Depression
Depression is a state of low mood and aversion to activity that can affect a person's thoughts, behavior, feelings and sense of well-being.
Why do we need to know about depression
1. Annual prevalence
2. On average, about 5% in the community
3. Especially common among persons attending primary health care
4. Depression can affect physical disease. E.g.
5. It predisposes to myocardial infarctions
6. It reduces adherence to treatment for chronic diseases, incl. HIV and TB
Neurobiology of Depression
1. Depression is caused by lack of NA and Serotonin
Features of depression
1. Low mood
2. Fatiguability/ weakness of body
3. Anhedonia: decreased interest in pleasurable activities
Other features
1. Sleep
2. Appetite
3. Hopelessness
4. Helplessness
5. Worthlessness
6. Decreased interaction with others
7. Suicidal thoughts and ideas
Depression screening
1. Two symptoms in 2 weeks:
2. Low mood
3. Decrease interest in activities
Causes of Depression
1. Abuse. Past physical, sexual, or emotional abuse can cause depression later in life.
2. Certain medications. Some drugs, such as Accutane (used to treat acne), the antiviral drug interferon-alpha, and corticosteroids, can increase your risk of depression.
3. Conflict. Depression in someone who has the biological vulnerability to develop depression may result from personal conflicts or disputes with family members or friends.
4. Death or a loss. Sadness or grief from the death or loss of a loved one, though natural, may increase the risk of depression.
5. Genetics. A family history of depression may increase the risk. It's thought that depression is a complex trait that may be inherited across generations, although the genetics of psychiatric disorders are not as simple or straightforward as in purely genetic diseases such as Huntington's chorea or cystic fibrosis. Eg Serotonin gene
6. Major events. Even good events such as starting a new job, graduating, or getting married can lead to depression. So can moving, losing a job or income, getting divorced, or retiring.
7. Other personal problems. Problems such as social isolation due to other mental illnesses or being cast out of a family or social group can lead to depression.
8. Serious illnesses. Sometimes depression co-exists with a major illness or is a reaction to the illness.
9. Substance abuse. Nearly 30% of people with substance abuse problems also have major or clinical depression
What is the difference between mild , moderate and severe depression?
1. Mild depression means that the depressive symptoms are not having a significant impact on a person's daily functioning
2. Moderate/severe depression means that there is a significant impairment in daily life
Antidepressants , TCA
Dose of Amitryptyline:
1. Initiate treatment with 25- 50 mg at bedtime.
2. Increase by 25 to 50 mg every 1 – 2 weeks, aiming for 75 – 150 mg by 4 – 6 weeks depending on response and tolerability.
3. Side Effects:
a. orthostatic hypotension (falls risk), dry mouth, constipation, difficulty urinating, dizziness, blurred vision, sedation,mania
SSRI
Dose of Flouxetine
1. Initiate treatment with 10 mg once daily and increase to 20 mg if the medication is tolerated.
2. If no response in 4 – 6 weeks or partial response in 6 weeks, increase dose by 10 mg (maximum dose 40 mg) according to tolerability and symptom response
3. Side effects:
a. restlessness, nervousness, insomnia, anorexia, gastrointestinal disturbances, headache, sexual dysfunction,
Primary Care Depression Management
(Learn to prescribe at least one antidepressant)
Fluoxetine 20 mg in am x3-4 weeks
No Response Response
Response Continue
6-12months
No response
When not to prescribe antidepressants
1. Do not prescribe an antidepressant if the depression is mild
2. Do (not) prescribe an antidepressant if there is a recent history of bereavement or major loss
3. Do not prescribe an antidepressant if the depression is due to a physical cause
4. Do not prescribe an antidepressant if the person is a child/pregnant/breastfeeding
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