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Back to Basics: Mood Disorders Dr. Valerie Primeau PGY5 Psychiatry April 5th, 2013

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1 Back to Basics: Mood Disorders Dr. Valerie Primeau PGY5 Psychiatry April 5th, 2013

2 MCC Objectives (1)  Distinguish between the normal condition of sadness (e.g., bereavement) and the presence of one of the clinical syndromes (e.g., depressive disorders).  Through efficient, focused, data gathering:  Diagnose the presence of depression (depressed mood, loss of interest in all activities, change in weight/appetite, sleep, energy, libido, concentration, feeling of hopelessness, worthlessness or guilt, recurrent thoughts of suicide, increase in somatic complaints, withdrawal from others).  Determine intensity and duration (weeks or years) of depression, antecedent event, and its effect on function.  Determine whether a general medical condition is present, use or abuse of drugs (or withdrawal).  Examine for slowness of thought, speech, motor activity or signs of agitation such as fidgeting, moving about, hand-wringing, nail biting, hair pulling, lip biting; examine vital signs, pupils, and skin for previous suicide attempts, stigmata of drug and/or alcohol use, thyroid gland, weight loss.  Elicit history of elevated, expansive or irritable mood (for at least 1 week) with impairment in function or without impairment and lasting only 4 days.  List and interpret critical clinical and laboratory findings which were key in the processes of exclusion, differentiation, and diagnosis:  Select patients only when high index of suspicion requires further investigation for medical condition or drugs that affect mood (e.g., thyroid function, toxicology screen, electrolytes, etc.).  Conduct an effective initial plan of management for a patient with a mood disorder:  Outline and describe treatment available for mood disorders under categories of medications, physical treatment, and psychologic treatment.  Select patients in need of specialized care.

3 MCC Objectives (2)  Depressive Disorders  Major Depressive Disorder  Atypical Depression  Dysthymic Disorder  Grief & Bereavement  Depression With Associations  Seasonal Affective Disorder  Postpartum Depression  Substance-Induced Mood Disorder  Mood Disorder Due to a General Medical Condition/Therapy  Depression With a Manic Episode  Bipolar Disorder  Cyclothymic Disorder

4 References  CANMAT guidelines 2007-2009  Caplan et al. Mnemonics in a Mnutshell: 32 aids to psychiatric diagnosis  Stephen Stahl, Depression and Bipolar Disorder  Kaplan & Sadock’s Synopsis of Psychiatry  DSM-IV  Toronto Notes Thank you to Dr. Gillis

5 Overview of Mood Disorders David J. Robinson, Psychiatric Mnemonics & Clinical Guides, 1998

6 General Concepts

7 Important tips!  All Mood Disorders must cause clinically significant distress of impairment in social, occupational, or other important areas of functioning  DDx always includes substance use or a general medical condition  Cognitive behavioral therapy is indicated for almost everything  Know the name and the starting dose of at least one medication of each class ex: citalopram 10 mg

8 Lifetime Prevalence  Major Depressive Disorder  Women = 10-25%  Men = 5-12%  Dysthymia = 6%  Bipolar Disorder  Type I = 0.4-1.6%  Type II = 0.5%

9 In a family practice setting  Depression is one of the top five diagnoses made in the offices of primary care physicians  25% of all patients who visit their family physicians will have a diagnosable mental disorder  The incidence of major depression is 10% in primary care patients  Effective treatment can reduce morbidity and decrease utilization of other health services  Medical patients with major depression have a worse prognosis for their medical recovery

10 History taking – Key Points (1)  Mood Disorders are usually episodic  An episode is demarcated by either  Switch to an opposite state ex: manic  depressive  Two months or more of partial or full remission after an episode  Inquire about current episode, but also past episodes  Confirm the diagnosis  Evaluate past response to treatment  Evaluate prognosis (inter-episode wellness)

11 History taking – Key Points (2)  Inquire about substance use and medications  Ask about family history and if positive, ask which treatment was effective  Always ask about safety issues!

12 Major Depressive Episode (1)  5 or more for 2 weeks nearly every day:  M ood depressed*  S leep ↑↓  I nterest ↓, libido ↓, social withdrawal*  G uilt, hopelessness, worthlessness  E nergy ↓  C oncentration ↓, indecisiveness  A ppetite↑↓, weight ↑↓, loss of taste for food  P sychomotor ↑↓  S uicidal ideation, recurrent thoughts about death

13 Major Depressive Episode (2)  Many patients with depression do not report feeling depressed, but will have loss of interest  Elderly patients often have new onset of somatic complaints but may deny feeling depressed  Patients can also present with panic attacks or obsessive-compulsive symptoms  Physical symptoms (sleep, appetite, energy level, psychomotor activity) are often referred to as “vegetative symptoms”  New onset of these symptoms can be a good predictor to antidepressant response

