PSYCHIATRIC

Case 25 Depression:
- Major depression: one or more episodes of mood disorder each of which lasts at least 2 wks. The most
prominent symptoms of major depressive disorder are depressed mood & loss of interest or pleasure.
Insomnia & weight loss often accompany major depression, but depressed patients may also have weight gain
& hypersomnia.
- Dysthymic disorder: a chronic depression of mood which does not meet the criteria for major depression, in
terms of either severity or duration of individual episodes, yet the patients still has loss of interest, lack of
appetite or pleasure, & low energy.
- Depression has a greater incidence in women & in the elderly.
- Symptoms must include at least 5 of the 9 following symptoms, must occur during the same 2-week time period, must
represent a change form previous functioning, & must include either depressed mood or loss of interest or pleasure.
o Depressed mood, diminished interest or pleasure, significant weight loss or weight gain, insomnia or
hypersomnia, psychomotor agitation or retardation, fatigue or loss of energy, feelings of
worthlessness, diminished ability to think or concentrate; indecisiveness, recurrent thoughts of
death, suicidal ideation, suicide attempt, or specific plan.
o Symptoms do not meet criteria for a mixed episode (both mania & depressive episode).
o Symptoms cause clinically significant distress or impairment of functioning.
o Symptoms are not a result of the direct physiologic effects of a substance or a generalized medical
condition.
o Symptoms are not accounted for by bereavement.
- The diagnosis of depression needs to be considered in scenarios where a patient presents w/ multiple
unrelated physical symptoms.
- Numerous medical conditions can cause depressive symptoms. Common among these are hypothyroidism &
anemia.
- All currently available antidepressant agents appear to work by increasing the amt of neurotransmitter
available to the postsynaptic nerve.
o They accomplish this by (1) enhancing neurotransmitter release, (2) reducing neurotransmitter
breakdown, or (3) inhibiting the reuptake of the neurotransmitter by the presynaptic neuron.
- Persons w/ depression have a greater chance of developing or dying from cardiovascular disease, even
after controlling for traditional risk factors such as smoking, blood pressure, & lipid levels.
- Women, especially those younger than age 30 yrs, attempt suicide more frequently than men, but men are more
likely to complete suicide.
o Firearms are the most commonly used method in completed suicides.
- Pharmacotherapy w/ psychotherapy is more effective than either pharmacotherapy or psychotherapy
alone. Treatment should be geared toward doing both to improve chances of successful therapy.
o Treatment failures typically result from medication noncompliance, inadequate duration of
therapy, or inadequate dosing.
o Patients treated for a 1st episode of major depression should be treated for at least 6 9 month;
recurrent depression needs to be treated for longer periods of time.
- All antidepressants carry an FDA Black Box warning that they increase the risk of suicidal thoughts &
behaviors in children, adolescents, & young adults, especially in the frst months of treatment.
- SSRIs are frequently used as 1st-line agents for the treatment of depression. It can take 3 6 wks of therapy
before significant improvement in mood occurs, dosage adjustments of these medications should occur no
more often than monthly.
o Common side effects include sexual dysfxn, weight gain, gastrointestinal disturbance, fatigue, & agitation.
- Serotonin-norepinephrine reuptake inhibitors (SNRIs) affect both the serotonergic & noradrenergic systems.
They act primarily on the serotonergic system at lower dosages & on the noradrenergic system at higher
doses.
- Pts on MAOIs must be on a tyramine-restricted diet to reduce the risk of severe, & sometimes fatal,
hypertensive crisis.
- Bupropion is associated w/ a risk of seizure at higher doses & is contraindicated in patients w/ a history of
seizure disorders.
- Trazadone carries the risk of causing priapism. It is also highly sedating & is frequently used as a sleep aid.
- Anxiety disorders is a classification of mood disorders that are common in the population such as panic disorder,
obsessive-compulsive disorder, generalized anxiety disorder, posttraumatic stress disorder (PTSD), & phobia.
o Patients w/ anxiety disorders are at high risk for developing comorbid depression.
- Bipolar disorder (manic depression) symptoms include the abrupt onset of increased energy, decreased need
for sleep, pressured speech, decreased attention span, hypersexuality, spending large amounts of money, &
engaging in outrageous activities. Episodes should last longer than 1 week & should be abrupt, not continuous.
 o All pts diagnosed w/ depression should be questioned about mania, as the treatments are different.
- Dysthymic disorder presents w/ continuous low mood as the primary symptom. Typically 2 yrs of low mood is
used for diagnosis.

