Week 7 Mental Health II 2022 PDF

Handout -- Mental Health Disorders Part II - Mood Disorders **[Depression ]** - Definition - syndrome of depressed mood, accompanied by other symptoms, such as fatigue, loss of energy, difficulty sleeping, changes in appetite. - Among leading causes of disability - Hopelessness, de...

Handout -- Mental Health Disorders Part II - Mood Disorders **[Depression ]** - Definition - syndrome of depressed mood, accompanied by other symptoms, such as fatigue, loss of energy, difficulty sleeping, changes in appetite. - Among leading causes of disability - Hopelessness, despair, gloom, emptiness **[Causation]**? - women twice as likely - patients with chronic or debilitating medical conditions - higher risk. - major life changes ↑ risk - family Hx of depression - changes in brain chemistry (i.e., neurotransmitters) - Treatment Approaches: combination of psychotherapy, medication, etc. **[Depressive Disorders: ]** - disruptive mood dysregulation disorder - major depressive disorder (including major depressive episode) - persistent depressive disorder (dysthymia) - premenstrual dysphoric disorder - substance/medication-induced depressive disorder - depressive disorder due to another medical condition - other specified depressive disorder - unspecified depressive disorder [ **Major Depressive Disorder**] -- the diagnosis of major depression requires the presence of at least one major depressive episode, which must: a. Last at least two weeks b. Represent a change from previous functioning. c. Cause clinically significant distress or impairment in social, occupational, or other important areas of functioning. d. Not be attributable to physiological effects of a substance or another medical condition. Diagnosis also requires [five] or more symptoms, one of which must be either a depressed mood or a loss if interest in previously enjoyable activities. 1. A depressed mood daily 2. Loss of interest or pleasure in all /almost all activities 3. Significant weight change (not dieting) 4. Insomnia or hypersomnia 5. Psychomotor agitation or retardation 6. Fatigue or malaise 7. Feelings of worthlessness or inappropriate guilt 8. Decreased ability to think or concentrate, make decisions 9. Recurrent thoughts of death, suicidal ideation, suicidal plans, or attempts Persistent Depressive Disorder (dysthymia or formerly [minor] depression) 1. Poor appetite or overeating. 2. Insomnia or hypersomnia. 3. Low energy or fatigue. 4. Low self-esteem. 5. Poor concentration or difficulty making decisions. 6. Feelings of hopelessness. **[Specifiers for Persistent Depressive Disorder: ]** - With anxious distress - With mixed features - With melancholic features - With atypical features - With mood-congruent psychotic features - With mood-incongruent psychotic features  With peripartum onset **[Premenstrual Dysphoric Disorder ]** Symptoms are associated with clinically significant distress and interfere with school, work, social activities, or relationships. 1. Marked affective lability (e.g., mood swings, feeling suddenly sad or tearful, or increased sensitivity to rejection). 2. Marked irritability or anger or increased interpersonal conflicts. 3. Marked depressed mood, feelings of hopelessness, or self-deprecating thoughts. 4. Marked anxiety, tension, and/or feelings of being on edge. 1. Decreased interest in usual activities 2. Difficulty in concentration 3. Lethargy, easy fatigability, or marked ↓energy. 4. Change in appetite; overeating; or food cravings. 5. Hypersomnia or insomnia 6. Feeling overwhelmed / out of control 7. Physical symptoms **[Substance/Medication-Induced Depressive Disorder ]** This disorder presents with a disturbance in mood that predominates and is characterized by depressed mood or markedly diminished interest or pleasure in all / almost all activities. The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning. Evidence suggests: - Symptoms developed during / soon after substance intoxication or withdrawal or after exposure to a medication. - The involved substance / medication can produce those symptoms. **[Depressive Disorder Due to Another Medical Condition ]** - prominent, persistent period of depressed mood or markedly diminished interest / pleasure in activities - direct pathophysiological consequence of another medical condition - not explainable by another mental disorder, should not take place during delirium. - clinically significant distress or impairment in social, occupational, or other important areas of functioning Specifiers for Major Depressive Disorders **[Major Depressive Disorder with Melancholic Features (formerly Melancholia) ]** A. One of the following is present during the most severe period of the current episode: 1. Loss of pleasure in all, or almost all, activities. 