- 1 Introduction
- 2 Aetiology
- 3 Epidemiology
- 4 Investigations
- 5 Diagnosis
- 6 Screening Tools
- 7 History
- 8 Assessing suicidal ideation
- 9 Management
- 10 Prognosis
- 11 Theories of Pathology Depression
- 12 Depression and pregnancy
- 13 Depression in children and adolescents
- 14 Depression in the elderly
- 15 Adjustment disorder
- 16 Related Articles
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 (15% 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 at any given time
- It is the most common GP diagnosis – and is present in 17% of people who present to general practice in any given year
- It accounts for 45% of all psychiatric diagnoses
- Lifetime risk of 15%
- Up to 60% of cases will not have had any interaction with medical services in the last 4 months
- In those with diagnosed depression, lifetime risk of suicide is 6%
- Mean age of onset is 27
- 40% of cases present before the age of 20
- 40% of patients will have a relapse within one year
- 50% of patients also suffer from anxiety
At the time of a first / new presentation, the following investigations may be considered to rule out an underlying case
- 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!
It is recommended that depression be diagnosed in line with the DSM-V diagnostic criteria for depression.
DSM-V Diagnostic criteria
Diagnosing depression requires a relative short history of at least 2 weeks.
At least FIVE of the following almost every day for the last 2 weeks. Numbers ONE and TWO are essential.
- Depressed mood
- Loss of interest or pleasure in previously enjoyed activities
- Change in weight (>5% in <1 month) OR change in appetite
- Changes in sleep – insomnia or hypersomnia
- Psychomotor agitation (e.g. symptoms of anxiety) or retardation
- Fatigue or low energy
- Feelings of worthlessness or guilt
- Reduced concentration or decisiveness
- Suicidal ideation or attempt
There may also be:
- Psychotic symptoms
Previously, depression had been thought of in terms of major and minor symptoms. It can still be useful to think in these terms.
- 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.
- Hospital Anxiety and Depression score (HADS) – despite its name is still used in general practice
- Patient Health Questionnaire (PHQ-9)
- ICD-10 depression Inventory (MDI)
- DASS 21 or DASS 42
- Also includes assessment of anxiety and “stress”
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 of 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
Assessing suicidal ideation
Although the predictive power of assessing suicide risk is sometimes controversial (evidence is poor that it is possible to truly predict suicidal risk), it is still important to undertake a suicidal risk assessment.
- Suicidal thoughts
- A suicide plan
- g. “I have a rope in my car and when I leave here I’m going to hang myself from the tree in my front garden”
- Are they planning on taking 10 paracetamol, or jumping off a cliff?
- Do they have access to firearms? To other dangerous equipment? What medications do they have at home?
- Past history
- Previous suicide attempts?
- What were they?
- Suicide of a family member or peer
The basic principles of management are:
- Psychological interventions
- This includes lifestyle factors that are known to improve mood – e.g. regular exercise, healthy diet, social interaction
- Cognitive behavioural therapy – either in person with a trained medical professional (psychologist or GP), or online – both are thought to be equally effective
- Antidepressant medication therapy
- Typically used in combination with psychological interventions
- Regular follow-up to review the effectiveness of psychological and antidepressant interventions
- The regularity of this depends on the severity of symptoms – it may range from weekly (in the acute or more severe cases) to once every several months (once in remission)
- ECT – electroconvulsive therpy
- Typically reserved for the most severe cases in an inpatient setting
Advise patient about the diagnosis and explain what it means.
Watchful waiting, psychology / CBT (often long waiting lists to see psychologist on NHS), computerised CBT, self-help, exercise, short psychological interventions (e.g. advise about activity scheduling, structured problem solving, negative though channelling), sleep hygiene.
Moderate and severe depression
All of the above, PLUS:
Medication (see below), psychological interventions, consider getting social support
Treatment-resistant, atypical/psychotic depression, those at risk
All of the above, PLUS:
Medication, complex psychological interventions, combined drug treatment
All the above, plus consider ECT
- Psychotherapy – the process of explaining the diagnosis and it’s effects
- CBT – cognitive behavioural therapy – a type of “talking therapy” which helps the patient to better understand their symptoms, and helps them to recognise negative thought patterns, and how to better manage these thoughts, including teaching new ways of positive thinking.
