A Review of Affective (Mood) Disorders

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A Review of Affective (Mood) Disorders

• Ashley Owen, Ph.D.
• Department of Family
• and Preventive Medicine

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Major Depressive Episode - Assessment

• A. Five or more of the following symptoms have
  been present during the same 2-week period and
  represent a change from previous functioning.
• 1. Depressed mood most of the day
• 2. Markedly diminished interest or pleasure in
  activities most of the day, nearly every day.
• 3. Significant weight loss when not dieting or
  weight gain or decrease or increase in
• appetite nearly every day.

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Major Depressive Episode - Assessment (contd)

• 4. Insomnia or hypersomnia nearly every day.
• 5. Psychomotor agitation or retardation.
• 6. Fatigue or loss of energy nearly every day.
• 7. Feelings of worthlessness or excessive guilt.
• 8. Diminished ability to think or concentrate.
• 9. Recurrent thoughts of death.

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SIGECAPS Assessment (Neurovegetative Sx)

• S- Is your sleep disturbed?
• I- Have you noted a loss of libido or interest in
  your usual activities?
• G-Are you feeling guilty or having
  self-deprecatory thoughts?
• E-Have you noticed a decrease in your energy
  level?
• C-Have you been having trouble concentrating?
• A-Have you experienced changes in your appetite
  or weight?
• P-Have you been physically slowed down or sped
  up? (psychomotor abnormalities)
• S- Have you had thoughts of hurting yourself,
  feelings of hopelessness, preoccupation with
  issues related to death, or suicide?

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Depression Screening - Assessment

• Ask
• 1.During the past month, have you been often
  bothered by little interest or pleasure in doing
  things?
• 2.During the past month, have you been feeling
  down, depressed, or hopeless?
• If yes to either further assessment
• SIGECAPS or administer a measure

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Depression Screening - Assessment

• Measures
• Beck Depression Inventory (BDI)
• Edinburgh Postnatal Depression Scale (EPDS)
• Geriatric Depression Scale (GDS)
• Pediatric Symptom Checklist (PSC)
• ALWAYS PERSONALLY REVIEW THE SUICIDE
• ITEM AND DISCUSS WITH YOUR PATIENT!

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Major Depressive Disorder

• A. Presence of a Major Depressive episode
• (single episode recurrent)
• B. Not better accounted for by Schizoaffective
  Disorder
• C. Never been a Manic Episode
• Some patients become preoccupied with somatic
• complaints such as bowel or bowel dysfunction.

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Specifier HighlightsWith Psychotic Features

• Important to assess!
• Additional features of hallucinations (auditory
  or visual), delusions, bizarre bx, or
  disorganized thinking.

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Specifier Highlights With Postpartum onset

• Onset within 4 weeks of postpartum though
  studies suggest an extension of process that
  begins during pregnancy
• affects 12-15 of women with good
  support/excited about being pregnant
• - Affects 20-25 of women who are
  single/young/family disocord/no support
• Baby blues (70) vs Postpartum Depression
  (10-15)
• - decreased participation in prenatal
• care and care following delivery
  (delayed social development)
• - fetal exposure to stress hormones
• - negative maternal outcomes
• - increased risk of divorce (2-3)

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Specifier HighlightsWith Atypical Features

• 1. Mood reactivity (mood brightens in response to
  actual or potential positive events)
• 2. Two or more of the following criteria
• Significant weight gain or increase in appetite
• Hypersomnia
• Leaden paralysis (heavy, laden feelings in arms
• or legs)
• Long-standing pattern of interpersonal rejection
  sensitivity that results in significant social or
  occupational impairment

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Specifier Highlights With Seasonal Pattern

• Hx of temporal relationship between season and
  onset of major depressive episode
• Typically notice onset
• in fall or winter with
• progressing resolution
• of sxs in spring
• or summer
• Depressive sxs generally
• atypical hypersomnia,
• hyperphagia, and weight gain

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Major Depressive Disorder -course and prevalence

• stressor ? mediators ? reduced depression
• (ex. social support, sense of control)
• Life stressors ? Normal depressogenic reaction
• Multiple major life stressors ? Multiple
  depressogenic reactions
• - cognitions this is my life
• extended periods of neurons being damaged by
  stress/depression
• ? depressions cycle on their own rhythm in
  absence of stressors
• ? increased risk of depression for the rest of
  the patients life without intervention

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Major Depressive Disorder -course and prevalence
(contd.)

