Snapshot A 51-year-old female presents to her PCP with a sore throat. Upon further screening, the patient shares concerns of difficulty with sleep, concerns about making mistakes in her life, and observations of decreased ability to focus at work as an administrative assistant for the past three months. She occasionally feels anxious about repeating past mistakes, which she cannot articulate. She goes on to express guilt about the death of some of her family members. She reports having experienced bouts of intense energy and uncontrollable thinking during which she felt very productive at work without need for sleep just prior to her current state. She denies any suicidal or homicidal thoughts. She denies any family history of depression or bipolar disorder. She denies worsened symptoms with menses. Physical exam is unremarkable, but the patient remarks a low appetite that has led to 3 pounds of weight loss. The PCP diagnoses the woman with major depressive disorder with mixed features and with anxious distress. The patient is started on escitalopram and scheduled for a follow-up appointment in two weeks. Introduction Mood state, syndrome, and/or mental disorder characterized by dysphoria (sad/irritable) Most common psychiatric disorder Epidemiology 18% prevalence in the United States females affected twice as often as males not associated with economic status or race incidence decreases with increasing age however, associated with presence of multiple medical comorbidities Classifications (DSM-V) unipolar major depression (major depressive disorder) persistent depressive disorder (previously called dysthymia) no scientifically meaningful distinction between chronic depression and dysthymia symptom persistence for > 2 years disruptive mood dysregulation disorder new diagnosis for children up to 18 years with persistent irritability and behavior dyscontrol created due to concerns of overdiagnosis of bipolar disorder premenstrual dysphoric disorder substance/medication induced depressive disorder depressive disorder due to another medical condition unspecified depressive disorder Presentation Symptoms SIG E CAPS Sleep decreased Interest decreased (anhedonia) Guilt increased Energy decreased Concentration decreased Appetite decreased Psychomotor retardation Suicidal ideations Evaluation Routine outpatient screening now recommended by USPSTF Patient Health Questionnaire-2 (PHQ-2) can be used if positive, follow up with PHQ-9 assess for suicidal ideation, plan, and intent Diagnostic criteria core symptom criteria have not changed in DSM-V one or more major depressive episodes a depressive episode must contain five or more of the above symptoms for episodes > 2 week period separated by 2 month period impairment of daily living medical causes has been ruled out (e.g., hypothyroidism, adrenal insufficiency, Huntington's disease, hypercortisolism, mononucleosis, Parkinson's disease, stroke, lupus, TBI, vitamin B12 deficiency) Subtype specifiers anxious distress atypical features appetite increased reactive to pleasurable stimuli hypersomnia heavy feelings in limbs longstanding pattern of hypersensitivity to rejection catatonia symptoms improve with benzodiazepines (i.e., lorazepam) mixed features at least three symptom criteria for mania/hypomania Treatment Routine outpatient screening now recommended by USPSTF Patient Health Questionnaire-2 (PHQ-2) can be used if positive, follow up with PHQ-9 1st line: psychotherapy + pharmacotherapy psychotherapy cognitive-behavioral therapy or interpersonal psychotherapy pharmacotherapy selective serotonin reuptake inhibitors (SSRI) first line drug fewer side effects overall need at least 4-8 weeks to take effect SNRI, atypical agents (bupropion, mirtazapine) second line drugs TCAs and MAO inhibitors third line Electroconvulsive therapy for refractory cases, depression with psychotic features, or if immediate symptom resolution is required Prognosis Prognosis medical therapy effective in up to 70% of patients though must allow sufficient time for success and treat for minimum of 6 months results observable typically in 2 weeks follow-up usually at 2 weeks because risk of suicide is greatest following initial use of antidepressants if patient has had 1 episode of major depression, pharmacotherapy can be discontinued after 6 months of no symptoms can be monitored using PHQ-9 (not PHQ-2) complications pseudodementia
