low levels of BDNFC brain derived Neurotrophic factor
6. Subtypes of MDD -Single Episode -Recurrent -Chronic (continuous for 2 years or more) -With psychotic features (delusions, hallucinations) -Mood-congruent -Mood-incongruent With melancholic features -Loss of pleasure in all activities or lack of reactivity to pleasurable stimuli -Worse in the morning -Early morning awakening -Marked psychomotor retardation or agitation -Significant anorexia or weight loss -Excessive or inappropriate guilt
With seasonal pattern 7. Course of MDD: -50-60% of those who have an episode will have a second episode. -70% of those experiencing two episodes will have a third. -90% of those having three will have a fourth episode. -5-10% of first episode patients will have a subsequent manic episode.
8. Differential Diagnosis: -Hypothyroidism (Myxedema) -Hyperthyroidism. (apathetic type) -Hyperthyroidism -Cushing's Disease -Addison's Disease -Multiple sclerosis -Stroke -Systemic lupus erythematosus -Congestive heart failure -Parkinsonism -Huntington's Disease -Infectious mononucleosis -Infectious hepatitis -HIV infection -Pancreatic carcinoma -Bipolar Disorder -Schizophrenic Disorder -Dementia ("pseudo dementia") -Uncomplicated bereavement -Dysthymic Disorder -Adjustment Disorder with depressed mood -Borderline Personality Disorder
-Drug induced: 0-sedatives, hypnotics, anxiolytics (e.g. barbiturates, benzodiazepines) -anti-hypertensives (e.g. reserpine, alpha-methyldopa) -oral contraceptives -steroids (and withdrawal) -anti-psychotics -stimulant withdrawal (e.g. cocaine) -alcohol
9. Treatment: A. Psychotherapy -supportive -psychodynamic -cognitive -interpersonal 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
Bipolar Disorder: -occurrence of one or more manic or mixed episodes in patient who is likely to have had one or more major depressive episodes Manic episode: Essential features: distinct period of abnormal, persistently elevated, expansive, or irritable mood -manic episode lasts at least a week -grandiosity (inflated self-esteem) -decreased need for sleep -pressured speech -flight of ideas -distractibility -psychomotor agitation or acceleration -involvement in dangerous or potentially financially ruinous activity -marked impairment in function or psychotic features (often requiring hospitalization)
Other signs and symptoms: -little insight, denial -impulsivity -lack of inhibitions (e.g. sexual) -unethical behavior (uncharacteristic) -poor judgment
10. Depressive episode: see MDD
11. Complications: -completed suicide (10-15%) -child abuse -spouse abuse -job loss -divorce -criminal activity -excessive activity may be dangerous for patients with cardiac conditions
12. Co-Morbidity: -Anorexia nervosa -Bulimia nervosa -ADD -Panic Disorder -Social phobia Substance-related disorders
13. Epidemiology: -Lifetime prevalence = .5-1 % -Women: Men = 3: 2
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) -SPECT switched from -high glucose utilization during mania -low glucose utilization during depression -Increased central dopaminergic activity
16. Subtypes: 1) Bipolar I -manic episode -major depressive episode -mixed episode 2) Bipolar II -hypomanic episode -major depressive episode 3) With seasonal pattern With rapid cycling
17. Differential Diagnosis: -Multiple Sclerosis -Stroke -Brain tumor -Epilepsy -Head trauma -HIV -Neurosyphilis -Cushing's Disease -Lupus (SEE) -ADD -Schizophrenic Disorder -Drug induced: -amphetamines -cocaine -methylphenidate -corticosteroids -ACTU -cyclosporine -levodopa -antidepressant agents
Other induced: -electroconvulsive treatment -light therapy
18. Treatment:
-Manic episode: -hospitalization -mood stabilizers 1. lithium carbonate 2. anti-consultants 3. neuroleptics -adjunctive agents -electro convulsive therapy -Major depressive episode: -increase dose of mood stabilizer or -add anti-depressant agent -discontinue ADA as soon as depressive symptoms lift -In general: -psycho education for patient and family -supportive psychotherapy -psychodynamic psychotherapy (if needed) between episodes -use sodium valproate for rapid cyclers (lithium may exacerbate Rapid cycling
Dysthymic Disorder Essential features: -chronically depressed mood -for most of the day -more days than not -two years or more -poor appetite or overeating -insomnia or hypersomnia -low energy or fatigue -low self-esteem -poor concentration -difficulty making decisions -feelings of hopelessness -low interest -self-criticism -feelings of inadequacy -loss of interest or pleasure in general -social withdrawal -guilt feelings -irritability or excessive anger -decreased activity, effectiveness, or productivity -symptom-free periods last no longer than 2 months -after 2 years of disorder patient may have superimposed MDD ("double depression")
Co-morbidity MDD Substance dependence Various personality disorders
Epidemiology: Lifetime prevalence = 6% Point prevalence = 3% Genetics: more common among first degree relatives with MDD
Differential Diagnosis: see MDD
Treatment: Psychodynamic psychotherapy Cognitive psychotherapy Antidepressant agents
BPD (Bipolar)
Type 1: Classic Manic Episodes and depressive episodesType 2: Hypomanic episodes
MDD (Major Depressive Disorder aka Unipolar depression
1E = 1st Episode (over 50% have another episode)R = Recurrent episodeTx is directed towards index episodes-maintainance Tx for Chronic MDD
