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Management of Clients with Mood Disorders:

Management of Clients with Mood Disorders:. A Practical Approach Brenda Patzel PhD, APRN. DEPRESSION MANAGEMENT. What have you seen in practice and how common is depression? . In the community 2 -4% In primary care 5-10% Medical inpatients 14%. Incidence of major depression:.

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Management of Clients with Mood Disorders:

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  1. Management of Clients with Mood Disorders: A Practical Approach Brenda Patzel PhD, APRN

  2. DEPRESSION MANAGEMENT

  3. What have you seen in practice and how common is depression? • In the community 2 -4% • In primary care 5-10% • Medical inpatients 14%

  4. Incidence of major depression: • Life time occurrence: 20% for Women 12% for Men • Less common in the Black population • Increased with advancing age • Associated with increasing medical illness and institutionalization

  5. Risks of untreated or undertreated depression: • Depression is associated with: • Heart disease • Diabetes • Suicide

  6. Criteria for Diagnosis of Major Depressive Disorder: DSM-IV TR • At least 5 of the following over 2 week time period that represent a change from previous level of functioning. • Depressed mood • Diminished interest or pleasure • Significant weight loss or gain • Insomnia or hypersomnia • Psychomotor agitation or retardation • Fatigue or loss of energy • Decreased ability to concentrate; indecisiveness • Recurrent thoughts of death and/or suicide

  7. Symptoms do not meet criteria for Mixed episode. Cause clinical significant distress and impaired functioning. Are not due to a direct physiologic effect, substance or general medical condition. Symptoms are not better accounted for by bereavement.

  8. Underlying Pathophysiology • Not clearly defined • Clinical and pre clinical trials suggest disturbances in monoamines ( Serotonin (5HT), Norepinephrine (NE), Dopamine (DA) • Clinical experience indicates complex interaction between neurotransmitter availability, receptor regulation and sensitivity and affective symptoms.

  9. Theoretically Depression is the Result of: • Inefficient or dysfunctional projections of • Serotonin (5HT) • Norepinephrine (NE) • Dopamine (DA) Into the Amygdala and Ventromedial Prefrontal Cortex . Amygdala VMPFC

  10. Sleep Disturbances Thalamus Hypoactivation of 5HT, NE, and DA Projections from brainstem nuclei to hypothalamus, thalmus, basal forebrain and prefrontal cortex hypothetically are involved in sleep disturbances PFC Hypothalmaus BFB

  11. Guilt/Worthlessness - 5HT projections to the amygdala and the ventromedial prefrontal cortex as part of the “emotional brain” is thought to effect these. -Projections into the orbital frontal cortex is hypothetically involved in suicide. VMPFC OFC Amgdala

  12. Theoretical effect of antidepressant actions. • Act to normalize the levels of three neurotransmitters • By blocking presynaptic monoamine transporters (reuptake pumps) • Antagonist activity at presynaptic inhibitory receptor sites, enhancing neurotransmitter release. • Inhibition of monoamine oxidase, reducing neurotransmitter breakdown.

  13. Differential Diagnosis-Medical considerations: • Mood disorders secondary to CNS conditions and Diseases • Inflammatory conditions • Sleep disorders • Endocrine disorders • Infectious processes • Pharmacologic agents

  14. Differential Diagnosis –Psychiatric considerations: • Substance use, abuse, dependence • Seasonal affective disorder • Dysthymia • Anxiety disorders • Eating Disorders • Other psychiatric disorders

  15. Assessment • Appearance and Affect - hygiene, slowing or increase in motor activity • Mood and Thought Process- dysphoria, irritability, mood swings, anhedonia, worthlessness, hopelessness, helplessness • Psychosis – rule out history of bipolar disorder, schizophrenia, schizoaffective disorder, substance abuse or organic brain syndrome.

  16. Cognition and Sensorium- Poor memory and concentration. Most commonly no deficits. Speech – Normal, slow, monotonic, or lacking in spontaneity and content. Pressured speech racing thoughts -think mania. Disorganized think psychosis Thought content – Consistent with dysphoric mood Assess for hopelessness, suicidal ideation or thoughts of harm towards others. History of suicide attempt or violence -Should be noted. Hallucinations and Delusions- command hallucinations, somatic delusions.

  17. Depression Screening Tests – Examples Mood Disorder Questionnaire PHQ-2 and PHQ-9 PHQ- 2 and PHQ-9 Available from : http://www.phqscreeners.com/terms.aspx Tools and Scoring; http://www.cqaimh.org/tool_depscreen.html

  18. Scoring: • 5-9 Minimal Symptoms Support/educate; Call, Re-check • 10-14 Minor depression Support, watch Dysthymia, or mild MDD Treat • 15-19 MDD, moderately severe Treat • >20 MDD, severe Treat

  19. PHQ-2 is a first step approach It includes the first two items for the PHQ-9. Patients who test positive for the PHQ-2 should be further evaluated by the PHQ-9, other diagnostic tests in addition to a direct interview.

