CRACKCast E111 – Mood Disorders

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This episode of CRACKCast covers Rosen’s Chapter 101 (9th Ed.), mood disorders. The podcast will focus on the diagnosis and management of common mood disturbances.

Shownotes – PDF Here

Rosens In Perspective:

Mood = subjective emotional state.

“A change in mood becomes a “mood disorder” when it significantly impairs functioning. In the emergency department, patients with mood disorders often present grossly debilitated, with thoughts of suicide, homicide, or profound self-neglect. These patients frequently present in emotional crisis, but this may not be their presenting complaint.”

Mood disorders fall into two big silos: DEPRESSIVE DISORDERS & BIPOLAR DISORDERS

“Mental health patients are the fastest growing group of patients presenting to the ED. In 2007, 13% of the 94 million ED visits in the United States were for psychiatric reasons, which was an increase from 5% in 2000. This increase is nearly double what would have been expected by population growth alone.

Up to 50% of Americans will meet the criteria for a DSM-5 disorder sometime in their life, with an estimated 21% having a mood disorder.”

[1] List the 3 neurotransmitters implicated in depression.

Low levels of these in the synapse:

  • Serotonin
  • Norepinephrine
  • Dopamine

Other neurotransmitter systems implicated:

  • Low levels of
    • Glutamate
    • γ-aminobutyric acid

[2] List the DSM V criteria for Major Depressive Episode.

 

Coles notes:

  • A change from baseline, with 2 weeks of daily depressed mood or loss of interest/pleasure and at least 5 of the SIGE CAPS items
  • Impaired social/job function
  • Not caused by a medical condition or drug ingestion
  • Not explained by another mental health disorder
  • No history of mania

BOX 101.1 (9th Ed.) Summary of DSM-V Criteria for a Major Depressive Episode

A. Five or more of the following symptoms have been present almost every day during the same 2-week period and represent a change from previous functioning; at least one of the symptoms is either (1) depressed mood or (2) loss of interest or pleasure. Note: Do not include symptoms caused by a general medical condition.

  1. Depressed mood (can be irritable mood in children and adolescents)
  2. Loss of interest or pleasure in activities
  3. Significant weight loss when not dieting, weight gain, or decrease or increase in appetite
  4. Insomnia or hypersomnia
  5. Psychomotor agitation or retardation
  6. Fatigue or loss of energy
  7. Feelings of worthlessness, or excessive or inappropriate guilt
  8. Diminished ability to think or concentrate, or indecisiveness
  9. Recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation, or a suicide plan or attempt.

B. Symptoms cause clinically significant distress or impairment in social, occupational, or other functioning.

C. Symptoms are not caused by direct physiologic effects of a substance (eg, drug of abuse, medication) or a general medical condition (eg, hypothyroidism).

D. Symptoms are not better explained by another mental health disorder.

E. There has never been a manic or hypomanic episode.

All depressed patients must be questioned about suicidal thoughts. Do a thorough suicide risk assessment. 

[3] Define Seasonal Affective disorder, Dysthymic Disorder and Cyclothymic disorder 

Seasonal Affective disorder

  • A specifier of MDD
  • “This specifier can only be used with a recurrent major depressive disorder. The criteria for this include the following: a regular temporal relationship between onset of depressive episode and a particular time of year, full remissions at a specific time of year, two depressive episodes within 2 years that demonstrate a temporal relationship, no nonseasonal episodes within the same period, and substantially more seasonal depressive episodes than nonseasonal episodes over the person’s lifetime.
  • Treatment: phototherapy

Dysthymic Disorder 

A new diagnosis, persistent depressive disorder, combines the former diagnoses of chronic major depressive disorder and dysthymic disorder. The diagnostic criteria are:

  • Depressed mood most of the day
  • Present most days for ≥2 years
  • And two or more of the following criteria:
    • Poor appetite or overeating
    • Low energy or fatigue
    • Low self-esteem
    • Poor concentration or decision-making ability
    • Feelings of hopelessness
    • Never asymptomatic for more than 2 months of the 2 year period
    • Causes significant distress or impairment in functioning
    • Not due to a substance or medical condition

Cyclothymic disorder 

Cyclothymic disorder is characterized by chronic mood swings that do not meet criteria for a hypomanic or depressive episode. The mood episodes must occur over at least 2 years, present for at least half the time, and the individual cannot be symptom free for more than 2 months at a time.

[4] Define Bipolar I and Bipolar II 

Bipolar I disorder includes at least one manic episode, and patients have typically had one or more major depressive episodes, although a depressive episode is not necessary for diagnosis.

Bipolar II disorder involves a hypomanic episode and at least one major depressive episode. A hypomanic episode includes the features of a manic episode without psychosis, marked impairment of function, or the need for hospitalization.”

