19. DEPRESSION AND MANIA

Depression and mania are mood disorders that affect how a person thinks, feels and behaves. Depression leads to persistent sadness and loss of interest, while mania causes abnormally elevated mood and increased energy. Both conditions may occur separately or together as part of bipolar disorder.

Depression

What is Depression?

Depression is a common mental disorder marked by sadness, hopelessness, tiredness, poor sleep or appetite, and reduced interest in daily activities. It can last for weeks, months or years and significantly affects work, social life and health.

Types of Depression

  • Major Depression: Low mood or loss of pleasure for at least two weeks with symptoms like sleep change, fatigue, guilt and suicidal thoughts.
  • Chronic Major Depression: Depressed mood for at least two years with fatigue, low self-esteem and poor concentration.
  • Dysthymia: Mild but long-lasting depression for over two years; patients may also experience major episodes (“double depression”).
  • Seasonal Affective Disorder (SAD): Depression during winter or low sunlight periods; improves with light therapy.
  • Bipolar Depression: Part of bipolar disorder where depression alternates with mania; antidepressants may worsen symptoms.

Special Features of Depression

  • Atypical: Increased appetite, excessive sleep, mood improvement after positive events.
  • Mixed Features: Depression with some manic symptoms.
  • Psychotic Features: Hallucinations or delusions.
  • Catatonia: Abnormal or fixed body movements.
  • Peripartum: Occurs during pregnancy or after childbirth.

Epidemiology

About 8–12% of people experience depression in their lifetime. More common in women. In India, stressful life events, lack of support, substance abuse and chronic illnesses increase risk.

Causes and Risk Factors

  • Genetic predisposition
  • Imbalance of serotonin and norepinephrine
  • Stressful events like divorce, financial issues or bereavement
  • Childhood trauma
  • Drugs such as corticosteroids, beta-blockers or alcohol
  • Chronic illnesses (diabetes, COPD, cardiovascular disease)

Pathophysiology

The most accepted theory is the monoamine deficiency hypothesis. Low serotonin (5-HT) and norepinephrine (NE) levels affect emotional and physical symptoms. Reduced serotonin production or receptor activity may contribute to low mood, poor sleep, appetite changes and pain sensitivity.

Symptoms

Symptoms occur most of the day for at least two weeks:

  • Sadness, crying, irritability
  • Loss of interest in previously enjoyable activities
  • Sleep changes (insomnia or excessive sleep)
  • Fatigue, low energy
  • Appetite and weight changes
  • Guilt, feelings of worthlessness
  • Slow movements or speech
  • Difficulty concentrating
  • Thoughts of death or suicide
  • Physical symptoms like headaches or back pain

Diagnosis

Diagnosis is clinical. Tests like CBC, thyroid profile and metabolic panel help rule out other causes. Psychometric tools assess mood changes. Brain imaging (CT/MRI) is used only when needed.

Treatment

Medications

  • SSRIs: Fluoxetine, Sertraline, Paroxetine
  • SNRIs: Venlafaxine, Duloxetine
  • Atypical Antidepressants: Trazodone, Mirtazapine
  • Tricyclics: Imipramine, Nortriptyline
  • MAOIs: Phenelzine, Tranylcypromine

Psychotherapy

  • Cognitive Behavioural Therapy (CBT)
  • Interpersonal therapy
  • Family and couples therapy
  • Problem-solving therapy
  • Psychodynamic therapy

Lifestyle Measures

  • Good sleep habits
  • Regular exercise
  • Avoiding alcohol or drugs
  • Social support and structured activities

Mania

What is Mania?

Mania is a period of abnormally elevated or irritable mood, increased activity and decreased need for sleep. It is a core feature of bipolar I disorder, but can also occur due to medical conditions or substance use.

Types of Mania

  • Hypomania: Mild form without major functional impairment.
  • Mania: Severe mood elevation affecting daily life.
  • Mixed State: Features of depression and mania occur together.

Causes

  • Genetic susceptibility
  • Dopamine and serotonin dysregulation
  • Stressful events
  • Substance abuse
  • Sleep disruption

Pathophysiology

Mania is associated with:

  • Dopamine overactivity, causing euphoria and impulsivity
  • Serotonin imbalance
  • Limbic system dysregulation
  • Circadian rhythm disruption

Symptoms of Mania

  • Overly happy or irritable mood
  • Increased energy and reduced need for sleep
  • Rapid speech
  • Racing thoughts
  • Impulsive behaviour (spending, risky sex, drug use)
  • Grandiosity or unrealistic confidence
  • Poor judgment

Diagnosis

Diagnosis uses DSM-5 criteria: elevated or irritable mood for at least one week, plus three or more symptoms such as rapid speech, decreased sleep, distractibility or risky behaviour. Medical causes like thyroid disorders or drug use must be ruled out.

Treatment of Mania

  • Mood stabilizers: Lithium, valproate, carbamazepine
  • Atypical antipsychotics: Olanzapine, Risperidone, Quetiapine
  • Psychotherapy: Psychoeducation, CBT, social rhythm therapy
  • Lifestyle changes: Regular sleep schedule, avoiding alcohol/drugs, stress management

Detailed Notes:

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