Mood Disorders: A rollercoaster of emotions
Mood disorders are pretty common and you will absolutely come across many patients during your medical degree and career who have, or have had, a mood disorder. Just think of some recent histories you’ve taken or looked through and I bet a good portion of them had a history of depression. In fact, in any given year, a staggering 6.2% of Australians will have an affective episode.
So, again, what are these disorders? There are the Depressive Disorders (unipolar) and Bipolar Affective Disorder. And that’s it – not too much to remember right? Things get a little more complex if you think about Schizoaffective Disorder but that’s really more of a psychotic disorder. Now, having said that things are relatively straight forward this post is only a guide and you will need to do your own reading around certain things, but fear not, I will include a few links along the way to some useful resources cos I’m nice like that. Ok, let’s jump in to this cave of wonders!
We’ll kick off with the depressive disorders as you’ll stumble upon these the most, and the biggest hitter of the bunch is Major Depressive Disorder (MDD). Anyone who has been unfortunate enough to experience MDD, and I put my hand up here (we’re all about de-stigmatising), or has held the hand of a loved one who’s been through the battle, will know just how lonely and disabling this disorder can be. How many times have you heard someone say, or have even said yourself, something like “just look at the bright side”, or “come on, cheer up” or my personal favourite “just get over it”. Erm… yeah, that’s not at all helpful. I’m sure you’ve all seen the many memes on Facebook trying to demonstrate how ridiculously absurd these statements are and how differently we treat mental illness to physical illness. Hang on, let me see if I can find one.
If anyone has read my post on anxiety you’ll know I’m a fan of a good analogy. Well, this was the one that kicked the others off. Having depression can feel like being stuck down a deep, dark hole with no escape. The walls are just slippery, wet dirt that you can’t get hold of so there’s literally no way to climb out of it, and certainly not by yourself.
The worse the depression, the deeper the hole and the harder it’s going to be to get out. It’s dark, and it’s lonely and people will only know you’re in there if they get really close and look down with a torch or if you shout, but shouting is scary because then people will ask how you managed to get yourself stuck down there in the first place, like it was a choice, when in reality, you don’t know how or when it happened, it just did. Keep this image in mind as we’ll come back to it in a bit.
Depression literally consumes you and it stops you from seeing things clearly, almost like you’re looking at everything through a thick fog. It makes it really hard to see any positives in your life or in the things around you and this will come across in what you say. If we’re after some buzz words (OSCE alert!) these would be negative cognitions, and if the same thoughts keep coming up these would be ruminations.
Depression doesn’t just effect your thinking though, it has some pretty hefty biological symptoms that can pack a real punch, particularly in the worst cases or melancholia. People can be absolutely exhausted but won’t be able to sleep. The insomnia that’s spoken about most is terminal insomnia, or early morning wakening, but in reality, that’s only in the very worst of cases, by far the most common is initial insomnia – dropping off to sleep. Your appetite is disturbed which effects your weight (either up or down), you can’t concentrate on anything so you think your memory’s going, everything, literally everything, is a massive effort that seems insurmountable and nothing in the world can give you a smile – anhedonia: the inability to derive pleasure from normally pleasurable activities.
For the full diagnostic criteria you will find some fun bedtime reading here
So, there are some specifiers which again I won’t delve too much into, such as with melancholic features or psychotic features, which you can have a read of yourselves. Just a quick note to say that with the psychotic features they occur only in the context of the mood episode and that any symptoms tend to be mood congruent – go ahead and look up “nihilistic delusions” as a hint.
Anyone that you are assessing for a mood disorder, or any mental health disorder to be honest, should be asked about suicide. Major taboo, though people are starting to come round to the idea that people think about this. It can be incredibly difficult and super awkward to ask about and everyone has their own way of getting there but the only way to become comfortable with doing it is to ask the question. Experience and practice. Bit of advice – steer clear of the “I’m going to ask you a question that we ask everyone” line. Innocent though it may sound, it is kinda dismissive and minimising, and invalidating of something that will be such a massive weight for the person you’re talking to. Be sure to ask about plans, intent to follow through with the plans, and what’s kept them hanging around (poor choice of words) until now.
Ok, now we know what depression is and have an inkling of what it might feel like, what do we do about it? Again, in theory this should be relatively straight forward and there are a bunch different guidelines out there such as here (this one involves a bit of a scroll) and here (much easier to navigate).
As with anything, we always use the biopsychosocial model (another OSCE alert buzz word!) and with the milder depressive episodes you can generally drop the bio portion of this and they can be managed quite successfully by psychosocial interventions.
Anywho, you will need to know about the different antidepressants of which there are like a bezillion, well, sometimes it feels like there are anyway.
Scrolling or clicking through the above guidelines you will see that first line approach is generally to use an SSRI. I won’t go into what they’re called or their common side effects because that would take another post in itself. Hopefully the SSRI of choice (doesn’t really make much difference which one but some are better tolerated that others) is the one but often you will have to go to a second line (eg. SSRI/SNRI/NARI) or even third line (eg. TCA).