QUESTIONS 1 of 5 1 2 3 4 5 Previous Next Lab Values Blood Hematologic Cerebrospinal Sweat, Urine, and BMI Blood, Plasma, Serum Reference Range ALT 8-20 U/L Amylase, serum 25-125 U/L AST 8-20 U/L Bilirubin, serum (adult) Total // Direct 0.1-1.0 mg/dL // 0.0-0.3 mg/dL Calcium, serum (Ca2+) 8.4-10.2 mg/dL Cholesterol, serum Rec: < 200 mg/dL Cortisol, serum 0800 h: 5-23 μg/dL //1600 h: 3-15 μg/dL 2000 h: ≤ 50% of 0800 h Creatine kinase, serum Male: 25-90 U/LFemale: 10-70 U/L Creatinine, serum 0.6-1.2 mg/dL Electrolytes, serum Sodium (Na+) 136-145 mEq/L Chloride (Cl-) 95-105 mEq/L Potassium (K+) 3.5-5.0 mEq/L Bicarbonate (HCO3-) 22-28 mEq/L Magnesium (Mg2+) 1.5-2.0 mEq/L Estriol, total, serum (in pregnancy) 24-28 wks // 32-36 wks 30-170 ng/mL // 60-280 ng/mL 28-32 wk // 36-40 wks 40-220 ng/mL // 80-350 ng/mL Ferritin, serum Male: 15-200 ng/mLFemale: 12-150 ng/mL Follicle-stimulating hormone, serum/plasma Male: 4-25 mIU/mL Female: premenopause: 4-30 mIU/mL midcycle peak: 10-90 mIU/mL postmenopause: 40-250 pH 7.35-7.45 PCO2 33-45 mmHg PO2 75-105 mmHg Glucose, serum Fasting: 70-110 mg/dL2-h postprandial:<120 mg/dL Growth hormone - arginine stimulation Fasting: <5 ng/mLProvocative stimuli: > 7ng/mL Immunoglobulins, serum IgA 76-390 mg/dL IgE 0-380 IU/mL IgG 650-1500 mg/dL IgM 40-345 mg/dL Iron 50-170 μg/dL Lactate dehydrogenase, serum 45-90 U/L Luteinizing hormone, serum/plasma Male: 6-23 mIU/mL Female: follicular phase: 5-30 mIU/mL midcycle: 75-150 mIU/mL postmenopause 30-200 mIU/mL Osmolality, serum 275-295 mOsmol/kd H2O Parathyroid hormone, serume, N-terminal 230-630 pg/mL Phosphatase (alkaline), serum (p-NPP at 30° C) 20-70 U/L Phosphorus (inorganic), serum 3.0-4.5 mg/dL Prolactin, serum (hPRL) < 20 ng/mL Proteins, serum Total (recumbent) 6.0-7.8 g/dL Albumin 3.5-5.5 g/dL Globulin 2.3-3.5 g/dL Thyroid-stimulating hormone, serum or plasma .5-5.0 μU/mL Thyroidal iodine (123I) uptake 8%-30% of administered dose/24h Thyroxine (T4), serum 5-12 μg/dL Triglycerides, serum 35-160 mg/dL Triiodothyronine (T3), serum (RIA) 115-190 ng/dL Triiodothyronine (T3) resin uptake 25%-35% Urea nitrogen, serum 7-18 mg/dL Uric acid, serum 3.0-8.2 mg/dL Hematologic Reference Range Bleeding time 2-7 minutes Erythrocyte count Male: 4.3-5.9 million/mm3Female: 3.5-5.5 million mm3 Erythrocyte sedimentation rate (Westergren) Male: 0-15 mm/hFemale: 0-20 mm/h Hematocrit Male: 41%-53%Female: 36%-46% Hemoglobin A1c ≤ 6 % Hemoglobin, blood Male: 13.5-17.5 g/dLFemale: 12.0-16.0 g/dL Hemoglobin, plasma 1-4 mg/dL Leukocyte count and differential Leukocyte count 4,500-11,000/mm3 Segmented neutrophils 54%-62% Bands 3%-5% Eosinophils 1%-3% Basophils 0%-0.75% Lymphocytes 25%-33% Monocytes 3%-7% Mean corpuscular hemoglobin 25.4-34.6 pg/cell Mean corpuscular hemoglobin concentration 31%-36% Hb/cell Mean corpuscular volume 80-100 μm3 Partial thromboplastin time (activated) 25-40 seconds Platelet count 150,000-400,000/mm3 Prothrombin time 11-15 seconds Reticulocyte count 0.5%-1.5% of red cells Thrombin time < 2 seconds deviation from control Volume Plasma Male: 25-43 mL/kgFemale: 28-45 mL/kg Red cell Male: 20-36 mL/kgFemale: 19-31 mL/kg Cerebrospinal Fluid Reference Range Cell count 0-5/mm3 Chloride 118-132 mEq/L Gamma globulin 3%-12% total proteins Glucose 40-70 mg/dL Pressure 70-180 mm H2O Proteins, total < 40 mg/dL Sweat Reference Range Chloride 0-35 mmol/L Urine Calcium 100-300 mg/24 h Chloride Varies with intake Creatinine clearance Male: 97-137 mL/minFemale: 88-128 mL/min Estriol, total (in pregnancy) 30 wks 6-18 mg/24 h 35 wks 9-28 mg/24 h 40 wks 13-42 mg/24 h 17-Hydroxycorticosteroids Male: 3.0-10.0 mg/24 hFemale: 2.0-8.0 mg/24 h 17-Ketosteroids, total Male: 8-20 mg/24 hFemale: 6-15 mg/24 h Osmolality 50-1400 mOsmol/kg H2O Oxalate 8-40 μg/mL Potassium Varies with diet Proteins, total < 150 mg/24 h Sodium Varies with diet Uric acid Varies with diet Body Mass Index (BMI) Adult: 19-25 kg/m2 Calculator ( ) xy AC 7 8 9 ÷ 4 5 6 × 1 2 3 - 0 . = + Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK (M3.PY.23) A 27-year old gentleman presents to the primary care physician with the chief complaint of "feeling down" for the last 6 weeks. He describes trouble falling asleep at night, decreased appetite, and recent feelings of intense guilt regarding the state of his personal relationships. He says that everything "feels slower" than it used to. He endorses having a similar four-week period of feeling this way last year. He denies thoughts of self-harm or harm of others. He also denies racing thoughts or delusions of grandeur. Which of the following would be an INAPPROPRIATE first line treatment for him? Review Topic QID: 103314 1 Psychotherapy 0% (0/0) 2 Citalopram 0% (0/0) 3 Paroxetine 0% (0/0) 4 Electroconvulsive therapy 0% (0/0) 5 Sertraline 0% (0/0) M2 Select Answer to see Preferred Response PREFERRED RESPONSE 4
Login to View Community Videos Login to View Community Videos Major Depression with Psychotic Features Thomas Heineman Psychiatry - Major Depressive Disorder 11/9/2012 43 views