• depression common and major cause of disability

Screening

”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 having little interest or pleasure in doing things?"

“During the past month have you been worrying a lot about everyday problems?”

Have you used drugs or drunk more than you meant to in the last year?

Have you felt that you wanted to cut down on your drinking or drug use in the past year

these 2 pick up 80% of current etoh and drug problems

HELP:

Is this something that you would like help with?

Risk/resilience

• risk

  • parental history of depression

  • difficult temperament as a child

  • attachment difficulties/parental neglect

  • family discord

  • previosu depression/anxiety

  • ruminating over negatvie circumstances

• reslience

  • good parenting

  • easy temperament as a child

  • good peer relationships

  • stability in love relationships

  • has coped with past difficulties well

Key symptoms

• at least one of these, most days, most of time at least 2 weeks

  • persistent sadness/low mood

    • "During the last month, have you often been bothered by feeling down, depressed, or hopeless?"

  • marked loss of interest of pleasure

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

• ask about associated features

  • disturbed sleep

  • decrease or increase appetite and/or weight

  • fatigue or loss of energy

  • agitation or slowing of movements

  • poor concentration or indecisiveness

  • feels of worthlessness or excessive or inappropriate guilt

  • suicidal thoughts or acts

• also:

  • duration

  • associated disability

  • past and hamily histoyr of mood disorders

  • social support

• subthreshold depressive symptoms

• \<5 symptoms

• mild depression

• ≥ 5 and only minor functional impairment

• moderate

• between mild and severe

• severe

• markedly interfere with functioning

• most symptoms

• with or without psychotic symptoms

• symptoms shoudl be present for at least 2 weeks and every symptom should be present for most of every day

DSM V - Major depressive episode

5 or more of for 2 weeks:

• depressed mood for most day, nearly every day

• markedly reduced interest or pleasure in all, almost all of days activities

• insomnia or hypersomnia

• worthlessness/excessive/inappropriate guilt

• significant weiht loss / gain

• psychomotor agitation or retardation

• decrease ability to think or concentrate or indecisiveness nearly every day

• recurrent thoughts of death/suicide/suicide attempt

Assessment

• K10

  • measures psychological distress

    • anxiety and depression

• PHQ9

  • 9 key symptoms of depression

  • how much they have been present over the last fortnight

  • 10-14 mild

    • Active management

      • lifestyle review

      • identification of stressors

      • supprt strategies

      • how to achieve change

  • 15-19 moderate

    • Active managmeent and either an SSRI or structured psycholigcal intervention

  • ≥20 severe

    • Active management

    • antidepressent

    • plus structured psychological intervention

• AUDIT

  • etoh and substance abuse

  • contrasts with CAGE questionnaire

    • used to assess eoth dependence

• GAD 7

  • anxiety

  • 7 questions

  • 5-9 = mild

  • 10-14 = moderate

  • 15-21 = severe

• factors that favour general advice and active monitoring

  1. ≤4 of above symptoms with little disability

  2. symptoms intermittent or ≤2week duration

  3. recent onset with identified stressor

  4. no past or family history of depression

  5. socail support availbale

  6. lack of suicidal thoughts

• Factors that favour more active treatment in primary care

  1. ≥5 symptoms with associated disability

  2. persistent or long sstanding symptoms

  3. personal or fhx of depression

  4. low social support

  5. occ. suicidal thought

• Factors that favour referrral to mental health professionals

  1. inadequate or incomplete response to ≥2 interventions

  2. recurrent episode within 1 yr

  3. history suggestive of bipolar

  4. person with depression or relatives request referral

  5. more persistent suicidal thoughts

  6. self neglect

• Factors that favour urgent referrla

  1. actively suicidal ideas or plans

  2. psychotic symptoms

  3. severe agitation accompanying severe symptoms

  4. severe self neglect

management

national depression initiative

The low down - young people’

moodgym - CBT/Interpersonal therapy

climate.tv - groups of websites

mild-moderate

Non pharmacological

• CBT

  • active structured intervention

  • work collaboratively identify effcts of:

