Chapter review

Fitzgerald PMHNP board review. ch08. Mood Disorders. This is drive 8 of 8. When I say Pause. Answer. wait, then I will give the answer. New section. Medical rule-outs, suicide risk, peripartum/special populations, and board traps. Topic. Board Trap: Bereavement Specifier. Bottom Line Summary. * **Major depressive disorder** requires five or more **SIGECAPS** symptoms present nearly every day for at least two weeks, with at least one symptom being depressed mood or **anhedonia**. * **Board trap**: Altered mood associated with bereavement is not a **DSM-5-TR** diagnostic criterion for a major depressive episode. * Normal grief follows a major loss, but if the patient meets full diagnostic criteria with five or more symptoms for two or more weeks causing functional impairment, a diagnosis of **major depressive disorder** is made concurrently with bereavement. * **Adjustment disorder with depressed mood** occurs within three months of an identifiable stressor and causes marked emotional distress or functional impairment, but fails to meet the five-symptom threshold for **major depressive disorder**. * **Safety alert**: Passive suicidal ideation without a plan is the most common form of suicidal thought in depression, and suicide risk must be evaluated at every visit. **Lithium** and **clozapine** are the only two psychotropic medications with proven independent anti-suicide effects. * **First-line**: Psychotherapy such as **cognitive behavioral therapy** or **interpersonal therapy** alone is effective for mild to moderate depression, while severe depression requires pharmacotherapy with an **SSRI** such as **sertraline** or **fluoxetine**, or combination therapy. * Antidepressant medications must be continued for four to nine months during the continuation phase after achieving full remission to prevent relapse, and should be tapered over six weeks when discontinued. High-Yield Concept Breakdown: Bereavement vs Major Depressive Disorder. Diagnostic Criteria and Timelines. * **Major depressive disorder** is defined by a cluster of symptoms lasting at least two weeks that significantly disrupt interpersonal, social, or occupational functioning. * The criteria are remembered using the **SIGECAPS** mnemonic: * **S**: Sleep disturbance (insomnia or non-restful hypersomnia). * **I**: Interest loss (**anhedonia**) or depressed mood (presents as irritability in children and teenagers). * **G**: Guilt, worthlessness, or inappropriate self-reproach. * **E**: Energy loss or fatigue. * **C**: Concentration impairment or indecisiveness. * **A**: Appetite changes or weight gain/loss (failure to make expected weight gain in children). * **P**: Psychomotor agitation or retardation observed by others. * **S**: Suicidal ideation, thoughts of death, or suicide attempts. * Under **DSM-5-TR**, bereavement or major loss does not exclude a diagnosis of **major depressive disorder**. Differential Diagnostics. * **Board trap**: Test writers often present a patient experiencing recent spousal death or significant loss and ask if depression can be diagnosed. If five or more **SIGECAPS** criteria are present for two or more weeks, diagnose **major depressive disorder**. Do not assume grief protects against depression or excludes the diagnosis. * **Bereavement / Normal Grief**: Characterized by waves of sadness interspersed with positive memories, self-esteem remaining intact, and thoughts focused on the deceased rather than persistent self-loathing or suicidal ideation. Altered mood associated with bereavement alone is not a **DSM-5-TR** criterion for a major depressive episode. * **Adjustment disorder with depressed mood**: Psychological symptoms develop within three months of an identifiable stressor and do not persist beyond six months after the stressor terminates. It causes impairment out of proportion to the stressor but does not meet the full five-symptom threshold for **major depressive disorder**. * **Persistent depressive disorder**: Requires a depressed mood plus at least two depressive symptoms present for at least two years in adults, or one year in children and adolescents, without being symptom-free for more than two months. Signposted Exam Strategy. * **Board trap**: Selecting altered mood associated with bereavement as a formal diagnostic criterion for major depression. Bereavement is a clinical context, not a criterion. * **Safety alert**: Assess for suicide at every encounter. In patients taking **SSRIs**, a boxed warning exists for increased suicidal ideation in adolescents and young adults up to age 24. * **First-line**: Select **cognitive behavioral therapy** or **interpersonal