Mood Disorders in Primary Care - UMass ...
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5/11/21
Mood Disorders in
Primary Care
Shari Harding, DNP
1
Objectives:
Describe Describe the assessment, diagnosis, and management of mood disorders
Differentiate Differentiate depressive disorders from bipolar disorders
Discuss psychopharmacology options for individuals with mood disorders
Discuss across the lifespan
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Key Takeaways
• Individuals presenting for care with symptoms of bipolar depression often look
very similar to those with unipolar depression
• The treatment of depression is quite different from bipolar disorder
• Bipolar disorder is frequently under-, over-, or misdiagnosed
• The assessment and diagnosis of these disorders can be challenging, ‘an art
and a science’ for clinicians
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Major Depressive Disorder
• Lifetime prevalence of nearly 17% (Sadock, Sadock, & Ruiz, 2015)
• Past-year prevalence of 7.1% (APA, 2013; NIMH, 2017)
• Higher in females (8.7%) than males (5.3%)
• Highest among adolescents (12-17 y/o) at 13.3% and adults ages 18-25
(13.1%)
• Adolescent females are particularly hard hit at 20% vs. 6.8% of adolescent
males
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Major Depressive Disorder
• Onset typically at least after puberty, peaking during the 20s, but can really
occur at any age, even later in life
• The course is variable among individuals
• Chronic course often r/t poorer outcomes and also comorbidities (APA, 2013)
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Major Depressive Disorder
• PHQ-9 Screening Tool may be helpful
• Diagnostic Criteria (must be present x a 2-week period):
• Depressed mood or anhedonia must be present plus 4 of the following (3 if the person has depressed
mood and anhedonia):
• Significant decrease/increase in appetite and/or weight
• Insomnia or hypersomnia
• Psychomotor agitation or retardation (observable by others)
• Fatigue or loss of energy
• Feelings of worthlessness or excessive/inappropriate guilt
• Diminished ability to think or concentrate or indecisiveness
• Recurrent thoughts of death or suicidality
• Must cause significant impairment in functioning
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Major Depressive Disorder
• SIG-E-CAPS:
• Sleep changes
• Interest (loss of)
• Guilt
• Energy (lack of)
• Cognition/concentration
• Appetite
• Psychomotor
• Suicide/death thoughts** (“never miss”, always
assess)
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MDD Assessment Tips
● Children and adolescents may present with more irritability than depressed
mood or sadness
● Adults and esp older adults may present with more somatic complaints, lack
of energy or feeling ‘blah’ or ‘empty’/no feelings
● Discuss ADLs/IADLS to get a sense of severity/impairment
● Discuss social and occupational functioning
● “Walk me through a typical day”
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MDD Assessment Tips
● Context - precipitants - ? increased psychosocial stressors?
● Assess sx over lifespan - when was the first depressive episode? How
frequently have they occurred? Was the person every entirely well for 2
months or longer (remission)?
● What treatments helped or did not help over time?
● Hospitalizations, comorbidities, suicide attempts?
