Mood (affective) disorders

In this article, we cover depressive disorders, bipolar affective disorder and schizoaffective disorder with an overview of the epidemiology, diagnostic criteria, assessment and management steps.

Depressive disorder

  • Annual prevalence of 5%
  • Depressive episodes last >2 weeks
  • Core symptoms: low mood, anhedonia, anergia
  • Associated: sleep disturbance (early wakening, insomnia or hypersomnia), poor appetite, loss of libido, poor concentration, low self-esteem, suicidal thoughts or behaviours
  • Differentials: cyclothymia, dysthymia, schizoaffective disorder, bipolar affective disorder, organic (hypothyroidism, Addison’s)
Classification
  • Mild: 2-3 symptoms, usually able to continue most activities
  • Moderate: 4 symptoms, difficulty in continuing with ordinary activities
  • Severe without psychosis: several marked symptoms, loss of self-esteem, worthlessness, hopelessness, nihilism, and suicidal ideation
  • Severe with psychosis: as above, with presence of hallucinations, usually mood congruent delusions (e.g. guilt, persecution, hypochondriasis)

What is a ‘death wish’?

Answer
Patients with mood disturbances may express thoughts that they feel they would be better off dead. This does not necessarily mean they have suicidal ideation.
Questions to consider in a depression history
  • Low mood: “How would you describe your mood?”
  • Anhedonia: “Do you still enjoy things like you used to?”
  • Anergia: “Do you have the same ‘get up and go’ that you used to?”
  • Future: “How do you feel about the future?”
  • Harm to self or others: “Do you ever have any dark thoughts that you want to harm yourself or others?”
  • Delusions of guilt: “Do you feel you have done anything wrong?”
Pharmacological management
  • 1st line: SSRI
  • 2nd line: different SSRI/mirtazapine (must remember to cross-taper)
  • 3rd line: mirtazapine if not already tried, or SNRI
  • 4th line: combination/augmentation therapy if severe and/or treatment resistant
  • Electroconvulsive therapy if life-threatening/indicated
Screenshot 2022 01 28 at 19.34.22

Bipolar affective disorder (BPAD)

  • Cyclical mood disorder, affects 1% of adult population
  • BPAD Type 1: must have manic/mixed episode
  • BPAD Type 2: must have hypomanic episode + major depressive episode

What is a mixed episode?

Answer
Rapid alternation and overlap of depressive and manic symptoms with emotional lability.
Mania vs hypomania
  • Both hypomania and mania are episodes in which patients experience an elated mood and high self-esteem with disinhibited behaviour. However, the severity of this is a factor in determining the impact on the patient’s function.
  • Differentials of mania: schizoaffective disorder, cyclothymia, drug-induced, organic (encephalitis, delirium, hyperthyroidism)

What is the difference between bipolar affective disorder and cyclothymia?

Answer
Patients with cyclothymia experience swings in mood between depressive symptoms and hypomanic. This is more frequent and without significant impact on function, unlike BPAD.
Screenshot 2022 01 28 at 20.01.18
Questions to consider in a mania history
  • Elated mood: “How would you describe your mood?”
  • High self-worth: “How do you see yourself compared to others”
  • Delusions of grandeur: “Do you have any special powers or talents?”
  • Restlessness: “You sound busy, have you got much sleep lately?”
  • Libido: “Have you slept with anyone else lately?”
  • Spending: “Have you spent more than you can afford?”
  • Depression: “I know you feel great now, but have you ever been depressed?”
  • Persecution: “Is anyone out to get you?”

Schizoaffective disorder

  • Essentially a combination of features of schizophrenia and BPAD
  • To consider as a diagnosis – patients must have psychotic symptoms that are separate from affective symptoms (either depressive or hypomanic/manic) by at least 2 weeks.
  • The management is similar to BPAD

Written by Dr Muhammad Zain Haq, Psychiatry Lead (F2)
Reviewed by Dr Patrick Ezeani (Consultant Psychiatrist)

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