Depression is the most common mental health disorder in the UK and is characterised by low mood, fatigue and feelings of worthlessness.
Diagnosis of depression
Depression is diagnosed using the DSM-5 criteria
- A diagnosis of depression can be made if 5 or more of the following core symptoms are present for 2 weeks or more:
- Depressed mood most of the time
- Anhedonia - diminished enjoyment or pleasure in most activities
- Weight change - Unintentional weight loss or weight gain
- Slow thought or movement
- Fatigue
- Feelings of worthlessness
- Difficulty concentrating or making decisions
- Thoughts of death or suicidal ideation
- Other symptoms include:
- Sleep disturbance – decreased or increased
- Abnormal appetite
- Irritability
- Classification of severity:
- <5 symptoms = subthreshold depression
- 5-6 symptoms with minor functional impairment = mild depression
- Moderate depression = somewhere in between mild/severe
- Most/all of the above symptoms = severe depression, severe functional impairment
Assessment of depression
- PHQ9 – assessment of symptoms over the last 2 weeks – 9 questions scoring 1-3 each
- NICE classifies depression according to severity, using the PHQ-9 scale:
- Less severe depression
- A score of less than 16 on the PHQ-9 scale
- Encompasses subthreshold and mild depression
- More severe depression
- A score of 16 or more on the PHQ-9 scale
- Encompasses moderate and severe depression
Management of depression
Less severe depression and does not want treatment/symptoms improving
- Offer active monitoring and review in 2-4 weeks
Less severe depression and wants treatment
- 1st line: Offer guided self-help (e.g. CBT)
- Do not routinely offer an antidepressant. If the patient wants drug treatment, commence SSRI.
More severe depression
- Offer any of the following as 1st line treatment options, depending on patient's wishes:
- Individual CBT
- Antidepressant medication
- Individual behavioural activation
- Group exercise
- If the patients wants to start treatment with an antidepressant - offer SSRI or SNRI 1st line
- Review in 2-4 weeks
Choosing an antidepressant
- First-line: SSRIs – Sertraline or citalopram preferred for most due to safety and tolerability.
- Caution: Citalopram may prolong QTc, requiring ECG monitoring
- SSRIs such as sertraline are also preferred in the context of physical health conditions, due to lower drug interaction risk.
- Sertraline has been shown to be safe in patients with IHD such as unstable angina/recent MI
- Fluoxetine is the preferred antidepressant for depression in children and young people.
Depression in elderly patients
Clinical features
- Elderly patients are less likely to complain of depressed mood and may have atypical symptoms such as agitation or insomnia.
- They may also be worried about memory loss and concerned about dementia - the memory loss they experience is global (whereas dementia affects more recent memories)
- Biological symptoms – weight loss, sleep disturbance
Management
- 1st Line: SSRI
Electroconvulsive therapy (ECT)
- Considered in cases of severe depression which is REFRACTORY to medical management
- Absolute contraindication: Raised intracranial pressure
- Adverse effects
- Short term: Headache, short term memory loss, Arrhythmias
- Long term: Impaired memory
Seasonal Affective Disorder
- Depressive symptoms occurring within the winter months
- Management is the same as ‘typical’ depression (i.e. CBT and SSRIs if required etc.)
Suicide: Risk stratification
There is increased risk of attempted and completed suicide with:
- Male sex
- History of deliberate self harm (DSH)
- History of alcohol/drug misuse
- Background of mental health illness
- History of chronic disease
- Increasing age
- Unemployment, lack of social network/isolation
- Living alone, loneliness
- Single/widowed or divorced