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

Table 5.1   Patient Health Questionnaire 9 (PHQ9)

*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