• Evidence of biological effects of depression
• Glucocorticoids (highly elevated) damage
  nervous system
• - hippocampuses atrophy (poor synaptic
  activity disrupting neuronal connections
  neuronal atrophy)
• - exercise/psychotropics/psychotherapy (or
  both) may impede this process and even
  initiate neurogenesis
• Similar in anxiety amygdala (arousal, fear
  conditioning) networks strengthened
• more connections,
• more resilient pathways
• Depression is a biological disorder that is very
  sensitive to the environment

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Major Depressive Disorder -course and prevalence
(contd.)
Lifetime prevalence in women 1 in 4
(highest in gt44)
men 1 in 8 Age of onset often in mid-20s
(possibly earlier and undetected) 2/3 complete
remission of sxs, 1/3 partial remission and
increased likelihood of future episodes Single
episode 50 have a future episode 70 of those
who have 2 episodes have a third 90 of those
with 3 episodes have a fourth Possible
increased fx of episodes with age - relapse
prevention.
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Dysthymic Disorder

• Depressed mood for most of the day, for at least
  two years.
• Presence, while depressed, of two or more of the
  following
• Poor appetite or overeating
• Insomnia or hypersomnia
• Low energy or fatigue
• Low self-esteem
• Poor concentration or difficulty making decisions
• Feelings of hopelessness

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Dysthymic Disorder (contd.)

• Sxs are less severe than those of MDD and
  neurovegetative sxs are fewer.
• Common clinical feature generalized anhedonia
  or anergia
• Also, social withdrawal, feelings of guilt or
  inadequacy, poor work or academic performance
• Can be frustrating to treat because of chronic
  dysphoria, self-pity, and seemingly irrational
  patterns of negative thinking things always go
  wrong for me negative filter

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Adjustment Disorder

• Develops within 3 months of a significant life
  stressor
• Symptoms are clinically significant as evidenced
  by either
• marked distress in excess of what would be
  expected given the nature of the stressor
• Or
• Significant impairment in social or occupational
  functioning

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Adjustment Disorder (contd.)

• Symptoms dont represent Bereavement.
• Presentation typically depressed mood, anxiety,
  helplessness, and worthlessness. Thoughts often
  predominated by activities that precipitated the
  event.
• If criteria are met for MDD, this diagnosis
  supersedes Adjustment Disorder
• Or when condition represents an exacerbation of a
  preexisting psych disorder
• Remember to evaluate criteria regardless of event
  because evaluating need for intervention could be
  essential to patient in need of treatment.

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Manic Episode

• A distinct period of abnormally and persistently
  elevated, expansive, or irritable mood, lasting
  at least one week.

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Manic Episode, contd.

• During the period of mood disturbance, at least
  three of the following symptoms have persisted
  (four if only irritable)
• Inflated self-esteem or grandiosity
• Decreased need for sleep
• Flight of ideas or subjective experience that
  thoughts are racing
• More talkative than usual
• Distractibility
• Increase in goal directed activity
• Excessive involvement in pleasurable activities

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Bipolar Disorder, Type 1

• Essential feature is occurrence of one or more
  Manic Episodes or Mixed Episodes (both Depressive
  and Manic episodes within 1-week period).
• Often individuals have also
• had one or more
• Major Depressive Episodes
• Episodes of Substance-Induced
• Mood Disorder or of Mood Disorder
• Due to a General Medical Condition
• do not count toward a diagnosis of
• Bipolar I Disorder.