    • thoughts

    • beliefs

    • interpretations

  • devleop skills to identify, monitor and counteract probelms

  • individual guided self help based on principles of CBT

    • include provision of written materials

    • supported by trained practitioner

      • typically facilitates self help programme

      • 6-8 sessionns

        • 9-12 weeks

  • computerised cognitive behavioural therapy

    • standalsne computer based or web based prgoramme

    • include explanation of cbt model

    • encourage tasks between sessions and use challenging and active monitoring of behaviour

    • supported by trained practitioner

    • 9-12 weeks

    • supported by trained practitioner

• structured group physical activity programme

• interpersonal therapy

• problem solving therapy

  • focuses on identifying specific problem areas adn working collaboratively to prioritise porbelms

    • break them down into speicfic manageable taks

  • choose solutions and develop appropriate coping behaviours

• behavioural activation

  • less robust evidence

Pharmacological

• SSRI

  • if prolonged (>2yrs)

  • past history of moderate - severe depression

Moderate-severe

• SSRI + high intensity psychological intervention

  • CBT

  • Interpersonal therapy

relapse

• continue medication for at least 6mo after remission

  • greatly reduces risk of relapse

  • antideprssant not associated with addiction

• if risk of relapse should continue therapy at maintenece dose for 2 yrs

  • have had 2 or more episdoes of depression in the recent past

    • significant functional impairment

  • other risk factors for relapse

    • residual symptoms

    • multiple previous episodes

    • history of severe or prolonged epsidoes or of inadequatge response

  • consequences of relapse likely to be severe

• psychological interventions for relapse prevention

  • individual CBT

  • mindful based cognitive therapy

response to treatment:

• remission

  • only minimal signs of illness

• response

  • improvement of more than 50%

• partial response

  • reduction in sympotm severity of at least 25%

Suicide risk

• most immediatley important factos are contextual triggerigng and current mental state

  • intent/definite plan

  • lethality of likely means

  • access to means

  • presence of risk factors

    • mental / physical illness

    • chronic pain

    • etoh use

  • hopelessness

  • psychosocial triggers

  • lack or presence of protective factors

• single men; young, olderpeople

• homelessness

• recent suicide attempt by whanaua/family memeber

Young person

strength’s based approach

• enhancing resiliency

• minimising obstacles

• componenets

  • identification and developments of skills and strengths

    • might not be obvious

  • building motivation to deal with probelms

  • iincreasesocial interaction and enhancing relationships

  • encourage social interactions and enhance relationships

structured problem solving activity

STEPS

• say what the problem is

• think about what you could do

• examine the possibilities and choose one

• put it into action

• see what happens

  • if it worked - great

  • if it diedn’t try again

immediate referral

• serious suicidal intent

• psychotic symptoms

• severe self-neglect

Urgent

• severe depression

• persistent symptoms

• profound hopelessness

• other serious mental or substance use disorders

• significnt functional impairment

• suspected bipolar disorder

routine

• active managmenet

  • active listening

  • problem identification

  • advice re simple self management strategies

  • active follow-up

• clinical reassessment 2-4 weeks

• if improvement

  • monitor q1-2monthly

• if no improvement

  • refer secondary care mental health

• antidepressants associated with increase suicidality in young people (1-2% to 2-4%)

  • however the most common reason for suicidality and completed suicide = untreated or worsening mood disorder

Medications

all antidepressant drugs approx. equal in effectiveness

indivdiual response may vary

moclobemide may be useful if intolerant of other antideprssants (reversibel selective MAOi)

• should notice response in 2-3 weeks

• at 3-4 weeks

  • if no improvement o rminimal response

    • re-evaluate treatment

      • add psychological intervention

• at 4-6wks ifno response

  • increase dose

  • change

  • cahde/add psych

• 1/3 of patients have a relatviely slow response to antidepressants

• all psychotropics lower seizure threshold

SSRI

• first line

  • equally effective

  • favourable risk-benefit ratio

• start at 20mg/day for most adults

  • take in morninng due to risk of insomina

• side effects

  • increase risk of bleeding

    • especially in older people

    • coprescribe

      • nsaid

      • oac

      • aspirin

  • consdier PPI

• fluoxetine, paroxetine = higher propensity for drug interactions than other SSRI

