QuestionSBA
QuestionChoice
While it is important to address the patient's emotional distress, a referral to a psychiatrist may not be necessary in this case. The patient's symptoms are consistent with normal grief reactions and do not suggest the presence of a mental health disorder.
62024
b
Refer to a psychiatrist
QuestionChoice
In this case, the patient is experiencing **normal grief reaction** after the loss of his wife. Grief can be a difficult and emotionally overwhelming experience, and it is important to provide support and reassurance to the patient. Offering social support, such as connecting the patient with a support group or community resources, can also help promote healing and coping with his grief.
62023
a
Reassure and offer social support
QuestionChoice
As this patient's symptoms are related to a precipitating event, a diagnosis of depression should not be made until after a normal grieving period, usually for about six months or more. Therefore, SSRIs are not offered immediately.
62025
c
Prescribe selective serotonin reuptake inhibitor (SSRI)
QuestionChoice
Risperidone is an antipsychotic medication and is not typically used to treat a normal grief reaction. Illusions and hallucinations of the deceased person are not uncommon, which resolve spontaneously after a few weeks to months. Therefore, it is not an appropriate intervention in this case.
62026
d
Risperidone
QuestionChoice
ECT is considered for treating severe depression in cases where a rapid response is necessary (life-threatening) or if other treatments have been unsuccessful.
62027
e
Electroconvulsive therapy (ECT)
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Noah
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Serotonin Complement
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canIhave12bottlesofbleachplease
Concept
Chapter
# Summary

Depression is a common mental health disorder typified by low mood, anhedonia, significant weight change, sleep and activity changes, fatigue, feelings of guilt or worthlessness, or poor concentration. It is defined by the DSM as the presence of 5 out of 8 symptoms for at least 2 weeks. It is more prevalent in females. Key investigations include FBC, TFT, U+E, LFT, Glucose, B12/folate, cortisol, toxicology screen, and CNS imaging to rule out organic causes. Management strategies encompass low to high intensity psychological interventions, pharmacotherapy including anti-depressants, and in severe cases, lithium or ECT.

# Definition

Depression is a mental health disorder characterised by:

- **ICD-11 Criteria:**
  - Depressive Episode: Depressed mood, loss of interest (anhedonia), and reduced energy (fatigue) persisting for at least two weeks.

- **DSM-V Criteria:**
  - Major Depressive Disorder (MDD): Presence of a major depressive episode lasting at least two weeks, with specific criteria regarding mood, cognitive, and physical symptoms.
  - Persistent Depressive Disorder (Dysthymia): A chronic form of depression lasting for at least two years. 

This consists of  the presence of at least five out of a possible eight defining symptoms, during the same two-week period, where at least one of the symptoms is depressed mood or loss of interest or pleasure

**Severity:**

- Mild: Few, if any, symptoms in excess of those required to make the diagnosis (associated symptoms, see below), and the symptoms result in minor functional impairment.
- Moderate: Symptoms or functional impairment between "mild" and "severe."
- Severe: The number of symptoms, intensity, and impairment are all greatly increased.


# Epidemiology

Depression is a highly prevalent mental health disorder. It represents the third most common reason for consulting a general practitioner in the UK. Depression demonstrates a higher prevalence in females.

# Aetiology

The aetiology of depression involves a complex interplay of genetic and environmental factors. History of previous mental health issues, physical illnesses, and social challenges like divorce, poverty, and unemployment can all contribute to its development.

# Clinical Features

Depression is defined by the Diagnostic and Statistical Manual of Mental Disorders (DSM) as the presence of 5 out of the following 9 symptoms, occurring nearly every day for at least 2 weeks:

1. **Depressed mood or irritability** for most of the day, indicated by either subjective report (feels sad or empty) or observation by others (appears tearful).
2. **Anhedonia:** Decreased interest or pleasure in most activities, most of the day.
3. Significant **weight change** (5%) or change in appetite.
4. **Sleep alterations:** Insomnia or hypersomnia.
5. **Activity changes:** Psychomotor agitation or retardation.
6. **Fatigue** or loss of energy.
7. **Guilt or feelings of worthlessness:** Excessive or inappropriate guilt or feelings of worthlessness.
8. **Cognitive issues:** Diminished ability to think or concentrate, or increased indecisiveness.
9. **Suicidality:** Thoughts of death or suicide, or formulation of a suicide plan.

### Additional Features (Severe Depression)
- **Psychotic Features:** Delusions (e.g. nihilistic delusions, Cotard's syndrome) and hallucinations.
- **Depressive Stupor:** Profound immobility, mutism, and refusal to eat or drink, sometimes necessitating electroconvulsive therapy (ECT).

