Depression

Clinical Features

Core symptoms - ↓Mood, ↓Energy, Anhedonia

Other symptoms:

• Disturbed Sleep

• ↓Appetite

• ↓Concentration, Memory

• ↓Self-esteem and Self-confidence

• Guilt, Worthlessness

• Self-harm or suicidal thoughts

• ↓Libido

• Headache

• Weight Loss

N.B. Early morning waking is a pathognomonic for depression.

Psychotic depression - depression symptoms + delusions + hallucinations

Differentials

Organic differentials:

• Neurological - Parkinson’s, Dementia and Multiple sclerosis

• Endocrine - Thyroid disease, Cushing’s, Addison’s

• Drugs - Steroids, Alcohol, Drug abuse, Isotretinoin, B-blockers, Benzos

• Chronic conditions - Diabetes, OSA

• Cancer

Psychiatric differentials:

• Dysthymia - Chronic, low grade depressive symptoms

• Bipolar disorder - Episodes of mania and depression

• Schizophrenia

• Dementia

• Seasonal affective disorder

• Bereavement

• Anxiety

Investigations

• Careful hx - Assessed with the PHQ-9 questionnaire

• Ruling out other potential differentials:

  • Bloods - FBC, TFTs, Cortisol, Glucose, Toxicology screen

  • MRI/CT Head

Assessed with the PHQ-9 questionnaire.

For a diagnosis, there needs to be 2 core + > 2 other symptoms that are present nearly every day for 2+ weeks.

Management

1st line - Group-based CBT, Interpersonal therapy

If the 1st line isn't effective, an SSRI can be given e.g. Sertraline, Citalopram, Fluoxetine

• Continue SSRI for at least 6+ months following remission of symptoms to reduce the risk of relapse, and the dose should be gradually tapered down

• Patients should be followed-up 1-2 weeks after initiating therapy, then monthly for the next 3 months.

N.B. Fluoxetine is the only one that can be used in children.

Side-effects of SSRIs:

• Prolonged QT interval

• GI upset (diarrhoea, n+v)

• Gastric Ulcer

• Anxiety and agitation

• Sexual dysfunction

• Hyponatraemia

Side-effects of TCAs - Anti-cholinergic activity - Can’t see (blurred vision), Can’t pee (urinary retention), Can’t spit (dry mouth), Can’ s*** (constipation):

• Blurred vision

• Urinary retention

• Dry mouth

• Constipation

N.B. SSRI's are usually avoided in patients with a higher risk of bleeding e.g. elderly that's already on anticoagulants.