MAJOR DEPRESSIVE DISORDER (MDD) 1. Introduction Major Depressive Disorder (MDD) is a mood disorder characterized by one or more major depressive episodes lasting at least 2 weeks, causing significant impairment in social, occupational, or other important areas of functioning. It is one of the leading causes of disability worldwide and is associated with increased morbidity and suicide risk. Depression affects emotions, cognition, behavior, and physical functioning. ⸻ 2. Epidemiology * Lifetime prevalence: 15–20% * Women affected approximately twice as often as men. * Mean age of onset: Mid-20s, although it can occur at any age. * Higher prevalence among: * Individuals with chronic medical illness * Family history of depression * Low socioeconomic status * Substance use disorders * Suicide risk: * Approximately 15% of severely depressed patients die by suicide. * Recurrence: * 50% after one episode * 70% after two episodes * 90% after three episodes Clinical Features Emotional Symptoms * Persistent depressed mood * Sadness * Hopelessness * Worthlessness * Excessive guilt * Irritability ⸻ Cognitive Symptoms * Poor concentration * Indecisiveness * Memory impairment * Negative thinking * Suicidal thoughts ⸻ Physical (Vegetative) Symptoms * Sleep disturbance * Fatigue * Appetite changes * Weight changes * Psychomotor agitation * Psychomotor retardation * Decreased libido ⸻ Behavioral Symptoms * Social withdrawal * Crying spells * Reduced productivity * Neglect of self-care ⸻ Psychotic Features (Severe Cases) Mood-congruent delusions: * Guilt * Poverty * Nihilism Hallucinations (rare) DSM-5-TR Diagnostic Criteria A major depressive episode requires 5 or more symptoms during the same 2-week period, representing a change from previous functioning. At least one symptom must be: * Depressed mood OR * Loss of interest or pleasure. Symptoms: 1. Depressed mood 2. Loss of interest (anhedonia) 3. Weight/appetite change 4. Sleep disturbance 5. Psychomotor agitation/retardation 6. Fatigue 7. Worthlessness or excessive guilt 8. Poor concentration 9. Recurrent thoughts of death or suicide Additionally: * Clinically significant distress/impairment * Not due to substances or another medical condition * No history of manic or hypomanic episodes ⸻ Specifiers * With anxious distress * With melancholic features * With atypical features * With psychotic features * With catatonia * With seasonal pattern * With peripartum onset Management Goals * Achieve remission * Prevent relapse * Restore functioning * Prevent suicide ⸻ A. Pharmacological Management First-line Antidepressants SSRIs Examples: * Fluoxetine * Sertraline * Escitalopram * Citalopram * Paroxetine Advantages: * First-line * Safe * Few side effects Common adverse effects: * Sexual dysfunction * GI upset * Insomnia ⸻ SNRIs * Venlafaxine * Duloxetine * Desvenlafaxine Useful when pain symptoms coexist. ⸻ Atypical Antidepressants Bupropion * Less sexual dysfunction * May aid smoking cessation Mirtazapine * Weight gain * Sedation ⸻ Tricyclic Antidepressants (TCAs) * Amitriptyline * Imipramine * Nortriptyline Reserved because of cardiotoxicity. ⸻ MAO Inhibitors * Phenelzine * Tranylcypromine Reserved for treatment-resistant depression. Need tyramine-free diet. ⸻ Treatment-Resistant Depression Options: * Lithium augmentation * Atypical antipsychotics * Electroconvulsive Therapy (ECT) * Esketamine (where available) ⸻ B. Non-Pharmacological Management Cognitive Behavioral Therapy (CBT) Most effective psychotherapy. ⸻ Interpersonal Therapy (IPT) Focuses on relationships. ⸻ Behavioral Activation Encourages meaningful activities. ⸻ Electroconvulsive Therapy (ECT) Indications: * Severe depression * Psychosis * Catatonia * High suicide risk * Pregnancy when rapid response is required * Treatment resistance ⸻ Repetitive Transcranial Magnetic Stimulation (rTMS) Alternative to ECT for selected patients. ⸻ Lifestyle Measures Regular exercise Healthy sleep Balanced diet Stress management Avoid alcohol and drugs Family education ⸻ 7. Prognosis Good prognostic factors: * Early treatment * Good social support * Mild illness * Good medication adherence Poor prognostic factors: * Psychosis * Multiple episodes * Early onset * Substance abuse * Personality disorder * Chronic illness Recurrence is common. Suicide remains the major complication.

