Fatima (Depression and its management 1) Flashcards
Depression definition
NICE:
Depression refers to a wide range of mental health problems characterised by loss of interest and enjoyment in everyday activities and experiences, low mood, and a range of associated emotional, cognitive, physical and behavioural symptoms
WHO:
Depression is a common mental disorder characterised by low mood, or loss of pleasure or interest in activities for long periods of time.
Depressive episodes last most of the day, nearly everyday, for at least two weeks.
Epidemiology
It is a common mental disorder.
It is the leading cause of disability worldwide and is a major contributor to the overall global burden of disease.
Globally, more than 250 million people of all ages suffer from depression.
More women are affected than men.
The lifetime risk is around 1 in 4 for women and 1 in 10 for men.
Depression is associated with an increased risk of self harm and suicide.
More than 700,000 people die due to suicide every year.
Suicide is the fourth leading cause of death in 15-29 year olds.
Causes
Exact cause is unknown.
Likely to result from a complex interaction of social, psychological and biological factors.
Risk factors include:
- Life events- can be ongoing or recent events
- ongoing events may include long-term unemployment, living in abusive or uncaring relationships or long term isolation, work stress, for social support
- recent events may include job loss, recent childbirth
Personal factors:
- Certain personality traits
- History of abuse
- Deprivation of maternal affection
- Personal history of depression or other mental health problems
- Drug and alcohol use
Genetics- play an important role in long term conditions. Risk is increased in first degree-relatives.
Other risk factors include:
- Long term conditions e.g. diabetes, CVD
- Some medications e.g. hypertensives, corticosteroids
Self-harm and self-injury
Refers to someone causing deliberate pain or damage to their own body (can be suicidal or non-suicidal in intent).
Usually done in secret and in places of the body not seen by others.
It is a sign that the person is feeling intense emotional pain and distress, and people self-harm as a way of coping.
Why do people self-harm?
To relieve, control or express distressing feelings, thoughts or memories.
Because they feel alone.
To punish themselves due to feelings of guilt or shame.
Suicide
Depression is one of a group of mental health disorders that are associated with suicide.
Approximately 75% of the total burden of suicide and self harm occurs in males.
Males are less likely to recognise depression and talk about/seek help for depression.
Suicidal thoughts and behaviours can occur at any time. Highest is among people aged 25-34, 15-24 and 35-44 years old.
Can be an increased risk when antidepressants are initially started. Therefore, it is important to weigh up benefits and harms of using a medication associated with emergent suicidality in a person who is considered to be at risk of suicide. It is important to:
- Inform them of the risk
- Have an action plan to follow if suicidal thoughts occur
- Have regular reviews with the patient
- Be hyperviligant
Depression severity/classification
Depression severity exists along a continuum and comprises three elements
- symptoms
- duration
- impact on personal and social functioning
Traditionally there were 4 categories but recent classification shows 2 categories
- Less severe depression - sub threshold and mild
- More severe depression- moderate and severe
Recognition and assessment of depression
If depression is suspected it should be screened using the 2 question test
- during the last month, have you often been bothered by feeling down, depressed or hopeless?
- during the last month, have you been bothered by having little interest or pleasure in doing things?
Yes to either question warrants further investigation- refer appropriately.
3 things to consider when assessing depression:
- Diagnostic criteria using the Diagnostic and Statistical Manual of Mental Disorders (DSM-5)
- Decide severity using the Patient Health Questionnaire (PHQ-9) score
- Assess psychosocial situation
DSM-5
- Depressed mood
- Anhedonia (loss of pleasure/interest)
- Unintentional weight change or change in appetite
- Insomnia or hypersomnia
- Psychomotor or loss of energy
- Fatigue or loss of energy
- Worthlessness or guilt
- Diminished concentration or indecisiveness
- Recurrent thought of death, suicidal ideation or suicidal intent
5 or more symptoms must be present for at least 2 weeks, with change from previous functioning. Low mood or anhedonia must be present.
PHQ-9
Used to assess initial depression severity and at follow up appointment.
If PHQ <16 - less severe
If PHQ >16 - more severe
Assess psychosocial situation
Life events (e.g. traumatic events)
Life at home (e.g. home circumstances)
Lifestyle (e.g. drugs, alcohol)
Life before (e.g. history of elevated mood, and history of suicide attempts)
Life lost (e.g. risk of suicide)
Assessment of depression
- Many patients may present with low mood, but time can help. Depression diagnosis should not be rushed.
- Communication skills such as active listening an empathy are important.
- People with depression may not present directly with low mood. Depression should be considered in repeat presentations with somatic symptoms and all patients with long term or chronic physical health conditions.
- Notice your own emotional response to the patient. If you are feeling low, hopeless, or experiencing a sense of ‘heartsink’ this may suggest that the patient is depressed
Assessment of risk
According to NICE
- at every initial assessment and follow-up, risk should be assessed by asking the person directly about suicidal thoughts and plans. This assessment should be acted upon by referring, safety netting and/or arranging follow-up as needed
- there should be safety-net future potential increases in risk by asking patient and families to look out for certain changes such as negatively, hopelessness especially during high risk times
Co-morbid depression and anxiety
- Co-morbid depression and anxiety is common but PHQ does not assess for anxiety symptoms
- Asking specifically about anxiety symptoms may be useful
- Generalised Anxiety Disorder Assessment (GAD-7) tool could be used as an additional screening tool
- GAD-7 is a seven item questionnaire that measures level of anxiety
- Priority is to treat depression first. However, if the person has a primary anxiety disorder with depressive symptoms consideration should be given to treating the anxiety disorder first
Symptoms of depression
Categories:
- Psychological
- Physical
- Cognitive
- Behavioural
Core features
- Persisting low mood
- Persisting anhedonia
