Approach to mood disorders: Clinical sciences

Mood refers to a long-lasting emotional state that influences how a person views the world and behaves. So, mood disorders are characterized by persistent and excessive experience of emotions such as happiness, sadness, and irritation to a degree that affects an individual's overall functioning.

Now, if a patient presents with chief concerns suggesting a mood disorder, first, perform a safety assessment.

Assess for features of psychosis, like agitation, paranoia, aggression, signs of auditory or visual hallucinations, and other forms of severely disorganized thoughts, speech, or behavior.

Additionally, look for signs of mania, such as rapid speech, a decreased need for sleep, and an increase in goal-directed activity.

Finally, ask specifically about homicidal and suicidal ideation. Patients experiencing psychosis, mania, and active homicidality or suicidality, are considered high risk to themselves and others, so proceed with acute management, which often requires psychiatric hospitalization, pharmacologic stabilization, and a one-to-one sitter, if appropriate.

On the other hand, if the patient is not experiencing these features, they are considered low risk to themselves and others, so your next step is to obtain a focused history and physical exam.

History will typically reveal a persistently euphoric, irritable, or depressed mood that is significantly different from their baseline. Next, on the exam, you will notice psychomotor changes, such as slowed or agitated movements; changes in the rate of speech, which can be increased or decreased; and extremes of affect, ranging from flat to exaggerated facial expressions. Finally, you might notice changes in appearance, such as being unusually unkempt. With these findings, you should consider mood disorder.

Now, here’s a clinical pearl to keep in mind! When assessing patients with mood disorders, be sure to rule out other medical conditions as potential causes of mood changes. For example, hypothyroidism can contribute to depression, while encephalitis can result in manic and psychotic symptoms. Additionally, intoxication or withdrawal from substances, such as alcohol, cocaine, amphetamines, opioids, and benzodiazepines, can also lead to mood disturbances. Next, assess for a current or past manic episode using the DSM-5 criteria.

Manic episodes are characterized by a persistently euphoric or irritable mood with increased energy. In addition, there must be at least 3 of the following symptoms, which can be remembered using the mnemonic DIG-FAST. DIG refers to Distractibility; Irresponsibility, including high-risk behaviors such as reckless driving, expensive shopping sprees, and sexual indiscretion; and Grandiosity and unrealistic self-confidence. Next, F stands for Flight of ideas; while A refers to psychomotor Agitation, but also increased goal-oriented Activities, involving excessive planning, multitasking, increased sociability, and sexual drive. Finally, S stands for Sleep deficiency but still feeling rested and energetic; and T for excessive Talkativeness that is rapid and hard to interrupt.

Sometimes, the patient might present with psychotic features, such as hallucinations, delusions, or severely disorganized thought, speech, and behavior.

Next, the manic episode must be at least one week or any duration of time if symptoms are severe enough to require hospitalization. Finally, symptoms must cause clinically significant impairment. If the patient meets the criteria for a current or past manic episode, diagnose bipolar 1 disorder.

Here’s another clinical pearl! To diagnose bipolar 1 disorder, the patient must meet the criteria for a manic episode. However, manic episodes in bipolar 1 disorder, can often be followed or preceded by hypomanic and major depressive episodes. Hypomania is a less severe, less impairing form of mania, and typically lasts for a few days, although some episodes can last weeks or even months. These episodes are often interspersed with periods of stable mood, but a person may switch directly from one pole, mania, to the other pole, depression.

On the other hand, if there is no history of a manic episode, assess for a current or past hypomanic episode using the DSM-5 criteria.

Like mania, hypomania is characterized by a persistently euphoric or irritable mood with increased energy and the presence of 3 or more DIG-FAST symptoms. But, in contrast to manic episodes, hypomanic episodes are not associated with psychotic features. Next, the hypomanic episode must last at least 4 days and should not require hospitalization. Finally, symptoms must cause clinically significant changes in function, but they cannot be severe enough to cause impairment. If the patient meets all the criteria for a current or past hypomanic episode, the likely diagnosis is bipolar 2 disorder.

Here’s a high-yield fact! In order to make the diagnosis of bipolar 2 disorder, the patient must experience at least 1 hypomanic episode, 1 major depressive episode, and no manic episodes. Similar to bipolar 1 disorder, mood episodes in bipolar 2 disorder also recur, with major depressive episodes being more frequent, longer lasting, and more severe compared to bipolar 1 disorder.

On the flip side, if there is no history of a hypomanic episode, assess for a current or past major depressive episode using the DSM-5 criteria. To diagnose a major depressive episode, the patient must have at least 5 of the following 9 symptoms.

These include consistently depressed mood; too much or too little Sleep; lack of Interest and pleasure in previously enjoyed activities, social withdrawal and decreased sexual drive; Guilt and feelings of worthlessness; decreased Energy; poor Concentration; changes in Appetite; Psychomotor slowing or agitation; and finally, Suicidality with recurrent thoughts of death, including passive thinking, active planning, as well as suicide attempts. Keep in mind that at least one of these symptoms must be a consistently depressed mood or lack of interest and pleasure in previously enjoyed activities. In addition to the consistently depressed mood, you can easily remember the last 8 symptoms using the mnemonic SIG-E-CAPS.

Additionally, the patient might present with psychotic features like hallucinations or delusions. Finally, symptoms must last at least 2 weeks and cause clinically significant distress or impairment. If the patient meets the criteria for a major depressive episode, think of major depressive disorder. Keep in mind that in order to diagnose major depressive disorder, your patient must experience at least 1 major depressive episode and have no history of manic or hypomanic episodes.

Here’s another clinical pearl! Individuals with bipolar mood disorders often present during a major depressive episode, making it crucial to assess all depressed patients for any history of mania or hypomania. This is important because starting antidepressant monotherapy might trigger or unmask manic or hypomanic symptoms. Additionally, after diagnosing major depressive disorder and initiating antidepressant therapy, monitor the patient for new manic or hypomanic symptoms and, if needed, update their diagnosis to bipolar 1 or bipolar 2 disorder.

Now, let’s go back and look at individuals with no current or past major depressive episodes. In this case, your next step is to assess for key features of the patient mood disorder.