Mood Disorders in Special Populations

Children & Adolescents: Mood Disorders - Tiny Tempests

• Presentation: Irritability, somatic complaints, ↓ school performance common. Less classic adult sadness.
• MDD: Anhedonia, changes in sleep/appetite, social withdrawal.
• Bipolar Disorder: Often misdiagnosed (e.g., ADHD). Note episodic nature, family history. Early onset = ↑ severity.
• DMDD: Persistent irritability, frequent temper outbursts (≥3/week). Onset <10 yrs. Cannot coexist with ODD, IED, Bipolar.
• Comorbidities: ADHD, anxiety, conduct disorder frequent.
• Tx: Psychotherapy (CBT, IPT) first. SSRIs (fluoxetine >8 yrs for MDD) cautiously (⚠️ Black Box: ↑ suicidal ideation).

⭐ In children, depression often manifests as irritability rather than pervasive sadness.

Geriatric Population: Mood Disorders - Golden Age Blues

• Late-Onset Depression: >60 yrs, often linked to vascular changes ("vascular depression").
• Atypical Presentation:
  • Somatic complaints, apathy, anhedonia > overt sadness.
  • Cognitive impairment ("pseudodementia") common.
• High Suicide Risk: Especially older males; lethal attempts.
• Key Considerations:
  • Polypharmacy interactions.
  • Comorbid medical illnesses.
  • Differentiating bereavement from clinical depression.
• Treatment:
  • SSRIs (e.g., Sertraline) preferred; "start low, go slow".
  • ECT: Safe & effective, esp. for severe/psychotic depression.
  • Avoid: TCAs (cardiac, anticholinergic), Benzodiazepines (falls, cognition).

⭐ Pseudodementia, a depression-induced cognitive deficit in the elderly, is reversible with effective antidepressant therapy, unlike dementia.

Pregnancy & Postpartum: Mood Disorders - Maternal Mood Swings

• Screening: Edinburgh Postnatal Depression Scale (EPDS). Score >10-12 suggests PPD.
• Key Differentiators:

⭐ High-Yield: Sertraline is often a preferred SSRI during breastfeeding due to its lower passage into breast milk.

Medical Co-morbidity & Substance Use: Mood Disorders - Body & Mind Bind

• Bidirectional link: Mood disorders ↔ Medical illness/Substance Use Disorders (SUDs). Each can worsen the other.
• Common Medical Co-morbidities:
  • Cardiovascular disease (CVD), Diabetes Mellitus (DM), Thyroid disorders (Hypo/Hyper)
  • Chronic pain, Neurological disorders (e.g., Stroke, Parkinson's disease)
  • Autoimmune diseases (e.g., SLE), Cancer
• Substance Use:
  • High co-occurrence (Dual Diagnosis).
  • Alcohol, opioids, stimulants commonly implicated.
  • Substances can induce/mimic/worsen mood; withdrawal is a trigger.
• Mechanisms: Inflammation (↑cytokines), HPA axis dysregulation, shared genetic vulnerability.
• Management:
  • Screen thoroughly for both. ⚠️ Missed co-morbidity worsens prognosis.
  • Integrated treatment approach is key.
  • Address lifestyle factors (diet, exercise).

⭐ Patients with depression have a ~40% increased risk of developing cardiovascular disease compared to the general population.

High‑Yield Points - ⚡ Biggest Takeaways

• Children & Adolescents: Irritability often key symptom, not just sadness; Fluoxetine (age >8) approved; SSRIs carry suicidality risk.
• Elderly: Late-onset depression common, often with medical illness or cognitive decline; ECT frequently safe & effective.
• Pregnancy: Sertraline is a preferred SSRI; Valproate is contraindicated. Untreated maternal depression harms both mother and child.
• Postpartum: Differentiate blues (common, transient), depression (requires treatment), and psychosis (psychiatric emergency, risk of infanticide).
• Medically Ill: Depression is prevalent and worsens prognosis in conditions like cardiac disease, stroke, cancer, and hypothyroidism.
• PMDD (Premenstrual Dysphoric Disorder): Severe mood symptoms in luteal phase; SSRIs are first-line treatment, can be given continuously or only in luteal phase.
• Bipolar Disorder in Children: Often presents with severe irritability, mood lability, and ADHD-like symptoms, making diagnosis challenging.