Depression

Background

• Characterised by persistent low mood and/or loss of pleasure in most activities and a range of associated features.
• Extremely common: about 1 in 20 adults experience an episode of depression every year (majority mild and reactive)

Risk Factors

• Complex interaction of:
  • Biological factors e.g. family history; head injury; physical illness
  • Psychosocial factors e.g. abuse, unemployment, lack of social relationships, poverty
  • Personality
• High risk factors include
  • History of depression, suicide or abuse
  • Significant physical illness
  • Other mental health condition (including learning disability)
  • Family history
  • Frequent GP/A&E visits

Assessment of a patient who is at risk or presents with low mood

• To screen ask about whether the patient has one of the core symptoms of depression
  • Have you been feeling down, depressed or hopeless recently (low mood)?
  • Do you have little pleasure or interest in doing things?
  • (Have you felt like you have no energy recently? While this is a core feature according to ICD, it is less specific for depression than the others.  NICE no longer consider it a core feature but as a minor feature)
• Other symptoms of depression include
  • Worthlessness/excessive or inappropriate guilt
  • Suicidal ideation; recurrent thoughts of death
  • Diminished concentration/indecisiveness
  • Psychomotor agitation or retardation
  • Poor sleep pattern (insomnia/hypersomnia)
  • Loss or gain of appetite +/- weight change
  • (Reduced self-confidence)
  • (Bleak and pessimistic views of the future)
• Ask about other psychiatric features, commonly anxiety
  • IMPORTANT to ask about mania/hypomania (e.g. feeling abnormally happy/high, irrational behaviour, expenditure etc) to exclude bipolar
  • Also eating disorders
  • Alcohol/substance misuse
  • Features of psychosis
• ALWAYS ask about thoughts of suicide and self harm and go into detail where possible
• Ask about possible triggers (e.g. relationship problems; employment issues; family problems etc), onset, timing, progression etc (i.e. take a full HPC)
• It is important to take an extensive history in patients with possible depression, including HPC; Past psychiatric history; PMHx and drugs; FHx; Social Hx (drugs and alcohol are extremely important; as are housing, employment history, acitivities/hobies, relationships); Personal Hx (including developmental hx; childhood/growing up/school; family relationships; personal relationships; etc)
  • In reality, this may not be possible due to time constraints, so screening questionnaires e.g. PHQ-9 and HAD scale, may be useful
• On MSE
  • Appearance and behaviour can vary from normal to unkempt, poor communication and eye contact, weepy, frustrated
  • Speech can be slowed and in extreme cases words may be few (word poverty)
  • Mood is often subjectively and objectively low and affect can be flat
  • There is rarely any disorder of thought or perception although the patient may obsess over ideas of suicide or self harm; guilt or worthlessness
  • Insight can be preserved or the patient may be so depressed as to be pessimistic about treatments
  • Cognition is rarely impaired significantly by depression but may be impaired by co-existent dementia

Diagnosis

• NB Different associations have different criteria
  • NICE
    • At least 5 out of 9 NICE features (at least one out of two core symptoms)
    • Mild depression is where all symptoms are relatively mild, with little impairment of daily living
    • Moderate depression is defined as ‘symptoms and functional impairment between mild and severe depression’ (some marked symptoms)
    • Severe depression would be 7-9 symptoms, some of which are severe and impair daily living
  • ICD-10
    • At least 2 core symptoms and at least two minor symptoms (mild)
      • 3-4 minor symptoms (moderate)
      • All three core symptoms plus 4 or more minor symptoms with impairment of daily activity (severe)

