Dec 30, 2015
Back to Basics: Mood DisordersDr. Valerie PrimeauPGY4 PsychiatryMarch 20, [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:
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.
List and interpret critical clinical and laboratory findings which were key in the processes of exclusion, differentiation, and diagnosis: 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
Major Depressive Disorder Atypical Depression Dysthymic Disorder
Grief & Bereavement Depression With Associations
Seasonal Affective Disorder Postpartum Depression Substance-Induced Mood Disorder Mood Disorder Due to a General Medical
Condition 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 NotesThank 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 classex: 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) Five 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 three of (four 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”)
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 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 Natural course of illness after one year
without treatment 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, two Major Depressive Episodes have occurred as above with no non-seasonal 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 Commonly have more Major Depressive
Episodes but not required for diagnosis Bipolar II Disorder = at least 1 Major
Depressive Episode & 1 Hypomanic Episode No past Manic or Mixed Episode
Not better accounted by another disorder, a general medical condition, a substance or medication (“Bipolar Disorder type III”)
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
Acute Manic Episode Lithium, valproic acid, atypical antipsychotics,
lithium + antipsychotic, VPA + antipsychotic Taper and discontinue antidepressants
Acute Major Depressive Episode Lithium, lamotrigine, quetiapine, lithium or VPA +
SSRI, olanzapine + SSRI, lithium + VPA Do not use antidepressant as monotherapy
Maintenance treatment Lithium, valproic acid, lamotrigine, olanzapine,
quietiapine, LA risperidone, lithium or VPA + quietiapine, aripiprazole
With Rapid Cycling Can be applied to Bipolar I and II At least four 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) According to MCC:
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) According to MCC (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
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)
QuickPractice Question!
Situation 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. Review of systems2. Similar past episodes3. Past history of manic
episode4. Current alcohol use5. Past history of
smoking cigarettes6. Hopelessness7. Menstrual history8. Degree of functional
impairment9. Recent stressors10. Consumption of
caffeine
11. Psychiatric family history
12. Parents’ cause of death
13. Developmental history14. Memory impairment15. Loss of interest16. Support network and
living situation17. Sexual orientation18. Psychotic symptoms19. Suicidal ideation20. Past history of abuse
or neglect