14 Manic Episode (1)  Abnormal persistent elevated, expansive or irritable mood lasting at least one week  Any duration if hospitalization is required  At least 3 of (4 if mood is irritable)  D istractibility  I ndiscretion, pleasurable activities with painful consequences  G randiosity  F light of ideas  A ctivity ↑  S leep ↓  T alkativeness

15 Manic Episode (2)  Mood disturbance is  Causing marked impairment in functioning  Severe enough to necessitate hospitalization to prevent harm to self or others or  Accompanied by psychotic features  Manic-like episodes induced by a medical condition, substance or medication do not count towards Bipolar Affective Disorder

16 Hypomanic Episode  Same criteria of Manic Episode except  Duration > 4 days, < 7 days  Unequivocal change in mood and functioning from baseline, observable by others  Change in function is not severe enough to cause marked impairment in social or occupational functioning or to necessitate hospitalization  Absence of psychotic features

17 Mixed Episode  Criteria met for both Manic and Major Depressive Episodes  Nearly everyday for one week

18 Mental State Examination  Psychomotor retardation, catatonic features  Psychomotor agitation such as fidgeting, moving about, hand-wringing, nail biting, hair pulling, lip biting  Speech (slow  pressured)  Affect  Type (depressed  euphoric)  Lability  Range (flat  expansive)  Reactivity  Thought process (paucity of content  flight of ideas)  Thought content (worthlessness, hopelessness, grandiosity, psychotic features, suicidal or homicidal ideation)  Cognition, distractibility  Insight, judgment

19 Physical Examination  Vital signs  Weight  Skin (look for previous suicide attempt)  Stigmata of drug and/or alcohol use  Thyroid gland  Cardiopulmonary  GI including liver  Neurological exam (pupils)

20 Laboratory Workup  CANMAT = when clinically indicated  Routine screening  Complete blood count  Thyroid function test  Liver function test  Electrolytes  B12, folates  Urinalysis, urine drug screen  Additional screening  Neurological consultation  CXR  EKG  CT-scan

21 Common Medical Conditions Associated With Mood Disorders  Pulmonary disease (COPD, asthma)  Endocrine disorders (Hypo/hyperthyroidism, diabetes)  Cancer  Cardiovascular disease, especially MI  CNS (migraine, infection, tumour, stroke, head injury, hypoxia)  Neurological disorders(Epilepsy, Parkinson's, Huntington's, Multiple Sclerosis)  B12, folate deficiency  Chronic pain, back problems  Sleep apnea

22 Drugs Commonly Associated With Mood Disorders  Antidepressant & somatic treatments for depression  Manic “switch”  FDA warning, increased suicidality in adolescents  Psychostimulants  Steroids, corticosteroids  Isotretinoin (Accutane)  Oral contraceptives, progesterone  Interferon A  Parkinson’s Disease agents (mostly psychotic symptoms)

23 Specific Mood Disorders

24 Major Depressive Disorder (1)  Mean age of onset = 30 years  50% of all patients have an onset between the ages 20-50  At least 1 Major Depressive Episode  Not better accounted by another disorder, medical condition or substance  No Manic, Hypomanic or Mixed episode

25 Major Depressive Disorder (2)  Etiology  Genetics (65-75% monozygotic twins)  Neurotransmitter dysfunction  Psychosocial  Low self-esteem  Negative thinking  Environmental ex: acute stressor  Co-morbid psychiatric disorders ex: substance use

26 Major Depressive Disorder (3)  Risk factors  Female > Male  Age (20-50 years old)  Rural > urban areas  Positive family history  Childhood experiences (loss of parent before age 11, abuse)  Personality structure  Recent stressors ex: loss of spouse, unemployed  Postpartum  Lack of support network

27 Major Depressive Disorder (4)  Treatment  Pharmacotherapy (ie SSRIs, SNRIs…)  Electroconvulsive therapy  Light therapy if seasonal component  Psychotherapy  Cognitive behavioral therapy  Interpersonal therapy (grief, transitions, interpersonal conflicts or deficits)  Social  Vocational rehabilitation  Social skills training

28 Major Depressive Disorder (5)  Light to moderate  Psychotherapy, medication depending on patient preference  Moderate to severe  Medication with or without psychotherapy, electroconvulsive therapy (ECT)  Depression with psychotic features  Combination of antidepressant and antipsychotic, gold standard is ECT

29 Major Depressive Disorder (6)  Treat until remission is complete  Duration of untreated illness affects future treatment response (untreated depression can last 6-12 months)  Maintain treatment to prevent relapse (at least 6-12 months for a first episode)  50% recurrence after 1 episode  75% after 2 episodes  > 90% after 3 episodes