Management

• For mild/subthreshold depression- provide information and wait, giving follow-up in 2 weeks to see if they are better
  • Consider psychological therapy if symptoms persist
• For moderate/severe depression
  • offer pharmacological therapy and high intensity psychotherapy
• Psychological
  • Low intensity for subthreshold/mild depression
    • e.g. individual guided self-help or computerised therapy based on CBT principles (e.g. MoodJuice website and phoneline); group based activity programmes e.g. Dundonald centre/group based peer support
  • High intensity for moderate-severe depression
    • Group or individual CBT; interpersonal therapy; behavioural activation; couples therapy
• Pharmacological
  • NB Consider toxicity and suicide risk; explain symptoms of anxiety may worsen initially and that most take some time to work
  • Usually, start with generic SSRI for most individuals (citalopram is often used first line, but fluoxetine, paroxetine and sertraline are alternatives)
    • Sertraline is often used in patients with significant physical illness due to its side effect profile
  • Antidepressant treatment should be trialled for minimum of 6 weeks (unless there are side effects after week 1)
    • If successful should be continued for 6 months before being reviewed and at least 2 years if the patient is at risk of relapse
    • If unsuccessful, trial another SSRI*
      • subsequently, other groups of antidepressants may be trialed
      • in general, stop the SSRI over 4 weeks before trialing a second (with fluoxetine, wait 4-7 days before starting alternative)
        • Venlafaxine may be cross-tapered

Dysthymia/Persistent low mood

• Defined as subthreshold features of depression lasting >2 years

Treatment refractory depression

• There are multiple definitions of treatment refractory depression
  • Some quote a minimum trial of at least 2 antidepressants of different classes (i.e. if followed guidelines- at least 3)
  • Some say at least four
• Chronic depression is defined as criteria for depression lasting >2 years
• In any case, it is important to rule out pseudo-resistance i.e. patient not taking medications
• Treatment options include pharmacological combination treatment (namely SSRI or venlafaxine with mirtazapine); augmentation therapy (usually with lithium, although the evidence for this is minimal); ECT which has been shown to be effective but does include side effects such as impaired cognition; Vagal nerve stimulation/DBS (rarely used due to highly specialist nature).

Psychotic depression

• Usually, there is pervasive low mood and marked psychomotor disturbance with accompanying delusions and/or hallucinations.  Constipation may be a feature (patients can think that their bowels have been sewn up or have turned to dust.
• Typically paranoid and mood-congruent, or hypochondriacal:
  • “People are out to get and kill me.”  “I’m being poisoned  to punish me for my sins.”  “I’ve got cancer because I deserve it.”
• Cotard’s syndrome
  • More commonly found in the elderly, Cotard’s is characterised by classic nihilistic delusions:
    • I’m dead- the world around me isn’t real.
• Treatment
  • For many of these patients, ECT will be an option for first line treatment (particularly effective).
  • Antipsychotic plus an antidepressent should be only used in combination with caution as both can enhance the side effect profile of the other. Careful monitoring is required.  Alternatively, drugs with dual-effects e.g. Amoxapine (TCA with D2 antagonism) or Olanzapine may be used, especially for episodic attacks.

Atypical Depression

• Clinical features seem depressive but are atypical (funnily enough).
  • Mood is low but reactive (i.e. able to ‘enjoy’ activities- maybe not as much as usual)
• PLUS 2 or more of
  • Hypersomnia (>10hrs/day at least 3 days/wk for 3 months)
  • Weight gain/ increase in appetite
  • Leaden paralysis (heavy arms and legs)- at least 1 hour/day, 3 days/week for 3 months
  • Over-sensitivity to perceived rejection- can result in significant social impairment/work problems.
• It is often associated with anxiety and often responds well to treatment with phenelzine (MAOI- which are usually 3rd line in depression).

Somatiform Depression

• This subtype of depression is often more described as ‘biological’ depression.  It can often be more severe that other forms but is also more amenable to pharmacological treatment.  ECT is also often effective in these patients
• It can be diagnosed in the presence of 4 or more of the following clinical features:
  • Marked loss of enjoyment/pleasure/interest in activities that are normally enjoyable (anhydonia)
  • Lack of emotional reaction to events or activites that normally produce an emotional response (blunt affect)
  • Early morning waking (>2hours before normal)
  • Depression worse in morning
  • Objective evidence of marked psychomotor retardation or agitation (reports from others)
  • marked loss of appetite and weight loss (>5% of body mass in 1 month)
  • marked loss of libido

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