Continuum Audio
Mood Disorders (Behavioral Neurology and Psychiatry December 2021)
December 01, 2021.Shae Datta, MD, Director of Concussion and Cognitive Neurology, NYU Langone Hospital--Long Island, East Meadow, NY
Educational Objectives
The goal of this program is to improve management of mood disorders in patients with neurologic diseases. After hearing and assimilating this program, the clinician will be better able to:
- Identify the most common clinical features of depressive and bipolar disorders.
- Diagnose mood disorders in patients with neurodegenerative diseases.
- Educate patients about the benefits and adverse effects of different medical and alternative therapies used in the management of depression.
Summary
Mood disorders (Behavioral Neurology and Psychiatry December 2021)
Overview: Mood disorders encompass depression and bipolar disorder; symptoms of depression have been reported in approximately 18.5% of the general population; the estimated annual prevalence of bipolar disorder in the United States is 2.8%; previously known as affective disorders, mood disorders can manifest as feelings of depression, mania, or both.
Classification: Depressive disorders — include major depressive disorder, persistent depressive disorder, disruptive mood dysregulation disorder, and premenstrual dysphoric disorder; bipolar disorder
Diagnostic criteria for depression: Presence of symptoms such as depressed mood, anhedonia, irritability, and emptiness; may be accompanied by neurovegetative symptoms (decrease or increase in appetite and sleep, decreased energy levels, concentration difficulties, or decreased interest); these clinical manifestations impair functioning and may cause insomnia, pain, and generalized fatigue.
Bipolar disorders: Multifactorial disorders with a strong genetic component; environmental factors, such as life events, play a role.
Major depressive disorder: Diagnosed when the depressive episode lasts longer than 2 weeks, with the presence of at least four defining symptoms, ie, insomnia or hypersomnia, increase or decrease in appetite, psychomotor agitation or retardation, decreased energy levels, decreased concentration, suicidal ideation, and thoughts of worthlessness or guilt; the mnemonic “SIG E CAPS” (ie, sleep, interest, guilt, energy, concentration, appetite, psychomotor, and suicidal ideation) is useful when screening for symptoms; major depressive disorder is a chronic disorder that causes persistent feelings of sadness and emptiness; clinicians should consider the timeline of symptoms and ensure that these cannot be attributed to another cause (eg, substance abuse, general medical condition, use of medications).
Genetic factors: The heritability rate for major depressive disorder (≈37%) is much lower than that for, eg, schizophrenia, bipolar disorder, (between 70% and 80%); genetic and psychosocial factors shape response to stress, resilience, and susceptibility to depression.
Neuroimaging findings in major depressive disorder: In some patients with major depressive disorder, imaging shows atrophy in the cortical and limbic regions and decreased prefrontal cortex and hippocampal volumes; as these features are not present in all cases, clinical correlation is required.
Biological underpinnings of depression: To date, no leading biological model for major depressive disorder has emerged; however, elevated cortisol levels may predict the onset or relapse of depression; the dysregulation of the hypothalamic-pituitary-adrenal axis has been shown to increase cortisol levels in 40% to 60% of patients with depression.
Cognitive deficits during depressive episodes: The diagnostic criteria for depression do not capture the full spectrum of cognitive deficits that may be present in patients with depressive disorders; these include a decline in executive functioning, attention, processing speed, and memory, which significantly reduce quality of life and have a negative impact on daily functioning.
Assessment of suicide risk: Patients with longstanding neurologic disorders may benefit from a multidisciplinary approach; neurologists should screen patients for suicide risk; factors to consider in addition to neurocognitive disorders include history of substance abuse, negative life events, and medical conditions; determine whether the patient has access to lethal means; ask about previous suicide attempts and family history of suicide; screening questions are an important first step in a proactive approach, which involves initiating medications or referring patients for psychotherapy as a bridge to management of care by a psychiatrist.
Persistent depressive disorder: Includes chronic depressive disorders, such as dysthymic disorder, recurrent major depression without recovery between episodes, major depressive episode (which superimposes on dysthymic disorder, ie, “double depression”), and chronic major depression, characterized by predominant dysphoria.
Depression in children and adolescents: Depressive disorders may manifest differently in children and adolescents than in adults; irritability is often the main symptom of depression in young patients; disruptive mood dysregulation disorder, a new diagnostic entity introduced in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), is characterized by persistent irritability or negative mood, anger, and temper tantrums; anger is disproportionate to the situation and may manifest verbally or physically; these clinical features are not necessarily consistent with classic criteria for depression.
Premenstrual dysphoric disorder: Characterized by psychological and physical manifestations; psychological features
Postpartum depression: Female sex hormones are believed to play a role in the pathogenesis; identified as a major depressive disorder with peripartum onset; symptoms begin during pregnancy or within 4 weeks after delivery; brexanolone — a new antidepressant agent developed specifically for postpartum depression; acts as an allosteric modulator of GABAA receptors.
