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w7 Mood Disorder

The document outlines a lecture on mood disorders, focusing on their identification, differences, screening tools, intervention strategies, and clinical outcomes. It provides statistics on depressive disorders, risk factors, presenting symptoms across different age groups, and assessment tools for various populations, including pregnant women. Additionally, it addresses suicide rates, risk factors, and the importance of differential diagnosis in mood disorders.

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0% found this document useful (0 votes)
16 views118 pages

w7 Mood Disorder

The document outlines a lecture on mood disorders, focusing on their identification, differences, screening tools, intervention strategies, and clinical outcomes. It provides statistics on depressive disorders, risk factors, presenting symptoms across different age groups, and assessment tools for various populations, including pregnant women. Additionally, it addresses suicide rates, risk factors, and the importance of differential diagnosis in mood disorders.

Uploaded by

Alan Ysn
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
You are on page 1/ 118

3/10/2025 Carla Groh, PhD, PMHNP-BC, FAAN 1

UNIVERSITY OF DETROIT MERCY

Mood Disorders
3/10/2025 NUR6250 2

Objectives for Lecture


1. Identify common mood disorders in primary care.
2. Describe how the common mood disorders differ.
3. Identify screening tools to make a differential dx.
4. Compare intervention strategies for the common
mood disorders.
5. Evaluate clinical outcomes based on intervention
strategy implemented.
6. Discuss educating patients/family on healthy
lifestyles.
3/10/2025 NUR6250 3

Mood Disorders
• Unipolar Mood Disorders:
• Dysthymia
• Major Depressive Disorder
• Post Partum Depression

• Bipolar Disorder Disorders


• BP I
• BP II
3/10/2025 NUR6250 4

Core Concept of Mood Disorders


• Development of abnormal mood characterized by:

• mania
• depression
• both symptoms in alternating fashion.

• Culturally influenced
3/10/2025 NUR6250 5

Facts About Depressive Disorders

• Common & severe disorder


• Affect approx. 280 million people globally1
• More disability than any other disease1
• Associated with 10 years loss of life2
• U.S. lifetime incidence approx. 18.5%4
• Costs >$100 billion in U.S. annually3
• Leading cause of suicide in U.S.1
• 1/3rd do not respond to treatment

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

4 MMWR (June 16, 2023)

.
3/10/2025 NUR6250 6

Facts About Depressive Disorders


• Once suffer first episode of depression,
• probability of 2nd episode ranges from 50-80%;
• after 2nd episode, likelihood of a 3rd episode increases to 80%

• Longer a person remains symptomatic, lower chances


of complete recovery

American Psychiatric Associations


3/10/2025 NUR6250 7

Depression Across the Life Span:


Prevalence Rates 2021

• 12-month prevalence in United States 8.3% (21 million)

• Prevalence in 18- to 25-year-old highest of all age


groups (18.6%)

• Females experience higher rates (10.3%) compared to


males (6.2%)

NIMH, July 2023 (www.nimh.nih.gov/health/statistics/major-depression)


3/10/2025 NUR6250 8

Risk Factors for Mood Disorder


Family Social Determinants Medical Personal
Family history of Adverse childhood Chronic medical History of depression
depression, SA or events condition Low stress tolerance
suicide
Poverty Medications “acting out” behavior
Genetics Unstable housing or being impulsive
Postpartum period
Unequal education Insomnia Depressed mother
Food insecurity
Unemployment Anxiety Alcohol or drugs use
Major life events
Underemployment Recent stressful
Exposure to violence events

Limited healthcare Death


Discrimination Age
Smoking
Bullying
3/10/2025 NUR6250 9

Presenting Symptoms for Depression


Vegetative Non-Vegetative Other
Depressed mood evidenced Guilt Irritability & anger
by feeling sad, empty, Dysphoria
hopeless** (in children Hallucinations (auditory
mood may be irritable) Anhedonia and visual)
Worthlessness
Somatic complaints
Isolation (doesn’t answer
Suicidal thoughts phone; stays in room)
Fatigue, tiredness, and loss
of energy
Impaired Difficulty being in public
concentration and places with crowds
Weight loss when not decision making
dieting or weight gain
Paranoia and
suspiciousness
Insomnia or hypersomnia
3/10/2025 C. Groh, PhD, PMHNP-BC, FAAN 10

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

• Poor performance in school • Poor self-esteem or guilt


• Withdrawal from friends and • Indecision, lack of concentration or
activities forgetfulness

• Sadness and hopelessness • Restlessness and agitation


• Lack of enthusiasm, energy or • Changes in eating or sleeping
motivation patterns

• Anger and rage • Substance abuse


• Overreaction to criticism • Problems with authority

• Feelings of being unable to satisfy • Suicidal thoughts or actions


ideals
Depressive Symptoms in Women
• Feeling sad or "empty" • Not being able to sleep, or sleeping
• Feeling hopeless, irritable, anxious, too much
or guilty • Overeating, or not wanting to eat at
all
• Loss of interest in favorite activities
• Feeling very tired • Thoughts of suicide, suicide
attempts
• Not being able to concentrate or • Aches or pains, headaches,
remember details cramps, or digestive problems
3/10/2025 NUR6250 14

Depressive Symptoms in Women


• Women have more medical co-morbidity:

• Migraines
• Fibromyalgia
• Thyroid disease
• Chronic pelvic pain
• Chronic fatigue syndrome
• Irritable bowel syndrome
• ↑ risk for myocardial infarction
3/10/2025 NUR6250 15

Depressive Symptoms in Women

• Women three times more likely to attempt suicide but


men account for 65% of completed suicides.

