Download MOOD DISORDERS LEARNING OBJECTIVES Describe the clinical

SHAWN HERSEVOORT MD MPH
UCSF FRESNO PSYCHIATRY
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
Describe the clinical significance and high risk populations
for mood disorders.

List and described the different mood disorders and how to
differentiate between them.

List the major classes of antidepressants and describe the
general characteristics of each.

List the different types of mood stabilizers and describe the
general characteristics of each.

List and describe some of the psychotherapy techniques that
can help treat mood disorders.
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Clinical significance:
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10% of primary care patients fit criteria for major depressive disorder
30-40% with chronic medical illness
Leading cause of disability and premature death in patients 18-44
Highest risk ages bimodal: around 18 (12-24) and over 65
High risk populations
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Postpartum women
Family history
Advanced age
Neurological disorders
Physical illness
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The most severe form of fluctuant episodic unipolar depression
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Depressed mood and/or loss of interest or pleasure in life activities
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Clinically significant impairment in social, work, or other important areas of
functioning almost every day
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2 weeks or more
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5/9 (majority) of the following
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Depressed mood most of the day (must include 1 or 2)
Anhedonia diminished interest or pleasure in all or most activities (must include 1 or 2)
Appetite changes including significant unintentional weight loss or gain
Sleep changes insomnia or sleeping too much
Psychomotor symptoms of agitation or retardation noticed by others
Energy decrease or fatigue
Guilt (excessive) or feelings of worthlessness
Concentration difficulties or diminished ability to think or make decisions
Suicidal ideation or recurrent thoughts of death
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Modifiers:
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Mild, moderate, or severe
Single episode vs. recurrent
with/without psychotic features, mixed features, anxious distress
Mnemonic: S.I.G.E.C.A.P.S .
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sleep
interest
energy
concentration
appetite
psychomotor
suicide
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A type of less severe but unrelenting chronic unipolar depression
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Depressed mood
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Most of the day
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More days than not
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2 years or more
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2/6 or more of
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Appetite changes including significant unintentional weight loss or gain
Sleep changes insomnia or sleeping too much
Energy decrease or fatigue
Low self-esteem (vs. guilt in MDD)
Concentration difficulties or diminished ability to think or make decisions
Hopelessness (vs. suicidal thoughts in MDD)
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NOTE: compared to MDD
no
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(2) loss of pleasure
(5) psychomotor
downgraded
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(7) guilt/worthlessness low self-esteem
(9) suicide hopelessness
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A moderate to severe episodic cyclic depression
including mania and possibly psychosis
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TYPE I: the defining symptom is mania, or cycling episodes
of mania and depression
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TYPE II: the defining symptom hypomania, accompanied by
recurrent depression
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Manic episodes
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Elevated, expansive, or irritable mood which is distinct, abnormal, and persistent
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Clear disruption in function is demonstrated
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1 week or more (or any duration if hospitalization is necessary)
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3/7 or more of (4/7 if the mood is only irritable)
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Grandiosity or increased self-esteem or
Sleep decreased (e.g., feels rested after only 3 hours of sleep)
Talking increased from usual or pressure to keep talking
Flight of ideas or subjective experience that thoughts are racing
Distractibility (i.e., attention too easily drawn to unimportant or irrelevant external stimuli)
Activity increased towards goals or psychomotor agitation (either socially, at work or school, or
sexually)
Indiscretion or excessive involvement in pleasurable activities that have a high potential for painful
consequences (e.g., engaging in unrestrained purchasing, sexual encounters, distant travel, or
foolish business investments)
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Hypomanic episodes
Less severe than manic episodes (less elevated, expansive, or irritable)
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Less functional impairment and possibly none, or even increased productivity
(no hospitalization or psychosis)
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Less time required for diagnosis (4 days or more)
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MNEMONIC: DIG FAST
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distractible
indiscretion
grandiosity
flight of ideas
activity increased
sleep decreased
talking increased
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Modifiers:
Mild, moderate, or severe
 with/without psychotic features, mixed features, anxious distress
 Single vs. most recent episode hypomanic, manic, depressed, or mixed
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Rapid cycling: greater than 4 cycles per year
Mixed: simultaneous symptoms of hypomania or mania with depressive
symptoms
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NOTE: Mood instability: a rapid fluctuation in mood from minutes to hours that
is often confused with rapid cycling – can be seen in any mood disorder and is
common in patients in crisis or with personality disorders
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Related disorder: CYCLOTHYMIC DISORDER
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a chronic state of cycling between hypomanic and depressive
episodes that do not reach the diagnostic standard for a full
bipolar disorder
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Depressive symptoms that occur directly as a result of a
particular stressor or life event
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Situational rather than more broad reaching
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Less severe symptoms
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Resolution of symptoms generally occurs on their own with little or no
treatment
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Examples: job loss, breakup, loss of a pet
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A prominent and persistent disturbance of mood that is
judged to be due to the direct physiological effects of a
substance
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Mood can manifest as manic, depressed, or a mix
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Generally only present either during intoxication or
withdrawal
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Depressive symptoms of depression or mania which are a
direct physiological result of the medical condition
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Physical symptoms caused by illness, not just a psychological response
to a medical problem
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Requires and identified medical illness and a proposed physiological
mechanism for causing mental health symptoms
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Example: depression due to hypothyroid
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Central Nervous System
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Subdural hematoma
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Tumor
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Infectious
Metabolic/Endocrine
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Pneumonia
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Thyroid disorder
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Urinary tract
infection
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Adrenal disorder
Aneurysm
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Sepsis
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Severe hypertension
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Malaria
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Meningitis
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Legionnaire
disease
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Encephalitis
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Syphilis
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Normal-pressure
hydrocephalus
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HIV
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Seizure disorder
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Rheumatic fever
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Multiple sclerosis