Medication-induced depressive disorder: Medications used in the management of neurodegenerative disorders frequently cause or exacerbate depression; these include baclofen, which is used to treat multiple sclerosis (MS), many antiepileptic medications (eg, vigabatrin), and cholinesterase inhibitors prescribed to patients with Alzheimer disease or dementia; corticosteroids used in the management of MS may precipitate mania and depression; interferons, monoamine oxidase type B inhibitors, and tricyclic antidepressants, which are recommended for migraine prophylaxis and neuropathic pain, may precipitate mania; when initiating pharmacotherapy for neurologic disorders, clinicians should monitor patients for depression and teach patients and family members to recognize signs of mania (eg, irritability, hyperactivity, increased spending); the Beck Depression Inventory may be used as a screening tool; slow titration and starting at the lowest therapeutic dose is recommended; if use of depression-inducing medications cannot be avoided, consult with a psychiatric colleague and/or initiate antidepressant agents or mood stabilizers, if needed.
Differences between bipolar disorder and cyclothymic disorder: Bipolar disorder II
Neurologic Disorders That Cause Mood Disorders
Multiple sclerosis: A major cause of neurologic disability in young adults; reported prevalence of depression in patients with MS ranges from 4.27% to 59.6%; the etiology of depression may be genetic, immune, inflammatory, or related to structural changes in the brain; ferritin levels can be used as a biomarker for the diagnosis of depression in this patient population; Knyszyńska et al found that ferritin levels are inversely correlated with severity of depression in patients with MS; CBT is recommended to manage depression in the context of MS; options also include psychopharmacologic treatments and transcranial magnetic stimulation (TMS), but evidence about their efficacy is lacking.
Dementia: In patients with neurocognitive disorders, the average reported prevalence of major depression is 15.9%; nonpharmacologic interventions are preferred and are effective for reducing symptoms of mild to moderate depression in this population; options include animal therapy, cognitive stimulation exercise, social interaction, massage therapy, reminiscence therapy, occupational therapy, multidisciplinary care, and environmental modification.
Migraine: Highly comorbid with mood disorders, including depression and bipolar disorder; women are more often affected than men because they are more likely to have migraines; prevalence of bipolar disorder in patients with migraines is approximately 19.2%; comorbid mood disorders further deteriorate quality of life of patients with migraines; if left untreated, mood disorders worsen outcomes of management of headache.
Traumatic brain injury: Preexisting mood disorders (eg, anxiety, depression) predispose patients to greater functional disability and a higher burden of cognitive deficits after traumatic brain injury; adequate management is important; therapeutic strategies are guided by clinical presentation; CBT is recommended as a first-line intervention, followed by psychopharmacologic management.
Parkinson disease: Patients with Parkinson disease (PD) have high rates of depression (40% to 50%); depression may represent a premotor marker of PD; genetic alterations induced by PD may play a role in the development of depression; neuroimaging findings in PD suggest a complex interplay between neurochemical, anatomic, and functional changes; there is evidence of dysfunction in the aminergic systems of patients with PD and depression; structural changes include degeneration of subcortical and cortical neural pathways, neuronal loss in the substantia nigra, presence of Lewy body inclusions, and a decline in monoamine neurotransmitter systems; SSRIs, serotonin–norepinephrine reuptake inhibitors, tricyclic antidepressants, and other dopamine agonists, such as atomoxetine, can be considered for the treatment of depression in patients with PD.
Epilepsy: Depression is the most common mood disorder in patients with epileptic seizures and is associated with a decrease in quality of life; compared with patients who have other chronic conditions, patients with epilepsy are twice as likely to have bipolar disorder; adequate management is important because risk for suicide is increased 32-fold in patients with epilepsy and mood disorders; treatment options include SSRIs, serotonin–norepinephrine reuptake inhibitors, and mood-stabilizing agents.
Stroke: Poststroke depression is a commonly experienced contributor to poor stroke outcomes; prevalence of post-stroke depression is reported at 29% to 36%; initiation of antidepressant therapy in the inpatient setting (during stroke care) and continuation after discharge is associated with improved outcomes.
Evaluation and Management of Mood Disorders
History: Obtaining a thorough psychiatric history and determining the timeline of symptoms are the first steps toward initial diagnosis of depression or bipolar disorder; consider the patient’s medical history, family history, and history of substance use; when possible, obtain collateral information to corroborate that obtained from patients.
Laboratory tests: Thorough workup is recommended, including metabolic panel, complete blood count, thyroid-stimulating hormone (TSH) levels (can be low in depression, anxiety, and dementia), and levels of folate, vitamin B12, and vitamin D; testing for human immunodeficiency virus (HIV) and syphilis, as well as urine toxicology, can help confirm the diagnosis, particularly when mood disorders are related to general medical conditions or substance abuse.