○ May speak to ability to manage “in house” versus specialty referral
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MDD Differential Dx
● Bipolar disorder
● Mood d/o due to another medical condition
● Substance/medication-induced (beta blockers, alcohol, other drugs,
withdrawal from cocaine, etc. are common ones)
● ADHD
● Adjustment disorder
● Normative sadness, grief/bereavement
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Bipolar Potential
• Bipolar patients who present while in a depressed state are often misdiagnosed as major
depression
• Conversely, bipolar d/o can be over-diagnosed when sx like PTSD, borderline personality disorder,
low frustration tolerance, or SUDs are attributed to bipolar d/o
• Leads to inappropriate treatment with antidepressants instead of mood stabilizers, triggering
mania/hypomania or more frequent cycling
• Red flags for potential bipolar disorder
• Hx of abnormally elevated/irritable mood
• Periods of persistent increased energy
• Period of engaging in out-of-character behavior
• Behavior that is a noticeable change from baseline
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Hypomanic/manic criteria
DIGFAST:
• Distractible
• Indiscretion (excessive pleasurable activities with high
potential for painful consequences)
• Grandiosity
• Flight of ideas
• Activities (increased goal direction)
• Sleep deficit (decreased need for sleep)
• Talkativeness (pressured speech)
At least 3 of the above plus expansive mood, 4 of the
above if mood is only irritable. In mania, psychosis
may e present (APA, 2013; Carlat, 2016)
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DSM-5 Bipolar Disorders
Bipolar I: Bipolar II:
• Must meet criteria for having had at • Has had at least one major depressive
least one major depressive episode episode AND one hypomanic episode,
AND one manic episode has NOT had a full manic episode
• Manic episode must last at least 1 • Hypomanic episode lasts at least 4 days
week (less if hospitalized) • Hypomanic episodes may appear
• Manic episodes tend to be ‘flashy’, ‘productive’, impairment is not as severe
lead to trouble, severe impairment • No psychosis
• Psychosis may occur during episodes • More common
• Rare
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MDD Bipolar
Disorders
● Relatively rare: Bipolar I lifetime
● Lifetime prevalence of nearly
prevalence of up to 2.4% and
17%
Bipolar II up to 4.8%,
● Past-year prevalence of 7.1%
● Annual incidence less than 1%
● Onset typically at least after
● Mean age of onset is
puberty, peaking during the 20s,
approximately 18 years old,
but can really occur at any age,
literature mixed on possible
even later in life
‘second wave’ w/ menopause
● More common (~2x) in females
● Roughly equal prevalence in
males and females
(APA, 2013; Sadock, Sadock, & Ruiz, 2015)
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Assessment:
The chief complaint is depression, and the person is indeed depressed. Now
what?
A good history is your single most important tool
History of present illness, psychiatric review of symptoms, tx hx
Family History (esp. depression, bipolar, and schizophrenia)
History from collateral information (records, other close people)
As Stahl (2013) says: “Who’s your daddy?” and “Where’s your mama?”
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Screening Tools
Carlat (2016) screening questions:
● “Have you ever had a period of a week or so when you felt so happy and
energetic that you didn’t need to sleep and your friends told you that you were
talking too fast or that you were behaving differently and strangely?”
● “Have you had periods when you were snapping at people and getting into
arguments?”
If either is positive, review DIGFAST criteria
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Mood Disorder Questionnaire (MDQ):
Self-report questionnaire
13 symptoms of mania
“Did several of these happen at the same time?”
“How much of a problem did these cause you?”
Positive screening is at least 7 of the 13, ‘yes’ to occurring at the same time, and
causing moderate to severe problems
(STABLE Toolkit, n.d.)
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MDQ
Beware of false-positives. However, the 13 symptoms are helpful to guide the
conversation.
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Composite International Dx Interview (CIDI)
3.0
Clinician-administered tool, takes about 3 minutes to administer
Identifies 67 to 96% of true cases of bipolar disorder
Two stem questions and 9 symptom questions
The more symptoms endorsed, the more likely the person may have a true bipolar
disorder
(STABLE Toolkit, n.d.)
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Key Takeaway
Screening tools and questions can be helpful
● Standardizes your assessment process, initially
● Gives us a good working vocabulary of hypomanic/manic sx
Be mindful that screening diagnosis
Screening can be part of your assessment but does not substitute for a
comprehensive evaluation
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Assessment Clinical Pearls:
● Colloquial use of the term ‘manic’ is often quite different from the clinical use
of the term
● About 60% of manic episodes occur immediately before a depressive episode
(Sadock et al., 2015)
● Individuals are more likely to seek treatment for depression
● Sometimes euthymic periods cause a false-positive for questions about
hypomania/mania