• Women may have longer episodes of depression.

• Women more likely to develop a chronic or recurrent


course.
Depressive Symptoms in Older Adults

• Vague, nonspecific somatic • Demanding behaviors


complaints: • Cognitive changes “pseudo-
dementia”
• Fatigue
• Lethargy • Obsessive preoccupation with
• Hostility
the past
• Physical pain
3/10/2025 C. Groh, PhD, PMHNP-BC, FAAN 17

ASSESSMENT MOOD DISORDERS


3/10/2025 NUR6250 18

General Assessment for Mood Disorder:


Adults
• Family history of mental illness

• Assess for suicidal ideations

• History of depression or traumatic events

• Assess for auditory/visual hallucinations

• Assess all races and ethnicities**

• Complete history and physical to rule out medical conditions:

• Thyroid function tests and CBC


• Evaluate current medications for adverse effects
3/10/2025 NUR6250 19

Substances that Induce


Depressive Symptoms
• Stimulants
• Oral contraceptives
• L-dopa
• Antibiotics
• Central nervous system drugs
• Dermatological agents
• Chemotherapeutic agents
• Immunological agents
3/10/2025 NUR6250 20

Screening for Depression


• Mnemonic, SADAFACES:
• S – sleep problems
• A – appetite or weight changes
• D – dysphoria or bad mood
• A – anhedonia or lack of interest or pleasure
• F – fatigue
• A – agitation/psychomotor retardation
• C – concentration problems
• E – esteem problems
• S – suicidal thoughts
3/10/2025 NUR6250 21

Assessment Tools for Depression:


Adults

• Depression tools - screen only not diagnostic:

• PHQ-2
• PHQ-9
3/10/2025 NUR6250 22

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

Little interest or pleasure in doing things 0 1 2 3

Feeling down, depressed or hopeless

Trouble falling asleep, staying asleep, or sleeping too much

Feeling tired or having little energy

Poor appetite or overeating

Feeling bad about yourself: feel you are a failure or have let yourself
or family down
Trouble concentrating

Moving or speaking more slowly or being more restless and fidgety

Thought you would be better off dead or of hurting yourself some way

0-4 minimal or mild depression 15-19 moderately severe


5-9 mild 20> severe
10-14 moderate
3/10/2025 NUR6250 23

General Anxiety Disorder (GAD-7)


Over the past 2 weeks, how often have you been bothered by

Not at all Several More than half Nearly every


days the days day
Feeling nervous, anxious or on edge. 0 1 2 3

Not being able to stop or control worrying.

Worrying too much about different things.

Trouble relaxing.

Being so restless that it’s hard to sit still.

Becoming easily annoyed or irritable.

Feeling afraid as if something awful might happen.

0-4 minimal anxiety


5-9 mild anxiety
10-14 moderate anxiety
15-21 severe anxiety
3/10/2025 NUR6250 24

Assessment Tools for Bipolar Disorder:


Adults

• Mood Disorder Questionnaire


• Patient Mania Questionnaire (PMQ-9)
• Rapid Mood Screener
• Published in 2020
3/10/2025 NUR6250 25

Rapid Mood Screener


Item Responses
Have there been at least 6 different periods of time (of at least 2 Yes No
weeks) when you felt deeply depressed?
Did you have problems with depression before age 18? Yes No
Have you ever had to stop or change your AD because it made you Yes No
highly irritable or hyper?
Have you ever had a period of at least 1 week during which you Yes No
were more talkative than normal with thoughts racing through in
your head?
Have you ever had a period of at least 1 week during which you felt Yes No
any of the following: unusually happy, unusually outgoing or
unusually energetic?
Have you ever had a period of at least 1 week during which you Yes No
needed much less sleep than usual?
3/10/2025 NUR6250 26

Assessment for Depression:


Older Adults

• Basically, same as with adults

• Also, mini-mental state examination


3/10/2025 NUR6250 27

Assessment for Depression:


All Pregnant and Postpartum Women

• 10-20% pregnant women have MDD

• 2x rate in general population after first trimester

• Often associated with history of depression

• Screen all pregnant and postpartum women for depression using the
Edinburg’s Postnatal Depression Scale (EPDS)
3/10/2025 NUR6250 28

Assessment for Depression:


All Pregnant and Postpartum Women

• Significant effects related to untreated depression during pregnancy:

• 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
3/10/2025 NUR6250 29

Assessment for Depression:


All Pregnant and Postpartum Women

• Risk/Benefit Considerations for Medication Treatment in Pregnancy:

• Risk of untreated depression in mother:


• pre-term delivery, LBW

• Risk of medication treatment in pregnancy:


• neonatal toxicity, teratogenicity

• Underdosing as pregnancy alters medication blood levels:


• increased volume of distribution, increased metabolism of medications
3/10/2025 C. Groh, PhD, PMHNP-BC, FAAN 30

SUICIDE
3/10/2025 NUR6250 31

Suicide
• 49,449 died from suicide in 2022: 1 death every 11 min.