Case 32 Dementia:
- Executive functions: high-level cognitive abilities that control other, more basic abilities. Executive functions
include the ability to start & stop behaviors, alter behaviors to fit circumstances, & adapt behaviors to new
situations.
- The essential features of diagnosis of dementia are memory loss & impairment of executive fxns.
o Patients rarely report memory loss; the informants are usually their family members.
o Studies of aging have showed that nonverbal creative thinking & new problem-solving strategies may
decline w/ age, but information, skills learned w/ experience & memory retention remain intact.
- Patients w/ dementia have difficulty w/ one or more of the following:
o Learning & retaining new information (rely on lists, calendars)
o Handling complex tasks (banking, bills, payments)
o Reasoning (adapting to unexpected situations, unfamiliar environment)
o Spatial ability & orientation (getting loss driving, walking)
o Language (word finding, repetition, confabulation)
o Behavior (agitation, confusion, paranoia)
- The Folstein Mini-Mental Status Exam (MMSE) is the most widely used screening tool. It is most accurate in those
w/ at least a high school education.
- The Clock Test is another valuable test. It is quick, easy to administer, & evaluates executive fxn in multiple
cognitive domains.
- Alzheimer disease is the most common cause of dementia.
o Common diagnostic criteria include the gradual onset & progression of cognitive dysfxn in more than
one are of mental functioning that is not caused by another disorder.
o A validated test, such as the MMSE, should be used to confirm the presence of dementia.
o A definitive diagnosis can only be made by the presence of neuritic plaques & neurofibrillary tangles
detected on autopsy.
- Aphasia: loss of word comprehension ability.
- Apraxia: loss of ability to perform complex tasks involving muscle coordination.
- Agnosia: loss of ability to recognize & use familiar objects.
- Depression in the elderly can present w/ symptoms of memory disturbance. This is known as pseudodementia.
Similarly, hypothyroidism & vitamin B12 deficiency are common & treatable conditions that can cause
cognitive problems.
- Neuroimaging w/ either a non-contrast CT scan or an MRI of the brain is recommended to rule out other
confounding diagnoses.
- The management of Alzheimer disease must be directed both at the patient & at the patients family or
caregivers. The goals of therapy are to maximize the cognition, delay functional decline, & prevent or
improve the behavioral disturbances.
o Family members should understand that the medications may delay the progression of the disease but
may not reverse any decline that has already occurred.
o The FDA has placed a black-box warning against the use of antipsychotic medications for dementia-
related psychosis due to the increased risk of deaths.
- Vascular dementia, or multi-infarct dementia, is the 2nd most common cause of dementia. In vascular dementia,
there is neuronal loss as a consequence of one or more strokes. The symptoms are related to the amount &
location of the neuronal loss.
o Vascular dementia often has a sudden onset & progresses in a stepwise fashion.
o Treatment is aimed at reducing the risk of further neurologic damage.
- Parkinson disease commonly has an associated dementia, especially as the overall disease advances.
- Normal pressure hydrocephalus causes the triad of dementia, gait disturbance, & urinary incontinence.
- Lewy body dementia has symptoms similar to Alzheimer disease, but the dementia has a fluctuating course & is
often accompanied by hallucinations early in the course of the disease.
o Well-formed hallucinations, vivid dreams, fluctuating cognition, sleep disorder w/ periods of daytime
sleeping, frequent falls, deficits in visuospatial ability & REM sleep disorder.
- Dementia can be a complication of chronic alcohol abuse, reinforcing the need for a complete history of substance
abuse.
- Metabolic abnormalities, such as hyponatremia or abnormal calcium levels, & other infections, such as AIDS, can also
cause dementia.
- Delirium is an acute change in mental status that is characterized by fluctuations in levels of consciousness.
 o The treatment for delirium is treatment of the condition that precipitated it.
o Delirium is often reversible if the underlying cause can be found & aggressively managed.
o Pts w/ delirium have significantly longer hospital stays & increased mortality rates.