# Differential Diagnosis

The main differentials and their key signs and symptoms include:

- **Bipolar Disorder:** Characterised by periods of mania/hypomania (elevated mood, inflated self-esteem, decreased need for sleep, increased talkativeness, distractibility, increased goal-directed activity) alternating with depressive episodes.
- **Anxiety Disorders:** Persistent and excessive worry, restlessness, fatigue, difficulty concentrating, irritability, muscle tension, and sleep disturbance.
- **Psychotic Disorders:** Hallucinations, delusions, disorganised speech, grossly disorganised or catatonic behaviour.
- **Substance/Medication-Induced Mood Disorder:** Mood disturbance associated with intoxication or withdrawal from substances or side effects of medications.
- **Adjustment Disorders:** Development of emotional or behavioural symptoms in response to identifiable stressors.


Various organic causes should be considered and ruled out through careful history-taking, physical examination, and relevant investigations. These include:

- Neurological disorders such as Parkinson's disease, dementia, and multiple sclerosis.
- Endocrine disorders, especially thyroid dysfunction and hypo/hyperadrenalism (e.g., Cushing's and Addison's disease).
- Substance use or medication side effects (e.g., steroids, isotretinoin, alcohol, beta-blockers, benzodiazepines, and methyldopa).
- Chronic conditions such as diabetes and obstructive sleep apnea.
- Long-standing infections, such as mononucleosis.
- Neoplasms and cancers - low mood can theoretically be a presenting complaint in any cancer, with pancreatic cancer being a notable example.


# Investigations

- Standard investigations for depression may include Full Blood Count (FBC), Thyroid Function Test (TFT), Urea and Electrolytes (U&E), Liver Function Test (LFT), Glucose, B12/folate levels, cortisol levels, toxicology screen, and imaging of the Central Nervous System (CNS).
- These help rule out organic causes (listed above) such as endocrine disorders (e.g. thyroid disorders).
- There are several questionnaires that can also be used to help assess depressive symptoms, such as the Hospital Anxiety and Depression (HAD) Scale and Patient Health Questionnaire (PHQ-9).

# Management

Depression is usually managed in primary care. GPs can refer to secondary care (Psychiatry) if there is a high-suicide risk, symptoms of bipolar disorder, symptoms of psychosis, or if there is evidence of severe depression unresponsive to initial treatment.

**Persistent subthreshold depressive symptoms or mild-to-moderate depression:**

- 1st line = Low-intensity psychological interventions (individual self-help, computerised CBT). 
- 2nd line = High-intensity psychological interventions (individual CBT, interpersonal therapy) 
- 3rd line = Consider antidepressants 

**Mild depression unresponsive to treatment and moderate-to-severe depression:**

- 1st line = High-intensity psychological interventions + antidepressants (1st line = SSRI)
- 2nd line (Treatment-resistant depression) – switch antidepressants and then use adjuncts 

**Severe depression and poor oral intake/psychosis/stupor:**

- 1st line = ECT 
- Although the exact mechanism remains elusive, it is thought that the induced seizure, rather than the ECT procedure itself, has therapeutic benefits. Short-term side effects of ECT include headache, muscle aches, nausea, temporary memory loss, and confusion, while long-term side effects can include persistent memory loss. Due to the induced seizure, there is a risk of oral damage, and due to the general anaesthetic, a small risk of death.

**Recurrent depression:** 

- Treated with antidepressant + lithium 


Medical management of depression - additional notes:

- First-line pharmacological treatment typically involves a Selective Serotonin Reuptake Inhibitor (SSRI) such as sertraline. SNRIs such as venlafaxine can also be used first-line, but are less preferable due to the risk of damage from overdose, which is less likely with SSRIs.
- In people aged 18-25 there is an increased risk of impulsivity and suicidal risk upon commencing antidepressant medication and so they should have a follow-up appointment arranged after one week to monitor progress. Initial reviews can otherwise be arranged 2-4 weeks after starting medication in patients >25.
- Continuation of antidepressants for at least six months post-remission is recommended to mitigate relapse risk. Tapering should be done gradually over a four-week period when discontinuing antidepressants.



# NICE Guidelines

[NICE Guidance on the Management of Depression](https://www.nice.org.uk/guidance/cg90)
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General Practice
12466
A 76-year-old man presents to the GP clinic with chest pain. On further questioning, he breaks into tears and feels emotional about the loss of his wife six weeks ago. She passed away due to terminal-stage breast cancer metastasising to the brain. He now feels guilty for not taking care of her properly. He also mentions that he hears his wife's voice intermittently while cooking in the kitchen. His vital signs, serum troponin and ECG, are all normal. He has no past medical history.

What is the most appropriate next step in management?
a