Neuroimaging: May be considered on a case-by-case basis, eg, when manifestations such as depression or rapid eye movement (REM) sleep behavior disorder are suspected to be early symptoms of neurodegenerative disorders (ie, premotor symptoms of PD); fludeoxyglucose positron emission tomography (FDG-PET) and DaTscan can be used, as needed.
Neuromodulation: treatments used in depression include electroconvulsive therapy (ECT), transcranial direct current stimulation, repetitive TMS, and magnetic seizure therapy; surgical options include vagal nerve stimulation and deep brain stimulation, which is used in severe treatment-resistant depression; repetitive TMS is recommended for patients who do not respond to antidepressant therapy; ECT is typically reserved for second-line treatment but may be considered as a first intervention in patients who present with acute suicidal ideation and rapidly deteriorating physical status (eg, catatonia), have failed to respond to multiple antidepressant agents, or have had good response to ECT in the past.
Treatment of resistant depression: Recently, IV ketamine has been administered in monitored settings to patients with treatment-resistant depression; esketamine nasal spray has been approved by the US Food and Drug Administration (FDA) and can be used in outpatient settings with follow-up monitoring.
Complementary and alternative medicine treatments: Patients often are interested in, or may have already tried, herbs and nutraceuticals that may help manage mood symptoms; St. John’s wort — most common supplement used for depression; advise patients about interactions with other medications, including antidepressant agents, oral contraceptive pills, and medications used to treat cancer; valerian — used for anxiety and insomnia; patients should be made aware of drug interactions and adverse effects; other supplements — l-methylfolate and cerefolin are used for depression and mild dementia; chamomile, turmeric (considered to have antitumor and anti-inflammatory properties), omega-3 fatty acids, magnesium, S-adenosylmethionine, and green tea are also used to manage depression; phosphatidylserine is used for attention-deficit/hyperactivity disorder and mood disorders; although, in most cases, the use of dietary supplements is not evidence-based, clinicians may improve their relationships with patients by showing support and educating them about interactions and adverse effects (eg, apple cider vinegar can interact with agents used to treat epilepsy and migraine, thereby exacerbating symptoms of these conditions).
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Readings
Datta S, Suryadevara U, Cheong J. Mood disorders. Continuum (Minneap Minn) 2021;27(6, Behavioral Neurology and Psychiatry)
Knyszyńska A, Radecka A, Zabielska P, et al. The role of iron metabolism in fatigue, depression, and quality of life in multiple sclerosis patients. Int J Environ Res Public Health 2020;17(18):6818. doi:10.3390/ijerph17186818.
Disclosures
In adherence to ACCME Standards for Commercial Support, Audio Digest requires all faculty and members of the planning committee to disclose relevant financial relationships within the past 12 months that might create any personal conflicts of interest. Any identified conflicts were resolved to ensure that this educational activity promotes quality in health care and not a proprietary business or commercial interest. For this program, the following was disclosed: Dr Datta has received personal compensation for serving as an educational mentor for Residency Success.
Unlabeled Use of Products/Investigational Use Disclosure: Dr Datta discusses the unlabeled/investigational use of bupropion, divalproex sodium, and selective serotonin reuptake inhibitors for the treatment of bipolar depression; complementary and alternative medicine treatments for the treatment of mood disorders; electroconvulsive therapy and transcranial magnetic stimulation for mania; ketamine infusion for depression; neuromodulation techniques such as transcranial direct current stimulation and deep brain stimulation for the treatment of depression; psychopharmacologic treatments and transcranial magnetic stimulation for multiple sclerosis; and risperidone for adjunctive treatment of depression.
To view disclosures of planning committee members with relevant financial relationships, visit: legacy.audio-digest.org/continuumaudio/committee. All other members of the planning committee report nothing to disclose.
Acknowledgements
CME/CE INFO
Accreditation:
The Audio- Digest Foundation is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.
The Audio- Digest Foundation designates this enduring material for a maximum of 0 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.
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Lecture ID:
CA100603
Expiration:
This CME course qualifies for AMA PRA Category 1 Credits™ for 3 years from the date of publication.
Instructions:
To earn CME/CE credit for this course, you must complete all the following components in the order recommended: (1) Review introductory course content, including Educational Objectives and Faculty/Planner Disclosures; (2) Listen to the audio program and review accompanying learning materials; (3) Complete posttest (only after completing Step 2) and earn a passing score of at least 80%. Taking the course Pretest and completing the Evaluation Survey are strongly recommended (but not mandatory) components of completing this CME/CE course.
Estimated time to complete this CME/CE course:
Approximately 2x the length of the recorded lecture to account for time spent studying accompanying learning materials and completing tests.
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