Psychiatry — Mood and Anxiety Disorders, NMC MBBS licence examination syllabus (Nepal Medical Council).
Depression and anxiety: the commonest conditions you will not be shown
Most people with either present to a general clinic, complaining of something else.
Depression and anxiety are among the most common conditions in medicine and among the most frequently missed. The reason is structural rather than clinical: people rarely arrive saying they are depressed. They arrive with headache, fatigue, abdominal pain, palpitations or insomnia, and they are investigated for those things — sometimes repeatedly, sometimes for years.
So the diagnostic skill here is not pattern recognition on an obvious presentation. It is remembering to ask, in a consultation that appears to be about something else. A single question about mood, asked in a general clinic, uncovers more depression than any investigation.
🩺 Where this lives: Mental illness carries a treatment gap wider than almost anything else in medicine — a large majority of people with depression in low- and middle-income settings receive no treatment at all. The barriers are stigma, few specialists, and a service that is not looking. That last one is the one you personally control. Most depression is treatable in general practice, and most of the missed diagnoses were sitting in a consultation about a physical symptom.
💡 A note on scope. This chapter covers recognition and treatment. It gives no drug doses and names no first-line agent — antidepressant choice follows national formularies and local availability, and doses are titrated. It also contains no detail about methods of self-harm. Risk assessment is covered in the Delirium and Risk Assessment chapter, and the principles there apply to every patient in this one.
Recognising depression
The distinction that matters is between sadness, which is a normal and appropriate response to loss, and depression, which is a syndrome. What separates them is duration, pervasiveness, loss of function, and the presence of features that unhappiness does not usually produce — anhedonia, guilt and worthlessness, and hopelessness about the future. A grieving person can still enjoy things intermittently; a depressed person often cannot enjoy anything at all.
THE SCREENING QUESTIONS WORTH ASKING ROUTINELY
In a general consultation, two questions detect most
depression:
"During the past month, have you often been bothered by
feeling down, depressed or hopeless?"
"During the past month, have you often been bothered by
having little interest or pleasure in doing things?"
A yes to either warrants a fuller assessment. That is the
whole screen — it costs about twenty seconds.
WHY ANHEDONIA IS SO USEFUL: it is much more specific to
depression than low mood alone. Many people feel low for
understandable reasons; far fewer lose the capacity to
enjoy anything.
AND ALWAYS ASSESS RISK. Asking about suicidal thoughts does
NOT increase risk — see the risk assessment chapter, where
this is covered in full.
What to exclude first
💡 Exam angle: always ask about past elevated mood. A history of a manic or hypomanic episode makes the diagnosis bipolar disorder rather than unipolar depression, and that changes treatment fundamentally — antidepressants given alone in bipolar disorder may precipitate a switch into mania. This is a favourite question stem: a patient with depression whose history includes a period of reduced need for sleep, elevated mood and uncharacteristic overactivity. Also remember hypothyroidism, which mimics depression closely and is easy to test for.
Treatment
FOUR THINGS PATIENTS ARE NOT TOLD OFTEN ENOUGH
1. IT TAKES WEEKS. Antidepressant effect on mood is
delayed. A patient who expects improvement in three days
will conclude the drug has failed and stop it. Say this
BEFORE prescribing.
2. SOME SYMPTOMS LIFT BEFORE MOOD DOES. Energy and
psychomotor retardation may improve first, while
hopelessness persists. This period warrants attention to
risk, and is a reason for early review.
3. CONTINUE AFTER RECOVERY. Stopping as soon as mood lifts
is among the commonest causes of relapse. Treatment
continues for a period after remission — take the
duration from your national guideline.
4. DO NOT STOP ABRUPTLY. Withdraw gradually; abrupt
cessation causes discontinuation symptoms that are
easily mistaken for relapse.
NON-DRUG MEASURES ARE NOT FILLER: structured psychological
therapy is effective, and in mild depression it is
preferred over medication. Sleep, activity, alcohol
reduction and social contact all matter, and combining
therapy with medication works better than either alone in
moderate to severe illness.
The anxiety disorders
Anxiety disorders are separated from one another by pattern rather than by content. Persistent free-floating worry is generalised anxiety; sudden discrete attacks are panic; anxiety tied to a specific trigger with avoidance is phobic; intrusive thoughts neutralised by rituals is obsessive-compulsive; and re-experiencing with avoidance and hyperarousal after trauma is post-traumatic stress. Ask when and how the anxiety comes, not just whether the person is anxious.
Panic and the physical differential
💡 Exam angle: panic disorder is a diagnosis of positive features and exclusion. The symptoms are genuinely physical — palpitations, chest tightness, breathlessness — so they overlap with arrhythmia, acute coronary syndrome, thyrotoxicosis, asthma and withdrawal states. A question stem describing a first episode in an older patient with cardiac risk factors is testing whether you will investigate before reassuring. Explanation itself is therapeutic in genuine panic: understanding the vicious circle is what breaks it.
Clinical reasoning: four presentations
🔍 Case 1 — the patient investigated for a year
PresentationA 34-year-old has attended repeatedly over a year with headache, fatigue and abdominal discomfort. Investigations have all been normal. She is described in the notes as a frequent attender.
Key questionHas anyone asked about her mood?
