Depressed patients have a decreased quality of life, as well as increased mortality.
- Genetic susceptibility
- Life factors –i.e. social situation – e.g. single mums
- Alcohol/drug dependence
- Abuse (sexual or not) – particularly in childhood
- Previous psychiatric diagnosis
- Chronic disease
- Lack of a confiding relationship
- Urban population
- Post natal (10% of all women who give birth!)
- 10-16% of men, and 20-24% of women will have some symptoms of depression
- 2-4% of men and 7-8& of women will have actual depression
- It is the most common GP diagnosis – and accounts for about 12% of all new illnesses
- It accounts for 45% of all psychiatric diagnoses
- Haemotinics – folate and B12
- LFT’s– for alcohol / drugs / cancer
- CXR – to look for chronic infection (e.g. TB)
- ECG – can show up metabolic disturbances
- Mental state
- FULL HISTORY!
- Low mood
- Anhedonia – does not take any pleasure from any activities (or reduced pleasure from normal activities). Patients will often withdraw from social activities.
- Low energy levels
- Feelings of guilt, uselessness, worthlessness
- Thoughts of SUICIDE
- Always ask if they say they are having suicidal thoughts if they have acted upon any of these thoughts – e.g. have they started to ‘stock up’ on paracetomol.
- Poor concentration
- Difficulty getting to sleep
- Waking up several times during the night
- Early Waking - This is significant if the patient regularly wakes up 2 hours before ‘normal’
- Weight loss - This will be because the patient is eating less, either because they take no pleasure in eating and/or because they feel nauseous
Weight gain can also occur
- Patients may ‘comfort eat’
- Make sure you ask if the weight loss/gain is intentional!
- Weight change of >5% is significant.
- Loss of libido.
- Psychomotor retardation – the patient can be very ‘slow’ both in their thoughts and actions, to a degree that is noticeable by others.
- Agitated and fidgety – this can be both in their thoughts and physically. Patients may keep going over and over the same thoughts in their mind, or they may e.g. stand up and sit down constantly.
- Memory problems – people may complain of memory problems, but it is probably not their memory that is the issue. If you test them on memory things you may notice they do not concentrate when the information is first given, thus the information is not processed, and so they are not able to recall it – however it is the information processing and not the memory recall that is at fault.
- Diurnal variation of symptoms is common. Generally, symptoms are worse early in the morning and late at night than at other times in the day.
- Hallucinations and delusions – these may be present, and are generally congruent to the current mood.
- Schneider’s positive symptoms can occur in severe depression.
Mild depression – 1 core symptom, and 3 other symptoms for at least 2 weeks
- Reduced ability to perform at work, reduced willingness to socialise
Moderate Depression - 1 core symptom and 4-7 other symptoms (major or minor), for at least 2 weeks
Severe depression - 1 core symptoms and 7+ other symptoms (major or minor), for at least 2 weeks. There may also be:
- Psychotic symptoms
- Hospital Anxiety and Depression score (HADS) (external link) – despite its name is still used in general practice.
- Patient Health Questionnaire (PHQ-9) – (external link)
- ICD-10 depression Inventory (MDI) (external link)
Other variations may be used. Patients may complete these as questionnaires on paper, or they may complete them on the computer. The second method is more widely used, as you are able to easily and quickly compare progress over time.
These methods are able to give a rough guide to the severity f the depression, as well as to assess risk.
Questions to ask when taking a history
- Have you felt ‘low’ or miserable recently?
- Have you lost your emotions?
- Does it happen everyday?
- Does anything seem to have brought it on?
- Have you lost interest in things you usually enjoy? - Do you still see your friends often?
Does your current mood/experience interfere with your normal life?
- Weight (loss)
- feelings of guilt
- feelings of worthlessness
- Appearance and behaviour – poor self care, lack of eye contact, does not ‘engage’ in conversation, little movement, OR lots of fidgeting
- Speech – monotone, hesitant, slow
- D – Depressions
- E – Energy levels
- A – Anhedonia
- D – Death – thoughts about death and self harm – i.e. Risk!