therapy** for mild to moderate depression, especially in pregnant or lactating patients where medication avoidance is preferred. Select an **SSRI** or combination therapy for severe depression. Fitzgerald Sample Exam Questions. Question 1. Which of the following is not a DSM-5-TR criterion for major depressive episode? A. Hypersomnia B. Loss of food enjoyment C. Fatigue D. Altered mood associated with bereavement Pause. Answer. **Quick Answer**: Choice D is the correct answer because altered mood associated with bereavement is not a DSM-5-TR criterion for a major depressive episode. **Key Clue**: The phrase not a DSM-5-TR criterion in the question stem. **Best Answer**: D. Altered mood associated with bereavement. **Why It Is Correct**: Under **DSM-5-TR** criteria, a major depressive episode requires five or more symptoms from the **SIGECAPS** cluster present during a two-week period. While major loss can precipitate depression, altered mood associated with bereavement itself is not a diagnostic criterion for major depression. **Why the Other Choices Are Wrong**: * **A**: Hypersomnia represents the sleep disturbances criterion in the **SIGECAPS** mnemonic. * **B**: Loss of food enjoyment represents the appetite and weight change criterion in the **SIGECAPS** mnemonic. * **C**: Fatigue represents the energy loss criterion in the **SIGECAPS** mnemonic. **Test-Taking Pearl**: Memorize the **SIGECAPS** mnemonic cold. Any choice that falls outside sleep, interest, guilt, energy, concentration, appetite, psychomotor changes, or suicide is not a core **DSM-5-TR** criterion for major depressive disorder. Question 2. A 26-year-old married woman with a two-year-old daughter presents for evaluation of depression that she believes began after the birth of her daughter. She has a Beck Depression Inventory score of 23. She relates that she is overall healthy and is 16 weeks pregnant. Which of the following would not be an appropriate course of action? A. Advise no medication or psychotherapy at this time B. Refer for weekly interpersonal psychotherapy C. Initiate therapy with a therapeutic dose of citalopram D. Prescribe a therapeutic dose of sertraline Pause. Answer. **Quick Answer**: Choice A is the correct answer because doing nothing is an inappropriate clinical response for a pregnant patient with moderate depression. **Key Clue**: The modifier phrase would not be an appropriate course of action in the stem. **Best Answer**: A. Advise no medication or psychotherapy at this time. **Why It Is Correct**: A Beck Depression Inventory score of 23 indicates moderate depression. Leaving moderate depression untreated in a pregnant patient carries significant maternal and fetal risks. Active treatment with evidence-based psychotherapy or an **SSRI** such as **sertraline** or **citalopram** is appropriate. **Why the Other Choices Are Wrong**: * **B**: Interpersonal psychotherapy is an established first-line treatment for mild to moderate depression during pregnancy. * **C**: **Citalopram** is an evidence-based **SSRI** option during pregnancy when benefits outweigh risks. * **D**: **Sertraline** is a preferred **SSRI** during pregnancy and lactation due to low fetal and placental transfer rates. **Test-Taking Pearl**: On board exams, doing nothing or withholding treatment for documented moderate to severe psychiatric illness is almost always the wrong answer. Question 3. Which of the following is false when considering discontinuation of treatment for stable major depressive disorder? A. Psychotherapy has less risk of relapse than psychopharmacotherapy B. Treatment should be discontinued immediately rather than tapering doses C. Patients should be educated on signs and symptoms of relapse D. A follow-up visit should be scheduled two months following cessation of treatment Pause. Answer. **Quick Answer**: Choice B is the correct answer because abruptly stopping antidepressant treatment is false and unsafe. **Key Clue**: The word false in the question stem. **Best Answer**: B. Treatment should be discontinued immediately rather than tapering doses. **Why It Is Correct**: Antidepressant medications must always be tapered over several weeks to avoid antidepressant discontinuation syndrome. Abrupt discontinuation leads to the **FINISH** syndrome: flu-like symptoms, insomnia, nausea, imbalance, sensory disturbances (brain zaps), hyperarousal, and headache. **Why the Other Choices Are Wrong**: * **A**: Psychotherapy builds long-term coping mechanisms, resulting in lower relapse rates compared to medication alone. * **C**: Educating patients on early personal signs of relapse is a required component of maintenance and discontinuation planning. * **D**: Scheduling a follow-up evaluation two months after stopping treatment ensures early detection of potential relapse. **Test-Taking Pearl**: Always taper psychotropic medications over four to six weeks to prevent discontinuation syndrome and monitor closely for early relapse signs. Next Study Step. Review **Fitzgerald Chapter 9: Anxiety Disorders**, focusing on differentiating **generalized anxiety disorder**, **panic disorder**, and **PTSD** from depressive disorders and mastering first-line **SSRI** and **SNRI** dosing strategies. 