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Herpes
Cardiopulmonary
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Myocardial infarction
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Congestive heart
failure
Renal disorder
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Hypoxia
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Hepatic disorder
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Hypercarbia
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Wilson disease
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Hypo/hyperglyce
mia
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Vitamin
deficiency
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Systemic lupus
erythematosus
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Electrolyte
imbalance
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Anemia
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Porphyria
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Vasculitis
Other
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Many mild to moderate psychiatric illnesses can be treated
quite effectively in primary care
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In addition some more severe illness which have been
stabilized and are currently in good control can be managed
as well
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For more emergent or severe cases, psychiatric consultation
or transfer may be needed
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Mild to moderate, or dysthymia:
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psychotherapy and medications are equally effective
according to research
Severe:
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medications are the first line although psychotherapy can be
added as well
Adjustment disorder:
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support, brief therapy, or brief as needed medications are
likely adequate for resolution
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Type I or II:
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medications are always the first line although
psychotherapy can be added as well
Cyclothymia:
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psychotherapy or medications can be initiated first
based on circumstances
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Due to a substance:
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treat the substance use first, then use therapy and/or
medications
Due to a general medical condition:
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treat the underlying medical condition first, then therapy
and/or medications
Not otherwise specified:
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although more information is needed, treatment should
proceed along the lines of the most likely diagnosis
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Medication choice should be based upon:
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Diagnosis
Medical health of patient and drug metabolism
Side effect and safety profile of medications
Cost and availability
If patient has a positive history on a medication
previously, or has a 1st degree relative successfully
taking medication
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All antidepressants are considered to be equally effective
All mood stabilizers are not equally effective
All antidepressants and mood stabilizers have interactions – do a
multicheck when starting medication
 First line for depression is usually SSRI or bupropion, second line is
usually SNRI
 First line for bipolar is dependent on circumstances
 Long acting medications: preferred if available as they have
improved side effect profiles in every category except for insomnia
in stimulating medications which can be worsened (ex: bupropion
or venlafaxine)
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Starting dose:
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Increasing dose:
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2-4 week taper (at least) by ½ full dose steps if possible (ex: fluoxetine by 10mg)
Cross- taper:
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daytime for stimulating, and nighttime for more sedating medications
Discontinue medication:
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every 3-4 weeks if symptoms not improving
Timing:
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½ of the standard minimum dose if possible (long acting cannot be split)
if changing medication, cross taper by starting new med at low dose to test for side effects
then increase weekly while lowering other medications
Benefits:
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Early benefits: first 2 weeks
Full benefits: weeks 4-6
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worst in first week but should decrease after that
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Most common side effects for all antidepressants are:
 Feeling stimulated
▪ change to am dosing or augment with buspirone or (low dose) clonazepam
 Feeling sedated
▪ change to pm dosing or augment with (low dose) bupropion
 Nausea, diarrhea, or constipation
take with food, hydrate, OTC meds
 Dry mouth
▪ hydrate or use Xylitol gum
 Headache
▪ hydrate or use OTC meds
 Sex side effects
▪ wait, use lowest dose, or augment with buspirone, bupropion (low), or slidenafil
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For antidepressant medications it is helpful to have
baseline labs within 1 year including:
Complete metabolic panel
Complete blood count
TSH
 EKG
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 (suggested for bupropion and citalopram)
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Class,
brand
Generic
Dose (starting)
titrate monthly
Stimulation,
insomnia
Sedation,
weight gain
Nausea
Sex
Special positive
Special negative
Prozac
fluoxetine
20-80 (10)
***
*
***
***
no w/d
Mod interact
Zoloft
sertraline
50-200 (25)
***
*
***
***
best preg, low interact
Celexa
citalopram
20-50 (10)
*
*
*
***
best preg, low interact
Lexapro
escitalopram
10-20 (5)
*
*
*
***
best preg, low interact
Paxil
paroxetine
20-60 (10)
*
******
*
*****
worst preg, w/d
Paxil CR
paroxetine ER
25-75 (12.5)
*
******
*
*****
worst preg, w/d
Effexor
venlafaxine
75-375 (37.5)
*
*
***
*
pain adjunct
Htn, w/d
Effexor XR
venlafaxine ER
75-300 (37.5)
*
*
***
*
pain adjunct
w/d
Cymbalta
duloxetine
30-60 (15)
*
*
***
*
pain adjunct
liver tox, wd, high
interact
Remeron
mirtazapine
15-45 (7.5)
0
*****
*
*
pain adjunct, sleep
aide, best for nausea
Worst wt gain
bupropion
IR/ER-12/ER-24
300-450 (100)
*****
0
***
0
nicotine quit, sex
adjunct
cards, seizure, antabuse
effect, htn, worst anxiety
SSRI
cards over 40mg?
SNRI
NDRI
Wellbutrin
IR/SR/XL
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Luvox/fluvoxamine:
 SSRI with extensive side effects and drug interactions – good for OCD
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Serzone/nefazodone:
 SARI with extensive health risks (liver tox), side effects (sedation) – no sex side
effects
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Desyrel/Oleptro/trazodone:
 SARI with extensive side effects (sedation, priapism) – no sex side effects and good
sleep aide
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Tricyclic antidepressants:
 older antidepressants with extensive health risks, side effects, and interactions –
strong
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Monoamine Oxidase Inhibitors:
 older antidepressants with extensive health risks, side effects, and interactions --
strong
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Starting dose:
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Increasing dose:
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2-4 week taper if possible to avoid seizure (unless toxic side effect present)
Cross taper:
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limit use of BID or TID dosing if possible to increase compliance
Discontinue medication:
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at night if possible as most are sedating (unless BID dosing needed for Li IR ,VPA IR)
Multiple dosing:
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every 7 days until symptoms begin to decrease or blood level achieved
Timing:
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minimum effective dose
if changing medication, cross taper by starting new med at low dose to test for side effects then increase
weekly while lowering other medications weekly until crossed
Benefits:
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Early benefits: first 1-2 weeks
Full benefits: weeks 4-6
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worst in first week but should decrease after that
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Most common side effects for all mood stabilizers are:
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Sedation
▪
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Nausea
▪
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change dosing to pm, minimize other sedatives and anticholinergics
Headache
▪
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hydrate, change dosing to pm
Blurred vision
▪
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change dosing to pm, minimize other sedatives and anticholinergics
Dizziness
▪
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take with food, hydrate, OTC meds
Cognitive blunting
▪
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change dosing to pm
hydrate, OTC meds
NOTE: Splitting/dividing doses
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improves/decreases side effects but also worsens compliance
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For mood stabilizer medications it is helpful to have baseline
labs within 3 months including:

Complete metabolic panel
 (liver function required for valproate, renal for lithium)
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Complete blood count
 (required for valproate)
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TSH
 (suggested for lithium)
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EKG
 (suggested for lithium)
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Lithium and valproate do require ongoing labs
Lamotrigine and oxcarbazepine do not
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Liver panel:
 valproate every 3 months initially then 6 months then 12
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Renal panel:
 lithium every 3 months
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Blood levels:
 1 week after dose change, then 12 months, or signs toxicity/failure
▪ Lithium - aim for 1.0 (0.8-1.2 micrograms)
▪ Valproate - aim for 100 (50-125 micrograms)
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Indication,
brand
Generic
Dose (starting)
titrate weekly
Weight,
sedation
OD
toxic
Special
labs
Special positive
Special negative
best for classic
cycles, best preg, no
taper needed
renal/thyroid tox -thirst, polyuria,
tremor
Best for mixed/rapid
cycles, violence
liver/pancreas tox
Acute mania
bipolar I
Lithobid
lithium ER
900-1200 (300 BID)
***
*****
BMP,
TSH, EKG.
level
Depakote ER
valproate ER
1500-3000 (1000)
*****
***
Liver,
level
No acute mania
bipolar II
Lamictal
lamotrigine
100-300 (25)
*
*
no
rash/long titration
(25-50-100-200
weekly)
Trileptal
oxcarbazepine
1200-2400 (300 BID)
*
*
Na?
hyponatemia, less
data on
effectiveness
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Tegretal/carbamazepine:
 older mood stabilizer with extensive health risks,
side effects, and drug interactions
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38
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ECT, and to a lesser extent TMS, has been
demonstrated to be an effective treatment for
severe depression, mania, and psychosis in
conjunction with traditional medication treatment
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They can also be used alone when medications are
contraindicated such as during pregnancy or severe
medical or metabolic issues
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By maintaining good health maintenance the
patient can improve mood
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Good diet, exercise, sleep, socialization,
meaningful work, spiritual life
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Use a health plan
40
41
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Cognitive Behavioral Therapy is a simple, effective, and practical form
of therapy that can be taught very quickly in the outpatient setting – it
involves focusing on thoughts, actions, and physical sensations and how
they affect symptoms
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Forms of CBT called Behavioral Activation (BA) and Problem Solving
Therapy (PST) have demonstrated significant benefit in both treatment
of mental health disorders as well as other health behavior motivation
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A technique called Motivation Enhancement has demonstrated
significant advantages over classic techniques in working with patients
with substance abuse issues
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More intense or longer term therapy, including psychodynamic and
interpersonal, can be provided with a referral to a mental health services
provider
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EDUCATIONAL RESOURCES
 Handouts on diagnosis, medications, and treatment resources should
be made readily available to all patients
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SOCIAL RESOURCES
 Many patients are struggling with mood for very real reasons
 Support with housing, finances, and legal issues can be very helpful
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SUPPORT GROUPS
 Social isolation can be a particularly painful aspect of mood disorders
 Group therapy for depression or support groups aimed at particular
life issues can be very helpful
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SUPPORT ANIMALS
 Emotional support, therapy, service
43

