DepressionBy Sophie Stuart, Karen Yip, Omid Shokri and Maira Siddiq

Causes

Stressful events

• Bereavements

• Personal problems

• Family/relationship issues

Illness

• a longstanding or life-threatening illness, such as coronary heart disease or cancer.

• Head injuries are also an often under-recognised cause of depression A severe head injury can trigger mood swings and emotional problems.

• Some people may have an underactive thyroid (hypothyroidism) resulting from problems with their immune system. In rarer cases a minor head injury can damage the pituitary gland, a pea-sized gland at the base of your brain that produces thyroid-stimulating hormones.

• This can cause a number of symptoms, such as extreme tiredness and a loss of interest in sex (loss of libido), which can in turn lead to depression.

• Personality

• certain personality traits, such as low self-esteem or being overly self-critical. This may be because of the genes you've inherited from your parents, or because of your early life experiences.

• Family history

• If someone else in your family has suffered from depression in the past, such as a parent or sister or brother, then it's more likely you will too.

• Giving birth

• Some women are particularly vulnerable to depression after pregnancy. The hormonal and physical changes, as well as added responsibility of a new life, can lead to postnatal depression.

• Loneliness

• Alcohol and drugs

• Some people try to cope when life is getting them down by drinking too much alcohol or taking drugs. This can result in a spiral of depression.

• Cannabis helps you relax, but there is evidence that it can bring on depression, especially in teenagers.

Types

Major Depression aka "major depressive disorder."

• feeling depressed most of the time for most days of the week.

Persistent Depressive Disorder aka dysthymia.

• If you have depression that lasts for 2 years or longer, it's called persistent depressive disorder.

Bipolar Disorder

• Someone with bipolar disorder has mood episodes that range from extremes of high energy with an "up" mood to low "depressive" periods.

Seasonal Affective Disorder (SAD)

• Seasonal affective disorder is a period of major depression that most often happens during the winter months, when the days grow short and you get less and less sunlight.

Psychotic Depression• People with psychotic depression have the symptoms of major depression along

with "psychotic" symptoms, such as:• -Hallucinations • -Delusions • -Paranoia

Postpartum Depression• Women who have major depression in the weeks and months after childbirth

may have postpartum depression. Antidepressants can help.Premenstrual Dysphoric Disorder (PMDD)• Women with PMDD have depression and other symptoms at the start of their

period.'Situational' Depression• A depressed mood when you're having trouble managing a stressful event in

your life, such as a death in your family, a divorce, or losing your job. Your doctor may call this "stress response syndrome.”

Atypical Depression• If you have atypical depression, a positive event can temporarily improve your

mood.

Symptoms

Psychological symptoms

• continuous low mood or sadness

• feeling hopeless and helpless

• having low self-esteem

• feeling tearful

• feeling guilt-ridden

• feeling irritable and intolerant of others

• having no motivation or interest in things

• finding it difficult to make decisions

• not getting any enjoyment out of life

• feeling anxious or worried

• having suicidal thoughts or thoughts of harming yourself

Physical symptoms

• moving or speaking more slowly than usual

• change in appetite or weight

• constipation

• unexplained aches and pains

• lack of energy or loss of libido

• changes to your menstrual cycle

• disturbed sleep

Social symptoms

• not doing well at work

• taking part in fewer social activities and avoiding contact with friends

• neglecting your hobbies and interests

• having difficulties in your home and family life

DiagnosisThere are no physical tests for depression

The best way to diagnose depression is to have a conversation with the patient

Questions to ask the patient

Ask about patients daily moods, behaviours and life style habits. For example:

• In the past two weeks, how often have you felt down, depressed, or hopeless?

• Are you struggling with work or social commitments?

• Have you had any thoughts of suicide?

• How are you sleeping?

• How is your energy?

• How long have you been feeling this way?

Referral

Someone is thought to be clinically depressed if they are experiencing several of the symptoms of depression almost daily for over two weeks.

If this is the case the patient should be immediately referred to the GP.

