Depressive, Bipolar and Related Disorders

Transcription

1 Depressive, Bipolar and Related Disorders Robert Kelly, MD Assistant Professor of Psychiatry Weill Cornell Medical College White Plains, New York Lecture available at

2 Financial Conflicts of Interest As faculty of Weill Cornell Medical College we are committed to providing transparency for any and all external relationships prior to giving an academic presentation. I do not have an interest in any commercial products or services Robert Kelly, MD

3 Mood Disorder Criteria Distress or Impairment Clinically Significant Abnormal Involves Mood Elevated Expansive Irritable Depressed

4 Mood Disorders, DSM-5 Depressive Disorders Major Depressive Disorder Persistent Depressive Disorder Bipolar and Related Disorders Bipolar I Disorder Bipolar II Disorder Cyclothymic Disorder Schizoaffective Disorder Depressive Type Bipolar Type Adjustment Disorders Disorder Due to Another Medical Condition Substance-Induced Disorder Other Specified Unspecified

5 Case I 22-year-old, CC: SI + depressed mood College student Good social relationships No mood disorder history No substance abuse history No general medical condition history Only lasted 1-2 days Significant suicidal impulses Intense dysphoria

6 Substance/Medication-Induced Depressive Disorder Prominent and Persistent Depressed Mood or Anhedonia Elated, Expansive, or Irritable Evidence Temporal--intoxication or withdrawal Etiologically Related Not Due to Other Mental Disorder Not During Delirium Clinically Significant Distress or Impairment

7 Case II 62-year-old man, depressed after MI Depressed mood Anxiety about death Poor sleep Feelings of guilt about health Tired Poor concentration Poor appetite Thoughts that life is not worth living

8 Depressive Disorder Due to Another Medical Condition Prominent and Persistent Depressed Mood or Anhedonia Elated, Expansive, or Irritable Evidence Direct Physiological Consequence Not Due to Other Mental Disorder Not During Delirium Clinically Significant Distress or Impairment

9 Case III 80-year-old grief-stricken female Husband passed away one month ago Tearful Poor sleep Feels husband s death is her fault Tired Poor concentration Poor appetite Thoughts of wanting to jump in front of traffic Auditory hallucinations: husband s voice while awake

10 Major Depressive Episode Depressed Mood or Anhedonia Mood + SIGECAPS (most sx) Two Weeks Not Substance/Medication-Induced Not Due to Another Medical Condition Not Bereavement Clinically Significant Distress or Impairment

11 Major Depressive Disorder Major Depressive Episode Not Schizoaffective Disorder Not Superimposed on Psychotic Disorder Not Bipolar Disorder

12 Case IV 32-year-old woman, always depressed Low mood Low self-esteem Pessimistic Chronic fatigue Periodic insomnia During childhood very anxious rather than depressed Suicide attempt age 19 Some brighter periods, never more than 1 month

13 Persistent Depressive Disorder (Dysthymia) Depressed Mood Children and Adolescents: Irritability Two Years Children and Adolescents: One Year Two or more Symptoms SiGECAps Hopelessness Major Depressive Episode Can be Comorbid Never Manic or Hypomanic Episode Not Superimposed on Psychotic Disorder Not Substance/Medication-Induced Not Due to Another Medical Condition Clinically Significant Distress or Impairment

14 Case V 55-year-old male with bizarre delusions BIB police after threatening to stab others Claims he was defending himself No prior psychiatric history Increasingly irritable past month Says he is from another planet Says he has three heads Incoherent at times Oriented to time and place

15 Manic Episode Elevated, Expansive, or Irritable DIGFAST Distractibility Involvement in pleasurable, risky activities Grandiosity Flight of Ideas Activity Increase Sleep not needed Talkative (pressured speech) One Week Not Substance/Medication-Induced Not Due to Another Medical Condition Marked Impairment

16 Bipolar I Disorder Manic Episode (Major Depressive Episode) Not Schizoaffective Disorder Not Superimposed on Psychotic Disorder Clinically Distress or Impairment

