It is normal for all of us to experience some ups and downs or fluctuations in our mood within a day or from one day to the next. If these mood changes and fluctuations have a significant negative impact on a person’s daily life, family, work and social life, a mood disorder needs to be considered.
What is a mood disorder?
A mood disorder is a condition in which a person’s mood changes are more intense than usual and persist for a long time.
Not every mood change means a mood disorder
Emotions such as sadness, grief, joy, hatred, anxiety, fear, surprise and shame are universal and natural. We cannot call every instance of experiencing these emotions intensely a mood disorder. Intense pain and sadness after losing someone dearly loved, or elation after receiving happy news, may be strong and last for days. These are normal changes. Alongside the intensity and duration of an emotion, whether it is appropriate to the situation matters.
How many types of mood disorder are there?
There are many subtypes and related disorders, primarily depression and bipolar disorder. Major Depression is the most common mood disorder. Major depression is discussed in detail in its own section; here, primary depression, secondary depression, seasonal depression and depression with psychotic features will also be briefly discussed.
Primary depression
This is depression that develops independently of another medical or mental illness, or substance or alcohol use.
Secondary Depression
Secondary depression develops as a result of another physical or mental illness, or a substance or alcohol use disorder. In most cases, the symptoms of primary and secondary depression are difficult to distinguish. In this situation, the underlying illness is another condition, such as thyroid dysfunction, cancer, cardiovascular disease or schizophrenia; depressive symptoms arise from the psychosocial stress, worry, fear or helplessness caused by these illnesses.
Main symptoms of primary or secondary depression
- Depressed mood
- Lack of motivation, reduced pleasure, no longer enjoying things that used to be enjoyable,
- Low energy
- Problems with cognitive processes such as attention, concentration and decision-making
- Feelings of inadequacy, worthlessness, guilt and helplessness
- Thoughts of ending one’s life, suicidal intent
- Sleep and appetite problems
- Changes in weight
- Distress, anxiety, decreased or increased psychomotor activity
- Physical symptoms (abdominal pain, headaches, muscle and joint pain, etc.)
What is depression with psychotic features?
Psychotic symptoms such as hallucinations (hearing sounds or seeing things that are not there) and delusions (fixed, unshakeable beliefs, e.g. ‘The Turkish National Intelligence Organization is following me!’, ‘I am the Mahdi!’, etc.) can occur in any depressive episode, but are more common in depression in older adults or in patients hospitalised for depression.
Depression with psychotic features can be confused with a psychotic disorder. It is necessary to distinguish whether the psychotic symptoms are due to a separate psychotic disorder or occur as symptoms of a severe depressive episode. Very close and detailed monitoring of this group of patients is important. This is because people who frequently experience psychotic symptoms during depressive episodes are more likely to receive a diagnosis of bipolar disorder later on.
Why is recognising depression in older adults important?
Depression in older adults can be overlooked more often, and 20% of suicides occur in older age. If the first depressive episode occurs in older age, the likelihood of recurrence is higher. Older adults may also respond less well to antidepressants than younger people with depression. Treatment should continue for longer in this age group.
Can depression lead to dementia?
Particularly in older age, Alzheimer’s disease (dementia) and depression can sometimes be confused with one another or occur together.
Pseudodementia
In some patients, severe depression that develops in older age may be indistinguishable from dementia. Particularly in older adults, depression that mainly presents with signs of cognitive decline can be difficult to distinguish from dementia, and the person may mistakenly be diagnosed with dementia. A differential diagnosis should be made through a detailed neurological and psychiatric assessment, a thorough history, psychometric tests, laboratory investigations and imaging.
Bipolar Disorder
Bipolar disorder is a chronic mental illness characterised by episodes of depression and mania. The main symptoms that may occur during a manic episode include excessive elation, joy or anger (inappropriate to the situation), an abnormal increase in energy, abnormal changes in thoughts and behaviour, markedly accelerated thinking and behaviour, increased activity, excessive spending, a substantial reduction in the need for sleep, an inflated sense of self, increased self-confidence, exuberance, an excessive increase in sexual desire and risky behaviour. Delusions and hallucinations may also occur. The person may not recognise these symptoms, although those around them may notice them.
