Depression
Dr Maryam Naeem
GPST2 Psychiatry
Depression
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RCGP Learning outcomes
Diagnostic criteria
NICE guidelines
AKT questions
RCGP Curriculum statement 13:
Care of people with mental health
problems
• Risk factors for mental health problems, the
difference between depression and emotional
distress
• Diagnostic criteria for people experiencing
mental health problems
• How to screen for mental illness, using
effective and reliable instruments
RCGP Learning outcomes
• Specific interventions and guidelines for
individual mental health conditions
(SIGN/NICE)
• Principles of mental health promotion
• Sufficient knowledge of the Mental Health Act
Depression in primary care
• Prevalence 5-10% in primary care
• Ranks 4th as cause of disability worldwide
• Suicide 2nd leading cause of death in persons
aged 20-35 years
• 2/3 of patients meet criteria for another
psychiatric disorder (anxiety, substance misuse,
alcohol dependency, PD)
Symptoms needed to meet criteria for
‘depressive episode’ ICD-10
• Group A symptoms
Depressed mood
Loss of interest and enjoyment
Reduced energy and decreased activity
Diagnostic criteria ICD-10
• Group B symptoms
 Reduced concentration
 Reduced self-esteem and confidence
 Ideas of guilt and unworthiness
 Pessimistic thoughts
 Ideas of self-harm
 Disturbed sleep
 Diminished appetite
Diagnostic criteria ICD-10
• Mild: At least 2 of A + 2 of B
• Moderate: At least 2 of A + 3 of B
• Severe: All 3 of A + at least 4 of B
• The severity of symptoms and degree of
functional impairment also guide classification
Biological symptoms
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Loss of emotional reactivity
Diurnal mood variation
Anhedonia
EMW
Psychomotor agitation or retardation
Loss of appetite and weight
Loss of libido
Other subtypes depressive disorder
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Atypical depression
Agitated depression
Postnatal depression
SAD
Premenstrual dysphoric disorder
Depression screening tools
• PHQ-9
• HADS
• Becks inventory
• EDPS
• GDS
NICE Guidelines
Key priorities for implementation
1) Screening in primary care and general hospital
settings
2) Watchful waiting
3) Antidepressants in mild depression
4) Guided self help
5) Short term psychological treatment
NICE Key priorities
• 6) Prescription of an SSRI
• 7) Tolerance and craving, and discontinuation/withdrawal
symptoms
• 8)Initial presentation of severe depression
• 9)Maintenance treatment with antidepressants
• 10)Combined treatment for treatment resistant depression
• 11) CBT for recurrent depression
Treatment of mild depression
• Watchful waiting
• Sleep & anxiety management
• Exercise
• Guided self-help
• Computerised CBT
Treatment of mild depressionPsychological interventions
• Consider psychological treatment specifically
focused on depression
Problem solving therapy
Brief CBT
Counselling
• 6-8 sessions over 10-12/52
• Where significant co-morbidity exists ,
consider extending treatment duration
Drug treatment mild depression
• ‘Antidepressants are not recommended for
the initial treatment of mild depression,
because the risk-benefit ratio is so poor’
• Persistent symptoms – SSRI
• Mild depressive episode in those with a hx of
moderate or severe depression - SSRI
Treatment of moderate to severe
depression
• ‘In moderate depression, offer antidepressant
medication routinely, before psychological
interventions’
• Delay in onset of effect
• Risk assessment – See those considered high
risk of suicide and <30 1/52 post initiation,
limit quantity prescribed
Treatment of moderate to severe
depression - SSRIs
Antidepressant, anxiolytic, amti-obsessive and
anti-bulimic effects
• 5HT2 agonism
Agitation, akithisia, anxiety/panic, insomnia,
sexual dysfunction
• 5HT3 agonism
Nausea, GI upset, diarrhoea, headache
Treatment of moderate to severe
depression - SSRIs
• As effective as TCAs and less likely to be discontinued
beacuse of SEs
• Generic – Fluoxetine or citalopram
• Consider toxicity in overdose in patients at significant
risk of suicide
• Highest risk TCAs (except lofepramine)
• Venlafaxine more dangerous than other equally
effective drugs
Treatment of moderate to severe
depression
• If increased agitation develops early in
treatment with an SSRI, provide appropriate
information and, if the patient prefers, either
change to a different antidepressant or
consider a brief period of concomitant
treatment with a benzodiazepine followed by
a clinical review within 2 weeks.
St Johns wort
• May be of benefit in mild to moderate
depression
• Should not be prescribed or advised –
uncertainty OTC potencies and liver enzyme
inducer
Failure of 1st line treatment
• Consider switching to another anti-depressant if no
response after 4/52
• If partial response, a decision to switch can be
postponed until 6/52
• Treatments such as dosulepin, phenelzine, combined
antidepressants, and lithium augmentation of
antidepressants should be routinely initiated only by
specialist mental healthcare professionals (including
General Practitioners with a Special Interest in Mental
Health)
2nd line treatment
• Choice for a 2nd antidepressant include a different SSRI
or Mirtazapine
• Alternatives include:
 Moclobemide
 Reboxetine
 Lofepramine
• Consider other TCAs (except dothiepin) and
venlafaxine, especially for more severe depression
Stopping or reducing drugs
• Reduce doses gradually over a 4/52 period
• Warn about possible reactions:
• SSRIs – headache, nausea, paraesthesia,
dizziness and anxiety
• Withdrawal of other antidepressants (esp
MAOIs) - nausea, vomiting, headache, ‘chills’,
insomnia, restlessness
Special considerations: Venlafaxine
• Increased likelihood of patients stopping
treatment because of SEs
• Uncontrolled hypertension
• 300mg or more only under supervision or advice
of psychiatrist
• Measure BP at initiation and during treatment
• Cardiac dysfunction
Special patient characteristics
• Women – poorer toleration of imipramine
• Sertraline 1st choice in those with recent MI or
unstable angina
• ECG and BP must be checked before starting a
TCA in a patient at significant risk of CVD
• Venlafaxine and TCA contraindicated in those
with recent MI or high risk serious cardiac
arrhythmias
Summary
• Mild: Non-pharmacological
• Moderate-severe: SSRIs, different SSRI or
Mirtazapine, Moclobemide, Reboxetine or
Lofepramine
• Assess risk - Always ask directly about suicidal
ideation
AKT Questions
• Which of the following is the most appropriate
first line management for mild depression?
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A) Citalopram
B) CBT
C) Fluoxetine
D) Paroxetine
E) Psychodynamic psychotherapy
AKT Question 2
• Which one of the following is a risk factor for
the development of depression?
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A) Antisocial personality traits
B) Anxious/avoidant personality traits
C) High incidence of expressed emotion
D) Male sex
E) Paranoid personality traits
AKT Question 3:
Side effects of antidepressants
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A) Amitriptyline
B) Citalopram
C) Fluoxetine
D) Lamotrigine
E) Mirtazepine
F) St Johns wort
G) Tryptophan
H) Venlafaxine
AKT Question 3
• 1) Sedation and weight gain are common side effects
• 2) This antidepressant can cause a rise in anxiety levels
during initial titration
• 3) BP should be monitored during initiation of this
antidepressant
• 4)EPSE can occur with this antidepressant
• 5)Caution should be exercised when choosing an
antidepressant in a patient who is self-medicating with
this
Final Question...
• Thank you
References
• 1)Semple et al, Oxford Handbook Clinical
Psychiatry, OUP 2005
• 2)NICE Summary PDF Depression 2007
• 3)Gelder et al, Shorter Oxford Textbook of
Psychiatry, OUP 2008