Psychiatry Learning Map

Psychiatry: disorder groups

Depressive disorders

Depressive disorders are persistent low mood or loss of interest with changes in sleep, energy, thinking and self-worth that impair daily life. They are among the most common conditions a psychiatrist treats, and a major cause of disability and suicide.

Depth by stage, Pre-U → Consultant (details)

What is it?

Depression is more than sadness. A person with a depressive disorder has low mood or loss of pleasure most of the day, nearly every day, for at least two weeks, along with problems such as poor sleep, low energy, poor concentration, guilt, changes in appetite and sometimes thoughts of death.

It ranges from mild episodes that can be helped by psychological therapy and lifestyle changes to severe depression with psychotic features, stopping eating or drinking, or a high risk of suicide. Some people have long-lasting milder depression (dysthymia).

Depression is common in Malaysia as elsewhere, and often presents first to general practitioners with physical complaints such as tiredness, pain or poor sleep.

Why does a psychiatrist need it?

Depression is everywhere in psychiatric practice: outpatient clinics, liaison work with medically ill patients, perinatal and old age services, and emergencies after self-harm. A psychiatrist must assess severity and risk, choose between therapy, antidepressants, combination treatment and ECT, and manage treatment-resistant cases.

What level is expected at each stage?

Scale: 1. Aware → 2. Understands → 3. Applies → 4. Masters / Teaches. What the levels mean.

  1. Pre-UNot expected
  2. Pre-clinicalAwareLearns depression as a common condition in behavioural science and its basic neurobiology.
  3. ClinicalUnderstandsTakes a depression history, screens for suicidal ideas and names common antidepressants.
  4. HousemanshipUnderstandsSpots depression in medical and surgical patients and assesses patients after self-harm with supervision.
  5. Medical officerAppliesDiagnoses, starts and reviews antidepressants, coordinates psychology referrals and assesses suicide risk.
  6. Psych traineeMasters / TeachesManages severe, psychotic and treatment-resistant depression, ECT decisions and psychotherapy; core exam area.
  7. Specialist / consultantMasters / TeachesLeads complex cases, service pathways and teaching on mood disorders.

What are the key topics?

Conditions

  • Single-episode and recurrent depressive disorder (ICD-11) / major depressive disorder (DSM-5-TR)
  • Dysthymic disorder / persistent depressive disorder
  • Mixed depressive and anxiety disorder (ICD-11)
  • Premenstrual dysphoric disorder
  • Depression with psychotic, melancholic or seasonal features
  • Depression secondary to medical illness or substances

Causes

  • Biopsychosocial model: genes, early adversity, life events, social isolation
  • Monoamine theory and its limits; neuroplasticity and stress-hormone (HPA axis) theories
  • Cognitive models: negative automatic thoughts and core beliefs
  • Physical illness links: thyroid disease, stroke, diabetes, heart disease, chronic pain
  • Medication causes such as some steroids and other drugs

Assessment

  • Core and associated symptoms, duration and severity
  • Screening and severity tools such as PHQ-9, HAM-D, MADRS, BDI
  • Suicide and self-harm risk assessment
  • Past hypomania (to exclude bipolar disorder)
  • Physical examination and blood tests (e.g. thyroid, blood count)
  • Social circumstances, supports and stressors

Treatment

  • Mild: guided self-help, behavioural activation, exercise, problem-solving
  • Moderate to severe: antidepressants (SSRIs, SNRIs, mirtazapine, others) and/or CBT, IPT
  • Antidepressant side effects, discontinuation symptoms and the early-treatment suicide warning in young people
  • Treatment-resistant depression: switching, augmentation with lithium or antipsychotics, newer options
  • ECT for severe, psychotic or life-threatening depression
  • Relapse prevention: continuing treatment, mindfulness-based approaches

Malaysian context

  • MOH has published a Clinical Practice Guideline on major depressive disorder
  • Many cases are managed in primary care; psychiatry sees severe or complex cases
  • Somatic presentation and stigma are common reasons for late diagnosis
  • Crisis support lines and NGOs supplement hospital services

How is it learned and assessed?

  • Behavioural science lectures in pre-clinical years
  • Undergraduate psychiatry clerkships and OSCE stations (depression and suicide risk history)
  • MO outpatient clinics and emergency assessments
  • MMed Part I and II; MRCPsych Paper A (pharmacology, psychology), Paper B (evidence on treatments), CASC (risk assessment, explaining antidepressants)

Typical textbooks and resources

  • Shorter Oxford Textbook of Psychiatry — Oxford University Press
  • The Maudsley Prescribing Guidelines in Psychiatry — Wiley
  • Cognitive Therapy of Depression — Aaron T. Beck and colleagues; foundational CBT text
  • MOH Malaysia Clinical Practice Guidelines on major depressive disorder — Ministry of Health

Titles are widely used examples; editions change. Use university libraries or legitimate purchases.

Common questions

How does a psychiatrist decide between therapy and medication for depression?

It depends mainly on severity, the person's preference, past response and access. Mild depression often improves with psychological approaches alone; moderate to severe depression usually benefits from antidepressants, therapy, or both.

Are antidepressants addictive?

They do not cause craving or compulsive use in the way addictive drugs do, but stopping suddenly can cause discontinuation symptoms, so doses are usually reduced gradually with the doctor's advice.

Related subjects

Official sources to check