BIPOLAR DISORDER 1. Introduction Bipolar Disorder is a chronic mood disorder characterized by episodes of mania or hypomania alternating with episodes of major depression. It causes marked impairment in functioning and carries a high risk of suicide. Types * Bipolar I Disorder: At least one manic episode (depression may occur but is not required). * Bipolar II Disorder: At least one hypomanic episode and at least one major depressive episode; no history of mania. ⸻ 2. Epidemiology * Lifetime prevalence: * Bipolar I: ~1% * Bipolar spectrum: 2–4% * Men and women are affected equally in Bipolar I. * Bipolar II is slightly more common in women. * Typical onset: Late adolescence to early adulthood (18–25 years). * Heritability: 60–85%, among the highest of psychiatric disorders. * Suicide risk: 15–20 times higher than the general population. Clinical Features Manic Episode Mood * Elevated mood * Expansive mood * Irritable mood ⸻ Behavior * Increased goal-directed activity * Hyperactivity * Excessive spending * Risk-taking behaviors * Increased sexuality ⸻ Speech * Pressured speech * Loud * Difficult to interrupt ⸻ Thought Process * Flight of ideas * Racing thoughts * Distractibility * Grandiosity ⸻ Biological Changes * Decreased need for sleep * Increased energy ⸻ Psychotic Features May occur in severe mania: * Grandiose delusions * Hallucinations (less common) ⸻ Hypomania Same symptoms as mania but: * Lasts ≥4 days * No marked functional impairment * No psychotic features * No hospitalization required ⸻ Depressive Episode Identical to Major Depressive Disorder. ⸻ 5. DSM-5-TR Diagnostic Criteria Manic Episode A distinct period of abnormally elevated, expansive, or irritable mood and increased energy lasting at least 1 week (or any duration if hospitalization is necessary). During this period, 3 or more symptoms (4 if mood is only irritable): 1. Inflated self-esteem or grandiosity 2. Decreased need for sleep 3. More talkative/pressured speech 4. Flight of ideas/racing thoughts 5. Distractibility 6. Increased goal-directed activity or psychomotor agitation 7. Excessive involvement in risky activities The episode causes marked impairment, requires hospitalization, or includes psychotic features. ⸻ Hypomanic Episode Same symptom pattern as mania, except: * Lasts at least 4 consecutive days * Observable by others * Does not cause marked impairment * No psychosis * No hospitalization ⸻ Bipolar I Disorder * At least one manic episode. * Major depressive episodes may occur but are not required for diagnosis. ⸻ Bipolar II Disorder * At least one hypomanic episode. * At least one major depressive episode. * No history of a manic episode. ⸻ 6. Management A. Pharmacological Mood Stabilizers Lithium * Gold standard for acute mania and maintenance. * Reduces suicide risk. Valproate (Divalproex) * Effective for acute mania and mixed states. Carbamazepine * Useful in acute mania and rapid cycling. Lamotrigine * Particularly effective for bipolar depression and maintenance. ⸻ Atypical Antipsychotics Used for acute mania, bipolar depression (selected agents), and maintenance. Examples: * Olanzapine * Quetiapine * Risperidone * Aripiprazole * Ziprasidone * Lurasidone * Cariprazine ⸻ Antidepressants Not used as monotherapy because they may precipitate mania. If needed for bipolar depression, they should be combined with a mood stabilizer. ⸻ B. Non-Pharmacological * Psychoeducation * Cognitive Behavioral Therapy (CBT) * Family-focused therapy * Interpersonal and Social Rhythm Therapy (IPSRT) * Regular sleep-wake schedule * Avoid alcohol and illicit drugs * Stress reduction * Electroconvulsive Therapy (ECT) for severe mania or severe bipolar depression, catatonia, or treatment resistance ⸻ 7. Prognosis Good prognostic factors * Good treatment adherence * Strong family support * Fewer mood episodes * Later age of onset Poor prognostic factors * Early onset * Rapid cycling (≥4 mood episodes/year) * Psychotic features * Substance use disorder * Poor medication adherence * Comorbid anxiety or personality disorders The disorder is typically lifelong, with recurrent episodes. Many patients achieve good functional outcomes with long-term mood stabilizers, psychotherapy, and regular follow-up.

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