• Suicide rate of 13.48 per 100,000

• Suicide 12th leading cause of death for all ages

• 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

CDC (2024). Preventing Suicide: Retrieved at https://www.cdc.gov/suicide/pdf/preventing-suicide-factsheet-2024-508.pdf


NIH (October 24, 2024). Retrieved at https://www.nimh.nih.gov/health/statistics/suicide.shtml
3/10/2025 NUR6250 32

At Risk Groups for Suicide


• Veterans
• People who live in rural areas, especially youth

• Sexual and gender minorities


• Middle-aged adults

• Tribal populations (American Indian/Alaska Natives)

• Nurses:
• Increased rates of depression, anxiety, SA, PTSD, burn-out
• 3 risk factors: stigma, system-related issues, access to care
3/10/2025 NUR6250 33

Suicide Risk Factors:


Individual

▪ Suffer from major psychiatric disorder (depression, BP, anxiety)


• Alcohol or substance abuse (increases impulsivity)

• Previous suicide attempt

• Social isolation
• Criminal problems

• Financial problems
• Legal problems

• Serious illness
Resource: CDC (2021). Facts about Suicide. Risks and Protective Factors. Disparities in Suicide.
3/10/2025 NUR6250 34

Suicide Risk Factors:


Relationship

▪ Adverse childhood experiences (ACE tool)


▪ Bullying

▪ Family history of suicide


▪ Relationship problems: break-up, violence, loss

▪ Sexual violence

Resource: CDC (2021). Facts about Suicide. Risks and Protective Factors. Disparities in Suicide.
3/10/2025 NUR6250 35

Suicide Risk Factors:


Community

▪ Barriers to health care

▪ Cultural or religious beliefs

▪ Suicide cluster in the community


3/10/2025 NUR6250 36

Suicide Risk Factors:


Societal

▪ Stigma related with mental illness and help-seeking

▪ Easy access to lethal means (e.g. firearms, medication)

▪ Unsafe media portrayals of suicide

Resource: CDC (2021). Facts about Suicide. Risks and Protective Factors. Disparities in Suicide.
3/10/2025 C. Groh, PhD, PMHNP-BC, FAAN 37

DIFFERENTIAL DIAGNOSIS
MOOD DISORDERS
3/10/2025 NUR6250 38

Dysthymia (Persistent Depressive Disorder)


• Depressive mood for most of the day, for more days than not

• Presence while depressed of two or more of the following:


• Poor appetite or over-eating
• Insomnia or hypersomnia
• Low energy or fatigue
• Low self-esteem
• Poor concentration
• Feelings of hopelessness

• Above symptoms experienced for at least 2-years, and person has


never gone longer than 2 months without these symptoms.

• Describes mood as “down in the dumps”; “I’ve always been this way.”

• Functional abilities vary greatly

DSM-5 TR (2022)
3/10/2025 NUR6250 39

Major Depressive Disorder (MDD)


• Five or more of the following symptoms for the same 2-week period
and represent a change from previous functioning:
• Depressed mood most of the day, nearly every day*
• Markedly diminished interest or pleasure in all or almost all activities most of the
day, nearly every day*
• Weight loss or gain
• Insomnia or hypersomnia
• Fatigue or loss of energy nearly every day
• Feelings of worthlessness or inappropriate guilt nearly every day
• Diminished ability to think or concentrate, or indecisive nearly every day
• Recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation with
or without a plan

• Symptoms cause clinically significant distress or impairment in


social, occupational, or other areas of functioning

*must include either depressed mood or anhedonia


DSM-5TR (2022)
3/10/2025 NUR6250: Carla J. Groh 40

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):

• Inflated self esteem or grandiosity


• Decreased need for sleep
• More talkative than usual
• Flight of ideas
• Distractibility
• Increase in goal-directed activity or psychomotor agitation
• Excessive involvement in high-risk activities
3/10/2025 NUR6250: Carla J. Groh 41

Bipolar Disorders
• Bipolar II:

• Needs to meet criteria for current or past hypomanic episode and


current or past major depressive episode.
• Hypomanic symptoms must last 4 consecutive days, most of the
day, nearly every day.

• Never a manic episode.


3/10/2025 NUR6250 42

DSM Criteria for Mania and Hypomania


According to TRENDAR Rubric
Distinct episode of at least 4 or 7 days of increased energy or goal-directed activity
that is abnormal and persistent and

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.

Racing thoughts Subjectively to individual or objectively during interview.

Esteem increased SE unrealistically high given the current circumstances.

Need for less sleep Decreased need for sleep, not just decreased sleeping time.

Distractibility Inability to focus on subject for long; thoughts shifting topics.

Activities increased Goal-directed activities or psychomotor agitation.

Risky business High risk activities with untoward consequences to person or


others ( e.g. buying sprees, sexual indiscretions, poor decisions)

4 days for hypomania; 7 days for mania.


3/10/2025 NUR6250: Carla J. Groh 43

Cyclothymic Disorder
• Diagnostic criteria:

• For at least 2 years, symptoms of hypomania that do not meet


criteria for a manic episode and periods of depression that do not
meet criteria for a major depressive episode.

