QUICK SUMMARY OF  DIAGNOSIS AND TREATMENT OF DEPRESSION

 

COMMON PRESENTATIONS OF DEPRESSION:

Tiredness; Not coping; Multiple physical symptoms; “Stress”;   Poor memory and concentration reading or watching TV;     Apathy; Negative view of everything;

 

CONCENTRATION:

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.

 

DEPRESSION:

Sadness or loss of interest on a 0-10 scale. Feeling miserable or emotionally numb

or emotionally empty. Less social contact, talking.

 

SUICIDAL THOUGHTS?

Any thoughts of life not worth living? Thoughts of taking action on 0-10 scale?

 

ANXIETY:

Anxiety or worrying on a scale of 0-10

  • Rating over the past few weeks
  • Rating over the past few years

 

TRIGGERS:

What are the stresses or recent events affecting the patient?

 

ALCOHOL and MARIJUANA

Is the amount being drunk or smoked a concern to the patient or to others involved with the patient?  Any physical complications or withdrawal symptoms?

 

THYROID:

Overactive =  Anxious;

Under-active = Depressed, demented. Blood test. Also check FBE, BS

 

IS IT UNHAPPINESS?

A) Concentration not impaired when interested in TV, magazines etc

B) Patient returns to complete normality at times or in certain situations

 

MAJOR ANTIDEPRESSANT GROUPS:

A) Agomelatine (Valdoxan) Rarely any side-effects. Circadian rhythm correction. Releases, dopamine, noradrenaline. 1-2 tabs nocte, sleep aided by melatonin receptors being stimulated. Safe combined with multiple medications. Check LFTs first 6 months.

 

B) SSRIs and SNRIs– Fluoxetine (Prozac), Paroxetine (Aropax), Sertraline (Zoloft), Citalopram (Lexapro; Cipramil); Fluvoxamine (Luvox), SNRI’s Vortioxetine (Brintellix), Venlafaxine (Efexor, Pristiq), Duloxetine(Cymbalta). Sexual problems, perspiration, weight gain. Take AM (not Luvox or Brintellix.) Start with ½ tablet to avoid agitation. Take Brintellix at bedtime to avoid nausea. Withdrawals like ‘flu and electicity

 

C) Moclobemide (Aurorix): Energising (take AM + lunch), Weak, insomnia, Dose 300mg tabs ½-1 bd

D) Reboxetine (Edronax): Energising (take AM & lunch). Anticholinergic, urinary hesitancy, postural hypotension. ½ – 1 bd.

E) Mirtazepine (Avanza): sedation; weight gain. ½ – 2 tablets at night.

F) Tricyclics: Sedating(Dothiepin), energising(Imipramine), weight gain, anticholinergic, ECG; 25–150 mg/d

G) Irreversible MAO inhibitors (Parnate, Nardil) Hypertensive crisis if cheese, Vegemite, cough mixture etc

 

AT 3 – 4 WEEKS:

Continue same dose if progressing well; Increase if slow progress; Change if minimal

 

MAINTENANCE:

12-24 months (Chemotherapy) at max tolerated (coat of armour). More if symptoms recur. Less if YES (Yawning, Expression problems, Silly mistakes).

 

ANTIDOTES:

Perspiration = Clonidine, Propantheline, Hytrin.  Anticholinergic = Bethanechol

 

VULNERABILITY FACTORS:

A) Prolonged anxiety: Relaxation, hypnosis.

B) Lack assertiveness and confidence: Assertion training.

C) Obsessionalism: Controlled by addiction.

D) Poor communication: Talk 20 mins/day, date 1/week

E) Low self-esteem, emotional trauma: psychotherapy.

 

IMPROVING EFFECT OF AN ANTIDEPRESSANT:

Best is to add atypical antipsychotic.  Some response to adding benzodiazepine, Lithium. Combination of 2 antidepressants widely used.

 

SUSPICIOUS DEPRESSION/BIPOLAR:

Brief periods of more extroversion, more energy, less need for sleep. (Severe, Under 25 first episode, Short, Postnatal, In the family, Crazy/psychotic ideas, Intermittent, Overeating/oversleeping, Unusually heavy limbs, Swings of mood).Mitchell P et al