Mood Disorders: Depression, Bipolar Disorder, Assessment and Management
Mood disorders are conditions in which persistent or episodic changes in mood, energy, activity, cognition and behaviour cause distress or functional impairment. The major clinical groups are depressive disorders and bipolar disorders. Accurate assessment matters because treating bipolar depression as unipolar depression alone may precipitate mania, while severe depression with suicide risk or psychosis may require urgent specialist treatment.
Learning objectives
- Describe depressive, manic and hypomanic episodes and their functional effects.
- Differentiate unipolar depression, bipolar disorder, psychotic mood disorders, adjustment reactions, grief and medical/substance causes.
- Perform a structured history, mental-state examination, risk assessment and targeted investigation plan.
- Compare psychosocial, antidepressant, mood-stabilising, antipsychotic and ECT treatment approaches.
- Plan monitoring, relapse prevention, pregnancy safety, family support and follow-up.
1. Mood-episode syndromes
| Syndrome | Core features | Clinical importance |
|---|---|---|
| Depressive episode | Low mood or loss of interest plus cognitive, emotional, physical and behavioural symptoms | Assess duration, severity, suicide, psychosis, bipolarity and function. |
| Mania | Elevated/irritable mood with increased energy/activity, reduced need for sleep and impaired judgement | Often requires urgent specialist care; psychosis or danger may require admission. |
| Hypomania | Similar change but less severe, without marked impairment, psychosis or need for admission | May be missed unless collateral history is obtained; suggests bipolar spectrum illness. |
| Mixed features | Depressive and manic symptoms occur together or change rapidly | High risk of impulsivity, substance use and suicide; specialist review is important. |
2. Depressive disorders
Ask about persistent sadness, loss of interest or pleasure, guilt/worthlessness, hopelessness, low energy, sleep/appetite change, psychomotor change, poor concentration, suicidal thoughts and physical symptoms. Document duration, pervasiveness, functional effect and whether symptoms are better explained by bipolar disorder, substances, grief or medical illness.
Severity
- Mild: distress and some impairment, but basic functioning remains possible.
- Moderate: multiple symptoms with clear functional impairment.
- Severe: pervasive symptoms, marked impairment, psychosis, self-neglect or serious suicide risk.
PHQ-9 or another validated tool can measure symptoms and change, but it does not diagnose bipolarity, psychosis or safety. Item-level suicide assessment is always required.
3. Bipolar disorders
Bipolar I disorder includes at least one manic episode; depressive episodes are common but not required for the diagnosis. Bipolar II involves hypomania and major depression without a history of mania. Other specified or cyclothymic patterns require longitudinal specialist assessment.
Mania assessment
- Elevated, expansive or irritable mood; increased energy/activity.
- Reduced need for sleep, pressured speech, racing thoughts, distractibility and grandiosity.
- Risky spending, sexual behaviour, driving, aggression, substance use or unrealistic projects.
- Psychosis, poor insight, impaired capacity, neglect of food/fluids and risk to others.
Ask about previous episodes, family history, antidepressant or steroid exposure, substances, thyroid symptoms, sleep deprivation and collateral observations. Use a timeline: mood symptoms, psychosis, sleep, substances, medicines and function.
4. Differential diagnosis
| Presentation | Alternatives to consider | Clues |
|---|---|---|
| Low mood | Bipolar depression, grief, adjustment, thyroid disease, anaemia, HIV, substances, medication effects | Past elevated episodes, atypical physical findings, exposure timeline and collateral. |
| High energy/irritability | Stimulants, corticosteroids, hyperthyroidism, delirium, seizures, sleep deprivation | New drug/substance, fluctuating consciousness, fever or neurological signs. |
| Psychotic mood symptoms | Schizophrenia-spectrum illness, delirium, substance-induced psychosis | Relationship of psychosis to mood episodes and attention/medical signs. |
| Bereavement | Normal grief, prolonged grief disorder, major depression | Trajectory, pervasive impairment, hopelessness, suicidality and loss of pleasure. |
5. Comprehensive assessment
- History: presenting symptoms, duration, episodic course, sleep, energy, appetite, cognition, trauma, substances and function.
- Past history: episodes, admissions, suicide attempts, psychosis, response/adverse effects and adherence.