• Symptoms of hypomania and depression have been present for at


least half the time and person has not been without the symptoms
for more than 2 months at a time.

• Criteria for hypomania, mania and major depressive never met.

• Symptoms cause clinically significant distress in social or


occupational areas of functioning.
3/10/2025 C. Groh, PhD, PMHNP-BC, FAAN 44

TREATMENT ISSUES
3/10/2025 NUR6250 45

Factors that Guide Treatment


• Treatment directed toward several goals:

• Most critical is correct diagnosis


• Focus on functional outcomes
• Safety of patient
• Complete diagnostic evaluation
• Address immediate symptoms but also prospective well-being of
patient
• Reduction of number and severity of stressors in patient’s life (as
able)
3/10/2025 NUR6250 46

Factors that Guide Treatment


• Concurrent medical illness

• Severity of depressive symptoms

• History of depression

• Patient preference, medication history, treatment


response, side effects and specific symptom features to
target
3/10/2025 NUR6250 47

Treatment Issues:
Women

• Lower renal clearance


• Higher plasma levels
• Longer half-lives of drugs
• Slower gastric emptying time
• Lower gastric acid secretion
• Higher percentage of body fat
• Decreased hepatic metabolism
• Greater sensitivity to side effects
3/10/2025 NUR6250 48

Treatment Issues:
Women

• Pregnancy and postpartum vulnerable time for women

• Menopausal transition

• Respond more favorably to SSRIs than men

• Augmentation helpful in women (estrogen with SSRIs in


postmenopausal period; lithium, stimulants)
3/10/2025 NUR6250 49

Treatment Issues:
Men

• Respond more favorably to TCA

• Augment with testosterone for non-responders or poor


responders
3/10/2025 NUR6250 50

Treatment Issues:
Older Adults

• Longer half-lives

• More side effects

• Higher blood levels

• Slower absorption, distribution, and renal clearance


3/10/2025 NUR6250 51

Treatment Issues:
Older Adults

• Start low, go slow

• Use TCAs with caution because of anticholinergic


effects

• ECT effective for those with cardiac problems, non-


responders, and those with regressed depression
3/10/2025 C. Groh, PhD, PMHNP-BC, FAAN 52

TREATMENT OPTIONS
3/10/2025 NUR6250 53

Treatment Options
• Pharmacotherapy

• Psychotherapy

• Augmentation therapy

• Phototherapy

• Electroconvulsive therapy

• Complementary alternative medicine (CAM)


• mild to moderate depression
Treatment Options
Mild to Moderate Depression

• Therapy: individual, group, marital, family, CBT

• Complimentary & Alternative Medicine (CAM):


• Yoga
• Exercise
• Meditation
• Light therapy
• Massage
Natural Medications

• 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

• Therapy: individual, group, marital, family, CBT

• Medications
3/10/2025 NUR6250 57

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)

• Psychedelic Assisted Therapy


• Ketamine
• Esketamine
• MDMA
• Psilocybin

• Botulinum Toxin
3/10/2025 NUR6250 58

Psychotherapy Interventions
• Combined with medication most effective

• Psychotherapy approaches:

• Interpersonal
• Family therapy
• Group therapy
• Cognitive behavioral therapy (CBT)
• Dialectical behavioral therapy (DBT)
• EMDR
3/10/2025 C. Groh, PhD, PMHNP-BC, FAAN 59

PSYCHOTROPIC MEDICATIONS
3/10/2025 NUR6250 60

Pharmacogenomic Testing
• Laboratory testing to improve the likelihood of selecting
an effective psychotropic medication.

• Identifies individual gene variants and person’s response


to medications: slow, rapid, ultra rapid metabolizer.

• Medicare & Medicare have approved reimbursement for


the testing.
3/10/2025 NUR6250 61

Major Depressive Disorders


• Medications commonly prescribed for depression:

➢ SSRI (Prozac, Paxil, Zoloft, Celexa, Luvox)


➢ Mixed action antidepressants (Serzone, Desyrel)

➢ Norepinephrine Reuptake inhibitors (Effexor, Effexor-XR)


➢ Dopamine-Reuptake Blocking Compounds (Wellbutrin)

➢ Tricyclic
➢ MAOI’s (Nardil, Parnate)

➢ Alpha 2-Adrenergic Receptor Antagonist (Remeron)


➢ Atypical Antipsychotics
3/10/2025 C. Groh, PhD, PMHNP-BC, FAAN 62

MAJOR DEPRESSIVE DISORDERS


3/10/2025 NUR6250 63

Categories of Antidepressants:
Selective Serotonin Reuptake Inhibitors (SSRI)

• Second-generation antidepressants

• Fewer side effects and lethality than TCAs

• FDA approved for treating anxiety, especially PTSD

• Side effects include:


• Neuropsychiatric (headache, insomnia, dizziness, fatigue)
• GI (nausea, constipation, diarrhea
• Excessive sweating, sexual dysfunction
• Anxiety and agitation
3/10/2025 NUR6250 64

Categories of Antidepressants:
Selective Serotonin Reuptake Inhibitors (SSRI)

• Fluoxetine (Prozac) • Fluvoxamine (Luvox)


• used to treat OCD

• Paroxetine (Paxil & Paxil CR)


• Escitalopram (Lexapro)

