Quick Summary of Diagnosis and Treatment of Depression
Common Presentations of Depression
Physical & Coping
Tiredness; Not coping; Multiple physical symptoms; “Stress”.
Cognitive Focus
Poor memory and concentration reading or watching TV.
Emotional State
Apathy; Negative view of everything; Emotional numbness or emptiness.
Social Behavior
Less social contact, talking. Feeling miserable.
Rating & Benchmarks
Concentration (Primary Indicator)
Concentration (and memory) not as good as usual when watching TV or reading. Does the patient have to re-read? Perhaps the best indicators of the beginning and end of an episode of depression.
The 0-10 Rating Scale
Assess over past few weeks AND past few years:
Ask: Any thoughts of life not worth living? Thoughts of taking action?
Diagnostic Distinction: Is it Unhappiness?
Triggers & Stresses
What are the stresses or recent events affecting the patient?
Alcohol & Marijuana
Is amount drunk/smoked a concern to patient or others? Check for physical complications or withdrawal symptoms.
SUSPICIOUS it is bipolar?
Brief periods of more extroversion, energy, less need for sleep.
- S – Severe
- U – Under 25 at first episode
- S – Short duration
- P – Post-natal illness
- I – Intermittent / recurrent
- C – Confused (delusions, hallucinations)
- I – In the family
- O – Overeating / oversleeping
- U – Unusually heavy limbs
- S – Swings of mood while depressed
(Derived from Mitchell PB et al 2008: Diagnostic guidelines)
Major Antidepressant Groups
A) Agomelatine (Valdoxan)
Circadian rhythm correction
Rarely any side-effects. Releases dopamine, noradrenaline. Safe with multiple meds.
Dose: 1-2 tabs nocte (Sleep aided by melatonin receptors).
Note: Check LFTs first 6 months.
B) SSRIs and SNRIs
Standard Treatment
Fluoxetine, Paroxetine, Sertraline, Citalopram, Fluvoxamine, Vortioxetine, Venlafaxine, Duloxetine.
Risks: Sexual problems, perspiration, weight gain.
Withdrawal: Like ‘flu and electricity.
Dose: Start ½ tablet (avoid agitation). Take AM (except Luvox/Brintellix). Brintellix at bedtime (avoid nausea).
C) Moclobemide & D) Reboxetine
Energising Options
Aurorix (C):
Weak, insomnia. Dose 300mg tabs ½-1 bd (AM + Lunch).
Edronax (D):
Anticholinergic, urinary hesitancy, postural hypotension. ½ – 1 bd (AM + Lunch).
E) Mirtazepine & F) Tricyclics
Mirtazepine (Avanza):
Sedation; weight gain. ½ – 2 tablets at night.
Tricyclics (Dothiepin, Imipramine):
Sedating/Energising, weight gain, anticholinergic. ECG required. 25–150 mg/d.
G) Irreversible MAOIs
High Risk / High Monitoring
Parnate, Nardil
Hypertensive crisis if cheese, Vegemite, cough mixture etc are consumed.
At 3 – 4 Weeks
Maintenance (Chemotherapy)
12-24 months at max tolerated dose (your “coat of armour”). More if symptoms recur. Less if YES (Yawning, Expression problems, Silly mistakes) symptoms appear.
Vulnerability Factors
Labs & Thyroid
Thyroid Check: Overactive = Anxious; Under-active = Depressed/Demented. Blood test required.
Also check FBE, BS.
Antidotes
Perspiration: Clonidine, Propantheline, Hytrin.
Anticholinergic: Bethanechol.
Improving Effect
Best is to add atypical antipsychotic.
Some response to adding benzodiazepine, Lithium.
Combination of 2 antidepressants widely used.