Do a suicide risk assessment. 

“Up to 80% of patients with bipolar disorder will exhibit suicidal behavior, and half will attempt suicide. Suicidal behavior can occur during all phases of bipolar disorder, but patients experiencing a depressed or a mixed episode are at higher risk, especially those with severe depressive symptoms and a sense of hopelessness.”

[5] List the DSM V Criteria for a Manic Episode (box)

Coles notes:

  • Duration > 1 week (or less if hospitalization needed)
  • 3 or more of GST PAID symptoms
  • Impairs social/job function
  • NOT caused by a medial or drug ingestion 

BOX 101.3 (9th Ed.). Summary of DSM-V Criteria for a Manic Episode

A. Distinct period of abnormally and persistently elevated, expansive, or irritable mood, and abnormally and persistently increased goal-directed activity or energy lasting at least 1 week (or any duration if hospitalization is necessary).

B. During the period of mood disturbance and increased energy or activity, three or more of the following symptoms have persisted (four, if the mood is only irritable) and have been present to a significant degree:

  1. Inflated self-esteem or grandiosity
  2. Decreased need for sleep (eg, feels rested after only 3 hours of sleep)
  3. More talkative than usual or pressure to keep talking
  4. Flight of ideas or subjective experience that thoughts are racing
  5. Distractibility (ie, attention too easily drawn to unimportant or irrelevant external stimuli)
  6. Increase in goal-directed activity (either socially, at work or school, or sexually) or psychomotor agitation
  7. Excessive involvement in pleasurable activities that have a high potential for painful consequences (eg, buying sprees, sexual indiscretions, foolish investments)

C. Mood disturbance is sufficiently severe to cause marked impairment in occupational functioning or social activities or to necessitate hospitalization to prevent harm to self or others, or psychotic features are present.

D. Symptoms are not caused by direct physiologic effects of a substance (eg, drug of abuse, medication) or a general medical condition (eg, hyperthyroidism).

Modified from American Psychiatric Association 

[6] List 8 general medical conditions and 8 medications that cause depression/mood disorders. 

Medical Conditions

  • Degenerative:
    • Parkinson’s disease
    • CAD
    • MI
    • Stroke
    • End stage renal disease
    • AIDS
    • Connective tissue diseases
    • Hyperthyroidism
  • Neoplastic
    • Pancreatic CA
    • Brain neoplasm
    • Lymphoma

Medications/drugs of abuse

  • Depression :
    • Antihypertensives
    • Anticonvulsants
    • Hormones
    • ETOH abuse
    • Sedative abuse
    • Hypnotic abuse
    • Anxiolytic / narcotic abuse
  • Mania
    • Antibiotics
    • Steroids
    • Cocaine
    • PCP
    • Hallucinogens
    • Amphetamines

[7] Describe 1st line medical therapy for depression and bipolar disorder.

Depression

  • SNRI / SSRI (plus psychotherapy!)
    • e.g. citalopram 20 mg daily

Bipolar disorder:

  • Antipsychotic (2nd gen)
  • Mood stabilizer
    • Lithium
    • Valproic acid
    • Carbamazepine

 [8] List 4 criteria for hospitalization of an acute psychiatric episode

  • actively suicidal
  • dangerous to others
  • possess severe mental debilitation precluding self-care
  • Patient with a first psychotic episode

Wisecracks

[1] Mnemonics for symptoms of depression and mania

BOX 101.2 (9th Ed.) Mnemonics for the Symptoms of Depression and Mania

MNEMONIC FOR THE SYMPTOMS OF DEPRESSION

SIG E CAPS

  • Sleep amount increased or decreased
  • Interest (anhedonia)
  • Guilt
  • Energy level decreased
  • Concentration decreased
  • Appetite increased or decreased
  • Psychomotor activity increased or decreased
  • Suicidal ideation

MNEMONIC FOR THE SYMPTOMS OF MANIA

DIG FAST

  • Distractibility
  • Irritability
  • Grandiosity
  • Flight of ideas
  • Activity increased
  • Sleeplessness
  • Thoughtlessness (impulsivity, increased risk taking)

GST PAID

  • Grandiosity or inflated self-esteem
  • Sleep – decreased need for
  • Talkative – pressured speech
  • Pleasure – engage in high risk and irrational activities for pleasure (sex, spending, drugs, etc)
  • Activity increased (goal-directed behaviors and agitation)
  • Ideas – flight of
  • Distractibility

This post was uploaded and copyedited by Owen Scheirer.

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Adam Thomas

Adam Thomas

CRACKCast Co-founder and newly minted FRCPC emergency physician from the University of British Columbia. Currently spending his days between a fellowship in critical care and making sure his toddler survives past age 5.
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Larissa Hattin

Larissa Hattin

Larissa is a medical student at McMaster University.
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