Serotonin syndrome is a serious and life-threatening reaction caused by excess serotonin in the CNS.
The classic triad
- Mental status changes (anxiety, restlessness, delirium, easy to startle)
- Autonomic hyperactivity (hyperthermia, hypertension, tachycardia, diaphoresis, vomiting, diarrhea)
- Neuromuscular abnormalities (hyperreflexia, myoclonus, tremor, muscle rigidity, and bilateral Babinski sign) – more pronounced in lower extremities
||Neuroleptic Malignant Syndrome
||Days to weeks (not
||Hyperreactivity (tremor, clonus)
||Severe muscle rigidity, hyporeactivity (bradyreflexia)
||SSRIs, TCAs, MAOIs, other serotonergic drugs
||Dopamine antagonists (antipsychotics)
||STOP AGENT! Benzodiazepines +/- Propranolol
||STOP AGENT! + Bromocriptine +/- Dantrolene
||Days to week
First thing’s first, it is important to understand the difference between a mood episode and a mood disorder.
The best way is to think of the episodes as the building blocks of the disorders.
Major Depressive Episode: 2 week period of depressed mood OR anhedonia plus 4 other symptoms of MSIGECAPS (useful mnemonic)
- Mood (low)
- Sleep (decreased)
- Interest (decreased)
- Energy (low)
- Concentration (poor)
- Appetite (decreased)
- Psychomotor retardation or agitation
- Suicidal ideation
Manic Episode: 1 week period of elevated or irritable mood with 4 or more of (mnemonic GST PAID)
- Grandiose thoughts
- Sleep, decreased need for
- Pleasurable activities with Painful consequences (gambling, spending lots of money, having lots of sex)
- Activity increased
- Ideas (flight of)
Hypomanic Episode: Same as manic except dialled down a notch. Only needs to be 4 days with 3 or more symptoms. People can still function and generally like being hypomanic, but their friends and family will notice a difference in them.
Mixed Episode: BOTH manic episode and major depressive episode at the same time (as in during the same day they’ll experience both depression and mania) in 1 week.
- 1 manic episode OR 1 mixed episode
- Treatment: mood stabilizer (lithium or anti-convulsant), consider adding atypical antipsychotic (quetiapine, clozapine, olanzapine)
- Carbamazepine, valproic acid, and lamotrigine do not have good antidepressant effects, they’re only antimanic
- Tegretol (carbamazepine) not used much because rush of Steven-Johnson’s syndrome, CP450 interactions and neutropenia
- MDE + hypomanic episode
- NO manic or mixed episodes
- Treatment: lithium, consider adding atypical antipsychotic
- >2 years, never without symptoms for >2 months.
- Hypomanic + Depressive Symptoms (not meeting the criteria for MDE)
- Treatment: lithium, anticonvulsants (divalproex, lamotrigine)