Depression and Suicide Andrew Matrunola ST3 Psychiatry

Depression Its been around a long time. Hippocrates: Melancholia: a distinct disease with particular mental and physical symptoms, broader than today’s concept of depression. Kraeplin (1921), a German Psychiatrist: ‘depressive states’ used term in context of ‘manic-depressive’ illness. Freud (1917): ‘Mourning and Melancholia’ shifted focus of clinical descriptions from objective behavioural signs to subjective symptoms.

Depression Depressive disorders are common, prevalence 2-5% (5-10% primary care settings). It affects around 121 million people worldwide (WHO) Associated with significant morbidity and mortality. Recently the WHO have announced it is likely to be the single cause for burden of any disease by 2030 due to years lost of life or through severe disability. More prevalent in developing countries

Sex ratio male: female 1:2 Lifetime rates 10-20% Risk factors: genetic personality traits Negative childhood experiences Social circumstances (e.g. employment, confiding relationship, adverse life events) Physical illness Aetiology: multifactorial!

Core Symptoms Depressed mood Anhedonia Weight change Disturbed Sleep: insomnia (less commonly hypersomnia) Psychomotor agitation/retardation Fatigue Reduced concentration Reduced libido Feelings of worthlessness/guilt Thoughts of death/suicide

Present for at least two weeks and represent a change from normal Not secondary to the effects of drugs/alcohol misuse, medication, medical disorder, bereavement May cause significant distress and/or impairment of functioning

Biological/Somatic symptoms Sleep disturbance Diurnal mood variation Anhedonia Early morning wakening Psychomotor agitation or retardation Loss of weight/appetite Loss of libido Constipation, amenorrhoea

Subtypes Mild Moderate Severe With psychotic symptoms: typically mood-congruent delusions, hallucinations Nihilistic delusions e.g. Cotard’s syndrome

Atypical depression: depression with increased sleep, appetite and phobic anxiety Dysthymia: chronic long standing low mood not meeting criteria for depression Seasonal affective Disorder (SAD) Postnatal depression

History

Tell me how have you been feeling? Can you still enjoy the things you normally do? How have you been sleeping recently? Have you been waking earlier than usual in the mornings? How’s your appetite been? Do you find it difficult to concentrate on a book/TV programme? Do you eve feel life’s not worth living?

MSE Appearance and behaviour Speech Mood Thoughts Perceptions Cognition Insight

Suicide In the UK the third most important contributor to life years lost after coronary heart disease and cancer Most common method among men is hanging Amongst women the commonest method is drug overdose Rates are higher in spring/summer vs. autumn/winter

Risk factors Male Increasing age Living alone Unemployed Recent life crisis Occupation (e.g. farmers, doctors)

Risk factors 2 Personality disorder esp. borderline type Mood disorder Alcohol or drug misuse Schizophrenia Past history of deliberate self harm Physical ill-health esp. epilepsy

Mental State Factors Depressed mood Expressed wish to die Detailed suicide plans Hopelessness and helplessness Lack of reasons to go on living

Assessment following self harm Important predictors: Planned attempt Personal affairs put in order beforehand Attempted to avoid discovery Did not seek help afterwards Used a method the patient considered dangerous Left a suicide note

Deliberate self Harm Intentional self harm that does not lead to death and may or may not have been motivated by a desire to die. Self poisoning, most commonly paracetamol and aspirin Self injury: most commonly lacerations to forearms and wrists. Increased risk of suicide! (100 x greater than general population in next 12 months and remains high thereafter)

Assessing suicide risk

Have you had thoughts of wanting to end your life? Have you thought about how you would do it? Have you made any preparations? Have you tried to take your own life in the past?

Treatment of depression Mild depression: watchful waiting, problem solving, exercise Mild/Moderate depression: consider CBT Moderate depression: antidepressants, SSRI generally first line

Antidepressants Selective serotonin reuptake inhibitors: SSRIs 1st line: citalopram, sertraline, fluoxetine, paroxetine Max effect 4-6 weeks Side effects: commonest GI side effects, headaches, insomnia Fewer anticholinergic side effects, less cardiotoxic so safer in overdose. Withdrawl effects; worse if stopped suddenly: nausea, dizziness, agitation, insomnia

Tricyclic Antidepressants Older: Imipramine, amitriptyline, Clomipramine Uptake inhibition of Noradrenaline and serotonin Side effects: weight gain, sedation Anticholinergic effects: dry mouth, blurred vision, constipation etc Toxicity in overdose

MAOIs Monoamine oxidase inhibitors Isocarboxazid, Phenelzine “Cheese reaction”: tyramine rich food can cause a hypertensive crisis: need to avoid foods rich in tyramine e.g. cheese, red wine, liver, yeast products. RIMA: moclobemide

Serotonin Syndrome Due to excess serotonin Can be due to SSRIs and other antidepressants Causes: overdose, drug combinations/interactions, sometimes at normal doses Can be fatal Symptoms: Neurological (confusion, agitation, coma), Neuromuscular (rigidity, tremors, myoclonus, hyperreflexia), Autonomic (hyperthermia, tachycardia, hyper/hypotension, GI upset)

ECT A life saving treatment! Highly effective in treatment of depression 6-12 treatments Indications: severe depression; failure of drug treatments, failure to eat and drink n depressive stupor, previous good response to ECT, patient choice. Side effects: memory loss (usually resolves), headache, temporary confusion, nausea, vomiting Requires general anaesthetic

Any Questions?