Done/mood
The depressive and hypomanic episodes in bipolar II disorder may resemble
the mood instability seen in borderline personality disorder. However, the
labile mood states in borderline personality disorder are brief, typically lasting
hours to days (rather than weeks to months). There is insufficient evidence to
diagnose borderline personality disorder in this patient; she does not exhibit a
lifelong pattern of identity disturbance, feelings of emptiness, intense anger,
splitting, or self-mutilating behavior.
*Diagnosis of bipolar I disorder does not require a history of major depressive
episodes. Bipolar II disorder is characterized by episodes of major depression
and hypomania (not mania, as in this patient) *
*Patients with bipolar I disorder may have psychotic symptoms (eg, delusions,
hallucinations) when they experience severe manic and depressive episodes.
The absence of psychotic symptoms outside of mood episodes, as in this
patient who is only psychotic when he is manic, rules out primary psychotic
disorders.
Medications commonly used in the treatment of acute bipolar depression
include the second-generation antipsychotics quetiapine and lurasidone and
the anticonvulsant lamotrigine. Lithium, valproate, and the combination of
olanzapine and fluoxetine have also demonstrated efficacy.
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Bipolar 1:
● Manic predominant.
● Elevated/irritable mood and increased energy plus 3 of the following (4
if the mood is irritable) for 7 or more days with functional impairment:
o Distractibility.
o Insomnia.
o Grandiosity.
o Flight of ideas/racing thoughts.
o Activities/agitation.
o Sexual exploit/sleep (decreased need). o Talkative/pressured speed.
• Diagnosis:
o Rule out stimulus.
o Rule out bipolar 2 and cyclothymia. • Treatment:
o Lifelong illness that requires maintenance pharmacotherapy to reduce the risk
of recurrent mood episodes.
** Lifelong maintenance indicated for those with severe course (suicide
attempt, frequent episodes, severe symptoms, hospitalization).
o First line for acute mania: antipsychotics, lithium, and anticonvulsant mood
stabilizers (valproate).
o Agitated (emergency department): antipsychotics or benzodiazepines (can be
given IM).
o Mood stabilizers: lithium (mania > depression).
Second choice: valproic acid (mixed affective).
Third choice: carbamazepine (rapid cyclers) or lamotrigine (depression >
mania).
o First line medications for treatment of acute bipolar depression second
second-generation antipsychotic.
generation antipsychotics such as quetiapine and lurasidone.
o Monotherapy for all patients.
o Inadequate response to monotherapy, severe episodes lithium or valproate
and
Bipolar 2:
● Hypomania+ major depressive disorder.
● Hypomania criteria:
Grandiosity.
Decreased need for sleep.
Talkativeness.
Racing thoughts.
Distractibility.
Hyperactivity.
Risky behavior.
o If there were psychotic features—>mania. •
● No functional impairment.
● Rule out catatonia and rule out psychosis.
● Usually seen after MDD takes SSRI ,you reveal hypomania.
Cyclothymia:
• Hypomania and MDD without meeting criteria of either. Rapid cycling:
● 4 or more switches in mood in 1 year.
● 2 months in between attacks if they are the same (mania to mania or
depression to
depression) or 1 month when the attacks are different.
●
Mixed affective:
• Depression and mania develop at the same time (few hours in between).
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Hyperactivity of the HPA axis —> increased cortisol.
● Decreased hippocampal and frontal lobe volumes and changes in
sleep architecture.
REM sleep latency and slow-wave sleep (stage 3 and 4) are decreased.
● Older patients and children present with somatic complaints such as
insomnia.
● Atypical depression: increased sleep, increased appetite, and leaden
paralysis.
After diagnosis of depression—>assess for suicidal ideation.
—What to do depends on how close to suicide are they—
-Has a plan and the means to carry out the plan —>hospitalize.
-No plan and no means to carry out the plan —> contract safety.
- Assess for psychotic features such as delusions and hallucinations with
depressive
themes.
o Treatment: antidepressants + antipsychotics or ECT.
● Rule out mania prior to initiating antidepressants.
● Treatment:
o SSRI/SNRI.
Titrate the dose until you reach the maximum tolerable dose and
continue for 2 months.
● Adequate trial: adequate dose and duration for 6 or more weeks.
● Patients with minimal to no improvement with initial antidepressant
treatment can be switched to another antidepressants, Options:
- SSRI to SNRI.
- Or bupropion, mirtazapine, or serotonin modulators
(vitazodone).
-Washout period of 2 weeks
—>Failed several trials TCA or MAO inhibitors (after washout of 5 weeks).
o Psychotherapy.
o Best treatment: electroconvulsive therapy.
Used for refractory cases, catatonia, or psychosis.
Premedicate with atropine, methohexital, and succinylcholine. ADRS: amnesia.
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Major depressive disorder is associated with
. hyperactivity of the hypothalamic-pituitary-adrenal axis, resulting in
increased cortisol levels.
. decreased REM sleep latency (ie, decreased time from sleep onset
.
until the start of the first REM sleep period) and decreased slow-
wave sleep
**sleep findings in depressed patients include decreased slow-wave sleep
and increased REM sleep duration and density, as well as disruptions in sleep
continuity. Sleep disturbances in MDD typically return to normal with
antidepressant treatment.