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Bipolar Disorder-Type II

• Essential feature - occurrence of
• one or more Major Depressive Episodes and at
  least one Hypomanic Episode
• (not euthymia that follows remission of a
  Depressive Episode).
• Episodes of Substance-Induced Mood Disorder or
  of Mood Disorder Due to a General Medical
  Condition do not count toward this diagnosis
• (sxs consistent with manic sxs, but only have
  to last 4 days)

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Cyclothymic Disorder

• The presence of numerous periods with hypomanic
  symptoms
• Numerous periods with depressive symptoms that do
  not meet criteria for a major depressive episode
  lasting for at least 2 years.
• No major depressive episode, manic episode, or
  mixed episode.

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Differential Diagnosis

• Lyme disease
• Fibromyalgia
• Chronic Fatigue Syndrome
• Rheumatoid disease
• Endocrinopathies
• Intimate Partner Violence
• Other Psychiatric Disorders

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Suicidality

• About 15 of depressed patients take their life
• Assess for
• Thoughts (ideas, wishes, motives)
• Intent (degree to which pt intends to act on
  those thoughts) - 1013
• Plans (for self-harm)
• Assess and document suicidality in all patients
  who report depressed mood, hopelessness,
  helplessness, or suffering
• asking does not put ideas into their heads
• Do you ever feel so badly that you would prefer
  not to go on living?

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Psychotherapy Treatment

• Psychodynamic approach
• Cognitive-Behavioral approach
• Interpersonal approach
• Psychoanalytic therapy
• Family therapy

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Drug Classes

• Selective Serotonin Reuptake Inhibitors (SSRIs)
• Atypical Antidepressants
• Tricyclic antidepressants (TCAs)
• Others (MAOIs-monoamine
• oxidase inhibitors, ECT, Bright Light)

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General Information

• Antidepressants show similar efficacy.
• Seventy percent of patients will respond after
  4-6 weeks of therapy.
• Approximately 7000 deaths per year from Tricyclic
  Antidepressant overdose.

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SSRIs Class Side Effects

• Nausea, diarrhea
• decreased libido (especially in women)
• Decreased appetite (especially Prozac)
• Headache
• Delayed orgasm

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SSRIs Class Side Effects

• If activation/ Insomnia (15)
• ----gt take in morning.
• If sedation(15)
• ----gt take at bedtime.
• Reduce GI side effects by taking medication with
  meals.
• Dont use SSRIs in combination with MAOIs. Must
  wean SSRI before starting MAOI.
• Lowest potential for toxicity from an overdose

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SSRIs Prozac/fluoxetine

• Long half-life
• Reduced risk of SSRI Discontinuation Syndrome
• Dose range is 10 - 80 mg/day

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SSRIs Prozac/fluoxetine

• Prozac has several interesting features
• Tends to be activating (stimulation/restlessness).
  Consider another antidepressant for angry,
  irritable, depressed patients.
• Weight loss a more dominant
• side effect than weight gain.
• Secondary to its effect on delayed ejaculation,
  it may be useful in treating premature
  ejaculation.

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SSRIs Zoloft/sertraline

• Shown efficacy for
• Depression
• Obsessive compulsive disorder (OCD)
• Panic Disorder
• Posttraumatic stress disorder (PTSD)
• Dose range is 50-200 mg/day start at 25mg first
  week
• Stimulating/GI and sexual side effects

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SSRIs Paxil/paroxetine

• Possibly more sedating than activating, but
  fairly neutral.
• Efficacy shown in studies for
• - major depressive disorder (MDD)
• - obsessive compulsive disorder (OCD)
• - panic disorder (PD)
• Decreases seizure threshold
• Dose range is 10-50 mg/day