ReasoningDepression very commonly presents with physical symptoms, particularly where mental illness is stigmatised. Repeated normal investigations for multiple unexplained symptoms should prompt the two screening questions, not another test.
AnswerAsk about low mood and anhedonia, take a full history including sleep, appetite, function, alcohol and risk, and examine for organic causes such as hypothyroidism and anaemia before concluding.
🔍 Case 2 — depression with a history worth hearing
PresentationA 26-year-old has clear moderate depression. Two years ago he had a fortnight of elevated mood, barely slept, spent money uncharacteristically and talked incessantly. An antidepressant alone is proposed.
TrapTreating the episode in front of you without asking about the opposite pole.
ReasoningThat fortnight describes a manic or hypomanic episode, which makes this bipolar disorder. Antidepressant monotherapy here risks precipitating a switch into mania.
AnswerDo not start an antidepressant alone. Refer for specialist psychiatric assessment and management of bipolar disorder per national guideline.
🔍 Case 3 — chest pain in the emergency department
PresentationA 58-year-old smoker with hypertension presents with sudden chest tightness, palpitations, breathlessness and a fear of dying, resolving over 20 minutes. He appears anxious, and panic attack is recorded without investigation.
TrapUsing the patient's anxiety as the diagnosis.
ReasoningThe symptoms fit panic — but they also fit acute coronary syndrome and arrhythmia, and this is a first episode in an older patient with cardiac risk factors. Anxiety is an entirely normal response to frightening chest symptoms and does not distinguish the two.
AnswerInvestigate the physical differential first — ECG, troponin per protocol, and consider thyrotoxicosis. Panic disorder can be diagnosed once the alternatives are excluded.
🔍 Case 4 — better after a week, and stopping
PresentationA patient started on an antidepressant returns at 10 days saying it is useless and she has stopped it. She feels no different.
What went wrongExpectation, not the drug.
ReasoningAntidepressant effect on mood is delayed by weeks. At 10 days an absent response is expected, not evidence of failure. Warning the patient in advance is part of prescribing.
AnswerExplain the time course, address side effects and concerns, restart with agreement and arrange early review — assessing risk at each contact. Also confirm she has not stopped abruptly enough to cause discontinuation symptoms.
A first episode with risk factors must be investigated.
Generalised anxiety vs panic
Continuous worry versus discrete attacks
Different pattern, different management.
No response at 10 days vs failure
Effect on mood takes weeks
Premature stopping is a common cause of failure.
Recovery vs time to stop
Treatment continues after remission
Stopping at recovery invites relapse.
Rapid revision
MUST-KNOW FACTS
1. Depression commonly presents with PHYSICAL symptoms.
2. Repeated normal investigations should prompt asking about mood.
3. Core features: persistent low mood, ANHEDONIA, fatigue.
4. ANHEDONIA is more specific to depression than low mood alone.
5. Biological features: EARLY MORNING WAKENING, diurnal variation.
6. Also appetite and weight change, loss of libido, psychomotor change.
7. Cognitive features: guilt, worthlessness, hopelessness.
8. Sadness differs by duration, pervasiveness and loss of FUNCTION.
9. Two screening questions detect most depression in general practice.
10. ALWAYS ASK ABOUT PAST ELEVATED MOOD — bipolar changes everything.
11. Antidepressants alone in bipolar disorder may precipitate mania.
12. Exclude HYPOTHYROIDISM, anaemia and chronic disease.
13. Alcohol is both a cause and a consequence of depression.
14. In older patients distinguish depression, dementia and delirium.
15. Assess risk in every patient — see the risk assessment chapter.
16. Asking about suicide does NOT increase risk.
17. Mild depression: psychological therapy and lifestyle measures first.
18. Moderate to severe: antidepressant and/or structured therapy.
19. Combination therapy works better than either alone.
20. ANTIDEPRESSANTS TAKE WEEKS to improve mood.
21. Warn about the delay BEFORE prescribing.
22. Energy may improve before mood — attend to risk in that window.
23. CONTINUE treatment after recovery to prevent relapse.
24. Never stop an antidepressant abruptly — withdraw gradually.
25. Generalised anxiety: persistent free-floating worry.
26. Panic disorder: sudden discrete attacks peaking in minutes.
27. Phobic anxiety: specific trigger with avoidance.
28. OCD: obsessions relieved by compulsions, with insight retained.
29. PTSD: re-experiencing, avoidance and hyperarousal after trauma.
30. Panic symptoms are genuinely physical — exclude cardiac and thyroid causes.
31. Never diagnose panic in a first episode without considering the alternatives.
32. Explaining the vicious circle is itself therapeutic in panic.
💡 Exam angle: three threads recur. Depression hiding behind physical symptoms; the bipolar history that changes the treatment; and the panic attack that has to be distinguished from a cardiac event. Each is really the same lesson — the presenting complaint is not the diagnosis, and one extra question changes the answer.
Syllabus points
Why depression presents with physical symptoms
Core, biological and cognitive features
Sadness versus a depressive episode
The two screening questions
Asking about past elevated mood
Organic mimics: hypothyroidism and others
Treatment staged by severity
The delay to antidepressant effect
Continuing treatment and stopping gradually
Distinguishing the anxiety disorders by pattern
Panic and the physical differential
Why explanation is therapeutic in panic
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