2. Lack of reactivity to usually pleasurable stimuli (does not feel much better, even temporarily, when something good happens). B. Three (or more) of the following: 1. Distinct quality of depressed mood characterized by profound despondency, despair, and/or moroseness, empty mood. 2. Depression worse in morning 3. Early-morning awakening 4. Marked psychomotor agitation or retardation. 5. Significant anorexia or weight loss 6. Excessive or inappropriate guilt - slow onset of illness, hypochondriasis common - prognosis can be poor. - Tx: antidepressants, psychotherapy, possibly ECT - repetitive transcranial magnetic stimulation (rTMS) emerging therapy **[ECT ]** - considered 'last resort' by some for depression resistant to other treatments safer today than early versions. **[Major Depressive Disorder with Peripartum Onset ]** - incidence: 14% - Dx: MDD during / within 4 weeks postpartum - may include psychotic features... (0.1 -0.2% incidence), making infanticide possible. - may include anxiety / panic attacks. - Hx of depressive disorders ↑ risk - stress contributing factor. Think of the environmental / situational conditions in the postpartum time period: - Sleep deprivation - Workload increase - Hormonal fluctuation - Possibly lack of physical and emotional support (depending on situation) It is not surprising that PPD occurs, given the stress factors involved. Major Depressive Disorder with Seasonal Pattern (formerly known as Seasonal Affective Disorder) - applies to [recurrent] major depressive disorder. - Dx: - regular relationship with onset of MDD - remission also occurs cyclically. - pattern consistent for past 2 years+ - lifetime: seasonal MDDs \> nonseasonal - 'Winter blues', 'winter doldrums', 'winter blahs' - women at higher risk - often have hx of depression - high latitude = higher incidence - younger people at higher risk Signs & Symptoms: - loss of energy - noticeable decrease in interests during winter - overeating, weight gain (usually during winter), carb craving - hypersomnia - despair, misery, anxiety, irritability, antisocial behaviour, loss of sex drive - Treatment of choice: light therapy (phototherapy); others: antidepressants, psychotherapy **[Depression and Age ]** - Children - being frequently diagnosed with depression. - Adolescents - huge risk - Adults -- women: twice as much - Elderly - [adaptation to change] happens slower, experience significantly more [loss and] [grief], frequently [isolated.] **[Bipolar Disorder (DSM-5) ]** Bipolar Disorder used to be classified under Depressive disorders but now has its own category in the DSM-5. It includes the following disorders: - Bipolar I Disorder - Bipolar II Disorder - Cyclothymic Disorder - Substance / Medication-Induced Bipolar and Related Disorder - Bipolar and Related Disorder Due to Another Medical Condition - Other Specified Bipolar and Related Disorder - Unspecified Bipolar and Related Disorder - was known as manic depression / manic-depressive illness. - 1^+^ manic episodes with possibility of having 1^+^ hypomanic episodes or major depressive episodes (DSM-5) - extreme highs (mania) & (usually) extreme lows (depression) - onset: usually teens or early adulthood - unique cycle or pattern of moods - if untreated, average 8 -- 10 manic episodes/year o 10 -- 15% of people with Bipolar I complete suicide. - risk for suicide 15X gen public **[Diagnostic Criteria ]** For a diagnosis of Bipolar I Disorder, it is necessary to meet the following criteria for a manic episode. The manic episode may have been preceded by and [may be] followed by [hypomanic] or major [depressive] episodes. The occurrence of the manic and major depressive episode(s) is not better explained by schizoaffective disorder, schizophrenia, schizophreniform disorder, delusional disorder, or other specified or unspecified schizophrenia spectrum and other psychotic disorder. Bipolar II Disorder: 1^+^ hypomanic episode & 1^+^ major depressive - may have several hypomanic episodes, with several major depressive episodes, then have an all-out manic episode → Dx change from BPD II to BPD I **[Manic Episode ]** - distinct period of abnormally & persistently elevated, expansive, or irritable mood and abnormally & persistently increased activity or energy, lasting at least 1 week & present most of day, nearly every day. - during period of mood disturbance, increased energy or activity, 3^+^ symptoms (4 if mood only irritable) present to significant degree; (change from normal self) 1. Inflated self-esteem / grandiosity 2. Decreased need for sleep 3. More talkative than usual 4. Flight of ideas / thoughts racing 5. Distractibility 6. Increase in goal-directed activity or psychomotor agitation. 