- Family history: bipolar disorder, suicide, psychosis, substance use and medical illness.
- Physical/neurological exam: observations, glucose, thyroid signs, movement, pregnancy, nutrition and neurological red flags.
- Risk: suicide, self-neglect, violence, impulsivity, access to means, dependants, exploitation and protective factors.
- Collateral: sleep, spending, speech, behaviour, baseline and changes noticed by family.
6. Investigations
- Full blood count, electrolytes/renal function, glucose/HbA1c, liver function and thyroid tests when clinically indicated.
- Pregnancy testing where relevant before valproate, lithium, radiation or teratogenic treatment.
- HIV/syphilis, malaria/TB or other infection tests according to symptoms, risk and local epidemiology.
- ECG before QT-risk medicines, overdose, syncope, cardiac disease or significant electrolyte disturbance.
- Drug levels for lithium/selected anticonvulsants; toxicology when it changes management.
- Neuroimaging/EEG/CSF only when atypical, neurological, rapidly progressive or medically concerning features justify them.
7. Management principles
- Share a formulation and treatment plan; combine psychosocial, biological and social interventions.
- Address sleep, nutrition, activity, alcohol/drugs, physical health, trauma, housing and family support.
- Use the least restrictive safe care; admission may be required for high risk, psychosis, severe self-neglect, mania or inability to engage safely.
- Agree measurable targets: sleep, mood, activity, suicidal thinking, function, mania symptoms and adverse effects.
8. Psychological and social treatment
- CBT, behavioural activation, interpersonal therapy and problem-solving for depression.
- Psychoeducation, family-focused therapy, routine/sleep stabilisation and relapse planning for bipolar disorder.
- Exercise, meaningful activity, social connection, supported education/employment and substance-use care.
- Collaborative safety plan: warning signs, coping strategies, trusted contacts, professional contacts and means safety.
9. Antidepressants
SSRIs are commonly first-line for unipolar depression and anxiety. Screen for past mania/hypomania, psychosis, suicide risk, substances and interactions before prescribing.
| Medicine | Typical adult educational dose | Important cautions |
|---|---|---|
| Sertraline | Start 25–50 mg daily; usual 50–200 mg/day | GI effects, sexual dysfunction, activation, hyponatraemia, bleeding and serotonin syndrome. |
| Fluoxetine | Start 10–20 mg daily; usual 20–60 mg/day | Activating, long half-life and enzyme interactions; discontinuation is less common. |
| Escitalopram | Start 5–10 mg daily; usual 10–20 mg/day | QT and dose cautions in older age, hepatic disease or cardiac risk. |
| Mirtazapine | Start 15 mg at night; usual 15–45 mg/day | Sedation, appetite/weight gain and metabolic effects; may help insomnia/poor appetite. |
| Venlafaxine | Start 37.5–75 mg/day; common range 75–225 mg/day | Blood-pressure monitoring, withdrawal, activation, serotonin syndrome and overdose toxicity. |
Review early after initiation or dose change, especially when suicide risk or activation is present. Continue after remission for the recommended period and taper gradually to reduce withdrawal. Avoid antidepressant monotherapy when bipolar disorder is suspected.
10. Bipolar disorder medicines
Lithium
- Uses: acute mania and long-term relapse prevention; selected augmentation and suicide-risk reduction.
- Dose/levels: commonly 400–1200 mg/day, individualised by level, kidney function, age and formulation. Target levels vary by phase and protocol; document sample timing.
- Baseline/monitoring: renal function/eGFR, electrolytes/calcium, thyroid, weight, pregnancy status and ECG when indicated; repeat levels after changes and during maintenance.
- Interactions/toxicity: dehydration, low sodium, NSAIDs, ACE inhibitors/ARBs and diuretics can raise levels. Coarse tremor, vomiting, diarrhoea, ataxia, dysarthria, confusion or seizures require urgent assessment.
Valproate
- Uses: selected acute mania or maintenance when specialist guidance supports it.
- Typical range: often 500–2000 mg/day, adjusted to response/formulation.
- Risks: weight gain, tremor, sedation, thrombocytopenia, hepatotoxicity, pancreatitis and hyperammonaemic encephalopathy.
