Psych & Behavioral Health EOR Study Guide
Depressive, Bipolar & Related Disorders
1) Bipolar I Disorder
a. RF: FHx/1st-degree relative is strongest RF, men = women
b. 1% of population, avg age of onset is 20s-30s, new onset is rare after 50 yrs
c. The earlier the onset, the greater likelihood of psychotic features & the poorer the prognosis
d. Diagnostic Criteria:
i. At least 1 manic or mixed episode (only requirement) – manic episodes often cycle
with occasional depressive episodes but major depressive episodes are not required
for the dx
ii. Mania = abnormal & persistently elevated, expansive or irritable mood at least 1
week (or less if hospitalization is required) with marked impairment of social
occupation/function
1. At least 3:
a. Mood – euphoria, irritable, labile or dysphoric
b. Thinking – racing, flight of ideas, disorganized, easily distracted,
expansive or grandiose thoughts (highly inflated self esteem), impaired
judgement
c. Behavior – physical hyperactivity, pressured speech, decreased need
for sleep, increased impulsivity, excessive involvement in pleasurable
activities including risk-taking, hypersexuality, disinhibition & increased
goal directed activity
iii. Psychotic symptoms (paranoia, delusions, hallucinations) may be seen
iv. Sx not due to a medical condition or substance use
e. Management:
i. Mood Stabilizers: Lithium is 1st line
1. MOA: unknown, but thought to alter neuronal Na+ transport & influence
reuptake of serotonin and/or NE
2. Indications: bipolar disorder (manic & depressive episodes), Schizoaffective
disorder
3. ADRs:
a. Endocrine: hypothyroidism, nephrogenic DI, hyperparathyroidism,
hypercalcemia, hypermagnesemia, Na+ depletion, increased thirst (pts
should drink 8-10 glasses of water/day)
b. Neuro: seizures, tremor, HA, sedation
c. GI: N/V/D, weight gain
d. Arrhythmias, Leukocytosis
4. Narrow Therapeutic Index: baseline EKG, chemistries, thyroid fx, b-hCG & CBC
should be done, check levels after 5 days then q2-3 days until therapeutic,
then monitor levels q4-8wks
a. May be toxic if levels > 1.5
5. CI: pregnancy (assoc. with Ebstein’s anomaly in 1st trimester), severe renal dz,
cardiac dz
6. Cautions: use w/ NSAIDs, ACEs, Thiazides, impaired renal fx assoc. with
increased Lithium levels
ii. Valproic acid or Carbamazepine for rapid cycling or mixed features
iii. 2nd gen Antipsychotics (Risperidone, Quetiapine, Olanzapine, Ziprasidone)
1. Effective as monotherapy or adjunct to mood stabilizers (faster & more
effective as combo therapy)
iv. Psychotherapy: cognitive, behavioral & interpersonal, good sleep hygiene
v. Bipolar Depression Lithium, Quetiapine, Lurasidone or Lamotrigine
vi. Antidepressants may be used as an adjunct to mood stabilizers for severe depression
but antidepressant monotherapy may precipitate mania or hypomania!!
f. Acute Mania:
i. Antipsychotics (Risperidone or Olanzapine > Haloperidol) or Mood Stabilizers
(Lithium, Valproate) most effective
, ii. Antipsychotics or BZDs helpful for acute psychosis or agitation
iii. ECT especially helpful for refractory or life threatening acute mania or depression
(also best tx for pregnant women with manic episodes)
2) Bipolar II Disorder
a. Recurrent major depressive episodes w/ hypomania
b. Diagnostic Criteria:
i. H/o at least 1 major depressive episode + at least 1 hypomanic episode
1. Any current or prior manic episode = Bipolar I
ii. Hypomania = abnormal & persistently elevated, expansive or irritable mood for < 1
week, does not require hospitalization, not associated w/ marked impairment of
social/occupational function & not associated w/ psychotic features
1. At least 3 sx affecting mood, thinking or behavior (sx otherwise similar to
mania)
c. Management: same as Bipolar I
i. Mood Stabilizers: Lithium = 1st line (also decreases suicide risk) OR 2nd generation
(atypical) antipsychotics (Risperidone, Quetiapine, Olanzapine, Ziprasidone)
ii. Valproic Acid or Carbamazepine useful for rapid cycling
3) Cyclothymic Disorder
a. Similar to Bipolar II but is less severe
b. Approximately 1/3 will eventually develop Bipolar disorder
c. Men = women, may coexist w/ Borderline personality disorder
d. Diagnosis:
i. At least 2 years of prolonged, milder elevations & milder depressions in mood that do
not meet criteria for full hypomanic episodes or major depressive episodes (at least 1
year in children)
ii. Symptom free periods don’t last longer than 2 months at a time
iii. Major depressive, manic or mixed episodes do not occur
e. Management:
i. Similar to bipolar I – mood stabilizers (Lithium, Valproic acid) or 2 nd gen Antipsychotics
(Risperidone, Olanzapine, Quetiapine, Ziprasidone)
4) Major Depressive Disorder
a. RF: FHX, Female > male, peak onset is in 20s
b. Pathophys: alteration in NTs – serotonin, NE, epi, dopamine, ACh & histamine, genetic factors
i. Neuroendocrine dysregulation – adrenal, thyroid or GH dysregulation
c. 15% of pts commit suicide (esp. men 25-30 and women 40-50), higher rates in pts with
detailed suicide plan, white males > 45 y/o & concurrent substance abuse
d. PHQ-2 form for initial screen, if positive use PHQ-9
e. Diagnostic Criteria:
i. @ least 2 distinctive episodes of at least 5 assoc. symptoms (must include either
depressive mood or anhedonia) almost every day for most of the days x2 weeks:
