Mood Disorders in 3 Clinical Reports

Introduction to 3 Clinical Reports on Mood Disorders
Depressive disorders and bipolar and related disorders have their own chapters in DSM-5, but the challenges for diagnosing and treating these disorders remain the same. Some of the most common challenges include the diagnosis of a mood disorder, especially a bipolar disorder, and the assessment and management of comorbidities and suicidalities in patients with a mood disorder. In this Special Report on mood disorders, chaired by by Keming Gao, MD, PhD, the authors of the 3 articles have attempted to address these issues.

1. Phenotypic Boundaries of Bipolar Disorder
There is no substitute for understanding one’s patient as an individual, and treating accordingly, keeping in mind the possibility that not all psychosis is schizophrenia and that moodiness may or may not indicate a place in the bipolar spectrum. With this in mind, Dean F. MacKinnon, MD, uses 2 patients as examples to illustrate phenotypic differences in bipolar disorders. He concludes “soft” symptoms are not easily discerned. Clinicians should pay close attention to the “soft” symptoms during interviews.

Significance for the practicing psychiatrist: The elusive nature of bipolar diagnoses, especially atypical forms of bipolar disorder, requires an understanding of the patient's phenotype and functioning. Because it is a discrete disease entity, bipolar disorder is often difficult to fit cleanly into formal diagnostic categories. For a larger view of this slide, click here.

Lessons Learned: Suicide
Among all the psychiatric conditions, bipolar disorder has the highest risk for suicide and suicide attempts. To reduce deaths by suicide in patients with bipolar disorder, the International Society for Bipolar Disorder Task Force on Suicide Risk and Prevention in Bipolar Disorder made a collaborative effort to study the risk factors for suicide and suicide attempt and to develop strategies to assess and manage suicide risk. In their article on suicide risk and prevention in bipolar disorder, Ayal Schaffer, MD, and Manuel Sanchez De Carmona, MD, share some findings from this collaboration. The authors first review the prevalence of suicide and suicide attempt and summarize the risk factors for suicide. They also provide a specific clinical model for bipolar disorder suicide risk assessment, and propose strategies for managing suicide risk.

Significance for the practicing psychiatrist: Issues related to suicide risk are especially important to keep in mind, especially because the risk of death by suicide is over 10-fold greater in people with BD. The impact of the illness of BD on suicide rates is greater in women than men. Lithium and other treatment for BD have been shown to lower rates of suicide attempts and deaths in people with BD. For a larger view of this slide, click here.

Comorbid ADHD and Depression
A significant number of patients with a mood disorder, especially those with bipolar I disorder, also have ADHD. Commonly used medications for ADHD have the potential to worsen anxiety symptoms and provoke mania or hypomania. In adults, episodes of major depressive disorder MDD cause significant morbidity and mortality, but when they occur with ADHD, such episodes are more prolonged, more likely to result in suicidal behaviors and hospitalizations, and more likely to convert from unipolar to bipolar mood disorders.

W. Burleson Daviss, MD, and Joseph B. Bond, MD, review the prevalence, assessment, and treatment of comorbid ADHD and depression. Their review not only provides an update on this important topic, but also helps clinicians understand the challenges and unmet needs in this population. They discuss potential risk factors related to comorbid ADHD and depression, strategies for proper diagnosis, and treatment approaches.

Significance for the practicing psychiatrist: Comorbid ADHD and depression frequently occur together, often leading to long-term impairment and treatment challenges. The general strategy for psychopharmacology and therapy is to treat the more severe and impairing condition first before treating the second condition. For a larger view of this slide, click here.