• Citalopram (Celexa) • Sertraline (Zoloft)


3/10/2025 NUR6250 65

Categories of Antidepressants:
Serotonin-Norepinephrine Reupdate Inhibitors (SNRI)

• Duloxetine (Cymbalta)

• Venlafaxine (Effexor, Effexor XR)

• Desvenlafaxin (Prestiq)
3/10/2025 NUR6250 66

Categories of Antidepressants:
Serotonin-Norepinephrine Reupdate Inhibitors (SNRI)

• Also effective in decreasing pain and increasing vigilance

• Major issue is discontinuation symptoms (hypertension,


tachycardia, diaphoresis)

• Side effects include:


• potential for hypertension
• sexual dysfunction
• weight gain
• serotonin syndrome
3/10/2025 NUR6250 67

Categories of Antidepressants:
Norepinephrine-Dopamine Reupdate Inhibitors (NDRI)

• Blocks norepinephrine and dopamine

• Wellbutrin, Wellbutrin XL, & Wellbutrin SR

• Only antidepressant that does not cause weight gain or sexual


dysfunction

• Side effects include agitation, irritability, insomnia, even psychosis

• More serious side effects include seizures and mild hypertensive


reaction
3/10/2025 NUR6250 68

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
3/10/2025 NUR6250 69

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
3/10/2025 NUR6250 70

Categories of Antidepressants:
Mixed Serotonin Agonists/Antagonists

• Nefazodone (Serzone)
• Trazodone (Desyrel)
• Vortioxetine (Brintellix)
• Vilazodone (Viibryd)
3/10/2025 NUR6250 71

Categories of Antidepressants:
Alpha 2-Adrenergic Receptor Antagonist

• Mirtazapine (Remeron)

• Major side effects are weight gain and sedation

• Often prescribed for the medically ill who are depressed


because minimal effect on CYP isoenzymes
3/10/2025 NUR6250 72

Categories of Antidepressants:
Tricyclic Antidepressants (TCAs)

• Equally as effective as SSRIs – major issues are side effect profile


greater risk for lethality in overdose.

• Block norepinephrine and serotonin

• Anticholinergic side effects:

• Dry mouth
• Confusion
• Constipation
• Blurred vision
• Urinary retention
• Orthostatic hypotension
3/10/2025 NUR6250 73

Categories of Antidepressants:
Tricyclic Antidepressants (TCAs)

• Nortriptyline (Aventyl, Pamelor)


• Clomipramine (Anafranil)
• Desipramine (Norpramin)

• Doxepin (Sinequan)
• Trimipramine (Surmontil)
• Amitriptyline (Elavil)-- useful with pain

• Amoxapine (Ascendin)
• Maprotiline (Ludiomil)
• Protriptyline (Vivactil)
3/10/2025 NUR6250 74

Categories of Antidepressants:
Monoamine Oxidase Inhibitor (MAO)

• Two most used in US:

• Phenelzine (Nardil)
• Tranylcypromine (Parnate)

• Rarely used today because of severe interaction effects


with tyramine and dietary restrictions

• MAOI transdermal patch for depression (EMSAM®)


3/10/2025 NUR6250 75

Atypical Antipsychotics Approved


for MDD Treatment
Initial Dose Recommended Adverse Effects
Dose
Aripiprazole (Abilify) 2-5 mg 5-15 mg Weight gain; sedation,
akathisia
Quetiapine/quetiapine 50 mg 150-300 mg Sedation, weight gain
XR (Seroquel)
Olanzapine/fluoxetine 6/25 mg 6/25 – 12/50 mg Sedation, weight gain,
(Symbyax) blurred vision, abn liver tests
Brexpiprazole (Rexulti) 0.5 – 1 mg 2-3 mg Weight gain
Cariprazine (Vraylar) 1.5 mg 1.5 – 3 mg Akathisia

Reference: clinicaloptions.com
3/10/2025 NUR6250 76

Residual Symptoms of Depression May Include


• Depressed mood
• Emotional blunting/anhedonia (related to higher doses)
• Cognitive problems
• Eating problems
• Sleeping problems
• Psychomotor problems
• Fatigue or decreased energy
• Worthlessness and/or guilt
• Suicidal ideations
• Lack of motivation (related to higher doses)

Culpepper (2015). Am J. Med, 128:51.


3/10/2025 C. Groh, PhD, PMHNP-BC, FAAN 77

BIPOLAR DISORDERS
3/10/2025 NUR6250: Carla J. Groh 78

Major Drug Classifications


for Treatment of BP
• Mood stabilizers
• Anticonvulsants
• Atypical antipsychotics
• Antidepressants

• Drug used depends, initially, if presenting with symptoms


of mania/hypomania or depression
3/10/2025 NUR6250: Carla J. Groh 79

Pharmacological Treatment:
Acute Bipolar I Depression
1st line 2nd line 3rd line
Lithium Divalproex Carbamazepine

Lamotrigine Lurasidone Olanzapine

Quetiapine Quetiapine + SSRI Lithium + carbamazepine


Quetiapine XR Adjunctive modefinil Lithium or divalproex +
venlafaxine
Lithium or Lithium or divalproex + Lithium + MAOI
divalproex + SSRI lamotrigine
Olanzapine + SSRI Lithium or divalproex + Lithium or divalproex or AAP
lurasidone + TCA
3/10/2025 NUR6250: Carla J. Groh 80