17 Schizoaffective Disorder Mood Episode Mood, not anhedonia Bipolar or depressive types Schizophrenia-like period Two weeks No prominent mood symptoms Delusions or hallucinations Prominent Mood Symptoms Most of the Time Not Substance/Medication-Induced Not Due to Another Medical Condition

18 Case VI 45-year-old female with increased zest for life H/o MDE s Mood no longer depressed, feels very good Good energy, sleeps 5 hours/night (7 normal) Talks rapidly Unprotected sex with multiple partners over 2 months Now embarrassed about promiscuity and risks

19 Hypomanic Episode Elevated, Expansive, or Irritable DIGFAST Distractibility Involvement in pleasurable, risky activities Grandiosity Flight of Ideas Activity Increase Sleep not needed Talkative (pressured speech) Four Days Unequivocal, Observable Change Not Substance/Medication-Induced Not Due to Another Medical Condition NOT Marked Impairment

20 Bipolar II Disorder Hypomanic Episode Major Depressive Episode Never Manic Episode Not Schizoaffective Disorder Not Superimposed on Psychotic Disorder Clinically Distress or Impairment

21 Cyclothymic Disorder Hypomanic Periods Depressive Periods Two Years Children and Adolescents: One Year No Other Episodes Involved Major Depressive Manic Mixed Not Superimposed on Psychotic Disorder Not Substance/Medication-Induced Not Due to Another Medical Condition Clinically Significant Distress or Impairment

22 Case VII 19-year-old male, admitted after suicide attempt BIB police, found ready to jump from bridge Partner left him 3 days prior to attempt Significant suicidal impulses Intense dysphoria College student Good social relationships No mood disorder history No substance abuse history No general medical condition history

23 Adjustment Disorders Emotional or Behavioral Symptoms Temporal Relationship with Stressor Onset within 3 months Resolution within 6 months Not Due to Other Mental Disorder Not Bereavement Clinically Significant Distress or Impairment

24 Case VIII 13-year-old female with anger issues BIB police after threatening school principal Irritable No sleep disturbance Good grades Hears commenting voices while in bed Hears name being called while walking on street

25 Disruptive Mood Dysregulation Disorder Frequent, Severe Temper Outbursts Persistent Irritability Children Ages 6-18 Duration: 1 year Onset prior to age 10 Not Due to Other Mental Disorder Clinically Significant Distress or Impairment

26 Unspecified Mental Disorder Replacement for Nonexistent Unspecified Mood Disorder Distress or Impairment Not Any Other Disorder Lack of Information or Clinician Chooses Not To Specify

27 Prevalence (Yearly) Depressive Disorders Major Depressive Disorder (7%; 1.5-3x higher for women) Persistent Depressive Disorder (2%) Bipolar Disorders Bipolar I Disorder (0.6%) Bipolar II Disorder (0.8%) Adjustment Disorders (2-8%) Disruptive Mood Dysregulation Disorder (2-5%)

28 Lifetime Prevalence Depressive Disorders Major Depressive Disorder (women 10-25%; men 5-12%) Persistent Depressive Disorder (6%) Bipolar Disorders Bipolar I Disorder ( %) Bipolar II Disorder (0.5%??) Cyclothymic Disorder (0.4-1%) Schizoaffective Disorder (0.3%)

29 Suicide Completed Suicide 60-70% suffering from significant depression Young: mostly substance-induced Elderly: mostly major depressive episode, but minor depression also poses risk Lifetime Risk for Selected Disorders Bipolar I or II Disorder: 15% Mood Disorders, generally: 10-15% Schizophrenia/Schizoaffective: 5% Borderline Personality Disorder: 10%

30 Treatment Medication Psychotherapy Electroconvulsive Therapy (ECT) Transcranial Magnetic Stimulation (TMS) Vagal Nerve Stimulation (VNS) Deep Brain Stimulation (DBS) Exercise Light Therapy Others Placebo Effect

31 Medication SSRIs SNRIs TCAs MAOIs Treatment Food restrictions, possible fatal outcome Other antidepressants Mirtazapine Bupropion Mood stabilizers Lithium Valproic acid Lamotrigine Carbamazepine Antipsychotics, 2nd Generation Others

32 Treatment Psychotherapy Supportive Psychodynamic CBT Others