Depressive and bipolar disorders: criteria, distinctions and first-line treatment

AI-narrated overview made with Google NotebookLM. The written lesson below is by Dr. Andrew Wichterman.

Areas of Clinical Focus is the second-largest domain, 29 percent of the scored items, and mood disorders are its center. The exam asks for the criteria that separate one diagnosis from another and for the treatment the evidence supports.

Major depressive disorder

Major depressive disorder requires five or more of nine symptoms during the same two-week period, with at least one being depressed mood or loss of interest or pleasure: the others are weight or appetite change, insomnia or hypersomnia, psychomotor agitation or retardation, fatigue, worthlessness or excessive guilt, poor concentration, and recurrent thoughts of death. Symptoms cause significant distress or impairment and are not attributable to a substance or medical condition. A single episode or recurrent; specifiers include with anxious distress, with melancholic features, with atypical features, with psychotic features, with peripartum onset, and with seasonal pattern. Grief is no longer an automatic exclusion, but the clinician distinguishes bereavement, in which sadness comes in waves tied to the loss and self-esteem is intact, from a depressive episode.

Persistent depressive disorder and the rest

Persistent depressive disorder, formerly dysthymia, is depressed mood most of the day, more days than not, for at least two years in adults, one year in children and adolescents, with two or more of: poor appetite or overeating, sleep change, low energy, low self-esteem, poor concentration, hopelessness. It is chronic and lower-grade; double depression is a major episode on top of it. Disruptive mood dysregulation disorder is severe recurrent temper outbursts with persistent irritability in children aged six to eighteen, onset before ten; it was created to reduce pediatric bipolar diagnoses. Premenstrual dysphoric disorder ties mood symptoms to the luteal phase. Substance- or medication-induced and due-to-another-medical-condition depressive disorders are the rule-outs the exam expects you to consider first.

Bipolar I and II

A manic episode is a distinct period of abnormally elevated, expansive or irritable mood and increased energy lasting at least one week, or any duration if hospitalization is needed, with three or more of: grandiosity, decreased need for sleep, pressured speech, flight of ideas, distractibility, increased goal-directed activity or agitation, and risky behavior; four if mood is only irritable. Mania causes marked impairment or psychosis. A hypomanic episode has the same symptoms for at least four days without marked impairment or psychosis. Bipolar I requires at least one manic episode; a depressive episode is common but not required. Bipolar II requires at least one hypomanic and one major depressive episode and no manic episode. Cyclothymic disorder is two years of hypomanic and depressive symptoms that never meet full criteria. Antidepressants alone can trigger mania in a bipolar client, which is why screening for past hypomania precedes any depression referral.

Differential diagnosis

The distinctions the exam tests: duration separates major depressive disorder, two weeks, from persistent depressive disorder, two years; severity and duration separate mania, one week with impairment, from hypomania, four days without; the presence of a manic episode separates bipolar I from II. Adjustment disorder with depressed mood begins within three months of a stressor and does not meet criteria for a depressive episode. Depression with psychotic features has delusions or hallucinations only during mood episodes; schizoaffective disorder has psychosis for at least two weeks without mood symptoms. Grief, medical causes such as hypothyroidism, and substance effects are ruled out first. Irritability in a child points toward DMDD or an anxiety disorder before bipolar disorder.

Treatment the evidence supports

For major depression, cognitive behavioral therapy, behavioral activation and interpersonal therapy have the strongest evidence; for moderate to severe or recurrent depression, combined psychotherapy and antidepressant medication outperforms either alone, and the counselor coordinates with a prescriber. SSRIs are first-line medications; the counselor knows they take two to six weeks to work and monitors for activation and suicidality early in treatment, especially in adolescents and young adults. For bipolar disorder, mood stabilizers, lithium, valproate, lamotrigine, and atypical antipsychotics are the foundation, and psychotherapy is adjunctive: psychoeducation, interpersonal and social rhythm therapy, family-focused therapy, and relapse-signature monitoring. Suicide risk is elevated in every mood disorder and highest in bipolar depression and mixed states, so risk assessment is continuous.