back to basics: mood disorders dr. valerie primeau pgy4 psychiatry march 20, 2012...

Back to Basics: Mood DisordersDr. Valerie PrimeauPGY4 PsychiatryMarch 20, 2012vprim090@uottawa.ca

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