Makindo Medical Notes

Related Subjects: |Psychiatric Emergencies |Depression |Mania |Schizophrenia |Suicide |Acute Psychosis |Delusions |General Anxiety Disorder |Obsessive-Compulsive disorder |Wernicke Korsakoff Syndrome |Medically Unexplained symptoms |Postpartum/Postnatal Depression |Postpartum / Postnatal Psychosis |Eating disorders in Children |Anorexia Nervosa

In patients with low mood and depression, always inquire about suicidal thoughts and intentions, and document it carefully.

About

• Major depressive illness affects 5-10% of the population.
• Often presents as a relapsing, remitting illness.
• Individuals with a history of depression have a 10-fold higher risk of suicide.

Aetiology

• Genetic predisposition plays a role.
• Linked to reduced function of monoamine neurotransmitters.
• Elevated cortisol levels that don’t suppress with Dexamethasone, suggesting neuroendocrine dysfunction.

DSM-5 Criteria

• Core symptoms include:
  • Persistent feelings of sadness, hopelessness, or emptiness.
  • Loss of interest or pleasure in most activities.
• Associated symptoms (if at least one core symptom is present for most of the last two weeks):
  • Disturbed sleep (increased or decreased).
  • Changes in appetite or weight.
  • Fatigue or low energy.
  • Psychomotor agitation or retardation.
  • Poor concentration or decision-making.
  • Feelings of worthlessness or excessive guilt.
  • Suicidal thoughts or behaviors.
• Severity is determined by the number of symptoms and functional impairment:
  • Subthreshold: 2-5 symptoms.
  • Mild: More than 5 symptoms with minor functional impairment.
  • Moderate: Between mild and severe impairment.
  • Severe: Most symptoms, with marked functional interference.

Clinical Features

• Poor mood, anhedonia, fatigue, insomnia, early morning awakening.
• Impotence, suicidal ideation, per DSM-5 criteria.

Management

Psychotherapy

• Cognitive Behavioral Therapy (CBT) is effective for mild to moderate depression and may be used with medication.

Medications

• SSRIs (Selective Serotonin Reuptake Inhibitors)
• Tricyclic antidepressants (inhibit reuptake of Noradrenaline and Serotonin)
• Monoamine Oxidase (MAO) inhibitors (diet restrictions apply)
• SNRIs (Serotonin and Norepinephrine Reuptake Inhibitors)
• St. John’s Wort (caution with other antidepressants)

Electroconvulsive Therapy (ECT)

• Consider for life-threatening or treatment-resistant depression.
• Typically administered 2-3 times per week for 6-12 treatments.
• Contraindications: Stroke, space-occupying lesion, cardiac disease, high anaesthesia risk.

References

• NICE Guidance on Depression Diagnosis and Management (2021)