Table of Contents

Clinical Depression

Clinical depression should be distinguished from transient and fleeting feelings of irritation, dissatisfaction, disappointment, boredom or sadness. The term is used to describe consistent feelings of dysphoria (sadness or hopelessness) for a significant duration which seem disproportionate to the patient's circumstances. It is considered as a diagnosis when there is a consistently lowered mood with little reactivity for two or more weeks duration.

The patient is subjectively depressed, and the depressed mood is objectively corroborated by biological symptoms, although there may be atypical symptoms.

The diagnosis is missed sometimes in different situations. Masked depression is a condition when biological symptoms are present although the patient may complain of a different or unrelated complaint. Depression may be also a manifestation in undiagnosed underlying physical illness: for example an endocrine disease, drug or alcohol abuse or dementia.

Sometimes there are understandable reasons for feeling sad, such as unemployment, redundancy, debts, family illness & bereavement, severe or debilitating illness, cardiac or lung disease, or arthritis.

Some people with Personality disorders: such as borderline disorder may present with depression.

ASSESSMENT

BIOLOGICAL/VEGETATIVE SYMPTOMS

The cardinal symptoms are low mood, anhedonia (loss of enjoyment) with insomnia, early morning waking, anorexia, loss of weight, diurnal variation of mood, lack of energy (retardation), poor concentration, loss of libido, fatigue and lethargy.

In addition there is social withdrawal, self blame, sense of guilt and worthlessness which may become delusional, with a belief of futility of life and suicidal thoughts.

Atypical symptoms

Sometime depressed patient may have increased appetite, gain weight, and sleep excessively (hypersomnia). Symptoms should be subjectively reported and objectively corroborated (by observation or informants report). Negative thoughts may appear concerning the self (worthlessness, self blame, guilt), concerning the future (helplessness, hopelessness) and concerning the outside world. Cognitions may be internally directed, or may be overvalued or delusional.

ASSESSMENT OF PREMORBID PERSONALITY

Assessment of personality of the patient takes in consideration the occupational history, adequacy of intimate relationships, psychosexual history, and forensic history.

Depressed patients may have dependent, anxious, hysterical or obsessional personality traits. Patients with borderline personality disorder suffer dysthymia, chronic boredom with self cutting, overdosing, binge eating and binge drinking to relieve their dysphonia. They also have increased vulnerability to depression due to the underlying genetic and biological factors, the chaotic life style and stressful life.

MANAGEMENT

The following is used in isolation or combination: - Physical treatment (Medication, electroconvulsive therapy [ECT]) - Cognitive therapy - Behaviour therapy - Brief psychotherapy - Marital/family therapy - Analytic psychotherapy - Counselling

INDICATIONS FOR INPATIENT CARE

  • Suicide risk
  • Self neglect
  • Deteriorating physical health
  • Need for in-patient physical treatment such as ECT
  • Assessment of resistant depression

ASSESSMENT OF SUICIDE RISK

  • Does patient feels that life is not worth living?
  • Does the patient wish to die?
  • Does the patient have suicidal thoughts? * Are they fleeting and easily resisted or persistent and intrusive? * What are the reasons not to act on them?
  • Are the suicidal thoughts so many, distressing, hard to resist?
  • Does the patient lives alone, socially isolated?
  • Did the patient try self-harm in the past? Any preparatory measures?
  • In case of attempt at self-harm will rescue be available?
  • Are the suicidal thoughts violent and graphic?
  • Are their protective factors?
  • Are there delusional thoughts?

RELATIVE RISK FACTORS

  • Social isolation.
  • Perceived rejection by others.
  • Life situation very bleak.
  • Medical illness.
  • Age
  • Male sex
  • Past attempts
  • Alcohol
  • Clinical diagnosis of depression.
  • Biological symptoms (anhedonia, anergia, anorexia, early morning waking.