Dysthymia-Waxes and Wanes-not as severe as MDD
MDDR
MDD1E
BPD type 1
BPD type 2
Mood
Euthymia
Hypomanic Symptoms + Depressive
Time: days - years
50% of patients
Treatment at index episode = acute treatmentProphylactic treatment = remission
Manic Episode
BPD can present with depressive episodeif manic episodes are known, treatment is different
Single episode, or recurring
most striking symptoms -depression -elderly: mood changes, aggressive
Vegetative symptoms: sleep abnormalities usually insomiasubtypes have hypersomiaAnorexia, loss of libido, insomniasubtypes can have reverse of things
Psychosis: delusions, feel like they did a crimehalucinaitons that are accusitory
means: what other disorders will people havedysthymic: double depression -may improve from MDDE1 but not return to euthymia
alcohol and substance abuse
CVD: lots of liturature -commonality, both effect each other -using antidepressents treats MIs -SSRI are anticoagulants too
These tumors can present with depressive episode
somatic complaints can reach delusional proportions
High Previlence
Lifetime over the course of illness, the cost $$$ of MDD is closeto CVD (very expensive bc its so prevalent)
Adolescence to patients at age 80usually adolescence to middle agesbread and butter of what psychiatrists treat
Why do people have MDD??Psychological theory simply -retroflexed anger turned inward -instead of externalizing, internalizing -thinking aobut death of parent, caused death -feel guilty about death, internalized
Depression is biologically driven
Definitely runs in families, and stronge geneticconnection, EX 2 parent famliy, both with MDD -5 childen 4 girls (2 twins) -he has treated all the girls -one depressed -one schizoaffective disorder + SLE -one bipolar disorder -one was suicidal -male: medical student, broke down some doors -treated with Li, he has been stable for 25yrs -still on Li maintainence
Most work these days is on the biogenic amine hypothesisoriginally: treatment with some anti-hypertensives became depressed -reserpine depletes biogenig aminesINH for Tb, sometimes saw a elevation in mood, it is an analogue to a MAOiBiogenic Amine Hypothesis: need proper regulation of brain 5HT, NE, we treat MDD by elevating 5HT and NE, or both (to a lesser extent DA, GABA, ACh)
there is neuroendocrine changeslow BDNFdeceased hippocampal size
Subtypes: MDDE1, MDDR, Chronic (tough to treat)Chronic = treatment resistant depression
MDD can have psychotic features Mood congruent: delusions are in line with depression -mood is depressed, delussions are depressed Mood incongruent: depressed but think they are the king (usually is a different disorder psychotic MDD is bad for prognosis
Involutional Period: biological factors -menopause, old age, diurnal variation = worse in morning -diurinal variation is common in MDD
Seasonal: SAD, seasonal affective disorder -develop depression at this time of year -less light, improves with spring time -increase antidepressenent in winter months Classic MDD: season independent
MDD clinical course -50% of MDD1E have another -if you have another you are likely to have many disorder -can progess to mania, then we change the diagnosis -most do not progess to BPD -change the dx, bc Rx is different
Anything that affects the bodyaffects the brain
Rule out other psycologicalRule out system by systemhypothyroid can look like depressionMalignancy: lung, liver, pancrease like MDDHIV, MONO, LYMECVD, AI,Wilsons
both illicit and non-illicitantihypertensives, sedatives (barbs)BZDs, steroids, etOH
more often psycho-supportivesome psycho-dynamicMild MDD can respond to psychotherapy aloneusually we go to MDD
Anti-depressents: SSRI, SSNI, new 5HT agonistMAOis with side effects18 antidepressants on the marketProzac 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?
BPD: 2 pards -bipolar depressed looks like MDD -bipolar manic: going fast -usually psychotic, not in touch with rea;ity
Wash car at 3amother people notice these people
Bipolar sexual psychoticmuch more noticable, can be aggressive an assultivefeel inflative self esteem and grandiosityfeel like they know more than the doctor
Bipolar people at their peak dont want treatmenthe has seen of 2 cases of post-partum mania
erratic an unusual behavior
EX: tearful patient explaining how awesome he is
Anxiety disorders
rare, harder to treat
strong genetic correlations
anticonvulsantsanti psychoticslithium
DA and GABA too in addition toNE, 5HT
classic
hypomanic + MDD
many episodes over the year
rule out physical thingsdrugs are high, cocaine
Antidepressents, contraversial if they CAUSE mania
he said the electioconvolsive did it onceafter 8 ECTs hes seen it happen
psychotherapy doesnt work bc they are psychotic
often need hospitalization
depecote: valproatetegretal: carbamazapineantipsycotics = neuroleptics for schizophrenia (treat rapidly with haloperidole (potent) get them on a lithium and off of haloperidoloften BPD patients are on more than on drug
Exam Question: patient w BPD comes in with a depressive episode -take lithium, gave it up, 4 months later he is suicidal -dont give an antidepressant bc it will induce manic episode -increase the mood stabilizer -or can give mood stablizer + antidepressant (he tends to keep it like this)
dysthymic patients to not become psychotic
Smoldering depression
