Depression

• What is depression?

  Depression refers to both negative affect (low mood) and/or absence of positive affect (loss of interest and pleasure in most activities) and is usually accompanied by a variety of emotional, cognitive, physical and behavioural symptoms.
• Depression is the most common psychiatric disorder. It is the leading cause of disability globally.
• What are the risk factors of depression?(adult)

  Chronic comorbidities (chronic pain syndromes, diabetes, COPD, CVD)

  Other mental health problems (schizophrenia, dementia)

  Medication (corticosteroids)

  Female (but males are more at risk of suicide)

  Older age

  Recent childbirth

  Psychosocial issues (divorce, poverty, homelessness, unemployment)

  Personal Hx of depression

  FHx of depression

  Adverse childhood experiences (abuse, poor parent-child relationship)

  Personality factors

  Past head injury

  Pregnancy/postnatal
• What are the RFs for depression in children and adolescents?

  Family discord

  Bullying

  Physical/sexual/emotional abuse

  Comorbid disorders (drug & alcohol use)

  Hx of parental depression

  Ethnicity & culture

  Homelessness

  Refugee status

  Living in institutional settings
• How can depression present in the elderly?

  Pseudodementia

  abnormalities of memory & behaviour that are typical of true dementia
• What are the diseases associated with depression?

  Dysthymia (chronic depressive state for > 2 years that does not meet criteria for major depressive state)

  Eating disorders (anorexia nervosa, bulimia nervosa)

  Substance misuse

  Other psychiatric conditions (generalised anxiety disorder, panic disorder, OCD, personality disorders)

  Parkinson's disease

  Chronic diseases (diabetes & CVD)

  Cerebrovascular disease

  Endocrine disorders (hyperthyroidism, Cushing's, Addison's & hyperparathyroidism

  Cancer (esp. pancreatic)

  Autoimmune conditions
• How does NICE classify the severity of depression?

  Less severe depression -> scoring less than 16 on the PHQ-9 scale

  More severe depression -> scoring 16 or more on PHQ-9 scale
• What is chronic depression?

  people with symptoms which continually meet criteria for diagnosis of major depressive episode for > 2 years OR have persistent subthreshold symptoms with or w/o concurrent episodes of major depression for > 2 years
• What is seasonal affective disorder (SAD)?

  Episodes of depression which recur annually at the same time each year, with remission in between (usually appear in winter & remit in spring)
• What are the 2 'depression identification' questions?

  During the last month, have you often been bothered by feeling down, depressed, or hopeless?

  During the last month, have you often been bothered by having little interest or pleasure in doing things?

  If answer is 'yes' to either of Qs, ask about associated symptoms of depression
• Mirtazapine is a good option for cases of depression that are complicated with insomnia and/or poor appetite. As it has side effects of sedation & increased appetite.
• What are the signs & symptoms of depression?

  • Anhedonia
  • Persistent low mood
  • Disturbed sleep (decreased or increased compared to usual)
  • Decreased or increased appetite and/or weight
  • Fatigue/loss of energy
  • Poor concentration/memory
  • Feelings of worthlessness/excessive/inappropriate guilt
  • Suicidal ideation
  • Poor motivation
  • Irritability
  • Low self-esteem
  • Ruminations on the negative
  • Self neglect
  • Psychosis (delusions/hallucinations)
  • Low libido
  • Psychomotor retardation/agitation
  • Social withdrawal
• What is psychomotor agitation?

  Observable restlessness (pacing up & down)
• What is psychomotor retardation?

  Significant slowing down of thought & reduction of physical movement
• How many symptoms & for how long leads to a diagnosis of depression?

  At least 5 symptoms, over 2 week

  At least 1 symptom has to be anhedonia or low mood

  Symptoms should also cause significant distress/impairment in functionality
• What is the DDx of depression?

  Bipolar disorder

  Dysthymia (persistent depressive disorder)

  Adjustment disorder with depressed mood

  Anxiety disorders

  Hypothyroidism

  Neurological disorders (PD, MS)

  Chronic pain syndromes

  Nutritional deficiencies (vit B12, folate, vit D)

  Endocrine disorders (Cushing's, Addison's)

  Substance misuse

  Medication-induced depression (beta-blockers, corticosteroids, isotretinoin)
• What is adjustment disorder with depressed mood?

  Depressive symptoms in response to significant life change/stressor

  Generally resolves within a few months after stressor has ceased
• What is the management of less severe depression?

