Chapter 19: Depression

Depressive illness, which is probably the greatest masquerade in general practice, is one of the commonest illnesses in medicine and often confused with other illness. Untreated, depression can result in disability and death.¹ It is present in at least 17% of patients who present to GPs² and has a 12-month prevalence of 5% and a lifetime risk of 15%.³ It is often unrecognised,¹ yet moderate to severe depression is as disabling as congestive heart failure¹ and with a morbidity comparable to coronary heart disease. Further, depression is the leading cause of disability for all conditions among both sexes, both in Australia and worldwide.^4,5 The lifetime risk of suicide in patients diagnosed with depression is 6% and treatment halves this risk.¹

Despite being treatable, 60% of sufferers have not used any form of health service in the previous months.⁴ Lack of awareness, stigma and shame on behalf of the patient contribute to this. Of those receiving treatment, three-quarters will be managed in general practice.^5,6 As Whitford⁴ notes:

Depression is a chronic relapsing organic brain disease. Its mean onset is at 27 years of age. However, 40% of sufferers present by 20 years of age.⁷ The average duration of episodes is 3–4 months and 40% of patients will relapse within a 12-month period.⁷

The cause of depression is multifactorial, having biological, psychological and social factors. Mood disorders in general have a strong familial tendency, and the risk of developing a depressive disorder can be thought of in terms of a ‘stress-vulnerability model’. That is, an individual may have a genetically determined vulnerability and if enough stress is endured a mood disorder may result. Those who are more genetically vulnerable require less stress, but if enough stress is applied, any individual can develop a mood disorder.

There are six clusters of depressive symptoms:

• mood, e.g. sadness, anhedonia, irritability

• vegetative, e.g. sleep, appetite, sexual drive

• cognitive, e.g. attention, memory, self-worth

• impulse control, e.g. suicide, anger, homicide

• behavioural, e.g. motivation, interests, tiredness

• physical, e.g. headaches, constipation

A useful working rule is to consider depression as an illness that dampens the five basic innate activities of humans:

• energy for activity

• sex

• sleep

• appetite and thirst

• elimination of waste

• The DSM-5 classification divides depressive disorders into major depressive disorder (MDD), disruptive mood dysregulation disorder, persistent depressive disorder (PDD) and premenstrual dysphoric disorder. Other ‘specified’ and ‘unspecified’ disorder categories allow for diagnosis of those patients who fall short of the various diagnostic criteria.

• MDD includes those disorders with one or more major depressive episodes. Excluding criteria include any previous mania or hypomania, and the episode not being attributable to a psychotic disorder, or a substance or medical condition.

  • – MDD is subclassified with coded course and severity specifiers. These include mild, moderate and severe, with psychotic features, in partial remission and in full remission.

  • – Non-coded specifiers can also be used, including ‘with anxious distress’, ‘with mixed features’, ‘with melancholic features’, ‘with atypical features’, ‘with mood-congruent psychotic features’, ‘with catatonia’, ‘with peripartum onset’ and ‘with seasonal pattern’.

• Persistent depressive disorder (PDD) refers to long-standing (2 years or more) depression of mild severity.

• Adjustment disorder with depressed mood is a less severe form of depression without sufficient criteria for major depression. It is very common and occurs in response to identifiable stressors (‘reactive depression’, e.g. loss of employment). Its duration is usually no longer than 6 months.

The two key criteria for major depressive disorder (MDD) in the DSM-5 are a pervasive depressed mood and marked loss of interest or pleasure (otherwise referred to as anhedonia) persisting for at least 2 weeks. Other criteria (listed below) include sleep issues, fatigue, lack of energy, poor concentration and feelings of worthlessness.

In a general practice setting, having a checklist of these symptoms to work through with a patient can be a useful part of the assessment of the depressed patient. However, the DSM criteria can be too rigid for general practice, with many patients whom GPs recognise as having psychological issues not meeting DSM-5 criteria.³ As Ian Hickie puts it, ‘Primary care psychiatry is not specialist psychiatry in general practice.’⁸

Questions to assess level of depression

• What do you think is the matter with you?

• Do you think that your feelings are possibly caused by nerves, anxiety or depression?

• Can you think of any reason why you feel this way?

• Do you feel down in the dumps?

• Do you feel that you are coping well?

• Do you have any good times?

• Has anything changed in your life?

• How do you sleep? Do you wake early?

• What time of the day do you feel at your worst?

• Where would you put yourself between 0% and 100% (a visual analogue scale is useful here)?

• Have you felt hopeless?

• Do you brood about the past?

• What is your energy like?

• What is your appetite like?

• Are you as interested in sex as before?

• Do you feel guilty about anything?

• Do you feel that life is worthwhile?

• Has the thought of ending your life occurred to you?

• Do you cry when no one is around (especially useful for children)?

Two particularly good questions are:

• In the past month, have you been bothered by the fact that you feel down, depressed or hopeless?

• In the past month, have you often been bothered by the fact that you have little interest or pleasure in doing things?

Depression scales

Depression scales are useful both to detect potential mood disorders (i.e. screening) and to monitor an individual patient over time. Scales commonly used include K10 (a distress score) and DASS 21 or 42 (for depression and anxiety symptoms).

Somatisation

Another issue with depression in the primary care setting is recognising somatising patients who present without obvious psychological symptoms. Non-specific symptoms such as insomnia, prolonged fatigue, headache, nausea and musculoskeletal pain are common presentations in people with depression.⁹ Studies suggest GPs find it challenging to identify these patients, and that using self-reporting patient-screening tools can help with identification.³

The rate of antidepressant prescribing for Australians over 80 years of age is higher than for any other age group.¹⁰ Despite this, depression in the elderly is underdiagnosed.¹¹ Depression can have bizarre features in the elderly and may be misdiagnosed as dementia or psychosis. Agitated depression is the most frequent type of depression in the aged. Features may include histrionic behaviour, delusions and disordered thinking.