• citalopram relatively weak inhibitor cyp2d6

• paroxetine associated with higher incidence of discontinuation symptoms

• fluoxetine has long half life (1wk) so be careful when switching

• reduce dose over 4 weeks

• citalopram

  • max = 40mg/day

  • higher dose increase risk of QT prolongation and incidence of torsafes de pointes

  • no treatment benefit >40mg

SNRI

• venlafaxine = highest risk of death from overdose

• venlafaxine exacerbates cardiac dysrhythmia

  • need to monitor BP

MAOi

• must avoid foods rich in tyramine or sympathomimetic medication

  • prevent hypertensive ccrisis

St. John’s wort

• may be of benefit in mild/moderate depression

• not prescribe or advise use

  • uncertainty about appr. dose

  • persistence of effect

  • variation in nature of preparations

  • potential serious interactions with other drugs

• advise different potentcies and of potential serious interactions

Lithium

• monitor renal and thyroid function before treatment and every 6mo during treatment

• consider ecg monitoring

• monitor lithium 1wk after initiation and each dose change and every 3mo therafter

Serotoniin toicity

• abdominal cramps

• agitation

• diarrhoea

• myoclonus

• tremulousness

• coma

• tachycardia

• hypotension

• disoreintation

• profuse sweating

• hyperpyrexia

contributing

• overdosage

• drug interaction

  • ssri + Maoi

  • SSRI + serotonergic tca

    • clomipramine a

    • amitriptyline

    • imipramine

• inadequate drug free interval

• idosyncratic

pregnancy

• ssri = firstline

  • paroxetine avoided due to teratogenic risk

• ? shorter acting

• consider TCA

  • increase risk of premature labour

• fluoxetine considred first choice

Postnatal depression

• vary from ‘baby blues’ to postnatal depression, bipolar, postpartum psychosis

• common

  • 15% of all women

• paternal derpession also common

  • risk factors

    • previous history of severe depression

    • depression and/or anxiety during antenatal period

    • partner who has developed derpession in the post natal period

    • limited eduction

    • other children in the family

  • EPDS has validity and reliability in men

• strongest risk factors

  • depression durin gantenatal period

  • past history of depression

  • previous diagnosis of postnatal depression

• symptoms

  • similar as those with general depression

  • subtle changes in behavior may be first symptoms

  • traditional symptoms may be hidden

    • libido

    • weight change

    • sleep disturbance

  • often:

    • appera/complain of overwhelmed by motherhood and needs of infant

    • feel trapped, angrey, fearful or panicky

  • symptoms;

    • depressed mood

    • irirtability

    • tiredness and fatigue

    • insomnia

    • loss of appeitie

    • low libido

    • poor concentration

    • feelings of guilt about inability to look after new infant

  • tiredness often first symptoms to be noticed and last to resolve

  • usually appear first 1-3mo following delivery

  • onset can occur at any time in first year

  • most cases resolve spont. within 3-6mo

    • 1 in 4 affected @ 1yr

  • Edinburgh postnatal depression scale

    • mother how feeling in previous 7d

    • all items must be completed

    • should complete self

    • avoid discussing by self

    • score:

      • 0-9 = mild

      • 10-12 = repeat 2/52 and continue

      • 13+ = likelihood depresison = high

    • on item 10 needs further evaluation before leaving

    • link

Baby blues

• temporary condition

  • 70-80% of women

• so common often considered normal part of emotional changes

• symptoms

  • mood lability

  • tearfullness

  • mild symptoms of anxiety or derpession

• symptoms usually peak d3-5 post partum

• should completley resolve 10-14d

• prolonged/severe = risk factor for post natal depression

• women should be reviewed after 10th postpartum day

Puerperal psychosis

• 2/1000 births

• sudden onset (1-2wk) post partum

  • psychotic ysmpotms

• life threatening to both mother and infant

• immediate referral

Bipolar disorder

• childbirth can trigger a bipolar disorder (severe)

• key factors whether previous episode of depression might have been bipolar:

  • onset \<20yo

  • presence of psychomotor symptoms

  • severe symptoms and signs

    • wothlessness

    • guilt

    • hopelessness

    • marked sleep disturbance

    • poor self-care

      • appetitet

      • weight loss

    • slowing of thought/movement

  • family history

Management

• collaboration

• active support and self management

  • execise

  • making time for pleasurable activity

• education and support

  • not a personal failure

  • commmon

    • erspons to treatment

    • especially in understaning and supportive environment

• Stepped care

  • mild - moderate

    • CBT

      • working with a therapist to challenge negative thoughts and beliefs

    • interpersonal therapy

      • work with a therapist to learn ways to improve your relationships with other people