The symptoms of a manic episode can vary in severity between individuals or at different times in the same person. When symptoms are not severe enough to require hospitalisation, there is no marked exuberance and the patient’s functioning is not seriously affected, this is referred to as hypomania.
Does bipolar disorder go away?
Bipolar disorder is a chronic, recurrent mental illness. It does not go away completely. The aim of treatment should be to minimise the number of episodes and reduce their severity and frequency so that the person’s functioning and quality of life are affected as little as possible. Preventive treatment, avoiding stressors, regular sleep and daily routines, and good psychosocial support play a very important role in managing the illness.
How are mood disorders treated?
Mood stabilisers, antidepressants and antipsychotics can be used to treat mood disorders, but treatment must be tailored to each patient. Non-medication treatment options include psychotherapies, TMS (Transcranial Magnetic Stimulation Therapy) or ECT (electroconvulsive therapy). Medication selection, dose adjustments and follow-up must be managed by a specialist physician. The most significant risk in untreated bipolar disorder is the possibility of a suicide attempt.
What is dysthymia?
It is the persistence of depressive symptoms for at least two years.
What is cyclothymia?
It is the persistence of hypomanic and mild depressive symptoms for at least two years.
Indicators of a favourable course in bipolar disorder
- Predominance of manic episodes
- Patient and family adherence to treatment
- Long periods of remission
- A high level of patient functioning
- Low expressed emotion in the family
Indicators of an unfavourable course in bipolar disorder
- Early onset
- Older age
- Residual symptoms between episodes, few periods of full remission
- A co-occurring mental illness
- More than 10 previous manic episodes
- A manic or mixed episode as the first episode of illness
- Mixed episodes
- Alcohol, substance or medication use disorder
- Prolonged depressive episodes
- Rapid cycling episodes
- Presence of a personality disorder
- A family history of substance use disorder
- High expressed emotion in the family
Is bipolar disorder genetic?
The greater clustering of mood disorders in some families indicates that the illness has a genetic component. Many studies have investigated and continue to investigate how bipolar disorder develops, and findings indicate that the illness results from the interaction of biological and psychosocial factors.
Can bipolar disorder be passed on to a child?
It can, but genetic factors do not fully explain the causes of this illness. If one parent has bipolar disorder, the likelihood of the child developing it is approximately 8%. If other family members also have a mood disorder, this risk increases.
Can someone with bipolar disorder become pregnant?
Pregnancy is a time when many psychological and physical stressors increase and may cause mood fluctuations. If someone with bipolar disorder discovers that they have an unplanned pregnancy, they should contact their doctor directly without stopping their medication on their own.
If someone is planning to become pregnant, they should plan this together with their psychiatrist and obstetrician.
If you are planning a pregnancy and have been diagnosed with bipolar disorder, first;
- Make sure your illness is stable. It is recommended that your mood has been stable for around 6 months before pregnancy. Consult your doctor about planning a pregnancy. If possible, include your partner in these consultations.
- Review your medications and doses with your doctor. Medication changes should be made under your doctor’s close supervision. Never stop your medication on your own.
- Stay in frequent contact with your doctor. If your doctor changes or reduces your medication, regular follow-up is recommended to assess the effects on your mood. The risk of relapse is high when medication is stopped or doses are reduced during pregnancy, so the earlier your treatment is planned, the better.
Although efforts are preferably made to minimise medication use during the first three months of pregnancy, if medication is essential to control the expectant mother’s illness, it may need to be continued under medical supervision. Each pregnant woman is assessed individually according to her risk factors and illness history. If the medications being used are known to be harmful to the baby, safer medications should be chosen.
When considering the baby’s health, the following should be kept in mind; even without taking any medication, the risk of a congenital anomaly in a newborn is around 1–3%. Some medications used for bipolar disorder increase this risk. The family should be informed, and the importance of treatment for the health of both mother and baby should be taken into account.