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SSRIs Celexa/citalopram

• Side effect profile similar to other SSRIs
  though stimulation/restlessness may be less than
  other SSRIs
• Dose range is 20-80 mg/day
• LEXAPRO - derived by isolating the Celexa
  (citalopram HBr) molecule improved efficacy and
  side effects
• Dose range is 10-20 mg/day

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SSRIs Serotonin Syndrome

• A syndrome involving

- Mental status changes
- High fever
- Muscular rigidity
- If not treated, potential coma and death
- Occurs in setting of multiple drugs which block
serotonin metabolism
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SSRIs SSRI Discontinuation Syndrome

• Flu-like (fatigue, myalgia, loose stools, and
  nausea)
• Lightheadedness/dizziness
• Uneasiness/restlessness
• Sleep and sensory disturbance
• Headache

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Atypical Antidepressants

• Desyrel/trazodone
• Major side effect of note are sedation (most
  sedating of antidepressants), GI, and priapism
• Starting dose is 50mg bid max dose 400mg
• Most commonly used as a sedative in patients who
  may be depressed.

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Atypical Antidepressants

• Serzone/nefazodone - similar to trazodone
• However, priapism not a side effect. Consider
  choosing this in men over trazodone.
• Potential hepatic consequences requires hepatic
  monitoring
• Should not be taken with antihistamines
• Does not have sexual dysfunction as a common side
  effect, as do the SSRIs.
• Major side effect is somnolence, though not as
  sedating as trazodone.
• Starting dose 100mg bid.
• May give up to 300-600 mg divided bid.

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Atypical Antidepressants

• Effexor/venlafaxine and Effexor XR
• Shown efficacy in
• depression,
• generalized anxiety disorder (GAD)
• social anxiety disorder
• GI and sexual side effects
• less sedation than many atypicals
• Starting dosage is 37.5mg bid
• maximum total daily dose is 375mg.

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Atypical Antidepressants

• Mirtazapine/Remeron
• Dose range is 15-30mg qHS (bedtime) max dose
  45mg, secondary to sedation.
• Side Effects
• Somnolence in 50 of patients.
• No increase in sexual dysfunction.
• Agranulocytosis (low white cell count) in 11000
  (actually same statistic as other
  antidepressants, but noted on most side effect
  profiles).
• Increased appetite and weight gain
• can use in depressed patients
• who are malnourished

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Atypical Antidepressants

• Wellbutrin/bupropion-Zyban (smoking cessation)
• Is an activating antidepressant - makes people
  energetic vs sleepy.
• Can also cause insomnia ----gt take in the morning
• Contraindicated in patients with seizure disorder
  or eating disorder
• Starting dose 100mg - dont give greater than
  200mg in one dose or greater than 450mg per day
• Zyban 150mg 1st 3 days then 150am and
  150pm-8hrs apart
• Some GI side effects
• Inducing mania in bipolar less common
• than other antidepressants
• Not associated with weight gain
• or disturbance in sexual fx

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Atypical Antidepressants

• Cymbalta/duloxetine
• 20-30 mg BID depression
• Diabetic peripheral neuropathic pain and
  depression-related pain sxs in elderly 60 mg
  once/day
• Side Effects
• -associated with slight increases in blood
  pressure
• -not indicated for patients with
• renal impairment
• hepatic insufficiency/substantial alcohol
  use

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Tricyclic Antidepressants

• Elavil/amitriptyline
• Tofranil/imipramine
• Sinequan/doxepin
• Pamelor/nortriptyline
• Norpramin/desipramine

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TCAs - Complex Side Effect and Drug Interaction
Potential

• Anticholinergic - dry mouth, blurred vision,
  constipation, urinary retention, increased pulse
  monitor use of other anticholinergic
  treatments.
• Cardiotoxicity - (contraindicated in pts w/hx of
  coronary event and recommended to obtain EKG
  prior to initiation)
• Greatest risk of inducing mania in bipolar
• Only class of antidepressants in which you can
  draw blood levels to document use
• If prescribing in suicidal patient, no more than
  a 1-week supply should be dispensed at a time.