● Hypomanic or manic sx are less likely to prompt treatment-seeking
○ Lack of insight and/or symptoms are desirable and/or embarrassing
○ Normalizing symptoms can help
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Assessment Clinical Pearls:
● Elements that may raise your index of suspicion for a bipolar disorder:
○ Impulsivity (APA, 2013)
○ Cognitive difficulties present even when not depressed (APA, 2013)
○ Multiple failed trials of antidepressants (Stahl, 2013)
○ Ask about periods of time when it seemed like ‘everyone was picking fights with
you’ or conversely periods of time when the individual received feedback from
multiple others that might indicate irritability
○ East-west travel issues (APA, 2013)
○ Sometimes, a lack of clear precipitants for mood episodes (Carlat, 2016)
○ Psychosocial history providing evidence of ‘erratic’ behavior over time
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Primary Care Depression Psychopharm
• SSRI
• SNRI
• NDRI – Wellbutrin (bupropion)
• Tricyclics
• Atypical or newer antidepressants
• Augmenting with mood stabilizers
• Rational polypharmacy vs. irrational polypharmacy
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Selective Serotonin Reuptake Inhibitors (SSRIs)
• Fluoxetine
• Sertraline
• Paroxetine
• Fluvoxamine
• Citalopram
• Escitalopram
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SSRI Common Class Side Effects
• Nausea, especially in the first 4 weeks of treatment & again at dose increases
• Sexual side effects
• Increased sweating
• Serotonin syndrome risk *esp with other agents*
• Increased bleeding
• Riskier with warfarin
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SSRI Class Side Effects
• Hyponatremia
▫ More common among older adults
• Sleep issues if taken at night
• Constipation and/or diarrhea
▫ IBS common comorbidity in psych
• FDA Black Box Warning increased SI in age 24 and under (but
controversial, Fornaro et al., 2019)
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Interclass Variations
• Within the SSRI class, each individual SSRI has different “secondary
pharmacologic actions” (Stahl, 2013)
• This may explain individual differences in efficacy and tolerability
• Pharmacogenetics is another potential explanation (individual metabolic
differences, CYP450 pathways)
• It is reasonable to try an SSRI, then try a second SSRI or another
antidepressant, then if both fail, consider specialty consult
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Prozac (fluoxetine)
• Long half-life (2 to 3 days)
• Adverse interactions to note:
• Fluoxetine + some beta blocker = increased BB levels
• Fluoxetine + tamoxifen = decreased tamoxifen levels
• Dosage range 10mg to 80mg daily
• Take in AM
• Start low and go slow in anxious individuals
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Zoloft (sertraline)
• Favored during pregnancy and breastfeeding (MCPAP for Moms, 2014)
• Loose stools is a common s/e
• Dosage range 25mg to 200mg daily
• Take with food to increase absorption
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Paxil (paroxetine)
• Anticholinergic = riskier in older adults
• Urinary retention, constipation, drying, dizziness
• Anticholinergic burden with other medications
• “Paxil packs on the pounds”
• Paxil + some beta blocker = increased BB
• Dosage range is 10mg to 60mg daily
• IR and CR formulations
• Can be sedating, take around dinner time
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Luvox (fluvoxamine)
• Clinically, used most often for OCD
• Sedating, sometimes dramatically
• IR and CR formulations
• Dosage range 50mg to 300mg daily
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Celexa (citalopram)
• Citalopram = racemic citalopram (R and S enantiomers)
• The R enantiomer problem
• Inconsistent at lower doses
• QTc prolongation at higher doses
• Dosage range 10mg to 40mg daily
• But max dose generally 20mg daily for older adults
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Lexapro (escitalopram)
• Escitalopram = removal of R enantiomer
• “Pure” SSRI
• Well tolerated
• Dosage range 5mg to 20mg daily
• Very common to start and stay at 10mg daily dose
• “Easy on, easy off”
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Serotonin-norepinephrine reuptake inhibitors
(SNRI)
• All SNRI can increase blood pressure
• May be more energizing
• Theoretically, lower risk of sexual s/e but in practice not necessarily
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SNRI
• Effexor (venlafaxine)
• IR and XR formulations
• Very hard to taper and d/c
• Dosage range 37.5mg to 225mg (sometimes 300mg) daily
• Pristiq (desvenlafaxine)
• Active metabolite of venlafaxine
• Extended-release formulation
• Dosage range 50mg to 100mg daily
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SNRI (continued)
• Cymbalta (duloxetine)
• Helpful in comorbid fibro, pain
• Dosage range is 30mg to 120mg daily (can dose once daily or divide in two
doses)
• Often starting at 60mg daily is helpful, in more sensitive or older individuals
would consider 30mg daily x 7 days then increase
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Norepinephrine dopamine reuptake inhibitor
(NDRI)
• Wellbutrin (bupropion)
• IR, SR (twice daily, but second dose before 3pm), and XL (once daily)
formulations
• Contraindicated if active eating d/o purging behaviors, binge drinking, or hx
of seizures
