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Chapter 225. Mood and Anxiety Disorders

Martha C. Ward, MD; Steven Garlow, MD, PhD

Depression

  1. What are the signs and symptoms of a major depressive episode (MDE)?

  2. What is the pathophysiology of major depression?

  3. What medications, intoxicants, and diseases cause depressed mood?

  4. What is adjustment disorder?

  5. What is the appropriate diagnostic workup for a patient with depressive symptoms?

  6. What is the treatment for major depressive disorder (MDD)?

  7. What are the complications of antidepressant use?

Bipolar Disorder

  1. What are the signs and symptoms of bipolar disorder?

  2. What medical conditions and substances can induce mania?

  3. What is the appropriate diagnostic workup for a patient with mania?

  4. How is bipolar disorder treated?

Anxiety Disorers

  1. What are the signs and symptoms of anxiety?

  2. What are the common anxiety disorders?

  3. How does generalized anxiety disorder differ from major depression?

  4. What medical conditions present with symptoms of anxiety?

  5. What studies should be ordered for the acutely anxious patient?

  6. What is the treatment for anxiety?

Introduction

Major depressive disorder (MDD) is widespread and devastating, with lifetime prevalence greater than17% in the general population. Total costs exceed $44 billion annually, including hospitalization, medications, and loss of productivity. In medically ill patients, mood disorders are even more common; six-month prevalence increases from 5.8% to 9.4% with at least one chronic medical condition. Despite this, many physicians fail to address depressive symptoms, believing them to be appropriate in illness (“I would be depressed too, if I were that sick”). This misconception leads to poor outcomes, as physical recovery is impeded by affective disorders. This chapter will aid the hospitalist in recognition, diagnosis, and treatment of MDD.

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Case 225-1

A 66-year-old man with a history of type-2 diabetes, hypertension, and tobacco use was admitted for non-ST elevation MI and cardiac catheterization with stent placement. During morning rounds, his care team noted that the patient ate only about 10% of his breakfast and appeared to have a blunted affect. He had a history of multiple episodes of depressed mood, insomnia, and anhedonia over the years. The patient reported feeling “worthless” and sometimes wishing that he'd “just gone ahead and died.” Though initially reluctant because of worries about dependence, Mr. G agreed to try an antidepressant, sertraline. At his 6-week post-hospitalization appointment he is free of mood symptoms, engaged in cardiac rehabilitation and feels hopeful about the future.

Pathophysiology

The primary etiology of major depression remains obscure. Dysregulation of CNS monoamine neurotransmitters (including norepinephrine, serotonin, and dopamine) occurs in MDD. Newer theories focus on broader neuroregulatory circuits involving cholingeric activation, GABA hypoactivity, and chronically elevated hypothalamic-pituitary-adrenal activity. Immune system abnormalities and increased inflammation likely play a role.

Diagnosis

Major Depressive Disorder

Major depressive disorder is defined by the occurrence of one or more major depressive episodes (see Table 225-1...

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