02 · Mood disorders: depression, mania and grief

2.1 What constitutes a depressive episode?

ICD-11: at least five of ten symptoms, including low mood or anhedonia, for at least two weeks, most of the day on nearly every day, with significant functional consequences.

Sleep and appetite can move either way. Occasional laughter or an obvious precipitant does not exclude depression. Irritability may dominate in younger people. Psychomotor retardation is observable slowing of speech and movement, beyond feeling tired.

Severity depends on intensity and impairment, not a PHQ-9 score alone. NICE's less/more severe treatment groups do not map perfectly onto ICD categories. ICD-11 permits psychotic symptoms in moderate or severe episodes.

Melancholic and cognitive features

Melancholia: profound anhedonia or reduced emotional reactivity, early waking, morning worsening, appetite/weight loss and marked agitation or retardation. No single feature proves the diagnosis or selects the drug.

Beck's negative triad = self, world, future. Hopelessness matters even without a stated plan. Poor concentration may resemble memory loss, especially in later life; depression and dementia can coexist, so apparent depressive cognitive impairment needs follow-up.

2.2 Differentials that alter the plan

Reduced need for sleep means feeling rested and energetic despite much less sleep. Insomnia leaves the person tired. Past activation with changed activity, confidence, speech and behaviour suggests hypomania/mania; an isolated good patch does not.

Think of hypothyroidism, anaemia, neurological illness, sleep disorders, pain, substances and medicines such as corticosteroids. Investigations follow the clinical picture and intended treatment.

Adjustment disorder centres on maladaptive preoccupation with a stressor and difficulty adapting. An identifiable stressor does not override a full depressive episode. The same applies after bereavement.

Weight loss can arise from lost appetite, fear of gaining weight, a belief that food is poisoned or physical illness. Similar behaviour can have very different mechanisms.

2.3 Initial treatment: why severity matters

Previous response, preference, access and comorbidity guide the choice.

Behavioural activation breaks withdrawal → fewer rewarding experiences → lower mood. CBT tests unhelpful meanings and predictions. IPT addresses depression around relationships, loss and role changes; it is not limited to mild illness.

SSRIs are common first choices because of tolerability and relative overdose safety versus most tricyclics. The target is remission and function, not sedation. Benefit takes weeks; adverse effects may arrive first. Little improvement after about four weeks at a therapeutic dose prompts review of adherence, diagnosis, dose, adverse effects and maintaining factors.

Antidepressant facts to retain

• Early nausea, headache, sleep disturbance and anxiety often settle; sexual dysfunction may persist.

• SSRIs increase bleeding risk, especially with NSAIDs/anticoagulants. Hyponatraemia matters particularly in older adults. Serotonergic combinations risk serotonin toxicity.

• Withdrawal is real, despite the absence of typical craving or compulsive drug-seeking. Dizziness, nausea, vivid dreams, anxiety and electric-shock sensations soon after reduction favour withdrawal over relapse. Individual tapering may take weeks or months.

• First review is usually within two weeks, or one week at age 18–25 or with particular suicide concern. Reassess new agitation, akathisia or suicidal thinking.

• Continue for at least six months after remission. Recurrent/severe illness, residual symptoms and ongoing adversity may justify longer prevention.

2.4 Apparent treatment resistance

A common working definition is inadequate benefit from at least two adequate antidepressant trials in the current episode. It describes treatment history, not a separate ICD diagnosis or an incurable illness.

First establish adequate exposure: dose, duration, actual ingestion and tolerability. Reconsider bipolarity, psychotic depression, substances, hypothyroidism, trauma, comorbidity and social pressures.

Liothyronine and lamotrigine are further specialist possibilities in selected cases. Remember venlafaxine → BP; lithium → level, renal, thyroid, calcium; antipsychotic → metabolic and movement monitoring.

2.5 Psychotic depression, agitation and stupor

Psychotic depression commonly brings delusions of guilt, ruin, incurable disease, punishment or non-existence. “My stomach no longer exists” may explain refusal of food. Persecutory content can occur too: mood-incongruent does not automatically mean schizophrenia.