      • non directive counselling

      • psychodynamic therapy

  • moderate- severe

    • antidepressant

      • indications

        • moderate - severe depression at least 2 weeks

        • significant anxiety or panic

        • psychomotor change or significant biological

        • previous response to antideprssant

      • in consultation with maternal mental health

      • SSRI = first choice

        • paroxetine, citalopram and fluoxetine ok with BF

  • monitoring

Older people

Causes/diagnosis

• associated

  • cerebrovascular disease

  • parkinson’s disease

  • coronary heart disease

  • endocrine disorder

  • sleep disorders

• medicines associated

  • bdz

  • opioids

  • antipsychotics

  • betablockers

  • corticosteroids

  • antivonculsants

    • increase gabapentin/carbamazepine

  • NSAID

  • antiparkinson agents

  • h2 antagonists

• diagnosis can be challenging

  • ddepression

    • often abrupt coinciding with life changes

    • duration = months - years

    • progression - variable and uneven

    • thinking inctact themes of helplessness/negative

    • memory selective/patchy

    • early morning wakneing

    • clear awareness

    • noraml alertness

    • minimal impairment of attention but eaily distracted

  • dementia

    • chronic generally insidious

    • months - years

    • slow but even

    • scarcity of thought, poor judfement, words hard to find

    • impairmed

    • sleep often disturbed, nocturnal wandering

    • clear awareness

    • normal alertness/attnetino

  • delirium

    • sudden onset - often twilight

    • duration hours - less than 1 mo

    • abrupt, fluctuationg progression

    • thinking, disorganised, slow, incoherent

    • memory, impaired, sudden

      • immediate memory loss may ne ntivable

    • nocturnal confusion

    • reduced awareness

    • fluctuating alertness

    • impaired attention - fluctuates

  • consider

    • 3ds

    • complete physcial

    • adverse effects of medicines

    • CBC and TFTs

    • Na, Cr, B12, folate

Assessment

• GPCOG

  • GP assessment of cognition

  • reliable, valid and efficient instrument

  • 2 parts; patient and informant

• GDS

  • score > 10 = depression

  • http://www.bpac.org.nz/BPJ/2008/February/depression.aspx#2

Management

• older people respond well

• exerices

  • avavilable evidence supports

• psychosocial

• antidepresants

  • moderate - severe

    • alwyas in conjucntion with non-pharmacological

• SSRI = first line

• similar effectiveness to TCA and are better tolerated

  • Citalopram

    • less drug interactions

    • less nausea

    • hosrt hlaf life

      • caution re discontinuation syndrome

  • Escitalopram

  • Fluoxetine

    • signifcnat number of drug interactions

    • long half like

      • slowewr reversal but discontinuation syndrome unlikley

    • active metabolite also inhibits hepatic enzyme

  • Paroxetine

    • very short half life

  • mirtazepine

    • cause weight gain

  • venlafaxine

    • raise BP

• antidepressant and risk of falls

  • sedation and impaired reaction time

  • impaired balance

  • insomnia

  • orthosttaic hypotension

  • cardiac rhythm and conudction disorder

  • tendnencey to cause movement disorder

• Co-morbidities;

  • cardica sisease

    • venlafaxine

    • TCA

  • epilepsy

    • most antidepressants lower seizure threhold

      • use low doses with gradual titration

  • Glaucoma

    • TCA can ppt. acute narrow angle glaucoma

    • SSRI less likely to be a problem

  • Prostatic disease

    • TCA may cause urinary retention

  • Parkinsons’

    • SSRI usually ok

• antidepressant induced hyponatraemia

  • risk factors:

    • older age

    • low body weight

    • female

    • previous history ofhyponatramiea

    • reduced renal function

    • concurrent intake of other hyponatraemic medicines

      • diuretics

  • usually occur in first 4 weeks

  • check baseline before starting

  • 2 weeks and agian 3mo and 12mo

  • consider after adding or changing dose