💡 *Next Step*: Would you like to review practice questions on antidepressant discontinuation syndrome or jump straight into Chapter 9 Anxiety Disorders? Next. Topic. Sample Question 17: Developmental Onset. Bottom Line Summary. * **Major depressive disorder** mean age of onset is **20 to 35 years**, with prevalence in adults aged **18 to 29 years** being **3 times higher** than in adults over **60 years**. * **Bipolar disorder** mean age of onset is **21 to 24 years**, with a **1%** incidence in children and adolescents. * In children and adolescents, the core mood equivalent for **major depressive disorder** is **irritability**, and appetite changes may present as **failure to make expected weight gain**. * Diagnostic duration criteria for **persistent depressive disorder** and **cyclothymic disorder** require **2 years** in adults, but only **1 year** in children and adolescents. * All **SSRIs** carry an FDA black box warning for increased **suicidal ideation** in children, adolescents, and young adults up to **24 years of age**. * **Peripartum onset** specifier is defined as mood symptom onset during pregnancy or within **4 weeks** following delivery; **lithium** is classified as Hale Category **L4** (hazardous) during breastfeeding, whereas most **SSRIs** are Category **L2**. High-Yield Clinical Teaching. First-Line Interventions Across Development. For children, adolescents, and adults presenting with mild to moderate **major depressive disorder**, first-line management includes **psychotherapy** alone, such as **cognitive behavioral therapy** or **interpersonal therapy**, or an **SSRI** such as **fluoxetine** or **sertraline**. In pediatric populations, **fluoxetine** is FDA-approved for depression down to age 8. When evaluating children, clinicians must remember that **irritability** replaces depressed mood as the cardinal symptom, and nutritional impairment manifests as **failure to make expected weight gain**. For **bipolar depression** across special populations, first-line monotherapy options include **lithium**, **lamotrigine**, **quetiapine** at 300 mg daily, **lurasidone**, or **lumateperone**. **Antidepressant monotherapy** is strictly contraindicated in bipolar illness because it can trigger manic switching or rapid cycling. In pediatric **bipolar mania**, mood elevation often presents as pathological happiness, silliness, or G-rated euphoria distinctly increased from baseline and accompanied by cyclic, non-goal-directed hyperactivity beyond the child's developmental level. Safety Alert. * **Suicide Risk**: The risk of suicide in **bipolar disorder** and **major depressive disorder** is highest during major depressive episodes or mixed states, not during pure euphoric mania. **Lithium** and **clozapine** are the only two psychotropics with proven independent anti-suicidal properties. * **Peripartum and Lactation Cautions**: **Lithium** readily passes into breast milk and is classified as Hale Category **L4** (hazardous). Breastfeeding is contraindicated when mothers are taking **lithium** due to fluid, electrolyte, and toxic risks in the infant. In contrast, most **SSRIs** like **sertraline** are Hale Category **L2** (safer). * **Pediatric Black Box Warning**: All **SSRIs** require close surveillance for emergent **suicidal ideation** in patients up to **24 years of age**, particularly during the initial 4 to 6 weeks of treatment or after dosage escalations. * **Geriatric Prescribing**: **Citalopram** dosing must be restricted to a maximum of **20 mg daily** in adults over **60 years** of age due to dose-dependent QTc interval prolongation. Board Trap. * **Misinterpreting Pediatric Irritability**: Board stems frequently present an adolescent displaying explosive anger, defiance, or moodiness. The board trap is choosing conduct disorder or oppositional defiant disorder instead of evaluating for **major depressive disorder** or **disruptive mood dysregulation disorder**. Always remember that **irritability** is the primary pediatric mood equivalent. * **Confusing Brain Stimulation Modalities**: Exam writers test the