Mood Disorders

Adjustment Disorder

Emotional or behavioral symptoms develop in response to an identifiable stressor beginning within 3 months of its onset. Symptoms are clinically significant, as shown by marked distress and/or impairment in functioning (occupational, social, etc). Symptoms do not meet criteria for another mental disorder or normal bereavement, and once the stressor has terminated, symptoms do not usually persist more than an additional 6 months.

Depending on the predominant symptoms, the disorder is specified as "with depressed mood," "with anxiety," or "with mixed anxiety & depressed mood." Lasting more than 6 months, it is specified as "persistent." In a hospital psychiatric consultation setting, Adjustment Disorder is often the most common diagnosis, frequently reaching 50%.

Major Depressive Disorder (MDD)

A diagnosis of MDD is made when an individual has 5 of 9 symptoms, present most of the day and nearly every day during the same 2-week period. At least one of the 9 symptoms must be depressed mood or loss of interest, and the symptoms must cause impairment in functioning.

Treatment of MDD

Treatment begins after your condition has been carefully assessed by your family doctor or mental health care provider. Mild cases often respond to psychotherapy (talk therapy). Moderate to severe cases may require antidepressant medication.

Major Depressive Disorder with Anxious Distress

Anxious distress describes the presence of at least 2 of 5 symptoms during a depressive episode, remembered by the acronym CRACK: Concentration difficulty due to worry, Restless feeling, Awful thing may happen, Control of self might be lost, Keyed up or tense.

It's important to recognize anxious distress — it's associated with greater severity of illness, increased suicide risk, and greater resistance to treatment.

Suicidal Ideation

One of the 9 diagnostic symptoms of MDD is recurrent thoughts of death, suicidal ideation with or without a specific plan, or a suicide attempt. Health care professionals may use the Columbia-Suicide Severity Rating Scale Screener to evaluate risk.

Monitoring Your Mood

The Patient Health Questionnaire (PHQ-9) consists of 9 questions, each evaluating one of the 9 MDD symptoms.

The clinician is expected to rule out physical causes of depression, normal bereavement, and a history of manic episodes. The QIDS-SR16 complements the PHQ-9 by tracking subtler symptom changes over the past week.

Impairment of Function

Almost all psychiatric disorders share 3 diagnostic components: required symptoms, a minimum time period, and impairment of functioning in major life areas. The WHO's 12-item disability assessment questionnaire is one way to measure the degree of impaired functioning.

Persistent Depressive Disorder (Chronic MDD)

The essential feature is a depressed mood that occurs for most of the day, for more days than not, for at least 2 years. Criteria for MDD may be continuously present for those 2 years — if so, the patient is given a diagnosis of both MDD and Persistent Depressive Disorder.

Unspecified Depressive Disorder

Depression is present with impaired functioning, but the patient has insufficient symptoms for a diagnosis of MDD. This diagnosis may be used when there is insufficient information (e.g. in emergency room settings).

Seasonal Affective Disorder

Seasonal Affective Disorder (SAD) is a subtype or qualifier of major depressive disorder or bipolar disorder. When at least 2 episodes of major depression start and stop at characteristic times of the year (e.g. start in the fall, recover fully in spring), the individual is suffering from SAD — more formally, Recurrent Major Depressive Disorder with Seasonal Pattern. In SAD, seasonal depressions outnumber any nonseasonal depressions over the individual's lifetime.

SAD affects 2–3% of the population, with prevalence increasing in more northern latitudes, where days are darker and shorter in winter. The "winter blues" affect 15% of Canadians but does not usually require medical attention. While a definitive cause is not known, research suggests that less sunlight in winter disrupts sleeping and waking patterns and interferes with melatonin and serotonin transmission. SAD is more common in women, young adults, those living in northern latitudes, and those with a family history of the disorder.

Treatment

Light Therapy during winter months (10,000 LUX, UV-free) for 30 minutes every morning is first-line treatment; devices are available on Amazon and at Day-Lights.com. The antidepressant Bupropion (Wellbutrin) has been approved for SAD, and SSRIs are often prescribed. Exercise and time outdoors in sunshine may help.

Bipolar Affective Disorder (BAD)

Bipolar Affective Disorder (previously called manic depression) is diagnosed when periods of depression alternate with periods of elevated, expansive, or very irritable mood. Manic phases last at least 7 days; hypomanic phases (the milder form) last at least 4 days. In mania there is marked impairment of functioning; in hypomania, function is less impaired. During the elevated mood phase, a patient will have at least 3 of 7 symptoms.

The more serious form with manic episodes is Bipolar Disorder Type I; the milder form with hypomanic episodes is Type II. In the United States, 60% of patients experience onset before age 19. About 50% of bipolar patients present with a depressive episode. Around 20% of bipolar patients are "rapid cyclers," with at least 4 episodes of either pole within 1 year.

Screening & Rating Scales

The MDQ is for screening purposes only and is not a diagnostic tool. A positive screen warrants a comprehensive evaluation. The RMS helps detect Bipolar I; it is not validated for Bipolar II/hypomania. The YMRS is an 11-item clinician-administered scale assessing severity of mania.

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