• Core (ICD/DSM) symptoms (need at least 2 for diagnosis):
o Low mood (most of the day, nearly every day)
o Anhedonia (loss of interest/pleasure)
o Low energy/fatigue
• Additional/somatic symptoms:
o Reduced concentration and attention
o Low self-esteem, feelings of guilt or worthlessness
o Sleep disturbance (early morning waking = "diurnal variation")
o Appetite and weight changes
o Psychomotor retardation or agitation
o Reduced libido
• Severe depression:
o Psychotic features (mood-congruent delusions or hallucinations, e.g., guilt, nihilism)
o Suicidal ideation or attempts
• Atypical depression:
o Mood reactivity, hypersomnia, hyperphagia, leaden paralysis
• In elderly:
o May present with more somatic complaints ("masked depression")
o Always screen for hypothyroidism, B12/folate deficiency, Parkinson’s, and dementia
• Treatment:
o First-line: SSRIs (e.g., sertraline; avoid paroxetine in elderly due to anticholinergic effects)
o Psychological: CBT, interpersonal therapy
o Severe or resistant: ECT (especially useful if urgent, e.g., severe psychosis or refusal to eat/drink)
• Mania:
o Elevated or irritable mood ≥1 week
o Grandiosity, inflated self-esteem
o Decreased need for sleep
o Pressured speech, flight of ideas
o Distractibility, increased goal-directed activity
o Risk-taking behaviours
• Hypomania:
o Similar features, but no psychotic symptoms
o Less severe, does not cause marked functional impairment or require hospitalisation
• Mixed episode:
o Simultaneous manic and depressive symptoms
• Treatment:
o Acute mania: antipsychotics (e.g., olanzapine, haloperidol), mood stabilisers (lithium, valproate)
o Maintenance: lithium (first choice), valproate, lamotrigine
Monitor lithium levels (target 0.6–1.0 mmol/L), renal and thyroid function
o Bipolar depression: quetiapine, lurasidone, or cautiously add antidepressant (only with mood stabiliser)
• Pregnancy considerations:
o Avoid valproate (teratogenic → neural tube defects), avoid lithium if possible in 1st trimester
• Pseudodementia (depressive "pseudo-dementia"):
o Patients often aware of deficits and answer "I don't know"
o Rapid onset; improves with treatment of mood
• True dementia:
o Confabulation to fill gaps
o Insidious onset, progressive
Extra Revision Pearls
• Suicide risk factors:
o Older age, male sex, living alone, physical illness, previous attempts
• SSRI side effects:
o GI upset, sexual dysfunction, hyponatraemia (especially elderly)
• ECT indications:
o Severe, life-threatening depression
o Severe psychotic depression
o Catatonia
• Lithium toxicity signs:
o Tremor, ataxia, vomiting, diarrhoea, confusion
o Precipitated by dehydration, NSAIDs, ACE inhibitors, diuretics
• Rapid cycling bipolar:
o ≥4 episodes per year; often harder to treat
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Author & Educational Disclaimer
Author:
Dr Phillip Cockrell BM FRCP DipClinEd
Dr Phillip Cockrell is a UK Consultant Physician in Internal Medicine, currently working at Queen Alexandra Hospital, Portsmouth University Hospitals NHS Trust. He has previously worked as a registrar across Intensive Care Medicine, Gastroenterology, Cardiology, Stroke Medicine, Acute Medicine, and Respiratory Medicine.
He has held senior leadership roles including Associate Clinical Director of the Acute Medical Unit, Clinical Director of Internal Medicine, and Chief of Medicine. Dr Cockrell has over 15 years’ experience in postgraduate medical education, having lectured extensively across the MRCP syllabus and contributed to MRCP revision teaching and course development.
Dr Cockrell holds a Bachelor of Medicine (BM), Fellowship of the Royal College of Physicians (FRCP), and a Diploma in Clinical Education (DipClinEd). His teaching approach is based on structured consolidation of complex medical topics to support efficient and effective revision for postgraduate examinations.
Purpose of this content:
The material on this page is intended solely for educational purposes to support revision for the MRCP (UK) Part 1 examination. It reflects examination-relevant principles of internal medicine and is designed to aid learning and pattern recognition.
Medical disclaimer:
This content is designed for postgraduate medical examination revision and does not constitute medical advice, diagnosis, or treatment guidance and must not be used as a substitute for professional clinical judgement, local guidelines, or specialist consultation. Clinical decisions should always be made in the context of individual patient circumstances and current national guidance.