  Self-help

  CBT (group/individual)

  Behavioural activation (group/individual)

  Mindfulness & meditation

  Interpersonal psychotherapy

  SSRIs

  Counselling
• What is the management for more severe depression?

  Combination of CBT & antidepressant

  CBT alone

  Behavioural activation

  Antidepressant (SSRI, SNRI, TCA etc)

  Counselling

  Interpersonal psychotherapy
• What is the treatment of life-threatening depressive episodes?

  ECT
• What are the 2 main depression questionnaires?

  PHQ-9 (Patient Health Questionnaire-9)

  • 9 point scale
  • Rates depression as mild, moderate or severe
  • Used in primary care and IAPT (CBT services)

  HADS (Hospital Anxiety & Depression Scale)

  • Adapted from PHQ-9 for hospital
• What are the vulnerability factors of depression?

  Genetics

  Adverse childhood events

  Female (2x)

  Substance abuse
• What are the stress factors for depression?

  Lots of stressors (cumulative stress)

  Bereavement

  Loss events (job, roles, partner etc)

  Situations where feel trapped/powerless (eg domestic violence, poverty/ debt, overwhelming carer stress)

  Chronic illness
• What are the possible complications of depression?

  Impacts personal & social functioning

  Increased risk of medical complications

  Increased risk of substance misuse

  Increased risk of self-harm, self-neglect & suicide
• Psychotic beliefs can occur in severe depression.

  • Common beliefs -> nihilistic beliefs (believing that all/part of you is dead)
  • Common delusions -> delusions of poverty, guilt, disease, punishment
  • Can also develop hallucinations (smelling like rotten flesh, seeing dead people, hearing voices telling them to kill themselves)
• What should you do if a pt is experiencing delusions around other people, especially children?

  EMERGENCY

  need assessment by mental health team

  Safeguarding concern -> children have been killed due to delusions in the past
• Why is ECT used in severe depression?

  Antidepressants don't work quick enough
• What is important to explain when initiating antidepressants?

  Meds will take 4-6 weeks to work

  Side effects (rare but pts might feel increased suicidality)

  Pt will need to stay on meds for 6 months (1st episode) or 2 years (recurrent)

  When stopping can get withdrawal -> so reduce slowly w/medical advice

  Meds are not addictive
• What do you need to consider before prescribing antidepressants?

  Consider risk of overdose

  Cardiac conditions (risk of arrhythmia), epilepsy (lowers seizure threshold), pregnancy (SSRIs associated w/autism) -> sertraline is the safest in these cases
• What is serotonin syndrome?

  Group of symptoms caused by excessive serotonin in CNS
• What are the symptoms of serotonin syndrome?

  Cognitive changes

  • agitation
  • confusion
  • euphoria
  • insomnia
  • hypomania
  • hallucinations

  Autonomic changes

  • tachycardia
  • HTN
  • fever
  • diaphoresis
  • mydriasis
  • arrhythmias
  • tachypnoea

  Neuromuscular changes

  • tremor
  • hyperreflexia
  • clonus
  • ataxia
  • incoordination
  • seizures
• What are the investigations to consider in depression?

  Metabolic panel - provides baseline, may reveal metabolic disturbances

  FBC - to rule out other causes of fatigue (e.g. anaemia)

  TFTs - to rule out hypothyroidism

  PHQ-9 - diagnostic questionnaire, 9-item depression questionnaire
• What is the PHQ-9?

  Patient Health Questionnaire

  Diagnostic & disease management tool

  Classifies current symptoms on scale 0 (no symptoms) to 3 (daily symptoms)

  Score out of 27

  Results

  • 5-9 -> mild depression
  • 10-14 -> moderate depression
  • 15-19 -> moderately severe depression
  • 20-27 -> severe depression
• What are the essential factors in a history of depression?

  Caring responsibilities (e.g. children or vulnerable adults)

  Social support

  Drug use

  Alcohol use

  Forensic history (e.g. violence or abuse)

  Risk assessment
• What are the RFs for relapse?

  Older age of onset

  Hx of recurrent episodes of depression

  Incomplete response to previous treatment (inc residual symptoms)

  Unhelpful coping styles of behaviours (avoidance/rumination)

  Hx of severe depression

  Other chronic physical/mental health conditions (esp in elderly)

  Ongoing personal, social, or environmental factors
• What are the factors that suggest a diagnosis of depression over dementia?

  Short Hx, rapid onset

  Biological symptoms (weight loss, sleep disturbance)

  Pt worried about poor memory

  Reluctant to take tests, disappointed with results

  Global memory loss (dementia usually causes recent memory loss)