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Bupropion
• Monotherapy or augmenting agent
• Most helpful for target sx of low energy, anhedonia, low concentration, or if
having sexual s/e from SSRI
• Anecdotally, can worsen anxiety, panic, or even cause tremor especially at start
of tx
• Dosage range 75mg to 300mg daily (typical start is XL 150mg AM)
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Tricyclic Antidepressants (TCAs)
• Amitriptyline, desipramine, doxepin, nortriptyline, imipramine
• Not first-line for depression or anxiety
• Fatal in overdose, cardiac arrhythmias
• Anticholinergic
• Sedating
• Used for other conditions including migraine prophylaxis, pain, fibro
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Other Antidepressants
• Remeron (mirtazapine)
• Tetracyclic (various actions on serotonin and norepi)
• Sedation and increased appetite/weight common
• Lower risk of sexual s/e
• Helpful in older adults
• Combo with SNRI ‘California Rocket Fuel’
• Dosage range is 7.5mg to 45mg at bedtime
• Lower doses may be more sedating
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Other (continued)
• Desyrel (trazodone)
• Lower doses, “sleep aid”
• Higher doses, antidepressant
• Can cause AM “hangover” effect
• Dosage range 50mg to 300mg, most common
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Other (continued)
• Trintillex (vortioxetine)
• Serotonin multimodal action
• Theoretically fewer sexual s/e, but clinically not necessarily
• Dosage range 5mg to 20mg daily
• Dutonin (nefazodone)
• SARI (serotonin action)
• Small but serious risk of hepatotoxicity
• 100mg twice daily to start, typical dose is 300mg to 600mg daily, up to max of
1200mg/day
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Client “When can I stop treatment?”
Antidepressants medications: continue x 4-9 months or even 12 months past
remission of first episode, then slowly taper if desired
Timing of stopping med is key (not before stressful events or New England
winters, for example)
If multiple episodes of depression, consider tx indefinitely
Bipolar d/o as a serious chronic illness with lifelong tx
Continuing therapy is recommended
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Switching vs. Augmenting
• If you have ‘some’ response, you should consider optimizing one agent for
monotherapy
• If higher doses are not effective OR not tolerated, lower the dose and consider
augmenting
• SSRI + NDRI
• SNRI or SSRI + mirtazapine or trazodone
• Antidepressant + lamotrigine or atypical antipsychotic likely specialty
initiation but you might do maintenance
• Rational polypharmacy vs. irrational polypharmacy
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Choosing an Antidepressant
• Individual symptoms
• E.g. hypersomnia versus insomnia
• Bipolarity “rule out”
• Past experiences with medications
• Response of blood relatives to certain agents
• Potential side effects that you want to capitalize on or avoid
• Client preferences
• Anticipate needs (e.g. childbearing females, aging)
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Building Your Clinical Toolbox
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Bipolar Psychopharm
• Lithium “gold standard” in bipolar I
• S/e burden, tolerability, renal function, thyroid risk long term, labs
• Depakote is another ”gold standard”
• s/e burden, tolerability, hair loss, weight gain, possible PCOS link in
females, liver function, labs
• Other “Mood stabilizers”
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Anticonvulsant Mood Stabilizers
• Lamictal (lamotrigine)
• “treats from the bottom”, not an anti-manic, utility in depression and
irritability, off-label PTSD
• Rare but serious risk of Stevens-Johnson syndrome, toxic epidermal
necrolysis, or drug hypersensitivity syndrome
• Most find this medication mildly sedating, some find it activating (may
benefit from switch to AM TOA)
• FDA dosing schedule
• Target dose for mood disorders is typically 200mg/day
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Anticonvulsant Mood Stabilizers
• Tegretol (carbamazepine)
• Labs, risk of blood dyscrasias, lots of CYP450 interactions
• Trileptal (oxcarbazepine)
• Not as much evidence
• No regular labs once stable; may cause hyponatremia
• Utility if failed lamotrigine or if prominent irritability
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Atypical Antipsychotic Mood Stabilizers
• Class effects: metabolic s/e, drug-induced movement disorder risks, FDA black box
warning in older adults with dementia, risk of prolactinemia
• Seroquel* (quetiapine), low potency, large dosage range, QTC prolongation
• Abilify* (aripiprazole), can be activating, akathisia common, IM option
• Latuda* (lurasidone), must be taken with at least 350 calories for absorption, weight
neutral at 1 year of tx
• Risperdal (risperidone), prolactin elevation common, IM option
• Invega (paliperidone), active metabolite of risperidone
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Atypical Antipsychotic Mood Stabilizers
• Rexulti (brexpiprazole), similar to Abilify, newer, ? Less akathisia
• Vraylar (cariprazine)
• Zyprexa (olanzapine), high potency, highly sedating, significant metabolic
• Geodon (ziprasidone), possible QTC
• Clozaril (clozapine): REMS
• Fanapt, Saphris: specialty, schizophrenia
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Case Discussions/Questions
• What have you seen clinically?