Describe the clinical significance and high risk populations for mood disorders.
10% PCP, 30% chronic illness – 18/65, pregnant, family hx, elderly, medically ill
(esp. neuro)

List and described the different mood disorders and how to differentiate
between them. MDD, dysthymia, bipolar 1 and 2, adjustment d/o, subst/medinduced, secondary to AMC

List the major classes of antidepressants and describe the general characteristics
of each. SSRI (safe), SNIR (pain), bupropion (MDD only), TCAs (pain, side effects)

List the different types of mood stabilizers and describe the general
characteristics of each. Lithium (classic/renal/thyroid)/VPA (atypical/liver)
lamotrigine (rash)/oxcarbazepine (hyponatremia)

List and describe some of the psychotherapy techniques that can help treat
mood disorders. Behavioral activation, CBT/PST, dynamic, motivational
enhancement
44
1.
2.
3.
American Psychiatric Association. (2000). Diagnostic and statistical
manual of mental disorders (4th ed., text rev.). Washington, DC:
Author.
American Psychiatric Association. (2013). Diagnostic and
statistical manual of mental disorders (5th ed.). Arlington, VA:
American Psychiatric Publishing.
Robert M. McCarron, Glen L. Xiong, James Bourgeois. Lippincott's
Primary Care Psychiatry Hardcover . Lippincott Williams & Wilkins, 2009
Questions?
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