w7 Mood Disorder
w7 Mood Disorder
Mood Disorders
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Mood Disorders
• Unipolar Mood Disorders:
• Dysthymia
• Major Depressive Disorder
• Post Partum Depression
• mania
• depression
• both symptoms in alternating fashion.
• Culturally influenced
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1WHO (2023). Depression and other common mental disorders. Global Health Estimates.
2 Walkeret al., (2015). Mortality in mental disorders and global burden implications: a systematic review and meta-analysis. JAMA
Psychiatry , 72(4), 334-341.
3Mrazek et al., (2014). Psychiatric Services
.
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DIFFERENCES IN SYMPTOMS
ACROSS LIFE SPAN
Depressive Symptoms in Children
• Changes in appetite -- either • Continuous feelings of sadness
increased or decreased and hopelessness
• Changes in sleep -- • Social withdrawal
sleeplessness or excessive
sleep • Increased sensitivity to rejection
• Irritability or anger
• Vocal outbursts or crying
• Fatigue and low energy • Reduced ability to function
during events and activities at
• Physical complaints (such as home or with friends, in school,
stomachaches, headaches) that extracurricular activities, and in
don't respond to treatment other hobbies or interests
• Difficulty concentrating • Feelings of worthlessness or
guilt
Depressive Symptoms in Adolescents
• Migraines
• Fibromyalgia
• Thyroid disease
• Chronic pelvic pain
• Chronic fatigue syndrome
• Irritable bowel syndrome
• ↑ risk for myocardial infarction
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• PHQ-2
• PHQ-9
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PHQ-9
Over the past 2 weeks, how often have you been bothered by
Not at Several More than Nearly every
all days half the days day
Feeling bad about yourself: feel you are a failure or have let yourself
or family down
Trouble concentrating
Thought you would be better off dead or of hurting yourself some way
Trouble relaxing.
• Screen all pregnant and postpartum women for depression using the
Edinburg’s Postnatal Depression Scale (EPDS)
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• Inadequate nutrition
• Sleep disturbance
• Non-adherence to prenatal care
• Substance abuse
• Poor maternal-child bonding
• Spontaneous abortion
• Low birth weight
• Delayed developmental milestones
• Postpartum depression
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SUICIDE
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Suicide
• 49,449 died from suicide in 2022: 1 death every 11 min.
• Gender Differences:
• Males commit suicide at nearly 4 times the rate of females
• 23 per 100,000 vs 5.9 per 100,000, respectively
• Suicide rate highest in people >85 (23 per 100,000)
• Among females, suicide rate highest in those aged 45-64 (10.2 per 100,000).
• Firearms most common method for males
• Poisoning most common method for females
• Nurses:
• Increased rates of depression, anxiety, SA, PTSD, burn-out
• 3 risk factors: stigma, system-related issues, access to care
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• Social isolation
• Criminal problems
• Financial problems
• Legal problems
• Serious illness
Resource: CDC (2021). Facts about Suicide. Risks and Protective Factors. Disparities in Suicide.
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▪ Sexual violence
Resource: CDC (2021). Facts about Suicide. Risks and Protective Factors. Disparities in Suicide.
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Resource: CDC (2021). Facts about Suicide. Risks and Protective Factors. Disparities in Suicide.
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DIFFERENTIAL DIAGNOSIS
MOOD DISORDERS
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• Describes mood as “down in the dumps”; “I’ve always been this way.”
DSM-5 TR (2022)
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Bipolar Disorders
• BP I Disorder:
• Must experience hypomania or mania at least once in lifetime; depression not necessary.
• Mania: distinct period of abnormally and persistently elevated, expansive, or irritable mood and
abnormally and persistently increased goal-directed activity lasting at least 1 week, present
most of day, nearly every day.
• During this period, 3 or > of the following have persisted (4 if only irritable mood):
Bipolar Disorders
• Bipolar II:
Mood that is abnormally and persistently elevated or expansive or irritable and at least
3 or 4 of the following:
Talkative More talkative than usual or pressure to keep talking.
Need for less sleep Decreased need for sleep, not just decreased sleeping time.
Cyclothymic Disorder
• Diagnostic criteria:
TREATMENT ISSUES
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• History of depression
Treatment Issues:
Women
Treatment Issues:
Women
• Menopausal transition
Treatment Issues:
Men
Treatment Issues:
Older Adults
• Longer half-lives
Treatment Issues:
Older Adults
TREATMENT OPTIONS
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Treatment Options
• Pharmacotherapy
• Psychotherapy
• Augmentation therapy
• Phototherapy
• Electroconvulsive therapy
• Natural Antidepressants:
• St. John’s Wort
• SAMe
• Omega 3
• Natural Anxiolytic-Hypnotics
• Kava
• Valerian
• Melatonin
• Cannabidiol (CBD)
• Often supplied as oil containing only CBD (no THC)
Treatment Options
Moderate to Severe Depression
• Medications
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Treatment Modalities
Treatment Resistant Depression (TRD)
• Neurotherapeutics:
• ECT
• Vagus Nerve Stimulation (VNS)
• Transcranial Magnetic Stimulation (TMS)
• Psychiatric Neurosurgies (e.g. lesion ablative procedures, deep brain stimulation)
• Botulinum Toxin
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Psychotherapy Interventions
• Combined with medication most effective
• Psychotherapy approaches:
• Interpersonal
• Family therapy
• Group therapy
• Cognitive behavioral therapy (CBT)
• Dialectical behavioral therapy (DBT)
• EMDR
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PSYCHOTROPIC MEDICATIONS
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Pharmacogenomic Testing
• Laboratory testing to improve the likelihood of selecting
an effective psychotropic medication.