INDICATIONS FOR ECT

  • Serious suicide risk.
  • Patient is not eating or drinking.
  • Psychotic depression
  • Resistant depression
  • Post partum depression
  • Depression in elderly

INDICATIONS FOR COGNITIVE THERAPY

  • Negative cognitions evident
  • Some hope
  • Biological features
  • Social problems
  • Personality difficulties
  • Psychologically minded
  • Motivated
  • Depression is not too severe

INDICATIONS FOR BRIEF PSYCHOTHERAPY

If there is a single issue related to depression which is understandable in terms of history and unconscious motivation, brief psychotherapy is indicated.

AIMS OF COGNITIVE TREATMENT

Cognitive treatment aims to modify thinking by identifying automatic negative thoughts and appreciating their effect upon mood while trying to replace negative with positive thoughts.

AIMS OF BEHAVIOURAL TREATMENTS

Behaviour therapy aim is the modification of behaviour by trying to increase the number of positively rewarding experiences and to decrease the negative ones.

AIMS OF BRIEF FOCUSED PSYCHOTHERAPY (12 weeks)

The aim here is the resolution of a crisis through an understanding of the historical and unconscious origins of that crisis. There is no attempt at "personality change" implied except for the normal process of personality growth.

CHOICE OF DRUG TREATMENT

  1. It depends on the type of illness. So if there is bipolar disorder Lithium and other mood stabilisers are used alongside the use of neuroleptics for psychotic symptoms in the manic phase. In psychotic depression both antidepressants and antipsychotics are used.

  2. Past history of good response to a specific treatment is an indication that the patient may respond better to this treatment.

  3. Family history of treatment response is also an indication of which treatment would be more successful.

  4. Patient's symptom profile may guide the choice of treatment such as the presence of anxiety, initial insomnia, anorexia, weight loss or weight gain.

  5. Patient's situation may also dictate which drug to use such as if he is working or driving.

  6. The presence of past history of deliberate self-harm or current suicide risk has a significant impact of treatment.

  7. Patients age and physical state or concurrent medication is also considered.

DRUG TYPES

Tricyclics (eg. Amitriptyline, Prothiaden)

Rarely used now due to side effects and toxicity although they remain effective treatments. Their sedative effect is useful in anxiety, however, their anticholinergic effects lead to constipation, urinary hesitancy, blurred vision, dry mouth. There is also sedation, tremor, postural hypotension, weight gain, lowering threshold to seizures. Side effects cause poor compliance. Because of their cardiotoxicity, they are dangerous in overdose.

MAOIs (eg. pheneizine, tranylcypramine)

They were used in the past. They have good effect in "atypical" and "neurotic" presentation. Dietary restrictions, leading to hypertensive crises, dangerousness in overdose and reluctance of patients to stop treatment due to dependence have made their indication limited.

Tetracyclics - (eg. Mianserin)

is less anticholinergic, less cardiotoxic but it causes bone marrow suppression.

5HT reuptake inhibitors

Fluoxetine, Fluvoxamine, paroxetine, Sertraline

These cause low incidence of anticholinergic side effects such as dry mouth, constipation, urinary retention, postural hypotension and cause less weight gain and are non sedative. They have no cardiovascular effects and are well tolerated in the elderly. Patients have better compliance with these drugs which are safer in overdose.

They are the first line antidepressants at the present time.

RIMAs

eg. Moclobemide (150-600 mg/day) inhibits monoamine oxidase A. Its effects are reversible.

Post treatment washout period is unnecessary. It has minimal interactions with other drugs (but avoid pethidine, codeine, SSRIs and Tricyclics). There are few dietary restrictions. It has low incidence of anticholinergic side effects and low risk in overdose. It is effective in depression with anxiety. It is less effective in atypical depression than the old fashioned MAOls.

MAINTENANCE

DRUG TREATMENT should be maintained for 6/12 after recovery from an episode - then reduced before discontinuation. Some patients are maintained on medication for a longer period.