30 Major Depressive Disorder (7)  Up to 15% of patients with Mood Disorders will die by suicide  Prognosis at 1 year  40% still meet criteria  20% have partial symptoms  40% have no mood disorder

31 Particularities of Depression  With Atypical Features  With Melancholic Features  With Catatonic Features  With Psychotic Features  With Seasonal Pattern  With Postpartum Onset  Grief & Bereavement

32 With Atypical Features  Mood reactivity  Mood brightens in response to actual or potential positive events  At least two of  ↑ appetite (carbohydrate cravings), weight gain  Hypersomnia  Leaden paralysis (heavy, leaden feelings in arms or legs)  Long-standing pattern of interpersonal rejection hypersensitivity

33 With Melancholic Features  At least one of  Anhedonia (inability to find pleasure in positive things)  Lack of mood reactivity (mood does not improve with positive events)  At least three of  Distinct quality of depression subjectively different from grief  Depression regularly worse in the morning  Early morning awakening (at least 2 hours)  Marked psychomotor agitation or retardation  Severe anorexia or weight loss  Excessive or inappropriate guilt

34 With Catatonic Features  At least two of  Motor immobility as evidenced by catalepsy (including waxy flexibility) or stupor  Excessive motor activity (purposeless, not influenced by external stimuli)  Extreme negativism (motiveless resistance to all instructions or maintenance of a rigid posture against attempts to be moved) or mutism  Peculiarities of voluntary movement as evidenced by posturing, stereotyped movements, prominent mannerisms, or prominent grimacing  Echolalia or echopraxia (automatic repetition of vocalizations or movements made by another person)

35 With Psychotic Features  Psychosis may be present in 10-15% of patients with a Major Depressive Episode  Associated with worse prognosis  Increase risk of suicide and homicide  Treatment implications  Antidepressant + antipsychotic  Consider ECT

36 With Seasonal Pattern  Only applies to a Major Depressive Episode  Regular temporal relationship between onset of Major Depressive Episode and a particular time of year, usually fall or winter  Full remission (or switch to mania) also occurs at a regular time of year, usually spring  In the last 2 years, 2 Major Depressive Episodes have occurred as above with no non- seasonal episode  Seasonal Major Depressive Episodes outweigh non-seasonal episodes in their lifetime

37 With Postpartum Onset  10% of postpartum women  Etiology likely a combination of neuroendocrine alterations and psychosocial adjustments  Onset has to be within 4 weeks after childbirth (DSM)  Distinguish from the “baby blues” (70%)  During 10 days postpartum, transient, not impairing functioning  Severe ruminations or delusional thoughts about the infant is associated with significantly increased risk of harm to the infant  Command hallucinations to kill the infant  Delusional belief that the infant is possessed

38 Grief & Bereavement (1)  Normal grief or bereavement reaction versus Major Depressive Episode  Complicated or pathological grief or bereavement (not in DSM-IV)

39 Grief & Bereavement (2)  DSM-IV = Normal grief reaction can present with depressive symptoms as long as it is < 2 months  Red flags that point towards Depressive Disorder  Feelings of guilt not related to the loved one's death  Thoughts of death other than feelings he or she would be better off dead or should have died with the deceased person  Morbid preoccupation with worthlessness  Marked psychomotor retardation  Prolonged and marked functional impairment  Hallucinations other than thinking he or she hears the voice of or sees the deceased person

40 Dysthymic Disorder (1)  Female > Male (2-3:1)  Depressed mood for at least 2 years, most days than not  Never without the symptoms for more than 2 months at one time  No Major Depressive Episode is present for the first 2 years  Treatment with psychotherapy ± antidepressants

41 Dysthymic Disorder (2)  H opelessness  E nergy ↓  S elf-esteem ↓  2 years of depressed, for more days than not (1 year in kids, mood can be irritable)  S leep ↑↓  A ppetite ↑↓  D ecision-making ↓, concentration ↓

42 Bipolar Disorder (1)  Bipolar I Disorder = at least 1 Manic or Mixed Episode  Commonly have more Major Depressive Episodes but not required for diagnosis  Bipolar II Disorder = at least 1 Major Depressive Episode & 1 Hypomanic Episode  No past Manic or Mixed Episode  Not better accounted by another disorder, a general medical condition, a substance or medication  “Bipolar Disorder type III”  Will change in DSM-V

43 Bipolar Disorder (2)  Male = Female (1:1)  Age of onset teens to 20s  Average age for first Manic Episode = 32  Family history of a major Mood Disorder in 60-65% of patients with Bipolar Disorder  Untreated Manic Episode can last 3 months  Untreated Major Depressive Episode can last 6-13 months

