Makindo Medical Notes

Related Subjects: |Psychiatric Emergencies |Depression |Mania |Schizophrenia |Suicide |Acute Psychosis |Delusions |General Anxiety Disorder |Obsessive-Compulsive disorder |Wernicke Korsakoff Syndrome |Medically Unexplained symptoms |Postpartum/Postnatal Depression |Postpartum / Postnatal Psychosis |Eating disorders in Children |Anorexia Nervosa

📝 In all patients with low mood or suspected affective disorder, always ask directly about suicidal thoughts, intent, or self-harm and document carefully. This is a key patient safety step. 🚨

📊 About Low Mood & Affective Disorders

• Major depressive illness affects 5–10% of the population at any time.
• Affective disorders include:
  • 🌧️ Depressive disorders (major depression, dysthymia).
  • 🌤️ Bipolar affective disorder (episodes of mania/hypomania and depression).
  • 🌪️ Cyclothymia (chronic fluctuating mild depression + hypomanic symptoms).
• Often follow a relapsing–remitting course, though chronic low mood states also exist.
• Patients with a prior history of depression have a 10-fold increased suicide risk.

🧬 Aetiology

• 🧬 Genetics: 30–40% heritability in depression; higher in bipolar disorder.
• 🧠 Neurobiology: Reduced monoamine neurotransmission (serotonin, noradrenaline, dopamine).
• ⚖️ Neuroendocrine dysfunction: Raised cortisol, non-suppression with dexamethasone (HPA axis dysregulation).
• 🌍 Psychosocial factors: Adverse childhood experiences, trauma, stress, social isolation, chronic illness.

📖 DSM-5 Criteria (Depression)

• Core symptoms:
  • 😔 Persistent low mood, sadness, hopelessness, emptiness.
  • 😶 Anhedonia – loss of interest or pleasure.
• Associated symptoms (need ≥1 core + total ≥5 symptoms for ≥2 weeks):
  • 😴 Sleep disturbance (insomnia or hypersomnia).
  • 🍽️ Appetite or weight change.
  • ⚡ Fatigue or low energy.
  • 🐢 Psychomotor retardation or agitation.
  • 🤯 Poor concentration, indecisiveness.
  • 😔 Guilt or worthlessness.
  • ⚰️ Suicidal thoughts, plans, or behaviours.
• Severity:
  • 📉 Mild: ≥5 symptoms, minor functional impairment.
  • 😟 Moderate: Marked impairment but not total dysfunction.
  • 😭 Severe: Most symptoms, often with suicidal ideation or psychosis.

🩺 Clinical Features

• 🌧️ Low mood, loss of pleasure, anergia.
• 😴 Sleep disturbance (classically early morning waking in depression).
• 💔 Loss of libido, appetite changes, weight change.
• ⚠️ Suicidal ideation (must always be assessed and documented).
• 🌀 In bipolar disorder – look also for history of manic or hypomanic symptoms:
  • ↑ Energy, ↓ need for sleep.
  • Pressured speech, flight of ideas.
  • Grandiosity, risk-taking behaviour.

🛠️ Management Principles

🗣️ Psychological Therapies

• 💬 CBT – effective for mild–moderate depression.
• 👥 Interpersonal therapy, counselling, behavioural activation.
• 📖 Psychoeducation and relapse prevention planning.

💊 Pharmacological Management

• SSRIs (e.g. sertraline, citalopram) – first line, generally well tolerated.
• SNRIs (e.g. venlafaxine, duloxetine) – useful if poor SSRI response, but more side effects.
• Tricyclic antidepressants (e.g. amitriptyline) – effective but toxic in overdose.
• MAOIs – rarely used; significant dietary restrictions.
• 🌿 St. John’s Wort – popular but interacts with many drugs (caution!).

⚡ Electroconvulsive Therapy (ECT)

• Consider in severe, resistant, psychotic, or life-threatening depression.
• Typically 6–12 sessions, 2–3 times/week.
• Relative contraindications: recent stroke, raised ICP, unstable cardiac disease.

🌤️ Management of Bipolar Disorder (brief overview)

• Mania: mood stabilisers (lithium, valproate), antipsychotics.
• Depression: quetiapine, lithium, or lamotrigine preferred (avoid antidepressant monotherapy due to risk of mania induction).
• Long-term: psychoeducation, relapse prevention, MDT support.

🚩 Risk Assessment & Safety

• Ask about suicidal thoughts, self-harm, or risk to others.
• Consider protective factors: family, faith, hope, coping strategies.
• Document risk assessment clearly.
• Refer to crisis team or admit if at high risk.

🧑‍⚕️ Clinical Cases

📚 References

• NICE Depression Guidance (2021)
• NICE Bipolar Guidance

Cases — Low Mood / Affective Disorders

• Case 1 — Major depressive episode 😔: A 34-year-old woman reports 2 months of persistent low mood, anhedonia, early morning waking, and poor appetite. She has feelings of worthlessness but no suicidal ideation. PHQ-9 score: 20 (severe). Diagnosis: major depressive disorder. Managed with CBT and initiation of an SSRI.
• Case 2 — Bipolar affective disorder (depressive phase) 🔄: A 28-year-old man with a history of hospital admission for mania now presents with 6 weeks of low mood, fatigue, hypersomnia, and social withdrawal. He has stopped going to work. Diagnosis: bipolar affective disorder — current depressive episode. Managed with mood stabiliser adjustment (lithium/lamotrigine) and psychiatric follow-up.
• Case 3 — Depression in physical illness 🏥: A 63-year-old man with type 2 diabetes and recent myocardial infarction complains of loss of interest, hopelessness, and poor adherence to treatment. He denies suicidality but neglects self-care. Diagnosis: depression secondary to chronic physical illness. Managed with psychological support, SSRI (sertraline chosen for cardiac safety), and liaison psychiatry input.

Teaching Point 🩺: Depression presents with core symptoms (low mood, anhedonia, low energy) and somatic features (sleep disturbance, appetite change, early waking). Always assess suicide risk and consider whether depression is unipolar, part of bipolar disorder, or secondary to physical illness/medication.