- S – Sleep pattern
- W – Worthlessness, guilt
- A – Appetite
- M – Mentation – decreased ability to think and concentrate
- P – psychomotor agitation and retardation
Post natal depression
Post natal depression – occurs about 1 year after baby
Post natal psychosis – can occur at any time, and involves delusions/hallucinations
Watchful waiting, CBT (not usually practical on the NHS due to long waiting lists), computerised CBT, self-help, exercise, short psychological interventions
Moderate and severe depression
Medication (see below), psychological interventions, consider getting social support
Treatment-resistant, atypical/psychotic depression, those at risk
Medication, complex psychological interventions, combined rugs treatment
All the above, plus consider ECT
SSRI’s – 1st line. E.g. fluoxetine, citalopram. Side effects include:
- Abdominal pain
- Sexual dysfunction
- Allow 4-6 weeks for beneficial effects
- Patient’s may describe how low feelings are not as pronounced, but the drugs do not increase’ happy’ feelings.
- If one SSRI is not successful, attempt another SSRI, before trying other drugs
If these are unsuccessful you can consider the following types of medication:
- Tricyclic antidepressants
- MAOI – monoamine oxidase inhibitors
- St John’s Wort
Theories of Pathology Depression
- Most serotonergic neurons arise in the Raphe area of the midbrain, and project to the limbic system and cerebral cortex.
- Most noradrenalin neurons are found in the locus cereleus and lateral tegumental areas of the brainstem.
- There are considerable links between Raphe and locus cereleus areas.
- There are reduced levels of 5-HT in the brains of depressed people
- There are increased number of 5-HT receptors in the brains of suicidal patients
There are also probably altered signalling pathways in response to 5-HT in depressed patients – basically G-coupling may no longer function properly.
Even more interesting is that CRH itself in excess quantities actually causes some of the symptoms of depression – such as anxiety, loss of appetite, reduced activity etc. and CRH levels are also usually raised in depression.
- ECT (electroconvulsive therapy) also promotes neurogenesis
- Many of the studies for this have so far only been conducted in animals, and thus it is still only a hypothesis.
Treatment of Depression
Block NA and 5-HT re-uptake
Increase stores of NA and 5-HT
Increase NA and 5-HT storage
Inhibits NA synthesis
Inhibits NA synthesis
Increases CNS responsiveness to 5-HT and NA
Increases 5-HT synthesis
General effects of drug treatment
- Increased monoamine levels in the brain
- Reversed damaged intracellular signalling pathways
- Reduced CRF production
- Inhibition of NMDA release
ECT – electroconvulsive therapy
Using a high electrical current increases the therapeutic effect, but increases the risk of memory loss and confusion.
- Unilateral treatment to the non-dominant hemisphere also reduces the risk of confusion and memory loss, but again has reduced efficacy. Patients who undergo this type of ECT require 2-4 more sessions than other individuals.
- ‘Sub-seizure’ currents do not have therapeutic benefit.
- Psychomotor retardation
- Early-morning wakening
- Psychotic features
- Severe weight loss
- Schizophrenia with severe depressive symptoms
- Schizophrenia with Clouding of consciousness
- Mania; when drug treatments (both neuroleptics and lithium) have been ineffective
- Unilateral – one on temporal region, one near vertex
- Bilateral – on each temporal region
- 2x per week until improvement is seen
- This is usually after 6-8 treatments
- Cardiac arrhythmias
- Dislocations and fractures – in cases where the muscle relaxant was not administered correctly or was ineffective
- Increased BP during treatment can cause:
- Cerebral haemorrhage
- Bleeding of peptic ulcer
Psychological side effects
- Mania – results from 5% of cases of ECT. This is a similar risk to anti-depressants, and occurs in those at risk of bipolar disorder
- Confusional state – occurs in almost all patients, but only lasts about ½ an hour. May be associated with headache
Memory loss – there is usually both retrograde amnesia (can’t remember what happened just prior to treatment) as well as anterograde amnesia (unable to lay down new memories for a short time after the procedure. Some patients may report difficulty recalling previously well-known materal – e.g. telephone numbers, although in objective tests, there is no obvious problems. Factors that increase the risk of memory loss include:
- Bilateral shock, shock to dominant hemisphere
- >12 treatments
- >3 treatments per week, with <48 hours between treatments
- Not giving O2 before treatment
- Using large current
- Large loss event precipitating the depression
- Normal pre-morbid personality