But like I said, medication is only a tiny piece of the treatment pie. We should be advising all of our patients of simple lifestyle or behavioural adjustments they can be doing for a boost such as making sure they’re eating good food, staying hydrated, cutting down on alcohol, getting out for a bit of fresh air and exercise and even the super simple stuff like getting out of bed, having a shower, brushing your hair, cleaning your teeth and getting dressed as these are the things that get forgotten or become too difficult.
Now, probably the most important part of the pie is psychological intervention. It’s an absolute must in my eyes and it’s staggering how many people don’t access it. There is heaps of evidence out there (I won’t even bother linking to them, have a very basic search yourself and you’ll see what I mean) demonstrating the immense benefit of even short style therapies such as Cognitive Behavioural Therapy (CBT), Acceptance and Commitment Therapy (ACT) and Interpersonal Therapy (IPT). In future there will be another blog post that touches more on what these are and I urge you to give it a read.
Anyone that you are assessing for a mood disorder, or any mental health disorder to be honest, should be asked about suicide.
Depression - Simple Criteria
Five or more of the following symptoms present for at least two-weeks. And not better attributed to substances or a medical condition.
- Depressed mood most of the day, nearly every day*
- Markedly diminished interest or pleasure in all, or almost all, activities*
- Significant weight loss when not dieting or weight gain
- Insomnia or hypersomnia
- Psychomotor agitation or retardation
- Fatigue or loss of energy
- Feelings of worthlessness or excessive or inappropriate guilt
- Diminished ability to think or concentrate, or indecisiveness
- Recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation
* at least one of either depressed mood or disinterest
Remember we’re stuck down this deep, dark, dank hole and getting out seems impossible. Depending on how deep your hole is (quiet up the back!) you will need different levels of assistance to get you out. The further down you are the more help you need. BUT you need all of the above to get you there, not just one or the other. Imagine the medication is a step ladder: it lifts you up a fair bit but still not far enough for you to be able to climb out. Now imagine the psychological intervention is someone reaching down to grab your arm to pull you out, but without that step ladder you can’t reach them, and without that person reaching down you can’t climb up. You need both. But you can’t be a floppy dead weight when it comes to being pulled out, you kinda need to help and be an active participant in the rescue mission with the lifestyle stuff perhaps being a bit of a rope ladder or climbing wall along the way. Is this making any of the sense? Are we keeping up?
If all of this doesn’t cut the mustard and you have an awful melancholic depression then you have to start thinking of electroconvulsive therapy, or ECT.
Now, don’t panic, it’s not like the media or TV & film industry would have us believe. When delivered appropriately it’s a very kind and very good treatment that is literally lifesaving. It is a fantastic treatment that gets people well, and well fast, but it comes with more risk than the above.
For those not in the know it is producing a current to a sort of specific area of the brain to bring about a seizure. It is done under a general anaesthetic and they are given a muscle relaxant to prevent the motor component of the seizure from causing injury. We don’t really know the nitty gritty on the ins and outs of how it exactly works but it could be thought of as a sort of reset – in super basic and non-scientific speak of course. There are people out there far more intelligent that I am that will do a better job of explaining this so I urge you to have a look here and have a read through the patient information on sites such as Beyond Blue and the Black Dog Institute.
Nowadays there are some newer and fancier treatments such as Transcranial Magnetic Stimulation which are more gentle and involve less risk as there’s no anaesthetic needed. There isn’t as much evidence out there for this as for ECT but the evidence that there is shows that it is an up and coming treatment which will hopefully be available in our region in the not too distant future.
Other forms of Depression
Ok, so that’s MDD, but what about Persistant Depressive Disorder (PDD). It’s exactly that. A depressive disorder that lasts and lasts like your Dulux outdoors paint. Nasty and miserable. Ergh. Some people might know it as Dysthymia but when DSM 5 rolled out they gave it a more cool and hip name for reasons only people sitting behind big oak desks curling their moustaches know. Having said that, it’s not a major depressive episode (MDE) that doesn’t go away, it’s a bit softer than that, but people do get spikes (or troughs more accurately) of MDEs, and this used to be called “double depression”. Sounds awful! Anywho, you can have a bit more a read through this here. You’ll see that overall, the treatment is not too dissimilar to MDD.
And to finish off the depression branch there’s Disruptive Mood Dysregulation Disorder (DMDD). Chances are you won’t really be coming across this a whole lot, if at all during med school but it is good to be aware of it. It’s a pretty new diagnostic entity, again, coming from those men in fancy suits and fancy offices, and it’s based in the child and adolescent population. It carries a similar symptom profile to other childhood/behavioural disorders such as ADHD, ODD and some anxiety disorders. I am not super familiar with this at all as I work with adults so I’ll just point you in the general direction of the Wikipedia page and back slowly away.
Hopefully this next group is a bit more upbeat as we say hello to the Bipolar (affective) Disorders (BPAD). Well, one of the two poles is upbeat. Sometimes.
A lot of the time it’s more anger and irritability which isn’t what we think mania to be.