  20. ANTIDEPRESSANTS • SSRIs • SNRIs • Atypical Antidepressants CLASSIC ANTIDEPRESSANTS • Tricyclic (TCA’s) • MAOI

  21. SSRIs: Selective Serotonin • Act by inhibiting the reuptake of serotonin. • All have different secondary pharmacological actions • Various degrees of SNRI and DNRI effects • Varying degrees of CYP 450 effects • Fluoxetine ( Prozac) – very long half life • Paroxetine (Paxil) – anticholinergic effects good for anxiety; some weak NE effect potent CYP45o inhibitor effects; rapid metabolism problems with discontinuation; sexual dysfunction. • Sertraline (Zoloft) – acts as dopamine reuptake inhibitor as well; other actions may contribute to anxiolytic effect; may be useful in psychotic depression

  22. SSRIs Continued • Fluvoxamine (Luvox)- efficacy as an anxiolytic; psychotic depression; OCD • Citalopram (Celexa) – has a mild antihistamine effect; well tolerated by elderly patients; at lowest dose is inconsistent in therapeutic action requiring increase I dose for effectiveness unfortunately now not to exceed 40mg. • Escitalopram (Lexapro)- lowest dose may be more effective; better tolerated with the fewest CYP450 drug reactions.

  23. SNRIs: Serotonin Norepinephrine Reuptake Inhibitors • Act on both serotonin and norepinephrine in the prefrontal cortex. • Venlafaxine (Effexor)- norepinephrine varies by dose but serotonin is moderately present at all doses; may have discontinuation problems; time released better tolerated. • Desvenlafaxine (Pristiq)-greater norepinephrine effect than serotonin; tested for perimenopause effect with good results. • Duloxetine (Cymbalta) – approved for neuropathic pain; useful for painful physical symptoms of depression; for geriatric depression with concurrent cognitive effects; CYP450 inhibitor, numerous drug interactions needs close monitoring; difficult to treat patients may use higher dose as well as twice a day dosing.

  24. Atypical Antidepressants • Bupropion (Wellbutrin)- An NDRI; low levels of NE combined with DA; effect on Striatum and nucleus accumbens useful for cravings (e.g. nicotine withdrawal); stimulating; no sexual dysfunction; contraindicated for patients with a history of seizures • Mirtazapine (Remeron) – potent 5-Ht2, 5-HT3, alpha-2 receptors result in higher levels of serotonin and NE; very sedating; adverse effects of drowsiness and weight gain improves over time; may have some anxiolytic effect. • Trazodone (Desyrel)- very sedating; more often used for sleep than depression.

  25. TCAs :Tricyclic Antidepressants • TCAs include: amitriptyline (Elavil), nortriptyline (Pamelor), desipramine (Norpramin), clomipramine (Anafranil), doxepin (Sinequan), imipramine (Tofranil) • Used less commonly now • Advantage is low cost • Disadvantages –considered to be most lethal in overdose; narrow therapeutic window • Adverse effects- anticholinergic and antihistaminic properties include sedation, confusion, dry mouth, constipation, sexual dysfunction, weight gain, cardiac/conduction effects • Not considered for first-line treatment

  26. MAOIs • Effective in broad range of affective and anxiety disorders • Risk of hypertensive crisis – patients must maintain diet low in tyramine. Multiple drug interactions • Seldom currently used as monotherapy; not considered for first-line treatment

  27. Treatment Strategies for Treatment Resistant Depression • Under use of medication • Under treatment • Non-adherence • Adding another antidepressant to augment current treatment • Consider mechanism of action

  28. Treatment Strategies for Treatment-Resistant Depression • Adding another classification of medication to augment • Antipsychotics • Abilify • Seroquel • Other medications

  29. Treatment Strategies for Treatment-Resistant Depression • Refer for therapy – increases efficacy of treatment • Consult or refer if options are exhausted or anytime if beyond comfort level • Suicidal Ideation • Mania • Psychosis • Continued worsening of depression and compromised health

  30. Possible Complications for Patients Receiving Antidepressant Therapy • Suicidal Ideation – Black Box Warning • Mania activation- patients with bipolar disorder may initially present with unipolar depression. • Serotonin Syndrome • Alterations in lab values • Na • Clotting time for patients on some anti-clotting medication • Osteoporosis • Sexual Dysfunction

