Psychiatry and Behavioral Health Rotation

Psychiatry EOR: Depressive Disorders and Bipolar Related Disorders (PEARLS)

Bipolar and related disorders
Bipolar I Disorder History of more mania than depression

Severe mood disorder with mania episodes alternating with depression; psychosis during manic episodes

Bipolar II Disorder History of more depression than mania

Low-level mania with profound depression; no psychosis

Cyclothymic disorder Alternating hypomanic episodes with a long-standing low mood state (dysthymia) for at least two years
Bipolar Related Disorders
Bipolar I disorder
Patient will present as → a 27-year-old man accompanied by his girlfriend. In the office, he seems to be running from topic to topic without a clear message. His speech is pressured. The patient’s girlfriend reports that he took steroids recently for a bad sinus infection and since he started them, his behavior has been abnormal. After discontinuing the medication, he has still been having symptoms. He has not had a normal night of sleep for the past ten days, and he just bought a new sports car though he has no need for one or the money to afford it. She also reports that she has caught him with multiple other women in the past few days, though they were in a committed relationship. The physical exam is benign and the patient’s vital signs are within normal limits.

Patient who is squandering savings, destroying relationships, neglecting work activities, etc. etc. 

A manic episode with or without major depressive episodes

By the DSM, mania is described as a mood disturbance sufficiently severe to cause marked impairment in occupational functioning or in usual social activities or relationships with others or to necessitate hospitalization to prevent harm to self or others, or there are psychotic features.

Treatment:

Lithium is considered a first-line medication for bipolar disorder and has been more widely studied than any other maintenance treatment for bipolar disorder and is consistently supported across multiple randomized trials.

  • Acute mania – Lithium, valproate, SGAs (olanzapine, aripiprazole), carbamazepine
  • Mania maintenance - SGAs, Gabapentin, lamotrigine (Lamictal)
  • If agitation – add antipsychotics (haloperidol, risperidone) or benzodiazepines
  • Family/group/cognitive therapy
Bipolar II disorder
Patient will present as → a 19-year-old male who has had bouts of sadness for a course of 1 year in which he says that often he cannot even get out of bed so he tells his parents he is ill. Jim states that he recently felt so energized that he could not keep his thoughts straight and jumped from one idea to another. During this energized state, he did become irritable and others stated that he was louder than usual and wondered if he took something that increased his energy. During the week of high energy, he maxed out two of his credit cards and is not sure how he will pay them off before he goes to school in the fall. It was only a week later that he became so depressed that he did not find any pleasure in anything he did, was so tired he did not want to get out of bed which has continued to be a struggle today.

A patient with bouts of sadness and distractibility and an episode of decreased need for sleep, a flight of ideas, and buying sprees

At least one hypomanic episode and at least one major depressive episode

  • There has never been a manic episode

By DSM hypomania is described as a mood disturbance is not severe enough to cause marked impairment in social or occupational functioning, or to necessitate hospitalization, and there are no psychotic features.

Treatment:

Lithium is considered a first-line medication for bipolar disorder and has been more widely studied than any other maintenance treatment for bipolar disorder and is consistently supported across multiple randomized trials.

  • Depressive episodes- SSRIs, quetiapine, or olanzapine + fluoxetine
  • MAOIs, TCAs – least likely used
  • Family/group/cognitive therapy
Cyclothymic disorder
Patient will present as → a 24-year-old male with c/o episodes of depression alternating with times of increased energy, restlessness, and decreased sleep for 2 years.

Alternating hypomanic episodes with a long-standing low mood state (dysthymia)

A chronic mood disorder characterized by episodes of depression and hypomania for at least 2 years

  • This is a less intense but often longer-lasting version of bipolar disorder
  • A person with cyclothymia has both high and low mood, but never as severe as either mania or major depression
Depressive disorders
Major depressive disorder A mood disorder in which a person experiences, in the absence of drugs or a medical condition, two or more weeks of significantly depressed moods, feelings of worthlessness, and diminished interest or pleasure in most activities.
Persistent depressive disorder (dysthymia) Mood disorder involving persistently depressed mood, with low self-esteem, withdrawal, pessimism, or despair, present for at least 2 years, with no absence of symptoms for more than 2 months.
Premenstrual dysphoric disorder A disorder marked by repeated episodes of significant depression and related symptoms during the week before menstruation
Suicidal/homicidal behaviors Mood disturbances, somatic complaints, feeling hopelessness, worthlessness, helplessness
Depressive Disorders
Major depressive disorder
Patient will present as →a 33-year-old woman complaining of fatigue and decreased interest in “the things that used to make me happy.”  She is sleeping less and eating less, and she says that she is forcing herself to eat “because I know I have to eat something.” She finds herself spending less time with her kids and husband as she retreats to her room. She feels guilty that she lacks the energy and enthusiasm she used to have.

Five or more SIEGECAPS for ≥ 2 weeks nearly every day and at least one of the symptoms is depressed mood or anhedonia

SIGECAPS

  • Sadness
  • Interest/anhedonia
  • Guilt
  • Energy
  • Concentration
  • Appetite
  • Psychomotor activity
  • Suicidal

SSRIs are the first-line treatment - although both TCA and MAOI classes of antidepressants are often helpful in depression, the SSRI class is associated with less morbidity, and drugs in this class are generally considered first-line treatment.

  • Continue to increase dosage q 3–4 wks until symptoms in remission. The full medication effect is complete in 4–6 weeks. Augmentation with 2nd medication may be necessary.
  • See within 2–4 weeks of starting medication and q2wk until improvement, then monthly to monitor medication changes
Persistent depressive disorder
Patient will present as → a 30-year-old married male who feels down most of the time for the past three years. He experiences frequent, intrusive thoughts that he is not good enough, despite personal and professional successes. He tries to overcompensate for his thoughts by taking on more than he can handle, which leads to failure and furthers his feelings of inadequacy. His wife suggests that he seek help after finding him crying.

A patient with chronic depression for two years or more

Chronic depressions - depressive symptoms for > 2 years

  • The individual has never been without the depressive symptoms in for more than 2 months at a time.
  • There has never been a manic episode or a hypomanic episode

Treatment:

  • SSRIs and other antidepressants
  • Psychotherapy
  • Physical exercise
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