Pharmacological Treatment:
Acute Bipolar II Depression

1st line 2nd line 3rd line


Quetiapine Lithium Antidepressant
monotherapy
Lamotrigine
Divalproex
Lithium or divalproex _
antidepressant
Lithium + divalproex
CANMAT: International Society
for Bipolar Disorders
Atypical antipsychotic +
antidepressant
3/10/2025 NUR6250: Carla J. Groh 81

Lithium (mood stabilizer)


• More effective with mania/hypomania:

• Still considered 1st line therapy for manic or mixed-episode along


with an anticonvulsant (Depakote);

• Must monitor lithium blood levels, thyroid, kidney function for


toxicity;

• Available in capsule, tablet, or liquid;

• Trade name of Lithobid, Lithane, Lithonate, Lithotabs, Cibalith-S

• Effective in persons with suicidal ideations


3/10/2025 NUR6250: Carla J. Groh 82

Anticonvulsants for Treatment BP


• Divalproex Sodium (Depakote)

• Carbamazine (Tegretol)

• Lamotrigine (Lamictal)
• Effective in treating BP depression
3/10/2025 NUR6250: Carla J. Groh 83

Divalproex Sodium
(Depakote)
• Recommended initial dose is 750mg divided doses

• Increase dose rapidly in acute mania until desired clinical


effect achieved

• Adverse effects include:


• Nausea
• Somnolence
• Dizziness
• Vomiting
• Accidental Injury
3/10/2025 NUR6250: Carla J. Groh 84

Carbamazine
(Tegretol)
• The dose usually ranges from 200-1600 mg/day

• Adverse effect include:


• Upset stomach
• Dry mouth
• Constipation
• Feeling dizzy or drowsy
3/10/2025 NUR6250: Carla J. Groh 85

Lamotrigine
(Lamictal)

• Usual dose: titrate up over 6 weeks:

• Weeks 1&2: 25 mg/day


• Weeks 3 &4: 50 mg/day
• Week 5 100 mg/day
• Week 6: 200mg/day (target dose)
3/10/2025 NUR6250: Carla J. Groh 86

Lamotrigine
(Lamictal)

• Common adverse effects include:


• ataxia, blurred vision, diplopia, dizziness, drowsiness, headache,
insomnia, nausea, rhinitis, skin rash, tremor, vomiting, abdominal
pain, and fever.

• Other side effects include: dysmenorrhea, dyspepsia, vaginitis,


abnormal gait, asthenia, bronchitis, constipation, pain, pruritus,
and emotional lability.
3/10/2025 NUR6250: Carla J. Groh 87

Antipsychotic FDA Approved for


Bipolar Depression
• Cariprazine (Vraylar®)
• Lurasidone (Latuda®)

• Olanzapine-fluoxetine combination (Symbyax®)


• Quetiapine (Seroquel®)
3/10/2025 NUR6250 88

FDA-Approved Drugs for Bipolar Disorder


Acute Mania Acute Depression Long-Term Maintenance
Lithium (1970) Olanzapine + Fluoxetine (2003) Lithium (1974)
Chlorpromazine (1973) Quetiapine (2006, 2008 XR) Lamotrigine (2003)

Divalproex (1996, 2005 ER) Lurasidone (2013) Olanzapine (2004)


Olanzapine, Olanzapine + Cariprazine (2019) Olanzapine + Samidorphan
Samidorphan (2021) (2021)

Risperidone (2003) Lamateprerone (2021) Aripiprazole (2005)


Quetiapine (2004, 2008 XR) Quetiapine XR (2008)

Aripiprazole (2004) Risperidone LAI (2009)


Carbamazepine ERC (2004) Asenapine (2017)

Asenapine (2015) Aripiprazole monohydrate LAI


Cariprazine (2019) (2017)

Aripiprazole monohydrate every


two months (2023)

Reference: clinicaloptions.com
3/10/2025 NUR6250: Carla J. Groh 89

Adverse Effects
Atypical Antipsychotics
• Sedation & somnolence
• Metabolic syndrome:
• Dyslipidemia
• Glucose dysregulation
• Abdominal fat
• Hypertension

• EPS: acute dystonia and acute akathisia


• Prolactin disorders
• Tardive dyskinesia***
3/10/2025 C. Groh, PhD, PMHNP-BC, FAAN 90

PRESCRIBING CONSIDERATIONS:
MAJOR DEPRESSION
3/10/2025 NUR6250 91

Key Factors

• Prioritize symptoms:
• Target most problematic for patient

• Patient’s acceptance of diagnosis and willingness to


take medication

• Previous treatment, and if helpful


3/10/2025 NUR6250 92

Key Factors

• Side effect profile


• match side effects to patient needs

• Co-morbid disorders (e.g., anxiety, ADHD)

• Presence of “atypical” features

• Potential drug-drug or metabolic interaction


3/10/2025 NUR6250 93

Key Factors
• Age of patient

• Race and ethnicity

• Coexisting medical problems

• Patient and/or family preference

• Insurance, co-pays or no insurance issues


3/10/2025 NUR6250 94

Key Factors
• If not previously treated for depression, select:

• Sertraline (Zoloft)
• Escitalopram (Lexapro)

• Consequences of untreated and undertreated depression:

• Increased risk of suicide


• Decreased functional ability
• Decreased quality of life
• Poor management of other medical conditions
3/10/2025 NUR6250 95

Prescribing Issues

• Start lower dose but titrate relatively quickly

• Increased potential for suicidal ideation when therapy


initiated

• Must receive adequate dose over adequate period

• Educate, educate, educate about purpose and action of


antidepressants
3/10/2025 NUR6250 96

Prescribing Issues

• Develop working relationship with patient to avoid


discontinuation of medication on own

• Antidepressants must be tapered to avoid rebound


depression
3/10/2025 NUR6250 97

Discontinuation Syndrome

• Withdrawal symptoms

• Most common effects: dizziness, nausea, lethargy,


headache, flu-like feelings, panic attacks, numbness,
agitation, insomnia

• Symptoms usually mild, start within a week of tx


cessation, usually resolve by end of 3rd week

• Must taper drug and educate patient to avoid abrupt


discontinuation of medication
3/10/2025 NUR6250 98

Treatment-Resistant Depression
(TRD)

• Failure to achieve therapeutic response with at least two


adequate trials of medication from different categories:
• Were trials adequate in dose and duration?

• Contributing factors to TRD:


• Misdiagnosis (e.g. bipolar disorder)
• Psychiatric comorbidities (e.g. SA, OCD, PTSD)
• Medical comorbidities (e.g. hypothyroidism)
• Psychotic features
• Pharmacokinetic factors:
• Concomitant use of metabolic inducers
• Rapid/fast metabolizer
3/10/2025 NUR6250 99

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

References: Kennedy (2016). Can J. Psychiatry; 61:540


Clinicaloptions.com
3/10/2025 NUR6250 100

Other Factors to Consider When


Deciding to Switch or Augment
Factor Comment
# failed trials in current episode Few treatments for depression have been studied in
the setting of multiple previous nonresponses.
Are there viable options? Some treatments may have unique efficacy (e.g.
ketamine, ECT, MAOIs, lithium).
Tolerability Are AE bothersome or medically significant?
Manageable/tolerable or do risks outweigh benefits?
Severe or unique symptoms Suicidal behavior and lithium; pain and noradrenergic
targets agents.

Comorbidities Stimulants and ADHD, anxiolytics

Timing of making change Sometimes safer to retain an existing partially effective


treatment and not discontinue until a new replacement
treatment has demonstrated efficacy.

Reference: Goldberg (2024). Clinical reasoning and decision-making in psychiatry.


Clinicaloptions.com
3/10/2025 NUR6250 101

Additional Factors to Consider When Deciding to


Change Depression Treatment Plan
Consideration Comment
Trial length Expect an improvement of 20% by 2 weeks but adequate
trial may be 6-12 weeks in chronic or TRD.
Adequate dosing Subtherapeutic dose is not adequate.
Pharmacogenetics Suspect ultrarapid metabolizers for a given substrate if no
response + no AE at optimal doses.
Adequate adherence Never assume!!
Comorbidities Depression + comorbid anxiety disorders required >6
weeks to determine efficacy in STAR*D study.

Reference: Goldberg (2024). Clinical reasoning and decision-making in psychiatry.


Clinicaloptions.com
3/10/2025 NUR6250 102

Is There a Need to Cross-Taper


if Switching Medication?
Factor Comments
Half-life of outgoing medication Long half-life outgoing AD (fluoxetine, vortioxetine,
aripiprazole, Cariprazine) will auto-taper, usually no
need for dose reduction before stopping; overlapping
cross-tapers may unnecessarily increase additive AE
burden.
Rebound effect? Abruptly stopping an anticholinergic drug (e.g.
paroxetine, quetiapine, TCA) may trigger cholinergic
rebound if the incoming medication lack
anticholinergic effects (e.g. aripiprazole)
Receptor redundancy or Serotonin transporter (switching SSRI to SNRI).
competition?

Goldberg (2024). Clinical reasoning and decision-making in psychiatry.


Clinicaloptions.com
3/10/2025 NUR6250 103

If Augmenting Current Treatment


• Augmentation studies favor:
• Aripiprazole (Abilify)
• Mirtazapine (Remeron)
• Levothyroxine (Thyroid)

• Emerging data supports second-generation antipsychotics:


• Cariprazine (Vraylar)
• Brexpiprazole (Rexulti)
3/10/2025 C. Groh, PhD, PMHNP-BC, FAAN 104

PRESCRIBING CONSIDERATIONS:
BIPOLAR DISORDER
3/10/2025 NUR6250: Carla J. Groh 105

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;

• Need to know name and phone number of that provider;

• Need to know name of drugs, dose, and frequency of


drugs prescribed.
3/10/2025 NUR6250: Carla J. Groh 106

Key Factors
• Need to know the side effect profile of those drugs in
order to assess for, monitor, and treat appropriately:

• Need to coordinate lab work, etc to prevent duplications;

• Need to know drugs most effective for acute versus


maintenance phase
3/10/2025 NUR6250: Carla J. Groh 107

Key Factors
• Need to be knowledgably about BPD: presenting signs & symptoms,
treatment options;

• If patient presents with new onset of symptoms suggestive of BPD,


refer immediately to a psychiatrist or PMHNP for treatment;

• Support the patient in their efforts to be adherent to their treatment


plan; become a partner with the patient and psychiatrist or PMHNP
for improved outcomes.