7. Excessive involvement in activities with high potential for painful consequences - mood disturbance sufficiently severe to cause marked impairment in social or occupational functioning / necessitate hospitalization to prevent harm to self or others / psychotic features. - episode not attributable to physiological effects of a substance or another medical condition Signs & Symptoms of [Manic] Phase: 7 days \- 'high' or euphoric feelings \- sustained periods of unusual, even bizarre behaviour, with significant risk-taking \- increased energy, activity, rapid talking & thinking (flight of ideas) o agitation, irritability, distractibility \- poor decision making, denial of problems, unrealistic beliefs in own abilities \- require little sleep to maintain full activities o frequently have increased sex drive \- mood can shift quickly to anger, depression \- usually resist Tx, transport **[Hypomanic Episode]** at least 4 days - distinct period of abnormally & persistently elevated, expansive, or irritable mood, abnormally & persistently ↑ activity / energy, lasting at least 4 consecutive days, present most of day, nearly every day. - During period of mood disturbance, ↑ energy & activity, three (or more) symptoms (four if mood irritable) persist (change from usual), present to significant degree: (same 7 symptoms as manic episode) - episode [not] severe enough for marked impairment (social or occupational) or to necessitate hospitalization If psychotic features, episode is then manic. - episode not attributable to physiological effects of substance or another medical condition **[Major Depressive Episode (in bipolar disorder)]** -- this is the same as seen in MDD. Bipolar Mixed Episode: Criteria for mixed episode: - both manic episode & major depressive episode during at least 1-week period - causes functional impairment, necessitates hospitalization, or psychotic features. - symptoms not due to substance misuse, general medical condition, or somatic antidepressant therapy **[Cyclothymic Disorder (DSM-5) ]** - characterized by minimum 2 years - numerous periods of hypomanic symptoms - do [not] meet criteria for manic episode, and - numerous periods with depressive symptoms - do not meet criteria for major depressive episode. - during 2-year period, person not been without mood symptoms for \>2 months at a time, and symptoms present at least half the time. **[Specifiers for Bipolar Disorder: ]** Bipolar Disorder can have many specifiers so they may present differently to you, depending on the specifier they have. - With Anxious Distress - With Mixed Features - Manic or hypomanic with mixed features - Depressive with mixed features - With Rapid Cycling - With Melancholic Features - With Atypical Features - With Psychotic Features - With Catatonia - With Peripartum Onset - With Seasonal Pattern Treatment for Bipolar Disorder Common therapies for bipolar disorder are pharmacological -- with higher doses required for acute phases, and smaller doses for prevention (i.e., chronic phase). Psychotherapy common. Some may even try electroconvulsive therapy \# of treatments depend on the person (ECT). Common bipolar medications include: Brand Name ---------------------- --------------- Carbolith lithium Depakene, Divalproex valproic acid Seroquel quetiapine Lamictal lamotrigine The Therapeutic Response to Bipolar and Depressed Patients - Ensure safe environment for patient (assuming it's already safe for you!) - Don't take things personally. - If agitated, provide tranquil environment, de-escalate. - Explore suicidality as appropriate. - Reinforce patient's ability to make personal decisions. - Include family members in problem-solving process (if appropriate) - Allow patient to talk! Use your best active listening skills. - Be informed i.e., depressive disorders, therapies, etc. - Encourage patient to seek professional help i.e., come to hospital. - Compassion!