At the GPs – Steps for diagnosis

• GP will have a conversation with the patient

• Give the patient, PHQ-9 a patient health questionnaire to monitor the severity of depression

• Do urine or blood tests to test for hypothyroidism

• Find out about family history of depression

TreatmentTreatment for clinical depression will usually be a combination of

medicines, talking therapies and self-help

Non-Drug Treatment

• Depression is treatable, but patients may feel reluctant to be diagnosed to receive treatment

• Social stigma

• Low awareness of physical symptoms of depression

• Aches and pains

• Fatigue and difficulty sleeping

Mild Depression

• “Wait and see” / Watchful waiting• See GP again two weeks after initial diagnosis

• Exercise

• Evidence that exercise can improve mental health – release of endorphins leading to improved mood

• Self-help groups

• Voicing their emotions out loud

Mild to Moderate Depression

Talking therapy – allows the patient to look deeper into their problems and fears so they can overcome them

• Cognitive Behaviour Therapy (CBT)

• Helps the patient to understand their thoughts and behaviours, and teaches them to overcome negative thoughts

• Available on the NHS as a short course of 6 – 8 sessions over 10 –12 weeks with a trained CBT counsellor

• Online CBT

• Type of CBT available on a computer

• Useful for patients who are uncomfortable with speaking about their condition out loud

• Interpersonal therapy (IPT)

• Focuses on the patient’s relationships with other people

Moderate to Severe Depression (1)

• Combination Therapy

• Antidepressants + Talking Therapy

• Mental health teams

• Team of psychologists, psychiatrists, specialist nurses and occupational therapists

• The patient receives intensive specialist talking treatments, as well as antidepressants

Moderate to Severe Depression (2)

• Electric shock treatment / Electroconvulsive Therapy (ECT)• For patients with severe depression where other treatments have

not worked• Patient is given an anaesthetic and muscle relaxant, and then given

an electric ‘shock’ to the brain through electrodes placed on the head

• Rapid short-term improvement of symptoms• However, this treatment has many disadvantages

• Not all patients are suitable• Not all clinics offer ECT• Serious side effects

• Lithium – lithium carbonate and lithium citrate• Given in addition with current antidepressant treatment• Reduces severity and frequency of mood swings• Patient will need blood tests every three months to check for lithium

toxicity

Drug Treatment

• Antidepressants

If you have depression you are twice as likely to improve with an antidepressant compared with not taking treatment.

• Combination therapy (antidepressant and cognitive behavioural therapy)

Antidepressants

• Selective serotonin reuptake inhibitors (SSRIs)

-Newest family of antidepressants

-Increase levels of serotonin in patients who suffer from depression

-Preferred as 1st-line agents over TCAs when there is a risk of overdose or diabetes.

-Committee on Safety of Medicines advises that SSRIs (citalopram, escitalopram, paroxeteine & sertraline) in <18’s is unfavourable due to risk of suicidal behaviour, self-harm and hostility.

-Caution: epilepsy, cardiac disease, diabetes mellitus

-Contraindications: if patient enters manic phase

-High risk of withdrawal reactions with paroxetine.

• Citalopram: 20mg OD (increased in steps of 20mg daily at intervals of 3-4 weeks if necessary). Max. 40mg dailySide-effects: palpitation, tachycardia, oedema, bradycardia

• Escitalopram: 10mg OD, increased if necessary to 20mg max daily.Side-effects: sinusitis, fatigue, restlessness, paraesthesia

• Fluoxetine: (major depression)20mg OD increased after 3-4 weeks if necessary, and at appropriate intervals thereafter. Max. 60mgSide-effects: hypotension, pharyngitis, euphoria, dysphagia

• Paroxetine: (major depression)20mg each morning. Max. 50mg daily.Side-effects: raised cholesterol, abnormal dreams, yawning

• Tricyclic antidepressants

-Work by blocking the serotonin and noradrenaline transporter to increase their relative concentrations in the synapse.

-Broader mechanism of action (also act as non-selective antagonists)

-Caution: patients with cardiovascular disease due to risk of arrhythmia; epilepsy; chronic constipation; significant risk of suicide.

-Contraindicated: immediate recovery period after MI; arrhythmias and in the manic phase of bipolar disorder.

-Treatment should be stopped if the patient enter the manic phase.

• Amitriptyline Hydrochloride (not recommended):

Initially 75mg daily (adolescents- 30-75mg) in divided doses or a single dose at bedtime increased gradually as necessary to 150-200mg.

Side-effects: abdominal pain, palpitation, hypertension, fatigue

• Lofepramine:

140-210mg daily in divided doses. Not recommended for under 18’s.

Side-effects: diarrhoea, headache, oedema

• Nortriptyline:

Low dose initially increased as necessary to 75-100mg daily in divided doses or as a single dose. Max. 150mg.

Adolescents and elderly: 30-50mg daily in divided doses.

Side-effects: abdominal pain, hypertension, fatigue, flushing

• Monoamine-oxidase inhibitors

-Prevent the breakdown of noradrenaline and serotonin

-Usually prescribed when several newer types of antidepressants have been tried but not have not been very effective/caused troublesome side-effects.

