What is the recommended treatment approach for a patient presenting with a mood disorder?

Treatment Approach for Mood Disorders

For patients presenting with mood disorders, the treatment approach depends critically on accurate diagnosis: Major Depressive Disorder (MDD) requires either cognitive behavioral therapy (CBT) or second-generation antidepressants (SSRIs/SNRIs) as first-line treatment, while Bipolar Disorder requires mood stabilizers (lithium or valproate) with ongoing maintenance therapy, making proper screening essential before initiating any treatment. 1, 2

Critical First Step: Differential Diagnosis

The single most important initial action is distinguishing between unipolar depression (MDD) and bipolar spectrum disorders, as this fundamentally changes treatment strategy and prevents potentially harmful interventions 3.

• Screen for bipolar disorder in all patients presenting with depressive symptoms using validated instruments like the Mood Disorder Questionnaire (MDQ), which has 73% sensitivity and 90% specificity for detecting bipolar spectrum disorders 4
• Bipolar disorder is misdiagnosed as MDD in approximately 40% of cases at first examination, with proper diagnosis often delayed by 10 years, leading to inappropriate antidepressant monotherapy that can worsen outcomes 5
• Clinical features suggesting bipolar rather than unipolar depression include: family history of bipolar disorder, early age of onset, psychotic features, postpartum onset, and history of antidepressant-induced mania 3

Treatment for Major Depressive Disorder

First-Line Options

The American College of Physicians strongly recommends either CBT or second-generation antidepressants as equivalent first-line treatments for MDD, with selection based on severity, patient preference, and practical considerations. 1

• For mild depression: Start with CBT alone, as it has equivalent effectiveness to antidepressants with moderate-quality evidence 1
• For moderate to severe depression: Initiate SSRIs or SNRIs selected based on adverse effect profiles, cost, and patient preferences 1
• For severe depression with high-risk features: Combination therapy (psychotherapy + antidepressant) produces superior outcomes, with remission rates nearly doubling (57.5% vs 31.0%, P < 0.001) compared to antidepressant monotherapy 1

Pharmacotherapy Specifics

• SSRIs are recommended as first-line agents due to favorable side effect profiles 6
• SNRIs (such as venlafaxine) are slightly more effective than SSRIs for improving depression symptoms, though they carry higher rates of nausea and vomiting 1
• Bupropion dosing for MDD: Start 150 mg once daily in the morning; after 4 days, increase to target dose of 300 mg once daily 7

Treatment Duration and Monitoring

• Continue treatment for at least 4-9 months after satisfactory response for first episodes 1
• For recurrent episodes, prolonged treatment (≥1 year or longer) is beneficial 1
• Assess response within 1-2 weeks of initiation, monitoring for therapeutic effects, adverse effects, and suicidality 1
• If inadequate response by 6-8 weeks, modify treatment through dose adjustment, switching agents, or adding augmentation strategies 1

Treatment for Bipolar Disorder

Acute Phase Management

Mood stabilizers (lithium or valproate) are the foundation of bipolar disorder treatment, with most patients requiring ongoing maintenance therapy to prevent relapse. 2

• Initiate either lithium or valproate as first-line mood stabilizer 2
• Allow 6-8 weeks for adequate trial at therapeutic doses before adding or substituting other mood stabilizers 2
• Atypical antipsychotics may be added for acute mania, but require careful metabolic monitoring 2

Maintenance Therapy

• Over 90% of non-compliant adolescents relapsed versus 37.5% of compliant patients in prospective studies 2
• Maintain the regimen that stabilized acute mania for 12-24 months minimum 2
• Many patients require lifelong therapy when benefits of continued treatment outweigh risks, decided case-by-case 2
• Median time to relapse after switching to monotherapy is 3 months 2

Critical Monitoring Requirements

Before initiating lithium: Complete blood count, thyroid function tests, urinalysis, BUN, creatinine, serum calcium, and pregnancy test in females 2

Once stable on lithium: Monitor lithium levels, renal and thyroid function, and urinalysis every 3-6 months 2

Before initiating valproate: Baseline liver function tests, complete blood count, and pregnancy test 2

Once stable on valproate: Monitor serum drug levels, hepatic and hematological indices every 3-6 months 2

For atypical antipsychotics: Baseline BMI, waist circumference, blood pressure, fasting glucose, and fasting lipid panel; follow BMI monthly for 3 months then quarterly; follow blood pressure, fasting glucose, and lipids after 3 months then yearly 2

Antidepressant Use in Bipolar Disorder

• Antidepressants have demonstrated little or no efficacy for depressive episodes in bipolar disorder 3
• Use antidepressants only as adjunct to mood stabilizers, never as monotherapy 3
• Treatment with stimulants for comorbid ADHD is safe once mood symptoms are stabilized with mood stabilizers 2

Mood Disorders Secondary to Medical Conditions

• First step: Treat underlying medical causes of depressive symptoms and delirium 6
• Review and adjust medications that may contribute to mood symptoms, considering dose reduction or substitution when possible 6
• SSRIs remain first-line pharmacological agents due to favorable side effect profile 6
• Psychotherapy, CBT, and exercise are effective non-pharmacological treatments 6

Common Pitfalls to Avoid

• Failing to screen for bipolar disorder before initiating antidepressants, which can precipitate mania or rapid cycling 3
• Inadequate dosing or premature discontinuation before therapeutic effects are achieved (typically 4-6 weeks) 1
• Not monitoring for suicidality, especially during initial treatment period 1
• Discontinuing treatment too early, before completing minimum 4-9 months after response 1
• Attempting to discontinue prophylactic therapy abruptly in bipolar disorder rather than gradually while monitoring for relapse 2
• Using unnecessary polypharmacy without discontinuing agents that haven't demonstrated significant benefit 2