Mood disorders are quite common.  Depression is by far the primary symptoms, although almost all patients also feel significant anxiety and some have other mood and thought disorder symptoms.  The Hamilton Depression Scale is the most popular psychiatrist rating tool for determining the amount of depression, while the Beck Depression Inventory is the most popular self-rating tool for measuring depression.  I also use the Inventory of Depression Symptomatology which gathers information to help determine the type of depression.

Mood disorders are given a number of different diagnoses depending on their features.  The Bipolar Disorders are covered under another section of this website (See Bipolar Disorder).  Those disorders have high swings, either manic or hypomanic (a little manic), in addition to any depression.  Depression without bipolar features is sometimes called unipolar depression.  The unipolar depressive disorders are Major Depressive Disorder, Dysthymic Disorder, and Depressive Disorder Not Otherwise Specified.   

For a diagnosis of Major Depressive Episode, the patient must show five or more of the following symptoms during the same two week period of time and must have either a depressed mood or loss of interest or pleasure: 1) feel or appear depressed most of the day, nearly every day; 2) markedly diminished interest or pleasure in almost all activities most of the day, nearly every day; 3) weight loss or gain when not dieting or decreased or increased appetite nearly every day; 4) insomnia or hypersomnia nearly every day; 5) psychomotor agitation or retardation nearly every day; 6) tired or loss of energy nearly every day; 7) feeling worthless or excessively guilty; 8) diminished ability to think or concentrate or indecisive nearly every day; 9) recurrent thoughts of death or suicide.  These symptoms must cause a significant distress or impairment in functioning in some important area.  The symptoms are not due to bereavement of less than two months without a markedly function impairment. The symptoms are not due to drugs, a medication, or a medical illness.

Dysthymic Disorder is the diagnosis given for a chronic depressed mood of less than a Major Depressive Disorder occurring for most of the day more days than not for at least 2 years.  For children, the mood may be irritable rather than depressed and must last for only one year.  For the diagnosis, there must also be at least two of the following: poor appetite or overeating, insomnia or hypersomnia, low energy or fatigue, low self-esteem, poor concentration or difficulty making decisions, and feelings of hopelessness. For the diagnosis, the person may not be symptom-free for more than 2 months. The person may not be Bipolar nor may the symptoms be due to a Psychotic Disorder or substance abuse or a medical condition.

A mood disorder due to a medical condition is diagnosed as Mood Disorder Due to ...[Name of the Medical Condition]. Examples of medical conditions causing mood disorders are Parkinson's disease, Alzheimer's disease, Huntington's disease, stroke, B-12 deficiency, thyroid problems, Cushing's syndrome, autoimmune diseases like lupus or multiple sclerosis, hepatitis, AIDS, mononucleosis, and certain cancers like cancer of the pancreas.

A mood disorder due to substance abuse is diagnosed as Substance-Induced Mood Disorder.  Examples mentioned in DSM-IV are depression due to alcohol abuse, amphetamine or cocaine abuse, hallucinogens or inhalant abuse, opioids, sedatives, or anxiolytics.  Oddly enough, despite research showing that tobacco and marijuana cause a large amount of depression due to their high rates of abuse, DSM-IV doesn't mention these.  There is an "Other" category that can be used for these.

There are some specific features of depression that may affect treatment.  Melancholic Features consists of a loss of interest or pleasure in almost all activities or a lack of reactivity when something good happens.  This is combined with three of the following: morning worsening, awakening in the morning, a distinct quality to the depression, motor retardation or agitation, anorexia or weight loss, and guilt (excessive). These features can be remembered with the mnemonic "MAD MAG."  Melancholia is more common in older individuals and is more likely to respond to medication or ECT.

Atypical Features are more common in women and often start earlier, e.g. while in high school.  The diagnosis is used when there is mood reactivity where the depressed person gets cheered up by pleasurable events, e.g. a compliment or a visit from one's children.  This is combined with at least two of the following: 1) weight gain or increased appetite, 2) 10 or more hours of sleep a day, 3) leaden paralysis (feeling heavy or weighted down, usually in the arms or legs, for at least an hour a day), 4) a long-standing pattern of interpersonal rejection sensitivity with social or occupational impairment.  This being touchy or overemotional may lead to stormy relationships, or substance abuse.  Some research has found that patients with Atypical Features do better on MAO Inhibitor medication.

Screening Test for Depression for General Practice Doctors: Two studies have found that asking just two questions, either in writing or verbally, is a sensitive screen for depression.  Of 37% general medical patients who responded positively to either had a more detailed brief interview.  In all, 6% of the patients were found to be clinically depressed. The two questions were: "During the past month have you often been bothered by feeling down, depressed, or hopeless?" and, "During the past month have you often been bothered by little interest or pleasure in doing things?" One study of these questions in writing reported a sensitivity of 96% and a specificity of 57% compared with the quick diagnostic interview schedule. Another with the questions asked verbally reported a 97% sensitivity and 67% specificity. Screening for depression in primary care with two verbally asked questions: cross sectional study. Bruce Arroll, Natalie Khin, Ngaire Kerse. BMJ  2003;327:1144-1146 (15 November),

Mandatory Screening for Depression in Nursing Home Doubles Treatment: In an experimental study of four nursing homes, 519 demented patients were screened for co-morbid depression. Those with scores of at least 5 on the Cornell Scale for Depression in Dementia were seen by a psychiatrist.  The percentage of patients on anti-depressants increased from 16% to 36%. Carl I. Cohen, State University of New York Downstate, Brooklyn. Am J Psychiatry. 11/2003;160:2012-2017

Thomas E. Radecki, M.D., J.D.

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