Physician Assistant Exam: Mood Disorders
You should be familiar with the evaluation and treatment of some major mood disorders for the Physician Assistant Exam (PANCE). Mood disorders involve major changes in a person’s emotions. You’re not simply dealing with a “moody individual.”
Major depression and dysthymia
Depression is a very common mood disorder, and it’s one of the main complaints elicited during outpatient visits to one’s primary care provider. Major depressive disorder has 14 entries in the DSM-IV-TR.
With major depressive disorder, someone experiences depressed mood and/or anhedonia, the inability to feel any joy in anything. The person can be barely interested in life itself or the activities of daily living and often doesn’t feel good about himself or herself, either. Here are some points concerning depression:
The symptoms can vary from sleeping all the time to having trouble sleeping.
Sufferers often hate themselves and have very low self-esteem.
Sufferers can have weight gain or weight loss.
The affected person, especially one with a full-blown depression, is often disheveled and odoriferous. The person is so depressed he or she doesn’t care about himself or herself at all, which can result in poor hygiene and an unkempt appearance.
The periods of depression often last a long time. By diagnostic criteria, they need to last for at least 14 days.
If a healthcare provider feels that someone may be depressed, the provider often uses a formalized questionnaire, such as the Beck Depression Inventory, to get a sense of the patient’s psyche.
The treatment for depression includes not only psychotherapy and a full medical evaluation but also medications, namely serotonin selective reuptake inhibitors and tricyclic antidepressants. Common side effects of the SSRIs can include weight gain and insomnia or hypersomnia. What a mix! Some of the SSRIs can cause hyponatremia. Tricyclic antidepressants can cause anticholinergic side effects as well as increase the risk of cardiac arrhythmias by prolonging the QT interval.
Dysthymia is a milder form of depression. People who are affected have many of the same symptoms of depression, including changes in eating habits, changes in sleep patterns, feelings of low self-worth, and/or feeling fatigued; however, these symptoms are milder. Before you can make a diagnosis of dysthmia, the person has to have had many of these depressive symptoms for at least 24 months.
You’re evaluating a 30-year-old woman who states that she has difficulty wanting to “get out of bed in the morning.” She says she just wants to be alone in the dark. You question her a little further and discover that 2 months ago, she gave birth to a son. What psychiatric condition are you most likely dealing with?
(D) Panic disorder
(E) Post-partum depression
The correct answer is Choice (E), post-partum depression. The key to answering this question is paying attention to the time period. The symptoms of post-partum depression can begin 30 days after giving birth. Some experts feel they can last several months.
As for the other choices, there’s no evidence of hypothyroidism on physical examination. Concerning dysthymia, the woman’s symptoms are pretty severe; by contrast, with dysthymia, the person is able to function nearly fully in society. As for cyclothymia, the question mentions no cycling of symptoms between hypomania and dysthymia; this person is really depressed. Finally, this person is having the symptoms opposite those of panic disorder.
Bipolar disorder and cyclothymia
Bipolar disorder used to be called manic-depressive disorder. The dictionary definition of bipolar is “having or relating to two poles or extremities.” The patient with bipolar disorder goes through tremendous mood swings, from a manic phase to a depressive phase, usually with a little bit of “normal” mood in between:
Manic phase: Clinically, elevated moods are called mania, which comes from the Greek word for madness. During a manic phase, you can expect to see symptoms such as decreased need for sleep, aggression, quick decision-making, and/or an unlimited supply of energy. In addition, the affected person can be delusional.
Depression phase: The body is geared toward balance, so after the manic high, the affected person can come crashing down into a deep depression. The symptoms can be exhaustive and can include hopelessness, anorexia, social isolation, and sadness. A major depressive episode can last from 2 weeks to over 6 months.
As you may expect, bipolar disorder interferes with functioning. Unfortunately for the clinician, symptoms can vary quite a bit. Some people demonstrate features of both mania and depression at the same time. And some people have rapid cycling, with no normal mood between manic and depressive episodes. The exact causes of bipolar disorder aren’t clear. Bipolar patients are at risk of suicide.
The first-line approach for treatment is medication. The most common medication is lithium carbonate. It’s approved by the FDA for treating depression, but it isn’t without side effects, which can include thyroid abnormalities, leukocytosis, and a benign tremor. The big-time side effect of lithium carbonate is kidney disease. Many people who’ve used this med for years have stabilization of their bipolar disorder, but their kidney function is affected.
Other medications used commonly clinically include lamotrigine and divalproex sodium. Lamotrigine can be associated with a skin rash that goes away with discontinuation of therapy. It’s very good for mood stabilization, preventing depressive episodes. Divalproex sodium can cause an increase in the liver function tests.
You can order psychotherapy after the person is initially stabilized with medication. It’s essential that he or she be receptive to treatment. Behavioral-based therapy can help identify potential triggers of manic and/or depressive behavior. In cases where a person poses a danger to himself or others, consider an involuntary commitment to the hospital.
Cyclothymia is a milder form of bipolar disorder in which the affected person alternates between periods of dysthymia and hypomania. Think of dysthymia as a milder form of depression and hypomania as a milder form of manic disorder. The key here is recognizing that many people with cyclothymia are functional.