- Reproductive safety: avoid in people who may become pregnant unless current national safeguards, specialist review and safer alternatives have been addressed; fetal malformation and neurodevelopmental risks are serious.
Lamotrigine and carbamazepine
Lamotrigine is mainly useful for bipolar depression prevention and must be titrated slowly; rash with mucosal lesions or fever is an emergency. Carbamazepine may treat mania but causes hyponatraemia, blood-count/liver problems and major enzyme interactions, including reduced contraceptive and antiretroviral concentrations.
11. Acute mania
Provide a calm, low-stimulation environment; assess capacity, violence, spending, sexual risk, driving, nutrition, sleep, substances and dependants. Treat severe mania urgently with a mood-stabilising antipsychotic and/or lithium under specialist guidance. Avoid antidepressant escalation. Admission is appropriate when risk, psychosis, poor insight, exhaustion, self-neglect or inability to contain behaviour makes community care unsafe.
12. Severe depression, psychosis and ECT
Psychotic depression, catatonia, refusal of food/fluids, severe suicide risk or life-threatening deterioration requires urgent specialist care. ECT may provide rapid benefit when illness is severe, treatment resistant or a rapid response is needed. It is a consented anaesthetic procedure; assess capacity, cardiovascular/anaesthetic risk, pregnancy, cognition and memory effects.
13. Pregnancy and postpartum care
Ask about pregnancy and reproductive plans routinely. Balance relapse risk against fetal/neonatal medicine risks with specialist obstetric and psychiatric input. Valproate requires particularly strict current safety precautions. Postpartum psychosis, severe insomnia with mood elevation, confusion or suicidal thoughts is an emergency requiring urgent assessment and safeguarding.
14. Relapse prevention and follow-up
- Record early warning signs: sleep reduction, rising energy, spending, irritability, social withdrawal, hopelessness, substance escalation or missed doses.
- Agree who will notice change, how medicines will be supported and where urgent help is available.
- Monitor mood, function, suicide, adverse effects, weight/metabolic health, lithium/valproate safety and pregnancy intentions.
- Involve family with consent; address stigma, finances, transport, housing and access to therapy.
15. Worked cases
Depression with hidden bipolarity
A patient with recurrent “depression” reports several episodes of reduced need for sleep, grandiosity and impulsive spending. Reassess for bipolar disorder before antidepressant monotherapy; obtain collateral and refer for specialist mood-stabilising care.
Severe suicidal depression
A patient has hopelessness, psychotic guilt, refuses food and has a plan to die. Arrange urgent containment, medical assessment, specialist medication and possible ECT; do not rely on outpatient counselling alone.
Acute mania
A patient has slept two hours nightly for a week, is spending heavily and threatening neighbours. Reduce stimulation, assess violence/suicide/medical risk, review substances and arrange urgent specialist care/admission if safety cannot be maintained.
16. Quick self-test
- What must be screened for before antidepressant monotherapy?
- Name five features of mania.
- Why is collateral history important?
- List baseline checks before lithium.
- Name three serious valproate risks.
- When may ECT be considered?
- What belongs in a relapse-prevention plan?
Answers
- Past/current mania or hypomania, psychosis, substances/medicines, suicide risk and medical mimics.
- Elevated/irritable mood, increased energy, reduced need for sleep, pressured speech, racing thoughts, grandiosity, distractibility and risky behaviour.
- It clarifies episodes, sleep, function, spending, adherence, risk and baseline when insight or memory is impaired.
- Renal function/eGFR, electrolytes/calcium, thyroid, weight, pregnancy status and ECG when indicated.
- Hepatotoxicity, pancreatitis, thrombocytopenia, hyperammonaemic encephalopathy, weight gain and major reproductive risks.
- Psychotic or life-threatening depression, catatonia, refusal of food/fluids, severe suicidality or selected treatment-resistant illness requiring rapid response.
- Early warning signs, coping steps, trusted/professional contacts, means safety, medication plan, family support and escalation thresholds.
References
- NICE: Depression in adults—treatment and management.
- NICE: Bipolar disorder—assessment and management.
- WHO: mhGAP guideline 2023.
- WHO: mhGAP Intervention Guide.
- NICE: Electroconvulsive therapy guidance.
- Use Uganda Ministry of Health and hospital protocols for reproductive safety, emergency referral, medicines and safeguarding.