44 Bipolar Disorder (3)  Pharmacotherapy (Bipolar I)  Acute Manic Episode  Lithium, divalproex, olanzapine,risperidone, quetiapine, quetiapine XR, aripiprazole, ziprasidone  Taper and discontinue antidepressants  Acute Major Depressive Episode  Lithium, lamotrigine, quetiapine, quetiapine XR  Do not use antidepressant as monotherapy  Maintenance treatment  Lithium, lamotrigine(limited efficacy in preventing mania), divalproex, olanzapine, quetiapine, risperidone LAI,aripiprazole (mainly for preventing mania)

45 With Rapid Cycling  Can be applied to Bipolar I and II  At least 4 mood episodes in previous 12 months (Major depressive, Manic, Hypomanic or Mixed episodes)  Episode demarcated by either switch to the opposite state or 2 months of partial or full remission between episodes  Rapid cycling diagnosis has treatment implications

46 Cyclothymia  Numerous periods of hypomanic and depressive symptoms for at least 2 years  Never without symptoms for more than 2 months  No Major Depressive, Manic or Mixed episodes  No evidence of psychotic symptoms

47 Ethics and Legal Considerations

48 Consent to Treatment (1)  MCC objectives:  Patients who are depressed can meet the criteria for decision capacity, but their preferences are clouded by their mood disorder  Overriding the wishes of a seemingly capable patient who is depressed is a serious matter and is one situation in which psychiatric involvement should be sought  Decisions to limit care should be deferred if possible until depression has been adequately treated

49 Consent to Treatment (2)  MCC objectives (continued):  If time pressures dictate the need to make a prompt choice, the physician should seek surrogate involvement  If the surrogate has previously discussed the patient's wishes at a time when he or she was not depressed, the surrogate will be able to explain whether the patient's choice is consistent with previously stated beliefs or has changed since the onset of depression

50 Consent to Treatment (3)  Specific to the issue  Informed – no misrepresentation  Voluntary – no coercion or persuasion  Capable

51 Consent to Treatment (4)  Diagnosis and nature of treatment  Purpose of proposed treatment  Anticipated risks and benefits of treatment  Alternative treatments and their risks and benefits  Prognosis, with and without treatment

52 Duty to Warn & Protect  Criteria for involuntary admission  Serious bodily harm to himself/herself  Serious bodily harm to another person  Serious physical impairment  Child in harm’s way  Warn Children’s Aid Society (CAS)  Dangerous driving  Warn Ministry of Transportation (MOT)

53 Quick Practice Questions!

54 MCQ 1  Mr. T is a 38 year old man diagnosed by his G.P. as having Major Depressive Disorder. Mr. T is reluctant to start a medication for his depression, as he has heard it can affect sexual performance. He reports marital difficulties with his wife.  What would you recommend to Mr. T as an initial treatment?

55 MCQ 1 a) Venlafaxine b) Bupropion c) Quetiapine d) Paroxetine e) Phenelzine

56 MCQ 2  You meet a 22 year old female university student with a history of depressed mood, hypersomnia, decreased concentration and suicidal ideation. She is interested in starting an antidepressant. You discuss with her in details the possible adverse events related with this type of medication.  What ethical principle is most illustrated in this vignette?

57 MCQ 2 a) Autonomy b) Fiduciary duty c) Non-discrimination d) Beneficence e) Non-maleficence

58 CDMQ 1 – Part 1  As the family physician running the walk-in clinic today, you meet a 45 year old female who complains of fatigue, insomnia and feeling discouraged. This is the first time you see this patient.  In this first interview, you see it as essential to explore the following elements:

59 1. Review of systems 2. Similar past episodes 3. Past history of manic episode 4. Current alcohol use 5. Past history of smoking cigarettes 6. Hopelessness 7. Menstrual history 8. Degree of functional impairment 9. Recent stressors 10. Consumption of caffeine 11. Psychiatric family history 12. Parents’ cause of death 13. Developmental history 14. Memory impairment 15. Loss of interest 16. Support network and living situation 17. Sexual orientation 18. Psychotic symptoms 19. Suicidal ideation 20. Past history of abuse

60 CDMQ 1 – Part 2  The patient further endorses depressed mood, decreased appetite and passive suicidal ideation.  She denies any significant medical history, physical exam and laboratory investigations are within normal.  Which of the following would be included in your management of this patient? Choose up to 5.

61 1. Psychodynamic psychotherapy 2. Review possible side effects of each treatment 3. Start lithium alone 4. Tell the patient it is her fault for being depressed 5. Psychoeducation about the illness and the treatments 6. Assess for short-term work disability 7. Watchful waiting 8. Interpersonal Therapy 9. Motivational interviewing 10. Exposure and relapse prevention therapy 11. Cognitive behavioral therapy 12. Start sertraline alone 13. Involuntary hospitalization 14. 12-step program

62 Thanks!

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