Depression

Lawrence Pike

Depression

Detection Diagnosis Treatment Suicide Referral Recurrence

Depression - Detection

50% missed, especially in patients with chronic physical disease

Consulting styles makes a difference Screening tools can help

Depression - Detection

Consulting styles– open questions– more time– more eye contact– less interuptions

Depression - Detection

Screening Tools:– consider for those at high risk as improve

detection– Hospital Anxiety and Depression Scale

• more sensitive than GPs (90% vs. 49%)• less specific than GPs (86% vs. 96%)

– Two question test• sensitivity 96% but specificity 57%

Depression - Detection

Two Question Test:– During the last month, have you often been

bothered by feeling down, depressed or hopeless?

– During the last month, have you often been bothered by little interest or pleasure in doing things?

Depression - Diagnosis

DSM-IV Criteria for Major Depression:– Over the last 2 weeks five of the following

features should be present of which one or more should be:

• 1/ depressed mood• 2/ loss of interest or pleasure

– continued

Depression - Diagnosis

• 3/ significant weight loss or gain or a change in appetite

• 4/ insomnia or hypersomnia• 5/ psychomotor agitation or retardation• 6/ fatigue or loss of energy• 7/ feelings or worthlessness or excessive guilt• 8/ diminshed ability to think or concentrate• 9/ recurrent thoughts of death (not just fear of

dying) or suicidal ideas

Depression - Treatments

General Drug Treatment Psychological Treatments Other Treatments

Depression - Treatments

General– whichever treatment is agreed and offered,

patients have a better outcome if given good clear information, especially a leaflet

Depression - Treatment - Drugs

Antidepressants are all equally efficacious

They have similar drop-out rates Costs vary considerably Trazodone and lofepramine are cost

effective and safe in overdose Patients anxious addictive and need

information and reassurance

Depression - Treatment - Drugs

When using tricyclics - use 100mg or 140mg for Lofepramine

Trial of 6 weeks If fails use a different class of drug Duration - 4-6 months after normal St John’s Wort as effective as TCA Stopping treatment- discontinuation

syndrome possible

Depression - Psychological Treatments Problem solving - can be performed by GP

with some training but takes time Cognitive Therapy

– of value in those who respond to concept, prefer psychological treatment or have not responded to drugs. “Beating the Blues”

Counselling - not shown to be more effective than GP although patients may prefer

Depression - Other Treatments

Written information – can improve mild to moderate

Exercise

Depression - Suicide

Ask about known risk factors– most important is how depressed the

patient is and whether they have made any suicidal plans (as opposed to passive thoughts)

Depression - Suicide Risk Factors

Active Suicidal ideationRecent self-harm 14Definite plan 5Hopelessness 5Severe depressive symptoms 3Psychotic symptoms (delusions,hallucinations)

3

Depression - Suicide Risk Factors

Background risk factors!st degree family history of suicide 4Bereavement 3Male ?Living alone ?Physical Illness ?Recent psychiatric hospitaldischarge

?

Depression - Referral

Serious suicidal intention Failure of treatment

– 2 courses of anti-depressant at full doses Difficulty with diagnosis For specific treatments (CBT) Severe psychomotor retardation

Depression - Referral

Referral letters should contain:– Considered diagnosis– Why referral is being made– Degree of urgency– Treatment tried - including doses, duration

etc

Depression - Recurrence

Recurrence Rate– 50% after one episode, 70% after two, 90%

after three.– 15% in first year after 6 months treatment,

40% after less than 4 months treatment Relapses reduced by long term

antidepressants

Depression - Recurrence

Cognitive behaviour therapy– some evidence reduces relapses but no

satisfactory long term trials Discussion with patient

– Balance between long term medication and risks of recurrence will need careful consideration

Depression

www.psychiatry.ox.ac.uk/