Depression and suicide risk assessment Flashcards
What are depressive disorders?
Depressive disorders are typically characterised by persistent low mood, loss of interest and enjoyment, neurovegetative disturbance, and reduced energy, causing varying levels of social and occupational dysfunction.
Can you give examples of depressive symptoms?
Depressive symptoms include depressed mood, weight changes, libido changes, sleep disturbance, psychomotor problems, low energy, excessive guilt, poor concentration, and suicidal ideation. In some cases, the mood is not sad, but anxious or irritable or flat.
Medical illness excluded
Bipolar disorder excluded
What is major depressive disorder?
To diagnose major depression, this requires at least one of the core symptoms:
-Persistent sadness or low mood nearly every day.
-Loss of interest or pleasure in most activities.
-Plus at least three or four of the following symptoms to a minimum total of 5 depressive symptoms:
Fatigue or loss of energy.
Worthlessness, excessive or inappropriate guilt.
Recurrent thoughts of death, suicidal thoughts, or actual suicide attempts.
Diminished ability to think/concentrate or increased indecision.
Psychomotor agitation or retardation.
Insomnia/hypersomnia.
Changes in appetite and/or weight loss.
Symptoms should have been present persistently for at least two weeks and must have caused clinically significant distress and impairment.
They should not be due to a physical/organic factor (eg, substance abuse) or illness (although illness and depression commonly co-exist).
What is the classification of depression?
Severity is based on the extent of symptoms and their functional impact:
Subthreshold depressive symptoms - <5 symptoms.
Mild depression - few, if any, symptoms in excess of the 5 required to make the diagnosis, with symptoms resulting only in minor functional impairment.
Moderate depression - symptoms or functional impairment are between ‘mild’ and ‘severe’.
Severe depression - most symptoms present and the symptoms markedly interfere with normal function. It can occur with or without psychotic symptoms.
What is a persistent depressive disorder?
Persistent depressive disorder (dysthymic disorder) is characterised by at least 2 years of three or four dysthymic symptoms for more days than not.
Dysthymic symptoms include depressed mood, appetite change, sleep disturbance, low energy, low self-esteem, poor concentration, and hopelessness.
What are the risk factors for depression?
Key risk factors include older age; recent childbirth, stress such as divorce, unemployment and poverty, or trauma; co-existing medical conditions (diabetes, cancer, stroke, MI, and obesity); personal or family hx of depression; other mental health problems such as schizophrenia or dementia; certain medications (e.g., corticosteroids) and female sex.
How do you screen for depression?
The NICE guidelines encourage a case-finding approach with at-risk groups (individuals with a past history of depression or a chronic health problem with associated functional impairment) using a two question approach:
During the past month, have you:
- Felt low, depressed or hopeless?
- Had little interest or pleasure in doing things?
Where there is an affirmative answer to either question, further evaluation should be triggered. NB: negative response does not exclude depression.
Which symptom scales are used to evaluate depression?
Self-report symptom scales are widely used and include:
- The Patient Health Questionnaire (PHQ-9).
- The Hospital Anxiety and Depression (HAD) Scale. (This is not available digitally, and must be purchased in paper format.)
- Beck’s Depression Inventory II (the adapted version must be purchased, although older versions are available online).
Whilst these can be helpful in staging depression, do not rely on a symptom count alone to make a diagnosis of depression.
How do you assess a patient presenting with low mood and
anhedonia?
An individual considered likely to have depression should be fully assessed, including:
- Full history and examination, including mental state examination, enquiring directly about suicidal ideas, delusions and hallucinations.
- Consider organic causes of depression such as hypothyroidism or drug side-effect. Establish the duration of the episode.
- Review of related functional, interpersonal and social difficulties.
- Involve family members or carers, with the patient’s consent, to obtain third-party history if appropriate.
- Note whether there is evidence of self-neglect, psychosis or severe agitation. Consider cultural factors.
- Past psychiatric history, including previous episodes of depression or mood elevation, response to previous treatment and comorbid mental health conditions.
- Patient safety and risk to others - suicidal intent should be assessed regularly. Directly ask about suicidal thoughts.
What are the differentials for depression?
Adjustment disorder with depressed mood Seasonal affective disorder Substance/medication Bipolar disorder Premenstrual dysphoric disorder (PMDD) Grief reaction Dementia Anxiety disorders Alcohol abuse Anorexia nervosa Hypothyroidism Obstructive sleep apnoea
What are the associated diseases of depression?
Dysthymia Eating disorders such as anorexia nervosa and bulimia nervosa Substance misuse Parkinson’s disease Cardiac disease Cerebrovascular disease Pancreatic cancer Autoimmune conditions
What are the investigations for depression?
Clinical diagnosis – DSM-5 diagnostic criteria
FBC- normal (rule out other causes of fatigue)
TFT- rule out hypothyroidism
PHQ-9- positive
Imaging (MRI or CT brain scanning) may be indicated where presentation or examination is atypical or where there are features suspicious of an intracranial lesion (eg, unexplained headache or personality change). Seek specialist advice.
What is the management of depression?
Doctors and patients can use Decision Aids together to help choose the best course of action to take.
General measures should include:
- Managing comorbidity (particularly alcohol and substance abuse, eating disorders, dementia, psychotic symptoms).
- Managing any safeguarding issues.
- Assessing and mitigating suicide risk.
- Appropriate monitoring/follow-up.
- Advising on sleep hygiene where relevant.
What is the management of subthreshold depressive disorder?
Consider watchful waiting, assessing again normally within two weeks.
Consider offering one or more low-intensity psychosocial interventions, guided by patient preference, usually via referral to IAPT:
Guided self-help based on cognitive behavioural therapy (CBT) principles supported by a trained practitioner. This may be by face-to-face contact, telephone sessions, computerised CBT or group-based.
Physical activity programmes in facilitated group sessions.
Counselling or short-term psychodynamic psychotherapy for those who decline other interventions.
Antidepressants are not recommended for the initial treatment of mild depression, because the risk:benefit ratio is poor.
What is the management of moderate to severe depression?
Offer antidepressant medication combined with high-intensity psychological treatment (CBT or interpersonal therapy (IPT) or behavioural couples therapy where relevant). (For an individual with a chronic health problem and moderate depression, this should be high-intensity psychological treatment alone in the first instance.)
Make an urgent psychiatric referral if the patient has active suicidal ideas or plans, is putting themself or others at immediate risk of harm, is psychotic, severely agitated or self-neglecting. The use of the Mental Health Act may be necessary in some instances.
Electroconvulsive therapy (ECT) is occasionally used by specialists to gain fast and short-term improvement of severe symptoms after all other treatment options have failed, or when the situation is thought to be life-threatening.
Anti-depressant- 1st line usually sertraline or citalopram
Psychotherapy- 1st line
Supportive interventions- self-help books
Computer-based interventions
