Depression is a common mood (affective) disorder characterised by persistent low mood, low energy and loss of interest/enjoyment in everyday activities (anhedonia)
The onset of individual episodes is often related to stressful events or situations, and it usually runs a relapsing and remitting course.
Causes/Factors
| Biological | Psychological | Social | |
|---|---|---|---|
| Predisposing | - Family history - Age - Female | - Personality - Childhood trauma | - Lack of support - Marital status |
| Precipitating | - Comorbid substance misuse - Physical health problems | - Traumatic life events - Low self-esteem | |
| Perpetuating | - Failure to come with loss - Ongoing loss | ||
| Protective | - Current employment - Support - Marital status |
Symptoms
Core three symptoms of depression
- Low mood
- Anhedonia (loss of interest or pleasure in most activities that they previously enjoyed)
- Lack of energy (anergia)
Other important symptoms are:
- weight change
- disturbed sleep - sleeping late, waking early, not being able to fall back asleep
- psychomotor changes - movement slower or more restless
- reduced libido
- feeling of worthlessness of guilt
- decreased concentration
- thoughts of self-harm
Risk assessment
Important to conduct -
- Risk to self - self-harm, suicide, neglect (commonest in depression)
- Risk to others - when depression presents with psychotic features such as command hallucinations, may be a risk to others
- Risk from others - may be more vulnerable to abuse, criminal acts or neglect
Investigations
ICD-10 Clinical diagnosis
- The presence of symptoms for at least 2 weeks (this may be less if depression is severe)
- The symptoms are not attributable to other organic or substance causes (e.g. normal bereavement)
- The symptoms impair daily function and cause significant distress
-
Patient-health-questionnaire-9
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FBC - macrocytic anaemia
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Thyroid function (hypothyroidism)
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Vitamin B12 - signs of paraesthesia and impaired memory
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Dexamethasone suppression test - Cushing’s disease/syndrome. Obesity and proximal muscle wasting
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CT head may be performed in patients with atypical features and other signs indicative of pathology
Management
- Mild depressive episode, with or without somatic symptoms
- Moderate depressive episode, with or without somatic symptoms
- Severe depressive episode, with or without psychotic symptoms: these may be mood-congruent or incongruent psychotic symptoms
- Recurrent depressive disorder: when one has two more depressive episodes
Management is based on the bio-psycho-social model.
| Severity | Short term | Long term |
|---|---|---|
| Mild depression | 1st line - low intensity psychosocial interventions Group CBT Individual CBT Counselling SSRIs***** | SSRIs take around 4-6 weeks before any benefit is noticeable. In the first 3 weeks might make things worse Assess for social support |
| Moderate or severe | 1st line - combination of antidepressants, and high intensity psychosocial interventions | Risk assessment Review response to treatment Relapse prevention plan Assess social support and previous issues flagged |
* although not routinely offered unless that is the patients preference. Need a past history of moderate or severe depression or mild depression that has been resistance to treatment
Complications/red Flags
- Suicide - 4x risk than patients without
- Substance misuse and alcohol use problems
- Persistent symptoms
- Recurrence
- Reduced quality of life
- Antidepressant side effects