1. Depressive mood, anhedonia, fatigue almost all day, insomnia or
hypersomnia, feelings of guilt or worthlessness, recurring thoughts of death or
suicide, psychomotor agitation or retardation, significant weight change,
decreased or increased appetite, decreased concentration or indecisiveness
2. NOT assoc. with mania or hypomania!
ii. Sx must cause significant distress or impairment (social or occupational)
iii. Sx are not d/t substance use, bereavement or medical conditions
f. Subtypes (“Course Specifiers”):
i. Seasonal Affective Disorder/Seasonal Pattern:
1. Presence of depressive sx at the same time each year (s/a MC in the winter d/t
decreased sunlight & cold weather)
2. Mgmt: SSRIs, light therapy, Bupropion
ii. Atypical Depression:
1. Shares many of the typical sx of major depression but pts experience mood
reactivity (improved mood in response to positive events)
, 2. Sx include significant weight gain/appetite increase, hypersomnia,
heavy/leaden feelings in arms or legs & oversensitivity to interpersonal
rejection
3. Mgmt: MAO-Is
iii. Melancholia:
1. Characterized by anhedonia (inability to find pleasure in things), lack of mood
reactivity, depression, severe weight loss/loss of appetite, excessive guilt,
psychomotor agitation or retardation, sleep disturbance (may lead to early AM
awakening or mood that is worse in the AM)
iv. Catatonic Depression:
1. Motor immobility, stupor & extreme withdrawal
g. Management:
i. Psychotherapy – CBT, interpersonal therapy, supportive therapy
ii. SSRIs = 1st line medical management, if not effective after 4 wks switch to another
SSRI
iii. 2nd line: SNRIs, Bupropion
iv. TCAs, Tetracyclines, MAO-Is
v. ECT – rapid response in pts unresponsive to medical therapy, unable to tolerate
pharmacotherapy or rapid reduction of sx
5) Persistent Depressive Disorder (Dysthymia)
a. DSM V combined Dysthymia & chronic major depressive disorder into PDD
b. MC in women, onset often in childhood/adolescence/early adulthood
c. Diagnostic Criteria:
i. Chronic depressed mood for at least 2 years in adults (at least 1 year in
children/adolescents) that lasts most of the day, more days than not
1. In 2 year period pt is not symptom free for >2 months at a time
ii. At least 2 of the following: insomnia or hypersomnia, fatigue, low self-esteem,
decreased appetite or overeating, hopelessness, poor concentration or indecisiveness
iii. May have major depressive episodes or meet criteria for MDD continuously
iv. Must never have had a manic episode (r/o Bipolar I) or hypomanic episode (r/o
cyclothymic disorder)
d. Management: psych + pharm!!
i. Psychotherapy – interpersonal, cognitive & insight-oriented
ii. Pharmacotherapy – SSRIs, SNRIs, TCAs, MAO-Is
Anxiety, Trauma & Stress-Related Disorders
1) Generalized Anxiety Disorder
a. MC in females, onset usually occurs in early 20s
b. Diagnostic Criteria:
i. Excessive anxiety or worry a majority of days for at least 6 months about various
aspects of life, usually out of proportion to the event
ii. Assoc. with at least 3 of the following: fatigue, restlessness, difficulty concentrating,
muscle tension, sleep disturbance, irritability, shakiness, headaches
iii. Not episodic (as in panic disorders), situational (as in phobias) or focal
iv. Sx cause significant social or occupational dysfunction
v. Not d/t medical illness or substance abuse
c. Management:
i. Antidepressants – SSRIs 1st line (Fluoxetine, Paroxetine, Escitalopram), SNRIs
(Venlafaxine)
ii. Buspirone can be adjunct to SSRIs (does not cause sedation)
1. MOA: Partial serotonin (5HT-1A) receptor agonist & dopamine receptor
antagonist
2. Indications: GAD (combo w/ SSRI), does not cause sedation & does not
potentiate the CNS depression of ETOH (almost negligible abuse/addiction
potential)
3. ADRs: HA, nausea, dizziness, RLS, extrapyramidal symptoms
iii. CBT & psychotherapy (in combo w/ pharmacotherapy)
