Depression

•    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)

Bipolar Disorder

•    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

Differentiation from Dementia

•    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