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MAOIs

• Nardil/phenelzine, Parnate/tranylcypromine
• Major side effect is hypertensive crisis
• Must be on a tyramine free diet (fermented
  cheese, yogurt, caffeine, chocolate, beer, and
  red wine)
• At least two week washout before changing from
  SSRI to an MAOI or MAOI to SSRI
• Drug and dietary interactions
• complex rarely needed in
• primary care

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Others

• Electroconvulsive therapy
• Severe depression/
• schizophrenia/bipolar
• (induce seizures)
• Retrograde amnesia
• Can improve neuronal activity
• and initiate neurogenesis
• 50-80 of patients relapse within 6 -9 months
  (lithium and nortriptyline combo significantly
  reduces risk)
• Bright Light used in seasonal affective disorder
• Alaska, Canada, in the winter

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When do you refer a patient to a psychiatrist?

• Severe/recurrent depression
• Suicidal patient

• Depression with psychotic features (delusions,
  hallucinations, loss of contact with
  reality)

• Bipolar disorder (Manic depression)
• Monitor with frequent visits until consistently
  under referring doctors care

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Special Cases

• Pregnancy/Lactation
• Consider SSRIs or buproprion (category B)
• Weigh exposure risk
• tx vs consequences of depression
• Elderly
• Consider SSRIs - beneficial side effect profile.
• E.g., no orthostatic hypotension, no
  urinary retention in men. Start at low doses.

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.

• Discuss side effects and determine whats
  acceptable to patient.
• Typically, no recipe determined a priori to be
  best for a patient an interactive process.
• The secret of patient care is caring for the
  patient, making sure, once that initial treatment
  is chosen, that it is an interactive tailored
  process over time.
• Patient will not respond if he or she stops the
  medication prematurely communication is key.

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Review Questions ?

• 1 You prefer to prescribe an antidepressant with
  the lowest potential for toxicity from an
  overdose. You should select
• Tricyclic antidepressants
• Monoamine oxidase inhibitors
• Selective serotonin reuptake inhibitors
• None of the above

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Review Questions ?

• 2. Which of the following antidepressants
  requires hepatic monitoring?
• Trazodone/Desyrel
• Nefazodone/Serzone
• Bupropion/Wellbutrin
• Paroxetine/Paxil

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Review Questions ?

• 3. There is an increased risk of developing
  serotonin syndrome if patients take a selective
  serotonin reuptake inhibitor along with
• A. St. Johns wort
• B. Nortriptyline/Pamelor
• C. Bupropion/Wellbutrin
• D. Kava Kava

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Review Questions ?

• 4. You are aware that a patient has been treated
  for depression with paroxetine. The patient
  presents with myalgias, disequilibrimum, and
  flu-like syndrome, and increased agitation. You
  should
• Discontinue the paroxetine.
• Double the paroxetine dose.
• Switch the patient to venlafaxine
• Determine whether patient has cut back or
  discontinued paroxetine.

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Review Questions ?

• 5. You believe a depressed patient would benefit
  from some sedation for sleep. Which of the
  following antidepressants is the most sedating?
• A. Trazadone/Desyrel
• B. Fluoxetine/Prozac
• C. Bupropion/Wellbutrin
• D. Nefazodone/Serzone

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Review Questions ?

• 6. Antidepressant medications may precipitate a
  manic or hypomanic episode in a patient with
  bipolar disorder. This is least likely to occur
  with
• A. Amitriptylin/Elavil
• B. Desipramine/Norpramin
• C. Bupropion/Wellbutrin
• D. Fluoxetine/Prozac
• E. Paroxetine/Paxil

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Review Questions ?

• 7. Whats FLUSH?

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Review Questions ?

• 8. Whats SIGECAPS?