- BEWARE OF USING ANTIDEPRESSANTS IN BIPOLAR DISORDER
- Ask about possible periods of mani or sub-mania before prescribing, to ensure it is not a case of bipolar disorder presenting with a low mood episode
- Anti-depressants can worsen bipolar disorder, and these patients are instead treated with mood stabilisers (typically lithium)
- Medications are particularly useful in moderate to severe depression, as well as depression with features of anxiety
- Antidepressants are roughly equally as effective as CBT / psychological interventions in treating depression
- Patients are about 20% more likely to achieve remission than with placebo
- In severe depression, antidepressants are more effective than psychological interventions, and the likely benefit is greater
- Assess the effectiveness of antidepressants at 6-8 weeks
- If no benefit is felt by 6 weeks, then it is likely the current drug is not suitable for the current patient
- Consider an alternative medication
- Typically a “washout period” of days to weeks should be used between antidepressants if medications are changed
- The aim of treatment is to induce remission
- 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
- See the article on SSRIs for more information
If these are unsuccessful you can consider the following types of medication:
- SNRI – serotonin-noradreline reuptake inhibitors – e.g. venlafaxine. May be superior to SNRI in severe depression
- Tricyclic antidepressants
- MAOI – monoamine oxidase inhibitors
General effects of drug treatment
- Increased monoamine levels in the brain
- Reversed damaged intracellular signalling pathways
- Reduced CRF production
- Inhibition of NMDA release
- BEWARE of serotonin syndrome – which is more likely if more than one drug with serotonerigc effects are given concurrently
Continuation of drug treatments
- If medication is successful, and remission is achieved, it is recommended to continue medication for at least 12 months
- If there are subsequent further episodes – continue treatment for 2-3 years when it is restarted
- Risk factors for relapse include:
- More than 2 episodes int he last 5 years
- More than 3 previous episodes in total
- History of severe or prolonged depression
- Co-morbid medical problems
- Life stressors
Summary of drug treatments
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
- The evidence for the effectiveness of any other agents (e.g. St John’s Wort, or other herbal treatments) is lacking
- However – up to 50% of the general population have taken an alternative medication int he last 12 months
- Public perception differ substantially from the evidence:
- 80% of people believe that complimentary therapies are likely to help with depression
- Only 30% of people believe that antidepressants are effective for depression
ECT – electroconvulsive therapy
- Generally considered safe although can cause some short and long-term memory impairment
- Should only be performs under psychiatrist supervision
- Typically in an inpatient setting
- A typical regimen might include 1-3 sessions per week for 8-12 weeks
- Depression not responsive to medications and psychotherapy
- Depression with psychotic features
- Severe psychomotor depression – e.g. refusal to eat, severe personal neglect
- It may also be used in:
- Schizophrenia with severe depressive symptoms
- Schizophrenia with Clouding of consciousness
- Mania when drug treatments (both neuroleptics and lithium) have been ineffective
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.
- ECT increases the activity of 5-HT cell, and increases the number of post-synaptic 5-HT receptors. It also enhances dopamine activity, and has similar effects on noradrenaline to anti-depressant drugs (particularly reduction in β receptors).
- Unilateral – one on temporal region, one near vertex
- Bilateral – on each temporal region
- 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
Theories of Pathology Depression
The pathology of depression is not well understood. However, one way of thinking about depression is with the stress vulnerability model. This states that individuals have a genetically defined level at which excessive stress will result in a mood disorder (i.e. depression). Subject any given individual to enough stress, and they will surpass this threshold, and begin to suffer from a mood disorder.
