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SHAWN HERSEVOORT MD MPH UCSF FRESNO PSYCHIATRY 1 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. 2 Clinical significance: 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 Postpartum women Family history Advanced age Neurological disorders Physical illness 3 4 The most severe form of fluctuant episodic unipolar depression Depressed mood and/or loss of interest or pleasure in life activities Clinically significant impairment in social, work, or other important areas of functioning almost every day 2 weeks or more 5/9 (majority) of the following 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 5 Modifiers: 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 . sleep interest energy concentration appetite psychomotor suicide 6 A type of less severe but unrelenting chronic unipolar depression Depressed mood Most of the day More days than not 2 years or more 2/6 or more of 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) 7 NOTE: compared to MDD no (2) loss of pleasure (5) psychomotor downgraded (7) guilt/worthlessness low self-esteem (9) suicide hopelessness 8 A moderate to severe episodic cyclic depression including mania and possibly psychosis TYPE I: the defining symptom is mania, or cycling episodes of mania and depression TYPE II: the defining symptom hypomania, accompanied by recurrent depression 9 Manic episodes Elevated, expansive, or irritable mood which is distinct, abnormal, and persistent Clear disruption in function is demonstrated 1 week or more (or any duration if hospitalization is necessary) 3/7 or more of (4/7 if the mood is only irritable) 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) 10 Hypomanic episodes Less severe than manic episodes (less elevated, expansive, or irritable) Less functional impairment and possibly none, or even increased productivity (no hospitalization or psychosis) Less time required for diagnosis (4 days or more) MNEMONIC: DIG FAST distractible indiscretion grandiosity flight of ideas activity increased sleep decreased talking increased 11 Modifiers: Mild, moderate, or severe with/without psychotic features, mixed features, anxious distress Single vs. most recent episode hypomanic, manic, depressed, or mixed Rapid cycling: greater than 4 cycles per year Mixed: simultaneous symptoms of hypomania or mania with depressive symptoms 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 12 Related disorder: CYCLOTHYMIC DISORDER a chronic state of cycling between hypomanic and depressive episodes that do not reach the diagnostic standard for a full bipolar disorder 13 Depressive symptoms that occur directly as a result of a particular stressor or life event Situational rather than more broad reaching Less severe symptoms Resolution of symptoms generally occurs on their own with little or no treatment Examples: job loss, breakup, loss of a pet 14 A prominent and persistent disturbance of mood that is judged to be due to the direct physiological effects of a substance Mood can manifest as manic, depressed, or a mix Generally only present either during intoxication or withdrawal 15 Depressive symptoms of depression or mania which are a direct physiological result of the medical condition Physical symptoms caused by illness, not just a psychological response to a medical problem Requires and identified medical illness and a proposed physiological mechanism for causing mental health symptoms Example: depression due to hypothyroid 16 Central Nervous System Subdural hematoma Tumor Infectious Metabolic/Endocrine Pneumonia Thyroid disorder Urinary tract infection Adrenal disorder Aneurysm Sepsis Severe hypertension Malaria Meningitis Legionnaire disease Encephalitis Syphilis Normal-pressure hydrocephalus HIV Seizure disorder Rheumatic fever Multiple sclerosis Herpes Cardiopulmonary Myocardial infarction Congestive heart failure Renal disorder Hypoxia Hepatic disorder Hypercarbia Wilson disease Hypo/hyperglyce mia Vitamin deficiency Systemic lupus erythematosus Electrolyte imbalance Anemia Porphyria Vasculitis Other 17 18 Many mild to moderate psychiatric illnesses can be treated quite effectively in primary care In addition some more severe illness which have been stabilized and are currently in good control can be managed as well For more emergent or severe cases, psychiatric consultation or transfer may be needed 19 Mild to moderate, or dysthymia: psychotherapy and medications are equally effective according to research Severe: medications are the first line although psychotherapy can be added as well Adjustment disorder: support, brief therapy, or brief as needed medications are likely adequate for resolution 20 Type I or II: medications are always the first line although psychotherapy can be added as well Cyclothymia: psychotherapy or medications can be initiated first based on circumstances 21 Due to a substance: treat the substance use first, then use therapy and/or medications Due to a general medical condition: treat the underlying medical condition first, then therapy and/or medications Not otherwise specified: although more information is needed, treatment should proceed along the lines of the most likely diagnosis 22 23 24 Medication choice should be based upon: 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 25 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) 26 Starting dose: Increasing dose: 2-4 week taper (at least) by ½ full dose steps if possible (ex: fluoxetine by 10mg) Cross- taper: daytime for stimulating, and nighttime for more sedating medications Discontinue medication: every 3-4 weeks if symptoms not improving Timing: 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: Early benefits: first 2 weeks Full benefits: weeks 4-6 27 worst in first week but should decrease after that 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 28 For antidepressant medications it is helpful to have baseline labs within 1 year including: Complete metabolic panel Complete blood count TSH EKG (suggested for bupropion and citalopram) 29 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 30 Luvox/fluvoxamine: SSRI with extensive side effects and drug interactions – good for OCD Serzone/nefazodone: SARI with extensive health risks (liver tox), side effects (sedation) – no sex side effects Desyrel/Oleptro/trazodone: SARI with extensive side effects (sedation, priapism) – no sex side effects and good sleep aide Tricyclic antidepressants: older antidepressants with extensive health risks, side effects, and interactions – strong Monoamine Oxidase Inhibitors: older antidepressants with extensive health risks, side effects, and interactions -- strong 31 Starting dose: Increasing dose: 2-4 week taper if possible to avoid seizure (unless toxic side effect present) Cross taper: limit use of BID or TID dosing if possible to increase compliance Discontinue medication: at night if possible as most are sedating (unless BID dosing needed for Li IR ,VPA IR) Multiple dosing: every 7 days until symptoms begin to decrease or blood level achieved Timing: 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: Early benefits: first 1-2 weeks Full benefits: weeks 4-6 32 worst in first week but should decrease after that Most common side effects for all mood stabilizers are: Sedation ▪ Nausea ▪ change dosing to pm, minimize other sedatives and anticholinergics Headache ▪ hydrate, change dosing to pm Blurred vision ▪ change dosing to pm, minimize other sedatives and anticholinergics Dizziness ▪ take with food, hydrate, OTC meds Cognitive blunting ▪ change dosing to pm hydrate, OTC meds NOTE: Splitting/dividing doses improves/decreases side effects but also worsens compliance 33 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) Complete blood count (required for valproate) TSH (suggested for lithium) EKG (suggested for lithium) 34 Lithium and valproate do require ongoing labs Lamotrigine and oxcarbazepine do not Liver panel: valproate every 3 months initially then 6 months then 12 Renal panel: lithium every 3 months 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) 35 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 36 Tegretal/carbamazepine: older mood stabilizer with extensive health risks, side effects, and drug interactions 37 38 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 They can also be used alone when medications are contraindicated such as during pregnancy or severe medical or metabolic issues 39 By maintaining good health maintenance the patient can improve mood Good diet, exercise, sleep, socialization, meaningful work, spiritual life Use a health plan 40 41 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 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 A technique called Motivation Enhancement has demonstrated significant advantages over classic techniques in working with patients with substance abuse issues More intense or longer term therapy, including psychodynamic and interpersonal, can be provided with a referral to a mental health services provider 42 EDUCATIONAL RESOURCES Handouts on diagnosis, medications, and treatment resources should be made readily available to all patients SOCIAL RESOURCES Many patients are struggling with mood for very real reasons Support with housing, finances, and legal issues can be very helpful 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 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? 46