Depression
- If pregnant, recent baby or stillbirth — see Perinatal depression and anxiety
- If depressive symptoms and hypomania (high energy levels, positive mood) but no manic episodes — consider Bipolar 2 disorder — medical/mental health consult
Ask
- About suicide
- About safety — theirs, children, others
- About signs and symptoms
- Feeling more sad, down, or miserable than usual, crying a lot
- Lack of interest or pleasure in things they usually enjoy
- Significant loss of self esteem
- Sense of hopelessness, loss, guilt, shame
- No appetite or hungry all the time, weight loss or gain
- Sleep disturbed, sleeping too little or too much, no energy, slow speech and thinking
- Irritability, trouble concentrating or thinking clearly
- Any triggers — relationship problems, domestic violence, death in family, gambling or money issues, housing problems
- About medicines and drugs person is using — consider if causing symptoms, eg side effect, withdrawal
- Previous episodes of depression and treatments — antidepressants or other medicines, side effects
- Cultural explanation — is the person affected by living away from their country, is presentation outside of what is normal in community now
Check
- Calculate age-appropriate REWS
- Adult — AVPU, RR, O2 sats, pulse, BP, Temp
- Child (less than 13 years) — AVPU, respiratory distress, RR, O2 sats, pulse, central capillary refill time, Temp
- Weight, BGL
- U/A, pregnancy test
- Head-to-toe exam — with attention to infection, anaemia, thyroid problems
Do
- FBC, UEC, Hb, HbA1c, LFT, TFT, B12, Folate, HIV, syphilis, urine drug screen
- Person taking lithium collect TFT every 6 months
- Standard STI check – man, woman, young person
- Suicide risk assessment
- Mental health assessment
- Depression screening — Patient Health Questionnaire 9 — see Table 5.1
- Medical consult
- Talk to mental health team about diagnosis, management, medicines
- Antidepressant medicines for moderate to severe depression
- Benzodiazepines (eg diazepam, temazepam) — short-term use only
- Person with severe depression may need to be sent to hospital
Patient Health Questionnaire 9 (PHQ9)
Screening tool to identify symptoms —diagnosis requires further assessment by a doctor
*Only count highest score for each of these sets of questions (ie 5a or 5b, 8a or 8b)
† If positive score on question 9 — Medical consult
Interpreting PHQ9 score
- 0–4 — likely to be well (unless positive answer to question 9)
- 5–9 — likely mild depression — talk with person about result, provide education. Offer referral to mental health team for further assessment if you or person concerned
- 10 or more — likely moderate to severe depression — medical consult
©PHQ9 adapted for use with Aboriginal people by Professor Alex Brown, South Australian Health and Medical Research Institute. Used with permission.
Follow-up
- Make management plan, mental health care plan if applicable
- Education about depression, benefits of physical activity and having regular sleep patterns
- Refer to mental health team if you or person concerned
Antidepressant medicines
Serotonin syndrome
- Rare reaction to too much serotonin in CNS — causes excess nerve cell activity. Severe cases can be fatal if not treated
- Symptom progression — restlessness, sweating, tremor, shivering, jerky muscle spasms or myoclonus (overactive reflexes), confusion, fits, death
- Increased risk with SSRIs or SNRIs if
- Given with other medicines that increase serotonin (eg other antidepressants such as MAOIs), stimulants (eg amphetamines), opioids (eg morphine, tramadol), serotonin receptor agonists (eg sumatriptan), lithium
- Not long enough wash-out period when changing medicines
- Starting medicine or increasing dose
- If you suspect serotonin syndrome — stop all medicines AND urgent medical consult
Choosing a medicine
- Medical consult
- Not much difference in effect between different antidepressants
- Consider severity and type of presentation, eg agitated, poor sleep
- Consider other medical conditions they have, medicines they are taking, pregnancy, breastfeeding, previous adverse effects, interactions with alternative medicines
- Risk of suicide — older tricyclic antidepressants more toxic in overdose than modern medicines (eg SSRIs, SNRIs)
Treating with antidepressants
- Must take every day — give tips on how to remember
- May take 4 weeks for full effect
- May be an increased suicide risk when starting medicine — before depression improves
- Review after 2 weeks — monitor side effects, adherence. May need dose adjusted
- Trial for at least 4 weeks before changing medicine type — unless severe adverse effects
- Check wash-out periods when changing medicines — see AMH, Therapeutic Guidelines
- Treatment needs to continue for at least 9 months for the first episode — less chance of relapse (depression coming back). If this is not first episode — check with mental health team for treatment timeframe
- Withdraw slowly when stopping treatment. If withdrawn too quickly — may feel very sick
- Review regularly during treatment and for 6 months after recovery
- Possible side effects at beginning of treatment — nausea, headache, agitation, insomnia, sedation, diarrhoea, high BP. Should pass in a week
- Possible long-term side effects — weight gain/loss, changes in libido/sexual function