distinction between **transcranial magnetic stimulation** (**TMS**) and **electroconvulsive therapy** (**ECT**). The board trap is assuming **TMS** causes cognitive deficits or seizures; in reality, **TMS** requires no sedation, causes no cognitive impairment, and its primary side effect is a **temporary headache**. Conversely, **ECT** is dosed **3 times per week for 3 to 4 weeks** and may cause transient memory loss that clears within weeks post-treatment. * **Diagnostic Masking in Bipolar Type 2**: Patients with **bipolar type 2 disorder** rarely seek care during hypomanic episodes because hypomania feels productive. They present during depressive episodes and are easily misdiagnosed with unipolar depression, leading to inappropriate **SSRI** monotherapy. Sample Board Practice Questions. Question 17. Which of the following is a potential adverse effect of transcranial magnetic stimulation (TMS)? A. Improved memory B. Temporary headache C. Reduced appetite D. Increased heart rate Pause. Answer. **Best Answer:** B. Temporary headache **Why It Is Correct:** **Temporary headache** or mild scalp discomfort during or immediately following stimulation is the most common adverse effect of **transcranial magnetic stimulation** (**TMS**). **TMS** delivers localized magnetic pulses to the prefrontal cortex without requiring general anesthesia, muscle relaxants, or inducing generalized seizure activity source 1. **Why the Other Choices Are Wrong:** * **A:** Improved memory is a potential therapeutic goal or cognitive finding rather than an adverse effect, and **TMS** does not cause the transient memory disruption associated with **electroconvulsive therapy** [1, 2]. * **C:** Reduced appetite is not a recognized adverse effect of **transcranial magnetic stimulation** source 1. * **D:** Increased heart rate is not a typical adverse effect because **TMS** magnetic pulses are localized to cortical brain regions and do not cause systemic autonomic or cardiovascular stimulation source 1. Question 19. Which of the following is false about electroconvulsive therapy (ECT)? A. A common adverse effects may be jaw pain or headache. B. Typical dose is one time per week for four weeks. C. ECT is safe and effective with elderly patients. D. ECT may cause forgetfulness that clears within weeks after treatment ends. Pause. Answer. **Best Answer:** B. Typical dose is one time per week for four weeks. **Why It Is Correct:** Option B is false because the standard acute treatment schedule for **electroconvulsive therapy** (**ECT**) is **3 times per week for 3 to 4 weeks** (totaling 6 to 12 sessions) source 2. A schedule of once per week is inadequate for acute remissive therapy source 2. **Why the Other Choices Are Wrong:** * **A:** Jaw pain and headache are common, transient post-procedure side effects resulting from muscle fasciculations and electrical stimulation during **ECT** source 2. * **C:** **ECT** is well-established as a safe and highly effective treatment modality in elderly patients and pregnant women who cannot tolerate psychotropic medications [2, 3]. * **D:** **ECT** frequently causes anterograde or retrograde memory impairment, but this forgetfulness is transient and typically resolves within weeks following treatment completion source 2. Question 15. A 22-year-old male with type 1 diabetes mellitus and generalized anxiety disorder is currently being successfully treated for major depressive disorder, recurrent. He has been symptom-free for the past six months and asks if he can stop taking his sertraline. You counsel that he has a high risk of recurrence because of which of the following? (Select all that apply) A. Past episodes of depression B. Presence of chronic medical condition C. Co-occurring anxiety disorder D. His age Pause. Answer. **Best Answer:** A, B, C, and D (All options apply) **Why It Is Correct:** All four listed factors significantly increase the risk of recurrent **major depressive disorder** [4, 5]. Recurrence risk factors include prior depressive episodes, younger age at onset, presence of co-occurring non-affective psychiatric conditions like **generalized anxiety disorder**, and comorbid chronic general medical conditions like type 1 diabetes mellitus [4-6]. **Why the Other Choices Are Wrong:** * **A, B, C, and D:** None of these choices are incorrect; each individual factor independently elevates the long-term risk of depressive relapse, making maintenance pharmacotherapy strongly indicated [4, 5, 7]. 💡 Would you like to review the diagnostic criteria and lab monitoring for **lithium** and **valproate** next, or move on to Chapter 9 on Anxiety Disorders? Next. End of this drive.