Depression

Introduction

Depression is a disorder of mood and affect in which the predominant emotion is sadness/ unhappiness.
It can occur alone (unipolar depression) or as part of an alternation disorder in which elevation of mood also occurs (bipolar disorder). It varies in severity from mild to severe. Life events, especially those involving loss, are often (but not always) the triggers. Strong genetic is vulnerability sometimes present
It occurs in about 2-5% of the population at any given time and in about 10 – 25% in their lifetime
Women are generally at an elevated risk

Clinical features

  • Sadness
  • Unhappiness
  • Feeling low
  • Loss of interest in usual activities
  • Reduced energy
  • Disturbance of sleep and appetite
  • Impaired concentration
  • Ideas of worthlessness, guilt, or failure
  • Morbid or suicidal rumination or ideation
  • Somatic complaints of various types

Differential diagnoses

  • Normal grief reaction.
  • Medical conditions causing lowering of mental and physical activities (e.g. anaemia, hypothyroidism)
  • Infections (e.g. viral)

Complications

  • Worsening of co-morbid physical illness
  • Suicide
  • Recurrence (in 50% or more)

Investigations

  • Full Blood Count and differentials.
  • Thyroid function test
  • Indicative infection screen

Treatment objectives

  • Normalize mood
  • Prevent suicide attempts
  • Return to active life
  • Prevent recurrence

Non-drug treatment

  • Cognitive-behavioural treatment
  • Inter-personal psychotherapy

Drug treatment

1st Line Treatment
Evidence Rating: [A]
Fluoxetine, oral,
Adults: 20 mg once daily for 2-4 weeks, Then Increase if necessary to max. of 80 mg
Children

  • 8-18 years; 10 mg once daily for 1-2 weeks, Then Increase if necessary to max. 20 mg once daily.
  • < 8 years; not recommended

Note

Use with caution in children with epilepsy. Stop if seizure occurs.

Or

Sertraline, oral,
Adults: 50 mg once daily, Then increase if necessary by increments of 50 mg at intervals of at least 1 week, to max. of 200 mg daily.
Children

  • 13-18 years; 50 mg once daily Then increase if necessary by increments of 50 mg at intervals of at least 1
    week, to max. of 200 mg daily.
  • 6-12 years; 25 mg daily, Then increase if necessary to 50 mg daily after 1 week. Further increase if necessary in steps of 50 mg at intervals of at least one week to a max. of 200 mg daily
  • < 6 years; not recommended

Or

Citalopram, oral,
Adults: 20 mg once daily, increase if necessary in steps of 20 mg daily, at intervals of 3-4 week, max. 40 mg.
Children

  • > 12 years; 10 mg once daily, Then increase if necessary to 20 mg once daily in the evening, over 2-4
    weeks (max. of 40 mg once daily)
  • < 12 years; Not recommended

Or

Imipramine, oral,
Adults: 25-50 mg once daily (early evening), Then increase by 25 mg every 3-5 days up to max. of 150 mg.
Children: Not recommeded

Or

Amitriptyline, oral,
Adults: 25-50 mg once daily (early evening), Then increase by 25 mg every 3-5 days up to a max. of 150 mg.
Child

  • > 16 years; 5-15 mg 12 hourly
  • < 16 years; Not recocommended

Management of patients with depression requiring night sedation
Lorazepam, oral,
Adults: 2-3 mg 8-12 hourly, max. 10 mg daily
Children: 2-18 years; 0.05 mg/kg 8 hourly, max. 2 mg daily

Or

Diazepam, oral,
Adults: 5-10 mg 6-12 hourly
Children:

  • 12-18 years; 10 mg 12 hourly
  • 5-12 years; 5 mg 12 hourly

Supportive measures

  • Supportive psychotherapy for patients and family/caregivers

Notable adverse drug reactions, caution

Tricyclic antidepressants:

  • Dryness of the mouth
  • Urinary retention
  • Constipation
  • Blurring of vision

Selective Serotonin Reuptake Inhibitors (SSRIs)

  • Sleep disturbance
  • Sexual dysfunction
  • Serotonin syndrome
  • Cardiac toxicity, especially in overdose with TCAs and SSRIS
  • Increased suicidal ideation in adolescents
  • Should be used with caution in patients with epilepsy, history of mania, cardiac disease, diabetes mellitus, and bleeding disorders
  • Caution is also required in patients receiving concurrent electroconvulsive therapy (reports of prolonged seizures with fluoxetine)

Prevention

  • Recurrence is reduced by continuing medication for at least 6 months after acute symptoms resolve.

Referral Criteria

Refer patients with atypical or unusual symptoms, hysterical or phobic
features, and those who do not respond to adequate anti-depressant treatment within 2 months, to a psychiatrist, as should children suspected to suffer from depression.
Patients requiring Cognitive Behaviour Therapy should be referred to a psychologist