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Case #1:
• Julie is a 30 y/o, recently married female. She has a 1 y/o daughter and is
currently a stay-at-home mom. She c/o depression which has worsened over
the past year. She describes a life-long hx of depressive episodes which
usually resolved on their own. She used to work as a makeup artist and stylist,
traveling and working with various TV shows. She felt her work was “exciting”
and now feels her life is “boring”. She has failed treatment with fluoxetine,
sertraline, and bupropion. She says she used to have “energy” and now feels
tired and “worn out”. She endorses depressed mood, anhedonia, and
overeating. She denies suicidal thoughts or thoughts of harming anyone else.
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Case #2:
• Roberto is a 40 y/o, married, male who describes having periods of ‘feeling really
down’ since he was in graduate school in his mid-20s. However, he was always able
to ‘pull himself out of it’ without formal treatment, stating the episodes never interfered
with his ability to go to work but did limit him socially. At age 39, he was clearing snow
off the roof of his home when he fell and sustained several significant injuries including
fractures in his back. Prior to the accident, he was working as a math teacher. He
enjoyed his job, but felt he could not return to work due to chronic pain and difficulty
concentrating. Over the past year, his mood has worsened. He has trouble sleeping.
He describes feeling “like a failure” because he is not supporting his wife financially
anymore. He has past failed trials of fluoxetine (caused bruising), citalopram (didn’t
work after 6 weeks on 40mg daily), and duloxetine (didn’t work after 8 weeks on 90mg
daily). He has a family history of depression in his older brother and his father. He
shares that his father is currently maintained on bupropion.
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Selected References
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5thed.). Washington, DC: American Psychiatric
Association Press.
Carlat D. J. (2016). The psychiatric interview (4thed.). Philadelphia, PA: Lippincott, Williams & Wilkins.
Fornaro, M., Anastasia, A., Valchera, A., Carano, A., Orsolini, L., Vellante, F., Rapini, G., Olivieri, L., Di Natale, S., Perna,
G., Martinotti, G., Di Giannantonio, M., & De Berardis, D. (2019). The FDA "Black Box" Warning on Antidepressant
Suicide Risk in Young Adults: More Harm Than Benefits?. Frontiers in psychiatry, 10, 294.
https://doi.org/10.3389/fpsyt.2019.00294
Johnson, K. & Vanderhoef, D. (2016). Psychiatric mental health nurse practitioner review manual (4thed.). Silver Spring, MD: American Nurses
Credentialing Center
Massachusetts Child Psychiatry Access Project (MCPAP) for Moms. (2014). Promoting maternal mental health during and
after pregnancy. Retrieved from https://www.mcpapformoms.org
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Selected References
Sadock, B. J., Sadock, V. A. & Ruiz, P. (2015). Synopsis of psychiatry (11th ed.). London, England: Lippincott, Williams, and Wilkins.
Stahl, S. (2013). Essential psychopharmacology: Neuroscientific basis and practical applications (4th ed.). Cambridge, England: Cambridge
University Press.
Standards for Bipolar Excellence (STABLE) National Coordinating Council. (n.d.). STABLE resource toolkit. Retrieved from
https://www.integration.samhsa.gov/images/res/STABLE_toolkit.pdf
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