Mood Disorders Summary

Depression Definition

  • Persistent low mood and/or loss of pleasure
  • ≥5 of 9 symptoms for ≥2 weeks with impairment
  • DSM-5 criteria

Risk Factors

  • Chronic illnesses, medications
  • Female gender, older age
  • Psychosocial stressors
  • Family history

Core Symptoms

  • Low mood, anhedonia
  • Sleep/appetite changes
  • Fatigue, poor concentration
  • Guilt, suicidal thoughts

Suicide Risk

  • Screen for thoughts, plans, history
  • 4x higher risk in depression
  • 20x higher in severe cases
  • High-risk groups: men, isolated

Bipolar Disorder

  • Manic: ≥1 week, impaired function
  • Hypomanic: ≥4 days, no impairment
  • Depressive: ≥2 weeks
  • ± Psychotic features

Management

  • Risk assessment essential
  • Considerable risk: Urgent referral
  • Low risk: Safety planning
  • Treat underlying factors

Depression and Bipolar Disorder

Assessment and management of mood disorders

Depression Overview

Depression is characterised by persistent low mood and/or loss of pleasure in most activities and a range of associated emotional, cognitive, physical, and behavioural symptoms.

Risk Factors for Depression

Medical Factors

  • Chronic comorbidities (diabetes, COPD, cardiovascular disease)
  • Chronic pain syndromes
  • Medications (corticosteroids)
  • Past head injury, including hypopituitarism post-trauma

Demographic Factors

  • Female gender
  • Older age
  • Recent childbirth

Psychosocial Factors

  • Psychosocial issues (divorce, unemployment, poverty, homelessness)
  • Personal history of depression
  • Family history of depressive illness
  • Adverse childhood experiences
  • Personality factors (neuroticism)

Clinical Features of Depression

DSM-5 criteria: At least five of nine symptoms for ≥2 weeks causing significant impairment:

Core Symptoms

  • Persistently low mood
  • Loss of pleasure or interest in normal activities

Additional Symptoms

  • Disturbed sleep (decreased or increased)
  • Decreased or increased appetite/weight
  • Fatigue/loss of energy
  • Agitation or slowing of movements
  • Poor concentration or indecisiveness
  • Feelings of worthlessness or excessive guilt
  • Suicidal thoughts or acts

Assessment Note

Depression questionnaires are helpful but should not be used alone to determine the need for treatment. Severity is determined by number/severity of symptoms and functional impairment.

Differential Diagnosis

Psychiatric Conditions

  • Grief reaction
  • Anxiety disorders
  • Bipolar disorder
  • Premenstrual dysphoric disorder

Medical Conditions

  • Neurological conditions (Parkinson's, MS, dementia)
  • Substance effects and adverse drug reactions
  • Hypothyroidism
  • Obstructive sleep apnoea syndrome

Complications of Depression

Physical Health

  • Exacerbation of pain, disability in physical diseases
  • Increased morbidity/mortality in CHD and diabetes
  • Reduced quality of life for patient and family

Suicide Risk

  • Main cause of increased mortality in depression
  • Commonest with comorbid physical/mental illness
  • 2/3 of suicide attempters experience depression
  • 4x higher risk vs general population
  • 20x higher risk in most severely ill

Functional Impairment

  • Limited activities of daily living
  • Employment problems (productivity, absenteeism)
  • Neglect of dependants
  • Family problems and relationship break-ups
  • Increased risk of substance abuse

Risk Assessment for Suicide

Initial Screening Questions

  • Do you have thoughts about death or suicide?
  • Do you feel that life is not worth living?
  • Have you made a previous suicide attempt?
  • Is there a family history of suicide?

If Positive Response:

Risk Factors for Suicide

Historical Factors

  • Previous suicide attempts or self-harm
  • Family history of mental disorder, suicide or self-harm
  • History of violent methods, planning, precautions against rescue

Current Factors

  • Active mental illness
  • Low socioeconomic status
  • Male gender
  • Unemployment
  • Physical health problems
  • Living alone, being unmarried
  • Abusive or violent relationships
  • Drug/alcohol dependence
  • Feelings of hopelessness
  • Exposure to suicidal behaviour

High Risk Groups

Management Based on Risk

  • Considerable immediate risk: Urgent referral to specialist mental health services
  • Low risk: Create safety plan with steps for deterioration
  • Assess social support, treatable risk factors (mental illness, substance use)
  • Assess safeguarding concerns for dependents

Bipolar Affective Disorder

Serious long-term mental illness characterized by episodic depressed and elated moods and increased activity (hypomania or mania).

Manic Episode

Abnormally elevated, expansive, or irritable mood lasting ≥1 week with ≥3 additional symptoms causing marked impairment or requiring hospitalization:

  • Increased energy/activity, decreased need for sleep
  • Pressure of speech or incomprehensible speech
  • Flight of ideas or racing thoughts
  • Distractibility, poor concentration
  • Increased libido, disinhibition, sexual indiscretions
  • Extravagant or impractical plans
  • Psychotic symptoms: grandiose delusions or hallucinations

Hypomanic Episode

Similar to manic episode except:

  • Symptoms last ≥4 days
  • Not severe enough to cause marked impairment
  • No hospitalization required
  • No psychotic features

Depressive Episode

Period of ≥2 weeks with either depressed mood, loss of energy, or loss of interest/pleasure, plus ≥4 additional symptoms.