  31. BIPOLAR DISORDER • Approximately 20%-30% of patients in the primary care setting have bipolar disorder, yet it remains underrecognized and undertreated

  32. Overview • Previously named Manic Depressive D.O. • Thought to be rare with one basic set of symptomology • Now seen as a spectrum of conditions • Quite common possibly effecting 2.2 million American Adults

  33. Bipolar Disorder Spectrum • Considered to be poles between depression and mania • Various forms of the disorders • Bipolar I • Bipolar II • Hypomania • Cyclothymia

  34. MOOD RANGE Depressed Normal Manic Major Depression Dysthymia Depressed Elation Bipolar Disorder Hypomanic Cyclothymia

  35. CriteriaThree or more of the following(four if mood is only irritable): • Inflated self-esteem or grandiosity • Decreased need for sleep • Hyperverbal, pressured speech • Flight of ideas, racing thoughts • Distractibility • Increase in goal directed activities

  36. Criteria continued: • Excessive involvement in: • buying sprees • sexual indiscretions • business investments

  37. Bipolar disorder is further characterized by number of manic episodes, as well as most recent and current episode.

  38. Underlying Pathophysiology • Not clearly defined • Monoamines ( Serotonin (5HT), Norepinephrine (NE), Dopamine (DA) are implicated in both the symptoms as well as the treatment of mood disorders. • Associated with inefficient processing in various brain circuits and functioning that is “out of tune.” • Clinical experience indicates complex interaction between neurotransmitter availability, receptor regulation and sensitivity and affective symptoms.

  39. Elevated/Expansive and Irritable Mood Theoretically symptoms of Mania are the Result of Malfunctioning Brain Circuits: Hyperactive NE, 5Ht, DA Projections Inefficient processing and hyperactivity in the Amgdala, Ventromedial Prefrontal Cortex and Orbital Frontal Cortex VMPFC O F C

  40. Mania SymptomsContinued: DLPFC Grandiosity, Flight of ideas, Racing thoughts – Related to inefficient information processing from hyperactivity in the Nucleus Accumbens. Hyperactive DA and 5HT Risk taking & Pressured Speech – Orbital Frontal Cortex; Dorsolateral Prefrontal Cortex & Ventromedial Prefrontal Cortex- 5HT DA and NE VMPFC O F C

  41. Mania SymptomsContinued: Thalamus BF SLEEP CIRUCITS Decreased need for sleep may be linked to inefficient information processing in the Hypothalamus, Thalamus and Basal Forebrain. Hyperactive 5HT, DA and NE Hypothalamus

  42. Mania SymptomsContinued: DLPFC DISTRACTABILITY/ CONCENTRATION Aberrant Information processing in the Dorsolateral Prefrontal Cortex related to Hyperactive DA and NE GOAL DIRECTED ACTIVITY OR AGITATION Inefficient information processing in the Striatum – Hyperactivity of 5HT and DA Striatum

  43. Presentation in Primary Care • Depression • Moodswings • Difficulty sleeping • Irritability • Fatigue • In ability to focus and concentrate • ETOH problems • STD’s • Social consequences of their illness

  44. CARDINAL SYMPTOMS OF BIPOLAR DIORDER • Manic Mood and Behavior – Euphoria, grandiosity, pressured speech, impulsivity, excessive libido, recklessness, social impulsiveness, diminished need for sleep • Dysphoric or Negative Mood and Behavior – Depression, anxiety, irritability, hostility, violence or suicide • Psychiatric Symptoms –Delusions and hallucinations • Cognitive Symptoms – Racing thoughts, distractibility, disorganization,

  45. COMORBIDITIES • PSYCHIATRIC: Anxiety disorders (92.9%); Substance abuse 71%; Conduct disorder; ADHD; Substance Abuse • MEDICAL: Migraines, Thyroid disease, Hypertension, COPD, Asthma

  46. Misdiagnosis • Major Depression • Personality Disorder • Post Partum Depression

  47. Detecting Bipolar D.O. - DIGFAST • D = DISTRACTIBILITY • I = INDISCRETION OR DISINHIBITION • G = GRANDIOSITY • F = FLIGHT OF IDEAS • A = ACTIVITY INCREASE • S = SLEEP DEFICIT OR DECREASED NEED FOR SLEEP • T = TALKATIVENESS

  48. MOOD DIORDER QUESTIONAIRE (MDQ) • Brief patient self report covering 13 different manic symptoms which patients record as “yes” or “no”. • Seven or more positive responses on the MDQ indicate the presence of concurrent manic symptoms and a moderate level of impairment. • Highly suggestive of bipolar illness. Available: http://www.dbsalliance.org/pdfs/MDQ.pdf

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