Case 41 Alcohol Dependence/Substance-Induced Depressive Disorder:

- Alcohol abuse: harmful use of alcohol which can be either physical or mental harm. Alcohol abusers drink despite
recurrent social, interpersonal, & legal problems as a result of alcohol use.
- Alcohol dependence: mental & physical need to consume alcohol in order to prevent the pains of w/drawal &
obtain certain results, & associated w/ increasing consumption to obtain same effect (tolerance).
- Despite higher thresholds & tolerance, in general, men are at least twice as likely to meet criteria for alcohol abuse
& dependence.
- The most commonly used instrument is the CAGE. The CAGE was designed for rapid verbal screening for alcohol
abuse& dependence in clinical practice.
o Have you ever felt you should cut down on your drinking?
o Have people annoyed you about your drinking?
o Have you ever felt bad or guilty about your drinking?
o Have you ever had a drink first thing in the morning to steady your nerves or get rid of a hangover (eye-
opener)?
o A positive response to 2 or more of the above questions is considered a positive screen.
- The AUDIT-C (Alcohol Use Disorders Identification Test) was better at detecting at-risk, hazardous, or
harmful drinking. A score of 3 or greater was considered a positive screen.
o How often do you have a drink containing alcohol?

0 pts =never, 1 pt for monthly or less, 2 pts for 2 -4 times/month, 3 pts for 2-3 times wk, 4 pts for 4 days/wk or
more.
o How many drinks containing alcohol do you have on a typical day when you are drinking?

0 pts for not drinking, 1 pt for 1 4 drinks, 2 pts for 5 6 drinks, 3 pts for 7 9 drinks, 4 pts for 10 or more drinks.
o How often do you have 6 or more drinks on one occasion?

0 pts for never, 1 pt for less than monthly, 2 pts for monthly, 3 pts for weekly, 4 pts for daily or almost daily.
- Alcohol dependence is when the patient exhibits a maladaptive pattern of alcohol use leading ot significant
impairment or distress & 3 or more of the following w/in 12 months.
o Need for markedly increased amts of alcohol to achieve intoxication or desired effect, or markedly
diminished effect w/ continued use of the same amt of alcohol.
o Alcohol w/drawal syndrome, or use of substances to relieve or avoid w/drawal symptoms.
o Persistent desire or unsuccessful efforts to cut down or control drinking.
o Drinking more than intended.
o Giving up or reducing activities due to drinking.
o Considerable time spent in activities to obtain alcohol, drink, or recover from alcohol effects.
o Continued drinking despite knowledge of having persistent or recurrent physical or psychological
problems exacerbated by alcohol use.
o Considered physical dependence (in addition to psychological dependence) if evidence of tolerance
or w/drawal.
- Alcohol abuse is defined when a patient exhibits a maladaptive pattern of alcohol use leading to significant
impairment or distress, does not meet the criteria for alcohol dependence, but does exhibit one or more of
the following w/in 12 months.
o Recurrent drinking resulting in failure to fulfill major role obligations.
o Recurrent drinking in situations in which it is physically hazardous.
o Recurrent alcohol-related legal problems.
o Continued alcohol use despite persistent or recurrent social or interpersonal problems caused
or exacerbation by alcohol.
- Depression only arising in association w/ alcohol intoxication or w/drawal states is likely to be substance induced.
o W/drawal states can be relatively protracted & substance-induced mood symptoms may be evident up to 4
wks after the cessation of substance use.
o Antidepressant medication is likely to be ineffective, if not harmful, to a patient w/ a significant alcohol
(or other substance) problem.
o Referral to substance abuse treatment should be the 1 st choice of treatment in such cases, w/ follow-up
for reassessment of depressive symptoms, about 1 month postabstinence.
- Signs & symptoms of alcohol w/drawal include tremulousness, insomnia, anxiety, depressed mood,
gastrointestinal upset, heart palpitations, & sweating.
o More severe symptoms associated w/ a long history of chronic alcoholism include generalized tonic-clonic
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seizures (w/in 6-48 hrs), hallucinations (w/in 12- 48 hrs), & delirium tremens (w/in 48-72 hrs), which is
characterized by hallucinations, agitation, tremor, sleeplessness, & sympathetic hyperactivity.
o Benzodiazepines or phenobarbital are the drugs of choice for managing alcohol withdrawal.
- A brief 5 10 minute discussion b/w physician & patient can lead to significant reductions in risky
& hazardous drinking. Approach needs to be nonconfrontational, nonjudgemental, & proceeds
based on how ready the client is to make any changes w/ regard to alcohol use.
o Establish rapport.
o Ask permission to
discuss alcohol use. o
Provide feedback.
o Assess readiness.
Enhance motivation, negotiate, & advise.