mood disorders 2013 Dr V Primeau

Report
Back to Basics:
Mood Disorders
Dr. Valerie Primeau
PGY5 Psychiatry
April 5th, 2013
[email protected]
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:






List and interpret critical clinical and laboratory findings which were key in the processes of
exclusion, differentiation, and diagnosis:


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.
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.
MCC Objectives (2)

Depressive Disorders





Grief & Bereavement
Depression With Associations





Major Depressive Disorder
Atypical Depression
Dysthymic Disorder
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
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

Overview of
Mood
Disorders
David J. Robinson, Psychiatric
Mnemonics & Clinical Guides, 1998
General
Concepts
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
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%
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
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)
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!
Major Depressive Episode (1)

5 or more for 2 weeks nearly every day:









Mood depressed*
Sleep ↑↓
Interest ↓, libido ↓, social withdrawal*
Guilt, hopelessness, worthlessness
Energy ↓
Concentration ↓, indecisiveness
Appetite↑↓, weight ↑↓, loss of taste for food
Psychomotor ↑↓
Suicidal ideation, recurrent thoughts about
death
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
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)







Distractibility
Indiscretion, pleasurable activities
with painful consequences
Grandiosity
Flight of ideas
Activity ↑
Sleep ↓
Talkativeness
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
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
Mixed Episode
 Criteria
met for both Manic and Major
Depressive Episodes
 Nearly everyday for one week
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
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)
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
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
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)
Specific
Mood
Disorders
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
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
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
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

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
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
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
Particularities of Depression
 With
Atypical Features
 With Melancholic Features
 With Catatonic Features
 With Psychotic Features
 With Seasonal Pattern
 With Postpartum Onset
 Grief & Bereavement
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
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
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)
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

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 nonseasonal episode
Seasonal Major Depressive Episodes outweigh
non-seasonal episodes in their lifetime
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
Grief & Bereavement (1)
 Normal
grief or bereavement reaction
versus Major Depressive Episode
 Complicated or pathological grief or
bereavement (not in DSM-IV)
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
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
Dysthymic Disorder (2)
 Hopelessness
 Energy
↓
 Self-esteem ↓
 2 years of depressed, for more days than
not (1 year in kids, mood can be irritable)
 Sleep ↑↓
 Appetite ↑↓
 Decision-making ↓, concentration ↓
Bipolar Disorder (1)

Bipolar I Disorder = at least 1 Manic or Mixed
Episode


Bipolar II Disorder = at least 1 Major Depressive
Episode & 1 Hypomanic Episode


Commonly have more Major Depressive Episodes
but not required for diagnosis
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
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
Bipolar Disorder (3)

Pharmacotherapy (Bipolar I)

Acute Manic Episode



Acute Major Depressive Episode



Lithium, divalproex, olanzapine,risperidone,
quetiapine, quetiapine XR, aripiprazole, ziprasidone
Taper and discontinue antidepressants
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)
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
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
Ethics and
Legal
Considerations
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
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
Consent to Treatment (3)
 Specific
to the issue
 Informed
 Voluntary
 Capable
– no misrepresentation
– no coercion or persuasion
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
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)
Quick
Practice
Questions!
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?
MCQ 1
a)
Venlafaxine
b)
Bupropion
c)
Quetiapine
d)
Paroxetine
e)
Phenelzine
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?
MCQ 2
a)
Autonomy
b)
Fiduciary duty
c)
Non-discrimination
d)
Beneficence
e)
Non-maleficence
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:
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
Review of systems
Similar past episodes
Past history of manic
episode
Current alcohol use
Past history of
smoking cigarettes
Hopelessness
Menstrual history
Degree of functional
impairment
Recent stressors
Consumption of
caffeine
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
Psychiatric family
history
Parents’ cause of
death
Developmental
history
Memory impairment
Loss of interest
Support network and
living situation
Sexual orientation
Psychotic symptoms
Suicidal ideation
Past history of abuse
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.
1.
2.
3.
4.
5.
6.
7.
Psychodynamic
psychotherapy
Review possible
side effects of each
treatment
Start lithium alone
Tell the patient it is
her fault for being
depressed
Psychoeducation
about the illness
and the treatments
Assess for short-term
work disability
Watchful waiting
8.
9.
10.
11.
12.
13.
14.
Interpersonal
Therapy
Motivational
interviewing
Exposure and
relapse prevention
therapy
Cognitive
behavioral therapy
Start sertraline
alone
Involuntary
hospitalization
12-step program
Thanks!

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