Psychiatry >
Depression

“Persistent low mood and/or loss of pleasure in most activities and a range of associated emotional, cognitive, physical, and behavioural symptoms”

Risk Factors
  • Chronic comorbidities and illnesses
  • Older age
  • Recent childbirth
  • Psychosocial issues
  • Personal history of depression
  • Family history of depressive illness
Aetiology
  • Interaction between biological, psychological, and social factors
Pathophysiology
  • Monoamine theory of depression
    • Decreased monoamine function (5-HT, noradrenaline, dopamine)
  • Psychological:
    • Certain personality traits (neuroticism) suggest negative biases in attention and processing
    • Childhood experiences may increase sensitivity to events
  • Social:
    • Disruption due to life events (births, job loss, divorce, illness)
    • Stress associated with a poor social environment and social isolation
Clinical Presentation

Symptoms must be present for at least 2 weeks with at least 2 core symptoms and >2 typical symptoms

  • Core symptoms:
    • Low mood
    • Little interest or pleasure in doing things (anhedonia)
    • Fatigue
  • Typical symptoms:
    • Disturbed sleep (decreased or increased compared to usual, early waking)
    • Decreased or increased appetite and/or weight
    • Agitation or slowing of movements
    • Poor concentration or indecisiveness
    • Decreased libido
    • Feelings of worthlessness or excessive or inappropriate guilt
    • Suicidal thoughts or acts
Investigations
  • Mainly taken from history
  • May use a validated depression questionnaire such as PHQ-9
Management
  • Step 1:
    • Assess the severity of depression, other comorbidities, risk of suicide
  • Step 2:
    • Offer low-intensity psychological interventions (e.g. non-facilitated self-help, individual guided self-help, psychoeducational groups)
  • Step 3:
    • High-intensity psychological interventions (CBT) or pharmacological
    • First line: SSRI (citalopram, fluoxetine, sertraline) for moderate-severe depression and for mild depression if psychological treatments insufficient
    • Second line: an alternate SSRI;
    • Third line: SNRI (venlafaxine) for major depression; mirtazapine (⍺2-adrenoceptor antagonist) for major depression;
    • Fourth line: tricyclic antidepressants (TCAs – amitriptyline, clomipramine) for moderate-severe depression however HIGH risk of overdose; monoamine oxidase inhibitors (MAOI – moclobemide, phenelzine)
    • Other: St John’s wort for mild depression (its use is not encouraged)
  • Step 4:
    • Refer for specialist treatment if the patient has not improved with step 3 intervention and/or is exhibiting or at risk of self-harm, self-neglect, suicide, or significant comorbidity such as substance misuse
Complications
  • Reduced quality of life for the person and their families
  • Increased morbidity and mortality in a range of comorbid conditions (IHD, DM)
  • Impaired ability to function normally
  • Increased risk of substance abuse Suicidal ideation and attempts
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