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.
Contents
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’?
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
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?
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?
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)