-Effective for the treatment of atypical depression.

-Must avoid foods containing tyramine (incalcoholic drinks, cheese, liver and yoghurt) as this can cause a very large, sudden increase in BP (hypertensive crisis).

-Must carry an MAOI antidepressant card with you at all times as it list the different foods, drinks and OTC medicines you cannot take.

• Phenelzine

15mg TDS, increased if necessary to QDS after 2 weeks. Gradually reduced to lowest possible maintenance dose (15mg on alternate days)

Side-effects: postural hypotension (especially in elderly), dizziness, euphoria, tremors

• Isocarboxazid

Initially 30mg daily in single or divided doses until improvement occurs. Max. 60mg daily for 4-6 weeks under close supervision. Usual maintenance dose 10-20mg daily but 5-10mg for elderly.

Side-effects: postural hypotension (especially in elderly), dizziness, euphoria, tremors

• Tranylcypromine

Initially 10mg BD not later than 3pm, increased to 20mg daily after 1 week if necessary under close supervision. Usual maintenance dose 10mg daily.

Side-effects: insomnia, postural hypotension (especially in elderly), dizziness, euphoria, tremors

St John’s Wort (Hypericumperforatum)

• Herbal remedy for low mood or mild depression.• Bought OTC from health food shops and chemists

for treatment of depression.• Not recommended for use in children or

adolescents due to lack of robust clinical trials.• Thought to be more effective than a placebo and

as effective as TCA’s with fewer side-effects. (PubMed)

• Not appropriate for people with severe depression or those at risk of suicide.

• Mechanism of action is unknown but is likely to be due to prolonged exposure of serotonin and noradrenaline in the synaptic cleft.

-Contraindications: pregnancy; lactation; CCB’s; anticoagulants; simvastatin and atorvastatin; with any other antidepressant, particularly SSRIs.

Side-effects

• Serotonin has a role in many bodily functions, such as digestion, sleep and mental clarity, therefore, that have a wide range of side effects.

• SSRI’s: less sedating and have fewer anti-muscarinic and cardiotoxic side-effects than TCA’s.

-GI effects: vomiting, dyspepsia, abdominal pain-feeling agitated or anxious

-dry mouth-insomnia

-hallucinations-serotonin syndrome-serotonin syndrome

• TCA’s:-arrhythmias or heart block, particularly after taking amitriptyline.

-tachycardia-CNS effects are common: anxiety, drowsiness, confusion, sleep disturbances,

-anti-muscarinic effects: dry mouth, constipation, blurred vision-endocrine effects: changes in blood glucose, increased appetite, weight gain

• MAOI’s:-postural hypotension

-dry mouth-insomnia -headache

-muscle aches

• St John’s Wort: better tolerated and result in fewer ‘drop-outs’ due to adverse effects, than standard antidepressants.

-Photosensitivity -Vivid reams-Restlessness-Dry mouth-Dizziness-Confusion

What if people treated physical illness like mental illness?

http://www.huffingtonpost.com/2014/11/13/mental-illness-physical-i_n_6145156.html?ncid=fcbklnkushpmg00000063

Monitoring

• See patients, who are not considered to be at increased risk of suicide, two weeks after starting treatment and continue to review regularly as appropriate.

• Monitor for signs of akathisia (a movement disorder characterized by a feeling of inner restlessness and a compelling need to be in constant motion), suicidal ideas and increased anxiety and agitation, particularly in the early stages of treatment.

• See patients, who are considered to be at increased risk of suicide or who are younger than 30 years old, one week after starting treatment. Regularly review (every 2-4 weeks) in the first three months or until the risk is no longer significant.

• Where there is a high risk of suicide, prescribe a limited quantity of antidepressants and consider additional support such as more frequent contacts with primary care staff, or telephone contacts.

• Where there is partial or no response to medication at 2-4 weeks:

- Check adherence to and side-effects from the treatment.

-Consider increasing the dose of the antidepressant.

-Consider switching to an alternative antidepressant – egmirtazapine, moclobemide, reboxetine, venlafaxine or a tricyclic. Avoid tricyclic antidepressants or venlafaxine when there is a risk of overdose.

References

• BNF Section 4.3

• http://www.nhs.uk/Conditions/Depression/Pages/Treatment.aspx

• http://www.mayoclinic.org/diseases-conditions/depression/in-depth/ssris/art-20044825

• http://www.helpguide.org/articles/depression/antidepressants-depression-medication.htm