Define and classify depression
Clinically low in mood with cluster of physical, psychological associated symptoms which distort thinking and reduced motivation. Depression may be mild, moderate, severe or severe with psychotic symptoms, depending on the number of sx and how pervasive the disease is. Biological sx tend to emerge as the disease becomes more severe (psychotic sx occur in very severe cases.)
1-year prevalence and lifetime prevalence of major depression
- The 1-year prevalence of major depression in the general population is 5.3%
- Lifetime prevalence of major depression is 13%.
Mean age of onset of depression
Mean age of onset of depression is 30 years.
Risk factors for depression
- Women have a higher prevalence, incidence and morbidity associated with depressive disorders compared to men (1 in 4 women compared to 1 in 10 men develop depression requiring tx)
- Past hx of depression
- Hx of mental health disorders (dementia, personality disorder) or chronic pain disorders
- Social factors
- More common in people from African-Caribbean Asian, refugee communities (not in native communities)
ICD10 criteria for depression diagnosis
ICD10 requires that the depressive episode must last for at least 2 weeks and represent a change from normal. It must not be secondary to other causes such as drugs, alcohol misuse, medication etc. Must have 2 of the 3 core symptoms (ICD11 categorises anergia under biological sx)
Core Symptoms:
- Low mood, Anergia, Anhedonia
Other (not core) symptoms of depression
- Irritability, anxiety, tearfulness, diurnal variation – classically mornings feel worse,
- Biological symptoms- poor sleep including ‘initial insomnia’ or ‘early morning wakening’, poor appetite and weight loss, poor concentration, poor motivation, loss of libido, aches and pains, constipation
- Cognitive symptoms- reduced self-esteem/self-confidence, slowing of thoughts, psychomotor retardation, Ideas or acts of self-harm or suicide. In older people loss of memory can be assumed to be dementia but will actually resolve with treatment of depression- ‘pseudodementia’
- Psychotic symptoms- Hallucinations or delusions which are usually ‘mood congruent’e.g second person ‘derogatory’ auditory hallucinations (visual is less common.) Delusions are often nihilistic, persecutory, or guilt related.
What is recurrent depressive disorder
when someone experiences at least two depressive episodes, separated by several months of wellness.
What is atypical depression
Depression with features such as increased appetite, increased sleep, fatigue, leaden paralysis
What is dysthmia
Chronic low grade depression >2 years, less severe than depression but low spontaneous remission rate
What is seasonal affective disorder
low mood related to season, likely related to melatonin synthesis responds to light therapy (can also give SSRIs)
Depression differentials
- Medications: antihypertensives (beta blockers, methyldopa, calcium channel blockers), steroids, Histamine H2 blockers, sedatives, muscle relaxants, retinoids, chemotherapy agents, sex hormones e.g. oestrogen etc, psychiatric medications.
- Substance misuse: alcohol, benzodiazepines, opiates, marijuana, cocaine, amphetamines etc.
- Psychiatric illness: BPAD, dysthymia, anxiety disorder, schizoaffective, schizophrenia (negative), personality disorder, adjustment disorder, normal bereavement
- Neurological: dementia, Parkinson’s disease, tumours, stroke etc
- Endocrine: hyper/hypothyroidism, Addison’s disease, Cushing’s disease, menopause, hyperparathyroidism
- Metabolic: hypoglycaemia, hypercalcaemia, porphyria
- Others: anaemia, infections, (syphilis, Lyme disease, HIV encephalopathy), sleep apnoea (might explain tiredness, anergia)
Necessary investigations (outline)
- Collateral history to establish baseline
- Exclude physical causes
- Scrrening tools
Required investigations for excluding physical causes of depression
- Blood tests: may include blood glucose, U&Es, LFTs, TFTs, calcium levels, FBC and inflammatory markers.
- Other tests may include magnesium levels, HIV or syphilis serology, or drug screening.
- Cognitive assessment where dementia/pseudodementia are differentials
- Imaging (MRI or CT brain scanning) may be indicated where presentation or examination is atypical or where there are features suspicious of an intracranial lesion e.g. unexplained headache or personality change.
Screening tools used to identify and classify depression
- Patient Health questionnaire-9 (PHQ-9): uses 9 questions to diagnose and assess the severity of depression. It takes about three minutes to complete. Scores are categorised as minimal (1-4), mild (5-9), moderate (10-14), moderately severe (15-19) and severe depression (20-27).
- Hospital anxiety and depression scale (HADS): It is designed to assess both anxiety and depression. It takes about 5 minutes to complete. The anxiety and depression scales each have seven questions and scores are categorised as normal (0-7), mild (8-10), moderate (11-14) and severe (15-21).
How can mild depression be managed in the community?
