Mood Disorders

Major depression (unipolar depression)

Major depressive disorder (unipolar depression)

  • ~20% prevalence , 15% commit suicide, ♀ > ♂ , RF: 1st° relative

  • Major depressive episode

    • DX: At least 5 sx for at least 2 weeks (DICESGAPS)

      • Depressed mood most days (must be present)

      • Interest ↓ in activities (must be present)

      • Concentration ↓ (indecisive)

      • Energy ↓ or fatigue

      • Sleep ∆ (insomnia or hypersomnia)

      • Guilt or feelings of worthlessness

      • Appetite or weight ∆

      • Psychomotor agitation or retardation

      • Suicidal ideation or thoughts of death

    • Distress impacts work or school

    • Not due to substance use or disease

  • Major depressive disorder DX:

    • SX NOT DUE to other psychiatric disorder

    • NO HX of manic/hypomanic episode (that would make the dx BIPOLAR)

Persistent depressive disorder (dysthymia)

  • Chronic (2years) of depressed mood for most of day, more days than not

    • Can't be asx for > 2 consecutive months

  • DX criteria: At least 2 sx present while depressed

      • Weight or appetite ∆

      • Insomnia or hypersomnia

      • Low energy/fatigue

      • ↓ concentration (indecisive)

      • Low self-esteem

      • Feelings of hopelessness

TX: Unipolar depression/dysthymia

  • CBT AND SSRIs (first line)

    • Escitalopram (lexapro) or sertraline (zoloft)

      • Switch to different SSRI before trying new class (if not working after 4-6wks)

        • Then try SNRIs

        • TCAs or MAOI last line

  • Electroconvulsive therapy if refractory to meds

  • With psychotic features: sertraline AND olanzapine (zyprexa)

Bipolar depression

Bipolar I

  • One manic episode = Bipolar 1 dx

    • ± major depressive and/or hypomanic episode (not required for dx)

Manic episode

  • At least 1 week (unless manic episode ➔ hospitalization) of:

    • Abnormally and persistently elevated or irritable mood

      • AND

    • Abnormally and persistently increased activity or energy

    • With noticeable change from usual behavior seen by at least 3 (4 if only irritable)

      • Distractibility

      • Irresponsible (shopping, gambling)

      • Grandiosity

      • Flight of ideas (racing thoughts)

      • Activity↑ (goal-directed)/psychomotor Agitation

      • Sleep not needed

      • Talkative/pressured speech

  • Manic episodes can have psychotic features (distorted perception of reality)

    • Delusions, hallucinations, disorganized behavior

  • Catatonia is MC in mood disorders

Bipolar II

  • At least one episode of hypomania (a full manic episode ➔ Bipolar I dx)

    • Hypomania AND one major depressive episode

      • Hypomania DOES NOT affect work/school

      • Hypomania DOES NOT result in hospitalization

      • Hypomania DOES NOT have psychotic features

Cyclothymic disorder

  • Persistent (2 years) of depression and periods of hypomania

TX Bipolar disorders

Severe mania TX: Mood stabilizer AND antipsychotic

  • Lithium OR valproate

  • AND typical (haloperidol) OR atypical antipsychotic

    • Avoid lithium in renal disease

    • Avoid valproate in liver disease and pregnancy

Hypomania first line monotherapy: atypical antipsychotic

  • Risperidone, olanzapine (zyprexa), quetiapine (seroquel), lurasidone (latuda)

    • Second line: lithium OR valproic acid (or add lithium OR valproic acid)

  • Antidepressants can be added but never give alone and stop if mania develops

  • Electroconvulsive therapy for refractory

Emergency TX

Agitated pt with known psychotic disorder

  • Haloperidol IM ± lorazepam IM/IV

    • OR droperidol OR olanzapine IM

  • "B52"

    • Benadryl 50mg

    • Haloperidol 5mg

    • Lorazepam 2mg

Peripartum mood disturbances

Postpartum blues

  • Typically within 1wk of delivery and remits in 2wks

  • Support and educate pt, BOLO postpartum depression

Postpartum depression (major depressive disorder with peripartum onset)

  • Develops anytime within 1yr after birth

  • At least 5 DICESGAPS for at least 2wks

  • CBT and SSRIs (not contraindicated in breastfeeding)

Postpartum psychosis

  • Sudden onset typically within 2wks of birth

  • Usually underlying bipolar

Suicidal

Suicide

  • 10th MCC death in US ➔ ~47,000

  • ~25 attempts per suicide

  • Men are more successful at completing, women attempt more

    • Men use more violent means

      • >50% of suicides are from people using firearms

  • Risk ↑ with age until peak at 45-64yo

    • Peaks again at >75yo (for men)

  • ↑ risk populations:

    • American Indian/Alaskan natives > white > black = hispanic > asian

RISK FACTORS

  • HX of attempts (strongest single predictive factor)

  • HX of psychiatric disorder

  • Single, divorced, widowed

  • Medical illness/chronic pain

  • Substance use

  • TBI/neuro disorder

  • Bi>homo>heterosexual

  • Military veterans > general population

  • Childhood trauma

  • Family hx

  • Rural>city

Management

Always ask about suicidal thoughts (directly) and access to firearms

  • Suicidal ideation: Thoughts (± plan) to intentionally kill self (attempt = suicidal behavior)

    • Active suicidal ideation: Thoughts of taking action to kill oneself "I want to kill myself”

    • Passive suicidal ideation: Wish for death “I'd be better off dead,” "...go to sleep and never wake up”

  • Active ideation with plan ➔ inpatient

  • Active ideation without plan or passive ideation ➔ can pt adhere to safety plan AND has support (family) ➔ partial hospital/IOP

    • I'd always pick inpatient on an exam...

  • Lithium reduces risk of suicide in unipolar/bipolar depression