The stereotype of the manic person is someone who is super happy, bouncy, indestructible and incredibly over the top. When someone’s mania is euphoric it’s infectious! They think they are the best in the world and everything that’s going on around them is the best ever, and they are giggly, and bubbly, and bright (eye-shatteringly bright at times) and it’s a fabulous and wonderful mood to be in. Lots of people like to survive in hypomania – they’re just bubbly and energetic enough and their drive and desire is like a buzz but it can also be very destructive and dangerous at times. I’ll explain why in a bit.
Doesn’t that all sound very lovely?! If only all mania was euphoric… Unfortunately a lot of manic episodes are irritable, angry and sometimes extremely nasty. Grandiosity can be almost narcissistic and lead the person to be less aware of the needs and desires of others.
You can often come out of the interview with such a person feeling >–< this small. It can be extremely unpleasant.
Both of these different presentations of mania carry the same diagnostic criteria and don’t really change the treatment at all. What is an important distinction to make is whether it is a mania or a hypomania – a mini-mania if you will.
If someone only ever has hypomanic episodes that’s BPAD 2 but if they have a mixed episode (depression and mania at the same time (I know, right?!)) or a manic episode, then it’s BPAD 1. It’s all semantics really.
Being manic is destructive to all facets of your life as you become disinhibited, impulsive, feel like nothing can go wrong and everything you do is the most right thing and best idea that you have ever ever had.
Some examples of things people who are manic do: impulse buying (mostly clothes, random crap you don’t need in excessive amounts , but sometimes brand new cars or boats that you can’t afford), reckless driving or other activities (jumping off things), become promiscuous (having affairs), say horrible and extremely hurtful things to friends and family (that aren’t even true), quit their job, or worse, do something incredibly embarrassing and career-damaging at work, use drugs if they don’t already, and so the list goes on. These cause irreparable damage to relationships, reputations, massive financial strain (people can spend their life savings), put themselves, and potentially others, at risk of harm through misadventure, etc.
So, whilst it might sound nice and rosy to start off with, especially hypomania, it’s not terribly good in the long run and both mania and hypomania need treating. Medication takes precedence here though the lifestyle stuff and psychoeducation is still important.
One of the main triggers for a manic episode is sleep disturbance which is why we’re so hot on people having a healthy sleep routine. You can have a read through the treatment guidelines yourself here and here.
Essentially, if someone is manic we need them to not be manic ASAP because of the above and the quickest way to do this is with second generation antipsychotics. They are anti-manic agents, so they are used even when there aren’t psychotic features present, and as an added bonus have some mood stabilising properties. Often people will be commenced on a mood stabiliser (such as lithium, which is an oldie but a goodie, or sodium valproate though there are a whole bunch of them as described in the guidelines) simultaneously, and later down the track the antipsychotic is often tapered and ceased due to the metabolic side effects. Essentially, aiming to get someone on monotherapy as it’s better and easier and stuff.
If the person is hypomanic they can often be treated with the mood stabiliser straight off which is more ideal.
So, the more observant readers will be aware that we have only talked about the treatment of hypo/mania here.
Whilst a depressive episode of a BPAD may look essentially the same as in unipolar depression (and in the vast majority of cases, a person’s first affective episode will be a depressive episode and will only be diagnosed with BPAD years later when they have a hypo/manic episode) it’s treatment is different – well, only if you know they have BPAD.
There is a tendency to freak out about using antidepressants in this instance due to the potential of a manic switch but they are not totally contraindicated. The above guidelines go into this a bit more and whilst ideally, and first line, you’d go for a mood stabiliser (lithium is the bees knees in terms of covering BPAD depression) there are certainly instances where it just won’t cut it and you will need to reach for the ADTs – just make sure they have the cover of a mood stabiliser and ideally try and get to monotherapy again once the episode has fully resolved as per the guidelines. Don’t forget the non-medication arms of intervention in bipolar depression; they’re still very important as they’re still stuck in that deep, dark hole and need to get out.
Mania and Hypomania - Simple Criteria
- High Energy Levels
- Positive Mood – which can lead to grandiosity
- Inappropriate Behaviour – for example increased risk taking (including increased consumption of alcohol and drugs)
- Increased Creativity & Activity
- Mystical Experiences, Special Significances
I’m not going to go into Cyclothymia here as it’s not as important for you to know about at this stage other than that it exists. It’s meant to be a mini form of BPAD with the elevated mood not meeting criteria for a hypo/manic episode and the depressed mood not meeting criteria for a major depressive episode. There’s a bit more info in the RANZCP guidelines linked to earlier and of course, there’s always wiki!
Excellent! We’ve made it to the end! Or have we…? The classification thingy further up the page mentions both primary and secondary mood disorders. So far we’ve only talked about the primary branches but it is important to consider the secondary when it comes to diagnosis as it will of course inform the management. By far the most common of these you’ll come across are the substance induced but the others are out there too. Now we’re finished! Congrats on making it the end and I hope you find this useful. I was hoping to sneak in another Disney reference but I guess I’ll just have to let it go.
I’ll show myself out.