Info
🌱 來自: Huppert’s Notes
Mood Disorders🚧 施工中
Mood Disorders
Major depressive disorder (MDD)
• Etiology: Multiple synergistic biopsychosocial risk factors at play. Abnormal functioning of many neurotransmitters (serotonin, norepinephrine, dopamine, GABA, and glutamate) and complex intracellular cascades involved in both pathogenesis and response to antidepressant medications.
• Epidemiology: Lifetime prevalence 20.6% (JAMA Psychiatry 2018;75(4):339), F:M = 2:1.
• Diagnosis: Patient experiences a depressive episode, which requires 5+ depressive symptoms for >2 weeks (with at least one symptom being either depressed mood or anhedonia); no history of hypomanic/manic episodes
• Depressive symptoms: SIG E CAPS – Sleep (↑ or ↓, multiple or early awakenings), Interest (↓), Guilt, Energy (↓), Concentration (↓), Appetite (↑ or ↓) Psychomotor slowing, Suicidal
• Subtypes:
- Melancholic: Anhedonia, motor agitation/retardation, cognitive impairment, interrupted sleep, loss of appetite, diurnal variation-mood/energy worse in the AM, affect does not respond to positive events
- Atypical: Hypersomnia, hyperphagia, leaden paralysis, longstanding history of rejection sensitivity, reactivity to pleasurable stimuli (i.e., feels better when positive events occur)
- Catatonic: Immobility, mutism, decreased alertness, resistance to all instructions/attempts to be moved, waxy flexibility, staring, purposeless motor activity, echolalia (senseless verbal mirroring), echopraxia (senseless physical mirroring)
- Psychotic (“with psychotic features”): Accompanied by delusions and/or hallucinations concurrent with mood symptoms
• Treatment: Screen with PHQ9 – goal is to get PHQ9 score <5
- 5–9: Mild → Reassurance
- 10–14: Moderate → Watchful waiting, supportive counseling
- 15–19: Moderately severe → Antidepressant (See Table 13.3) +/– psychotherapy (SSRI takes 4–8 wks to achieve maximal effect; for first episode, continue for at least 6–12 months)
- 20+: Severe → Antidepressant, psychotherapy, hospitalize if SI/HI; consider electroconvulsive therapy (ECT) if refractory
Other depressive disorders
• Persistent depressive disorder (dysthymia): ≥2 yr with depressed mood and at least two other symptoms, never symptom-free for >2 months. No history of mania/hypomania.
• Acute grief: Typically occurs following a death although other loss or anticipatory loss can precipitate; symptoms can include yearning for the deceased, loneliness, crying, disrupted sleep, social withdrawal, disbelief/shock, impaired attention/concentration/memory. Usually improvement seen within 6 months; if longer, consider complicated grief.
• Complicated grief: 6 months or more (though longer duration, up to 12 months, may be appropriate in some cultures) with symptoms of grief that cause significant distress or psychosocial impairment. Treatment: Therapy, SSRI.
Bipolar I disorder
• Etiology: Strong genetic component, 5–10% risk with first-degree relative
• Epidemiology: 2–3% of world population affected by bipolar spectrum disorders; average age of onset 21 yr
• Diagnosis: Patient experiences a manic episode, which requires 3+ manic symptoms that require hospitalization or persist for >1 week (with at least one symptom being euphoric mood or agitation)
• Manic symptoms: DIG FAST – Distractibility, Impulsivity, Grandiosity, Flight of ideas, Activity/agitation, Sleeplessness (i.e., goes days without need to sleep), Talkativeness (i.e., pressured speech); psychotic symptoms may or may not be present
• Treatment: See Tables 13.4 and 13.5
- Acute: Hospitalize. Anticonvulsant (e.g., valproic acid) + atypical antipsychotic (e.g., olanzapine).
- Long term: Lithium is typically first line. If the patient has CKD or develops renal failure, lithium is contraindicated and use valproic acid instead. If only 1 manic episode, can attempt to taper after 1 yr; if 2 manic episodes, typically requires years of treatment; if 3+ manic episodes, typically requires lifelong treatment.
Other disorders with mania
• Bipolar II disorder: 1+ hypomanic episode (DIGFAST symptoms for >4 days but <1 week without any psychotic symptoms) AND 1+ episode major depression
• Cyclothymic disorder: ≥2 yr of alternating hypomanic + depressive symptoms that DO NOT meet criteria for major depression, mania, or hypomania AND never symptom free 2+ months