Use the relationship between mood and psychosis over time. Schizoaffective disorder has its own full criteria. Severe guilt is not necessarily delusional; conviction, evidence, cultural meaning and origin matter.

Antidepressant plus antipsychotic is a standard specialist option; NICE gives olanzapine or quetiapine as examples. The antipsychotic may continue for several months after remission. ECT suits a need for rapid response, life-threatening failure to eat/drink, failed treatment or preference based on previous benefit.

Agitated depression combines depressive thinking with pacing/restlessness. Exclude mixed features, anxiety and akathisia before simply increasing an antidepressant.

Stupor means greatly reduced movement and responsiveness. It is a sign: consider depression, hypoglycaemia, delirium, intoxication, non-convulsive seizures, neurological disease and catatonia. Unresponsiveness does not prove unconsciousness.

Catatonia: recognise the syndrome

Think three or more characteristic features: mutism, stupor, negativism, posturing, catalepsy, waxy flexibility, stereotypies, echolalia, echopraxia or purposeless excitement. Catatonia occurs with mood disorders, psychosis, autism and medical illness.

A lorazepam challenge can support diagnosis; non-response does not exclude it. Scheduled benzodiazepine treatment may follow. ECT is important in severe, life-threatening or benzodiazepine-resistant cases.

Treat dehydration, malnutrition, aspiration risk, pressure damage and venous thrombosis alongside the syndrome. Use antipsychotics cautiously, especially with possible malignant catatonia/NMS. Lorazepam and ECT are not automatic treatments for dissociative unresponsiveness.

2.6 Mania and hypomania

Both require elevated, expansive or irritable mood with increased activity/energy. Reduced need for sleep, pressured speech, racing thoughts, distractibility, grandiosity and disinhibition complete the picture. Spending, sexual activity and unrealistic projects reflect altered judgement.

Flight of ideas retains recognisable links, sometimes rhymes/puns. Loosening of associations loses logical links. Pressure of speech is increased, difficult-to-interrupt output. Grandiosity may or may not be delusional.

Mania may be irritable, hostile or anxious. First mania in later life warrants particular attention to medical/drug causes: corticosteroids, stimulants, dopaminergic drugs and antidepressants. A full syndrome continuing beyond a drug's physiological effect may indicate bipolarity; brief activation is insufficient.

2.7 Bipolar diagnoses and phase-specific treatment

Treat the phase, not just the label.

Lamotrigine does not treat acute mania and needs slow titration because of serious rash risk. Lithium is not a rapid sedative and requires monitoring.

Valproate has major reproductive restrictions: new initiation below 55, the Pregnancy Prevention Programme where applicable and precautionary advice for men who may father children.

2.8 Relapse prevention and the consequences of a mood episode

Sleep disruption can be both trigger and warning sign. Psychoeducation links previous warning signs with medicines, substances, routines and support. Written relapse plans help when insight deteriorates during mania.

Debt, relationship damage, sexual-health consequences and shame can persist after mania and contribute to depression. Mixed symptoms can combine despair with energy or agitation; increased activity alone is not recovery.

Genetic contribution is substantial but not simple Mendelian inheritance. RCPsych estimates lifetime bipolar illness at about one in fifty adults, usually beginning in youth/early adulthood. Many regain substantial stability with sustained treatment.

2.9 Bereavement, depression and prolonged grief

Grief often comes in waves, with yearning, sadness, anger, guilt and altered sleep/appetite. Briefly sensing, hearing or seeing the deceased can occur without psychosis, especially with preserved understanding of the death and no wider psychotic syndrome. Keeping belongings is not itself pathological.

Depression more often brings pervasive anhedonia, global worthlessness and hopelessness extending beyond the loss. Both can coexist. Thoughts of joining the deceased still matter clinically.

ICD-11 prolonged grief: persistent yearning/preoccupation, emotional pain, impairment and a response beyond cultural expectations, at least six months after death. Time alone is insufficient.

Expected grief does not need routine antidepressants; coexisting depression needs treatment. Prolonged grief may benefit from grief-focused therapy.

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