At a cellular level, prolonged “stress” results in neuron cell death via two pathways:
- Mitochondrial dropout
- Increased glucocorticoids (i.e. cortisol) in response to stress leads to excessive mitochondrial activity, leading to “burnout” of the mitochondria, and subsequent neuronal death
- Glional dropout
- Brain-derived neurotrophin factor (BDNF) is a protein in the brain that protects neurons from damage
- The neurotransmitter serotonin, noradrenalines, and to a lesser extent dopamine all cause increased synthesis of BDNF
- In depression, there are reduced levels of BDNF and this leads to neuronal cell death
- The end result of these factors is decreased brain activity in the prefrontal cortex, and increased activity in the limbic system
- Microscopically, the brains of those with chronic depression can be seed to have neuronal cell death
- Macroscopially, on MRI, there may be seen up a 1/3 reduction in side of the hippocampus
- Therefore – real and significant physical brain changes can be seen in depression – it is not just “all in the mind”
- 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.
Depression and pregnancy
Depression around the time of pregnancy (“perinatal depression”) is extremely common, and affects about 10% of women during pregnancy, and 15% of women after birth.
It typically starts in the first few weeks, and peaks at about 12 weeks after birth. Particularly common symptoms are anxiety and agitation, mood swings, and other features typical of depression. In very severe cases, the wellbeing of the baby may be at risk – ask about infanticidal ideation and well as suicidal ideation.
- Previous perinatal depression
- Previous mental health problems
- Social or cultural isolation
- Abusive relationship (past or present)
- Family history of mental health disorder
- Other life stressors as for depression at any time
It is recommend to screen every pregnant women for depression, both before and after birth, using the Edinburgh Postnatal depression scale (EPNDS). Explain the process before jumping in and asking the questions. Those with a high score (10+), typically require more regular further screening. Those with a score of 13+ require urgent psychological or psychiatric referral. SSRIs can be used in pregnancy, but specialist advice should be sought.
Is typically the same as major depression – a combination of basic lifestyle factors, psychological therapies and medication.
Medications most likely used in the perinatal periods include:
- SSRIs – sertraline, paroxetine
- Other – amitriptyline, nortriptyline
Postnatal blues is a milder form of low mood, that typically 80% of new mothers, typically in the first two weeks after giving birth, and lasts <2 weeks.
Typical features include:
- Feeling down or depressed
- Mood swings
- Feeling emotional
- Feeling inadequate
- Muscle aches and pains
- Get as much rest as possible – ovoid over-tiredness
- Accept help around the house
- Share the workload of a new baby with your partner
- If symptoms last >14 days – consider post-natal depression
Depression in children and adolescents
Depression is common in teenagers, and probably under-diagnose in younger childhood age groups. In children, it is more likely to manifest as irritability and loss of interest in usual activities. Suicidal ideation and attempt is rare before adolescence.
Assessing for depression and other mental health disorders in teenagers can be difficult. Try not to be judgemental. An curious, non-intrusive approach is best.
A useful framework for history taking is the HEADS-ED assessment tool:
- H – Home
- How does your family get along with each other?
- E – Educations / employment
- How are you doing at school?
- Do you have a lot of school friends?
- Are you working?
- A – Activities and peers
- What do you do in your spare time?
- How are your relationships with friends?
- D – Drugs and alcohol
- Do you drink alcohol?
- Do you take any drugs?
- S – Suicidality
- Do you have any thoughts of wanting to kill yourself?
- E – Emotions, behaviours and thought disturbance
- How have you been feeling lately?
- Discharge plan
- Do you have any help? Do you want any help? Are you on a waiting list to see somebody (e.g. psychologist) ?
Depression in the elderly
Depression in the elderly is extremely common and often underdiagnosed. It is also often confused with, and associated with dementia.
Symptoms of depression in the elderly can be different to other age groups, and it more commonly associated with psychosis. It also commonly causes a change in sleep pattern.
Elderly patients are less likely to respond to medical therapies.
Adjustment disorder is a less severe type of depression, with depressed mood which doesn’t meet the DSM-V criteria, and typically occurs in response to a major life stressor – such as losing your job, or death of a close friend or relative. It typically lasts <6 months, and is not a chronic relapsing and remitting disorder – unlike depression. If symptoms do not resolve within the time frame, then the likely true diagnosis is depression