Makindo Medical Notes.com

In those with low mood and depression always ask about suicidal thoughts and intentions and document it

About

• Major depressive illness is seen in 5-10% of the population
• Major depression is generally a relapsing, remitting illness
• The risk of suicide is 10 times greater with a history of a depressive illness
• Always ask about suicidal thoughts and intentions and document it.

Aetiology

• There is a genetic predisposition
• There is reduced function of the monoamine neurotransmitters
• Elevated cortisol levels are found which do not suppress with Dexamethasone is a well-recognised finding in severe depression and suggests an underlying neuroendocrine dysfunction

DSM 5 Criteria

• During the last month has reported feeling down, depressed, or hopeless? Has little interest or pleasure in doing things?
• If at least one of the two 'core' symptoms have been present most days, most of the time, for at least 2 weeks, ask about the associated symptoms of depression:
  • Disturbed sleep (decreased or increased compared to usual).
  • Decreased or increased appetite and/or weight.
  • Fatigue/loss of energy.
  • Agitation or slowing of movements.
  • Poor concentration or indecisiveness.
  • Feelings of worthlessness or excessive or inappropriate guilt.
  • Suicidal thoughts or acts.
• Ask about Duration and associated disability, past and family history of mood disorders and availability of support.
• The severity of depression is determined by both the number and severity of symptoms, as well as the degree of functional impairment.
  • Subthreshold depression: 2-5 symptoms of depression.
  • Mild depression: More than 5 symptoms and minor functional impairment.
  • Moderate depression: Symptoms or functional impairment are between mild and severe.
  • Severe depression: most symptoms and they markedly interfere with functioning they can occur with or without psychotic symptom
  • Seasonal affective disorder is diagnosed if the person has episodes of depression which recur annually at the same time each year with remission in between (usually appearing in winter and remitting in spring)

Clinical

• Poor mood, Anhedonia, Fatigue, Insomnia, Early morning wakening
• Impotence, Suicidal ideation, See DSM above

Management- Psychotherapy

• Cognitive behavioural therapy can be useful in mild to moderate depression - same efficacy as drugs and depends on what you have locally or can try both.
• Can be used with concurrent antidepressant medication treatment

Medications

• Antidepressant medication generally should be taken for at least six to nine months
• Selective serotonin reuptake inhibitors (SSRIs)
• Tricyclic antidepressants inhibit the reuptake of Noradrenaline [US Norepinephrine] and serotonin
• Monoamine oxidase (MAO) inhibitors - severe hypertension with tyramine containing foods
• SNRIs that inhibit the reuptake of both serotonin and norepinephrine
• St. John's wort - do not use with other antidepressants. Serotonin syndrome with SSRI's

Electroconvulsive therapy

• If depression is life-threatening, ECT should be considered as an initial treatment or is used for major depression that is refractory to antidepressant medications
• ECT is usually administered 2 or 3 times per week for a total of 6 to 12 treatments
• C/I Stroke, Space occupying lesion, Cardiac disease, High anaesthesia risk
• S/E Headache, Memory loss, disorientation, and delirium .

References

• NICE guidance 2021 How do I diagnose depression?