• Patient education critical – their knowledge of BP may be limited.


3/10/2025 C. Groh, PhD, PMHNP-BC, FAAN 108

REFERRALS AND RESOURCES


3/10/2025 NUR6250 109

When to Refer to
Mental Health Professional
• Resistant to treatment

• Poor support systems

• Recurring depressive episodes

• First episode of mania (bipolar disorder)

• Suicidal thoughts, severe hopelessness, helplessness

• Complicated depression (e.g., psychosis, paranoia)


3/10/2025 NUR6250 110

Practice Guidelines for Mood Disorders:


Major Depression, Bipolar Disorder, Postpartum Depression

• National Guideline Clearinghouse


• http://www.guideline.gov/

• American Psychiatric Association


• http://www.psych.org/MainMenu/PsychiatricPractice/Practic
eGuidelines_1.aspx

• American College of Physicians


• http://www.acponline.org/clinical_information/guidelines
3/10/2025 NUR6250 111

Practice Guidelines for Mood Disorders:


Major Depression, Bipolar Disorder, Postpartum Depression

• CANMAT Guidelines for MDD in PC:


• https://themedicalxchange.com/en/2024/06/07/3032-primary-care-canmat-
guidelines-major-depressive-disorder/

• CANMAT (2018) Guidelines for Bipolar


• https://www.canmat.org/sdm_downloads/2018-bipolar-guidelines/
3/10/2025 NUR6250 112

Community Mental Health Resources

• Detroit Wayne Integrated Health Network (DWIHN):


• https://dwihn.org/
• 24-hour helpline: 800-241-4949

• Oakland Community Health Network:


• http://www.occmha.org/
• Resources and Crisis Line: 800-231-1127

• Macomb Community Mental Health:


• http://www.mccmh.net/
• Crisis Center: 586-307-9100.
3/10/2025 NUR6250 113

Community Mental Health Resources:


Families and Individual with MI

• National Alliance on Mental Illness (NAMI):


• https://www.nami.org/
• 12 affiliate offices in Michigan:
https://www.nami.org/Affiliate?state=MI
• Provides free support groups, information, advocacy
• Helpline: 800-950-6264

• Depression and Bipolar Support Alliance (DBSA):


• https://www.dbsalliance.org/
• 13 offices in Michigan
• Focuses on mood disorders (depression & bipolar disorder)
• Provides educational material, peer-supported groups, advocacy
• Crisis Helpline: (800) 273-TALK (800-273-8255)
3/10/2025 NUR6250 114

Behavioral Health Inpatient Facilities


• Harbor Oaks Hospital, New Baltimore • 586-725-5777

• Stonecrest Center, Detroit • 313-245-0649

• Behavioral Center of Michigan, Warren • 586-261-2266

• Havenwyck Hospital, Auburn Hills • 248-373-9200

• Henry Ford Kingswood Hospital, Ferndale • 248-398-3200

• St. John Providence, Southfield • 248-849-3000

• St. John Hospital System


• Warren • 586-573-5244
• Madison Heights • 248-967-7660
• Detroit • 313-343-7000
3/10/2025 NUR6250 115

Key Take Aways


• Early intervention and prevention should be a major priority

• Mood disorders major health issue in primary care

• Must differentiate between MDD and BP for most effective treatment

• Women twice as vulnerable as men

• Common with chronic medical illnesses

• Must identify and treat aggressively

• Can become chronic with significant impact on quality of life, family,


work, life expectancy
3/10/2025 NUR6250 116

Key Take Aways


• Complete remission always the goal – partial remission not
acceptable

• Educate patient and family about mood disorders and treatment


options

• Educate patient and family about healthy lifestyles

• Important to establish working r-ship with psychiatrist and other


mental health practitioners in the area
3/10/2025 NUR6250 117

People Diagnosed with Depression

• Gwyneth Paltrow • Reese Witherspoon


• Brooke Shields • Catherine Zeta-Jones
• Jim Carrey • Angelina Jolie-Pitt
• Ellen Degeneres • Britney Spears
• Demi Lovato • Billy Joel
• Princess Diana • Sheryl Crow
• James Taylor • Kurt Cobain
• Drew Carey • Eminem
• Harrison Ford • Jon Hamm
• Johnny Depp • Ann Hathaway
• Michael Phelps • Lady Gaga
• Brad Pitt
3/10/2025 NUR6250: Carla J. Groh 118

People Diagnosed with BP


• Brian Wilson (musician) • Vincent van Gogh (artist)

• Patty Duke (actor) • Virginia Wolf (novelist)


• Jane Pauley (journalist)
• Demi Lovato (actor)
• Amy Winehouse (musician)
• Catherine Zeta-Jones (actor)
• Kim Novak (actor)
• Carrie Fisher (actor)
• Mike Tyson (boxer)
• Linda Hamilton (actor) • Ernest Hemingway (writer)
• Sinead O’Connor (musician) • Macy Gray (singer)
• Richard Dreyfuss (actor) • Nina Simone (singer)

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