**Low levels of 5-hydroxyindoleacetic acid (5-HIAA) in the cerebrospinal
fluid (CSF) are associated with suicidal behavior. Low levels of CSF 5-HIAA
are thought to represent dysfunction of the serotonin system. **
**depressed adolescents may be irritable rather than sad. =
The degree of functional impairment at school and in relationships must be
assessed in adolescents with suspected major depressive disorder.
with marked change from her baseline.
significant academic dysfunction and social impairment inconsistent with
normal adolescent behavior,Other symptoms of major depressive disorder
include changes in appetite or weight loss/gain, excessive guilt/feelings of
worthlessness, and suicidal ideation.
**Pediatric depression often presents with symptoms of irritability rather
than depressed mood. The patient's symptoms warrant treatment because
they have resulted in a marked change from her baseline as well as significant
academic and social impairment. Treatment options for pediatric depression
include psychotherapy, pharmacotherapy, or a combination of these.
**Neuropsychiatric symptoms in Cushing syndrome are common and include
depressed or labile mood, anxiety or panic attacks, irritability, insomnia,
memory deficits, and fatigue. Mania and paranoia occasionally occur.
Patients who initially have psychiatric symptoms may be mistakenly diagnosed
with a primary psychiatric disorder.**
Patients with depression-related cognitive impairment are often more aware of
their cognitive deficits than patients with true dementia. The cognitive
impairment seen in MDD most often affects attention and episodic memory.
Major depressive disorder with psychotic features
is a subtype of depression characterized by severe depression and delusions
and/or hallucinations. First-line treatment consists of an antidepressant plus an
antipsychotic or electroconvulsive therapy ,but it is typically reserved for
patients who require rapid response due to severe suicidality or refusal to
eat or drink.
Dysthymia:
● Depressed mood within a 2-year period or longer.
● Never without symptoms for 2+ months.
● Get TSH to rule out hypothyroid.
● Treatment: SSRI, psychotherapy, or combination.
● Note: if mania or hypomania occurred then it is bipolar or cyclothymia
respectively.
●
postpartum psychosis, generally occurs within the first 2 weeks after
delivery. Clinical features include depressed and/or manic moods, severe
insomnia, agitation, disorganized behavior, and delusions and/or hallucinations,
with content frequently related to the infant
Hospitalization to ensure safety and rapid intervention with antipsychotic
medication are often necessary.
Postpartum psychosis is most often seen in patients who have a history of
bipolar disorder or who are later diagnosed with bipolar disorder based on
mood episodes occurring outside the postpartum period. These patients are at
especially high risk for recurrent episodes in subsequent pregnancies.
Grief Stages:
o Denial.
o Depression.
o Bargaining.
o Anger.
o Acceptance.
● PTSD/ASD: unexpected and violent stimulus. o Fear and anxiety.
●
● Adjustment disorder: non-life-threatening disorder ,adjustment.
● Not death or dying.
● Can’t be defined as bereavement.
suicide-risk assessment
The physician should ask specific questions in a direct and nonjudgmental
manner.
. These include: Do you wish you were dead?
. Are you having thoughts about harming or killing yourself?
. Have you made any plans or preparations to kill yourself?
. Have you ever tried to kill yourself?
exceptions that justify breaching confidentiality are to prevent a serious and
imminent threat to the health and safety of the patient or others (eg,
imminent suicide risk, homicidal ideation with plan to harm the spouse).
nonsuicidal self-injury (NSSI), her recent deep laceration was associated with
suicidal intent. In contrast to a suicide attempt (ie, act performed with some
intent to die), NSSI may be used to cope with distressing negative affective
states; it is seen in a wide range of disorders, including borderline personality,
eating, and dissociative disorders. Some patients engage in both NSSI and
suicidal behavior.
Postpartum:
● Postpartum blues:
- First baby.
-Mum cares.
-Onset and duration: within 2 weeks.
● Postpartum depression:
-After the first.
- Doesn’t care about the baby. o Neglect.
-Onset within one month.
-Duration is ongoing.
-Treatment: SSRI.
● Postpartum psychosis:
-Not in the first baby.
-History of bipolar disorder or who are later diagnosed with
bipolar.
-Fears baby.
- Kills baby
-Within first month.
-Ongoing
-Psychosis predominates.
-Treatment: antipsychotics.
PMS
A detailed menstrual history (diary) with prospective charting of daily mood
and physical symptoms over the course of 2 or 3 menstrual cycles is
commonly used. Demonstration that symptoms occur repeatedly and
predictably prior to menstruation and resolve with menses confirms the
diagnosis. If symptoms occur irregularly or throughout the menstrual
cycle, a primary mood or personality disorder is more likely.
Both continuous and late luteal-phase-only (starting on cycle day 14) SSRI
treatments are effective in PMS/PMDD. Valproate is an anticonvulsant mood
stabilizer used in bipolar disorder; it is not used to treat PMS/PMDD.