➢ Tricyclic
➢ MAOI’s (Nardil, Parnate)
Categories of Antidepressants:
Selective Serotonin Reuptake Inhibitors (SSRI)
• Second-generation antidepressants
Categories of Antidepressants:
Selective Serotonin Reuptake Inhibitors (SSRI)
Categories of Antidepressants:
Serotonin-Norepinephrine Reupdate Inhibitors (SNRI)
• Duloxetine (Cymbalta)
• Desvenlafaxin (Prestiq)
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Categories of Antidepressants:
Serotonin-Norepinephrine Reupdate Inhibitors (SNRI)
Categories of Antidepressants:
Norepinephrine-Dopamine Reupdate Inhibitors (NDRI)
Categories of Antidepressants:
Norepinephrine-Dopamine Reupdate Inhibitors (NDRI)
• Auvelity:
• Approved August 2022
• Rapid acting AD that can show results in about 1 week
• Works on changing level neurotransmitter glutamate by acting on
NMDA receptors.
• Combination of two drugs: Dextromethorphan (cough suppressant) and
Bupropion (antidepressant, slows metabolism of Dextromethorphan)
• Dosed once a day x 3 days, then BID (45 mg/105 mg)
• Common side effects:
• Dizziness
• Sleepiness
• Headache
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Categories of Antidepressants:
Norepinephrine-Dopamine Reupdate Inhibitors (NDRI)
• Auvelity:
• Black Box Warning: increased suicidal ideations
• Not indicated for management of anxiety disorders
• Contraindications:
• Seizure disorder
• Current or prior dx of anorexia or bulimia
• Abrupt discontinuation of alcohol, benzodiazepines,
barbiturates, or antiseizure medications
• Known sensitivity to bupropion, dextromethorphan, or other
components of Auvelity
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Categories of Antidepressants:
Mixed Serotonin Agonists/Antagonists
• Nefazodone (Serzone)
• Trazodone (Desyrel)
• Vortioxetine (Brintellix)
• Vilazodone (Viibryd)
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Categories of Antidepressants:
Alpha 2-Adrenergic Receptor Antagonist
• Mirtazapine (Remeron)
Categories of Antidepressants:
Tricyclic Antidepressants (TCAs)
• Dry mouth
• Confusion
• Constipation
• Blurred vision
• Urinary retention
• Orthostatic hypotension
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Categories of Antidepressants:
Tricyclic Antidepressants (TCAs)
• Doxepin (Sinequan)
• Trimipramine (Surmontil)
• Amitriptyline (Elavil)-- useful with pain
• Amoxapine (Ascendin)
• Maprotiline (Ludiomil)
• Protriptyline (Vivactil)
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Categories of Antidepressants:
Monoamine Oxidase Inhibitor (MAO)
• Phenelzine (Nardil)
• Tranylcypromine (Parnate)
Reference: clinicaloptions.com
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BIPOLAR DISORDERS
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Pharmacological Treatment:
Acute Bipolar I Depression
1st line 2nd line 3rd line
Lithium Divalproex Carbamazepine
Pharmacological Treatment:
Acute Bipolar II Depression
• Carbamazine (Tegretol)
• Lamotrigine (Lamictal)
• Effective in treating BP depression
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Divalproex Sodium
(Depakote)
• Recommended initial dose is 750mg divided doses
Carbamazine
(Tegretol)
• The dose usually ranges from 200-1600 mg/day
Lamotrigine
(Lamictal)
Lamotrigine
(Lamictal)
Reference: clinicaloptions.com
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Adverse Effects
Atypical Antipsychotics
• Sedation & somnolence
• Metabolic syndrome:
• Dyslipidemia
• Glucose dysregulation
• Abdominal fat
• Hypertension
PRESCRIBING CONSIDERATIONS:
MAJOR DEPRESSION
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Key Factors
• Prioritize symptoms:
• Target most problematic for patient
Key Factors
Key Factors
• Age of patient
Key Factors
• If not previously treated for depression, select:
• Sertraline (Zoloft)
• Escitalopram (Lexapro)
Prescribing Issues
Prescribing Issues
Discontinuation Syndrome
• Withdrawal symptoms
Treatment-Resistant Depression
(TRD)
Augment or Switch:
2016 CANMAT Guidelines
Switch Augment
1 failed trial 2 or more failed AD trials
Poorly tolerated adverse effects to Initial AD well tolerated
initial AD
<25% improvement in symptoms on 25% or greater improvement on initial AD
initial AD (nonresponse) (partial response)
Less severe symptoms and functional More severe symptoms and functional
impairment impairment
Patient preference to switch Patient preference for adding medication
PRESCRIBING CONSIDERATIONS:
BIPOLAR DISORDER
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Key Factors
• Chances are, you will not be the primary prescriber for
someone diagnosed with BPD: they need to be under the
care of a psychiatrist or PMHNP;
Key Factors
• Need to know the side effect profile of those drugs in
order to assess for, monitor, and treat appropriately:
Key Factors
• Need to be knowledgably about BPD: presenting signs & symptoms,
treatment options;
When to Refer to
Mental Health Professional
• Resistant to treatment