1. Major depression with melancholia is characterised by:
- marked loss of pleasure in all or almost all activities
- lack of reactivity of mood
- guilt,
- diurnal variation
- worse in the morning,
- early morning awakening
- loss of appetite and weight.

2. Mania occurring for the first time in later life may be secondary to medications, such as corticosteroids, or medical illnesses such as cerebrovascular disease, and acquired immunodeficiency syndrome. It should be fully investigated.

3. Referral to a psychiatrist should be considered when:
- bipolar disorder,
- active suicidal thoughts,
- no response to one or two trials of treatment,
- co-morbid medical, psychiatric, or substance use disorder,
- need for ECT.

4. Prophylactic treatment of bipolar disorder should be considered in a patient having 2 or more previous episodes of either mania or depression.

5. Prophylactic treatment of bipolar disorder: controlled trials have established the efficacy of lithium and carbamazepine. Sodium valproate is in widespread clinical use for maintenance treatment; controlled data have yet to be published.

6. In patients taking lithium, toxicity may occur in:
-intercurrent illness,
-fluid loss or use of diuretics,
-non-steroidal anti-inflammatory drugs,
-angiotensin converting enzyme inhibitors,
-reduce renal clearance.

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