- Resolves spontaneously if mild à watchful waiting approach or refer for supportive counselling or problem-solving therapy
- Advice on: Sleep hygiene, Exercise, Self-help, Access to CBT or counselling
- Address social stressors: time off work, respite for carers, support groups
Factors necessitating hospital admission
- Self-neglect, risk of suicide/ self-harm, risk to others, poor social support, psychotic symptoms, lack of insight, treatment-resistant.
Steps in depression stepped care model
- Always choose the least intrusive and most effective intervention
- Step 1: all known and suspected presentations of depression > Assessment, support, psychoeducation, active monitoring and referral for further assessment and interventions
- Step 2: persistent subthreshold depressive symptoms, mild-to-moderate depression > Low-intensity psychological interventions, psychological interventions, medication, referral for further assessment and interventions
- Step 3: Persistent subthreshold depressive symptoms or mild-to-moderate depression with inadequate response to initial interventions, moderate-to-severe depression > Medication, high-intensity psychological interventions, combined treatments, collaborative care and referral for further assessment and interventions
- Step 4: Severe and complex depression, risk to life, severe self-neglect > Medication, high-intensity psychological interventions, ECT, crisis service, combined treatments, multi-professional and inpatient care • Explain that symptoms may get worse soon after starting treatment (refer to help services such as crisis lines, Samaritans, A&E)
When are antidepressants usually indicated?
For moderate to severe depression, ideally alongside psychological interventions.
An antipsychotic is added in psychotic depression. SSRIs are the first choice antidepressants since they have more mild SEs and are less dangerous in overdose (should still be counselled on risk of suicide).
When can an effect be expected after commencing antidepressant treatment. For ho long should it continue?
Within 1-2 weeks of commencing antidepressant therapy. Treatment should continue for 6-9 months after recovery to prevent relapse and for up to 2 years after in recurrent depression.
Management of mild to moderate depression
- Should be managed in the community setting as above: sleep hygiene advice etc.
- Need to arrange a further assessment within 2 weeks
- Offer low-intensity psychological intervention:
- Individual-guided self-help based on the principles of CBT
- Computerised CBT: typically takes place over 9-12 weeks using CBT model
- Structured group physical activity programm
- Group CBT if low-intensity psychological intervention is declined
- ONLY offer medication if: past history of moderate or severe depression, sx have been present for >2 years (likely dysthymia), or symptoms persist after other interventions fail.
- Warn against St John’s wort- can cause serotonin syndrome and has unknown interactions
Management of moderate to severe depression
- Provide a combination of:
- Antidepressant medication
- High intensity psychological intervention > CBT or interpersonal therapy (IPT)
- After starting antidepressant medication: review after 2 weeks (if low suicide risk), then every 2-4 weeks thereafter for 3 months.
- Patients < 30 years old or who are at increased risk of suicide should be followed up after 1 week.
- Response to treatment should be reviewed after 3-4 weeks
- Antidepressants should be stopped over a period of 4 weeks
- Be especially cautious when switching the following antidepressants:
- From fluoxetine to other antidepressants (as fluoxetine has a long halflife)
- From fluoxetine or paroxetine to a TCA (both drugs inhibit TCA metabolism so a lower starting dose may be needed)
- To a new serotoninergic antidepressant or MAOI (because of risk of serotonin syndrome)
- From non-reversible MAOI: a 2-week washout period is required (other antidepressants should not be prescribed during this period)
What is CBT and how does it work?
This helps people think about their thoughts, feelings and behaviours. It is delivered individually or in groups, usually for a period of 8-24 weeks. It focusses on the present rather than past events. First involves behaviour activation using techniques such as activity schedules. Then identify negative automatic thoughts (NATs) including ‘cognitive distortions’ using a thought record. Finally identify rules and assumptions and core beliefs and then build up an alternative set of more realistic beliefs (e.g ‘Im not perfect, but Im ok.’) This process involves discussion and behavioural experiments. The whole process involves homework and active engagement.
What is interpersonal therapy?
Focuses on unresolved loss, role transitions, relationship conflicts and social skills defects.
What is psychodynamic psychotherapy and how does it work
Involves the development of a relationship between the psychologist and the patient. Psychologists attempt to draw out distorted transferences and draw them to the patient’s conscious awareness. This process usually takes place over a year or more, but can be distilled to 16-20 weeks.
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Practical Psychopharmacology (Antidepressants and Mood Stabilisers)41
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Depression29
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Bipolar Affective Disorder (BPAD)27
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Suicide and Self-harm17
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Psychotic Disorders54
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Anxiety Disorders43
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Medically Unexplained Symptoms13
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Eating Disorders16
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Personality Diosorders19
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Substance Misuse Disorders41
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Organic Psychiatry37
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Old Age Psychiatry35
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Learning Disabilities17
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CAMHS29
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Perinatal Psychiatry10
