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Mood-web.ppt
- 2. Archetypes • Depression – Major Depression • Mania – Bipolar Disorder (Manic-Depression)
- 5. Phenomenology: The Mental Status Exam • General Appearance • Emotional • Thought • Cognition • Judgment and Insight • Reliability
- 6. General Appearance • Depression • Mania
- 7. Emotions: Depression • Mood – Dysphoric – Irritable, angry – Apathetic • Affect – Blunted, sad, constricted
- 8. Emotions: Mania • Mood – Euphoric – Irritable • Affect – Heightened, dramatic, labile
- 9. Thought: Depression • Process – Slowed processing • Thought blocking • Content • Everything’s awful • Guilty, self-deprecating • Delusional
- 10. Thought: Mania • Process – Rapid – Pressured speech – Loosening of Associations • Content – Grandiose – Delusions
- 11. Cognition • Depression – Poor attention – Registration – Effort – “Pseudodementia” • Mania – Distractible – Concentration – May seem brighter, more clever
- 12. Insight and Judgment • Depression – Unrealistically negative • Mania – Unrealistically positive – Or just plain bad
- 15. Diagnosis and Criteria • Episodes Versus Disorders
- 16. Episodes • Major depressive • Manic • Mixed • Hypomanic
- 17. Major Depressive Episode • Time – 2 weeks • Change – From previous functioning • Symptoms – 5 or more – 1 has to be depressed mood or anhedonia • Global Criteria
- 18. Symptoms of Major Depressive Episode • “Sig E Caps” – Sleep – Interest – Guilt – Energy – Concentration – Appetite – Psychomotor retardation – Suicide • 5 or more
- 19. Manic Episode • Time – 1 week • Symptom list – 3 or more • Global Criteria
- 20. Symptoms of Manic Episode – Grandiosity – Decreased need for sleep – Pressured Speech – Flight of Ideas – Distractibility – Increased Activity/Agitation – Risky Activities • 3 or more
- 21. The Disorders
- 22. Major Depressive Disorder • “Classic Depression” • Major Depressive Episode • Rule outs – Some other disorder – History of mania/hypomania
- 23. Bipolar Disorder I • Classic “Manic-Depression” • At least one – Manic or, – Mixed episode
- 24. Epidemiology • Depression – 5-7% – 2:1 ♀:♂ – $53 billion/year in US – World: most costly (developed)
- 25. Epidemiology • Bipolar Disorders – 1% – ~1:1 ♀:♂
- 27. Genetics • Family studies – Higher rates – Breed true? • Twin Studies – Mono:Di ~4:1 • Linkage studies – Numerous (? Consistency) – Recent: Zubenko, Am J Genetics
- 28. Social/Environmental • Response to Loss – ex. Animal models • Other stress – Ex. Learned helplessness • What is role of social stress? – Ex. Nemeroff et al.
- 29. Neurotransmission • Neurochemical hypotheses – Catecholamine hypothesis • Norepinephrine – Ex. Axelrod – Depletions models • Serotonin – Refinements • Imbalances • Receptors • 2nd messengers
- 30. Neuroimaging • Stroke data – Dominant frontal – Basal ganglia • Fx Imaging
- 31. Other Physiological Findings • Neurophysiology – Circadian rhythms and sleep • Neuroendocrine – HPA axis • DST
- 32. Differential Diagnosis “We’re not living happily ever after any more”
- 33. Differential Diagnosis • Psychiatric Disorders • Medical Disorders • Substance Induced • Reactive disorders – Adjustment disorders – Normal reactions
- 35. Comorbidity • Anxiety disorders • Substance abuse • Psychotic disorders • Personality disorders • Depression in the medically ill.
- 36. Comorbidity
- 37. Course and Prognosis of Mood Disorders
- 38. Course and Prognosis of Mood Disorders • Recovery • Relapse • Recurrence
- 40. 0 10 20 30 40 50 60 70 80 90 0.5 1 2 4 5 Recovery
- 42. Predictors • # Episodes • Length of episodes • Symptoms – # and type • Comorbidity
- 43. Risk of Suicide • Depression – 10-15% severe (hosp) pts
- 44. “It is unfortunate that I didn’t get your care earlier, Mrs. Perkins.” Treatment
- 45. Treatment • Depression – Pharmacological – Psychotherapy – Other somatic treatments
- 46. Antidepressants
- 47. Antidepressants • 1st generation – Monoamine Oxidase Inhibitors (MAOIs) – Tricyclic Antidepressants (TCAs) • 2nd – Serotonin reuptake Inhibitors (SSRIs) – Other specifics (Buproprion, Trazodone) • 3rd – Venlafaxine, Mirtazapine, Nefazodone
- 48. Mechanisms of action • Monoamine Action – Increase • Norepinephrine • Serotonin – Various mechanisms • Inhibition of catabolism (MAOIs) • Reuptake inhibition (TCAs, SSRIs, Venlafaxine) • Direct effects (agonism/antagonism) (some 3rd gen)
- 49. Side effects • Predicable – Anticholinergic – Antihistaminic – Serotonergic • Idiopathic
- 50. Choice of antidepressant • Best? • Fastest? • Predictors of response – Past history – Family history • Major difference – Side effects
- 51. Treatment failure • Inadequate dose • Inadequate time • Nonadherence
- 53. Strategies for failure • Choices – Increase dose? – Augment? – New drug? Lithium Thyroid hormone Stimulants Atypical Antipsychotics 2nd Antidepressant
- 54. Long term treatment • Recurrent depression (3+) • Chronic depression (2 years) • Double depression • Others
- 55. Psychotherapy • Cognitive behavioral therapy • Interpersonal therapy • Others
- 56. Medications versus therapy • Severe depression • Moderate depression • Combination treatment • Prevention
- 57. Other treatments • ECT • TMH • Vagal nerve stimulation
- 58. ECT • Maybe the best. • Medication failure • Real serious depression • Time sensitive • So why don’t we give everybody ECT?
- 59. Bipolar Disorder • Lithium • Antipsychotics • Anticonvulsants
- 60. Lithium • First line • Best for mania • 2 weeks for effect • Therapeutic index • Side effects • Acute and preventive
- 61. Anticonvulsants • Sodium Valproate • Carbamazapine • Lamotrigine • Gabapentin • Antimanic • Antidepressant • Prevention • Side effects
- 62. Antipsychotics • Atypical (olanzapine) • Classic • May be as effective • Early and late effect
- 64. Other Diagnoses
- 65. Other Episodes • Mixed • Hypomanic
- 66. Other Mood Disorders • Dysthymic Disorder • Cyclothymic Disorder • Bipolar II • Due to a generalized medical condition • Substance Induced • NOS