Depression is often missed in the elderly because it is atypical and less expressive, and patients tend to be ashamed and reluctant to admit it.

A useful clue can be a change in sleep pattern. Medical illness is also an important precipitant of depression in the elderly.

Older patients may have more side effects from medications (especially nausea, dizziness, falls and hyponatraemia).¹¹ They also tend to have only a modest response to antidepressants, and, if medication is used, a low initial dose and slow increase is recommended.¹ Psychological therapies can be useful, but tend to be underused.¹¹

Sadness is common in children, but depression, although not as common, does occur and is characterised by feelings of helplessness, worthlessness and despair. Parents and doctors both tend to be unaware of depression in children.¹²

Major depression in children and adolescents may be diagnosed using the same criteria as for adults, namely loss of interest in usual activities and the presence of a sad or irritable mood, persisting for 2 weeks or more. In children, irritability may be more prominent than sadness.¹³ The other constellation of depressive symptoms, including somatic complaints, may be present. Examples include difficulty in getting to sleep, not enjoying meals, poor concentration and low self-esteem. Poor motor skills and family instability are an association. Depression can present as antisocial behaviour or as a separation anxiety (e.g. school refusal). Although suicidal thoughts are common, suicide is rare before adolescence.

Depressed adolescents are a difficult challenge for the general practitioner. Effective engagement and establishing rapport in a ‘youth-friendly’ environment is critical.¹⁴

See CHAPTER 97 for the evaluation and treatment of depression in adolescents.

This term refers to depression occurring either in the antenatal period or in the 12 months after delivery. It affects 9% of women during pregnancy and 16% after the birth¹⁵ and affects the well-being of the woman, the baby and significant others. Anxiety is likely to be as or more common.¹⁵ Women at risk of perinatal depression include those with previous mental health problems, those who do not have support, those who have been through difficult times (e.g. family problems, abuse or loss), or who feel isolated either by distance or culture or both.

Because it is so prevalent, routine screening is recommended by the beyondblue guidelines. This involves implementing the use of the Edinburgh Postnatal Depression Scale (EPNDS), a validated screening tool, at least once, preferably twice, both antenatally and postnatally. Asking permission and explaining the process before implementing the screening is helpful. Women at higher risk will require more intense screening and monitoring.

If perinatal depression is identified, the GP should take into account the individual woman’s context, her family and cultural setting, and use a family-centred approach. Because of the intense emotions involved in having a baby, establishing a strong therapeutic relationship, using an open collaborative approach and active listening techniques, will help to develop trust, confidence, mutual respect and empowerment. Psycho-education should be provided and appropriate follow-up and continuity of care, with (if appropriate) a co-ordinated team approach.

If a woman or a baby is at risk, urgent referral is recommended. Pharmacological therapies can be used in pregnancy, but the benefits need to be balanced against the risks to both mother and fetus. Psychosis in perinatal depression is fortunately rare but does occur, and requires urgent psychiatric assessment. Refer to CHAPTER 109.

Recurrent brief depression

There is a high prevalence in general practice of patients presenting with recurrent episodes of depression of short duration, about 3 to 7 days, as often as monthly. Premenstrual dysphoria may be a factor. As a rule antidepressants are ineffective. Lithium is an alternative medication for long-term use. Management is based on psychotherapy, especially CBT.

Seasonal affective disorder

SAD or ‘winter blues’ is a recurrent depressive disorder seen in people living in cold climates where the winters are bleak and dark. Features of depression include sleeping difficulty, sadness, lethargy, irritability and anxiety while atypical symptoms include somnolence and increased appetite (carbohydrate craving). Treatment is based on psychotherapy, phototherapy and medication such as the SSRIs. Refer to www.sada.org.uk.

Important considerations from the outset are:

• Is the patient a suicide risk?

• Does the patient require inpatient assessment?

• Is referral to a specialist psychiatrist indicated?

Suicide assessment

The rules of seven:

• 1 in 7 people with recurrent depression die by suicide

• 70% of suicides have depression

• 70% of patients who suicide have seen a GP within the last 7 weeks

• Suicide is the 7th leading cause of death

If the symptoms are major and the patient appears in poor health or is a suicide risk, referral is appropriate.

The importance of putting these safety issues at the beginning of the management process is reflected in the SET A PACE⁷ model of treatment, proposed by Mahli et al.

To clarify the risk of suicide and appropriate response, ask about:¹⁴

• suicidal thoughts

• plan

• lethality

• means

• past history

• suicide of family member or peer

Low risk (fleeting thoughts of self-harm or suicide but no current plan or means):

• Discuss availability of support and treatment options.

• Arrange follow-up consultation (timing of this will be based on clinical judgment).

• Identify relevant community resources and provide contact details.

Medium risk (suicidal thoughts and intent but no current plan or immediate means):

• Discuss availability of support and treatment options.

• Organise reassessment within 1 week.

• Have contingency plan in place for rapid reassessment if distress or symptoms escalate.

• Develop a safety plan (a prioritised written list of coping strategies and sources of support to use when experiencing suicidal thinking).

High risk (continual/specific suicidal thoughts, intent, plan and means):

• Ensure that the person is in an appropriately safe and secure environment.

• Organise reassessment within 24 hours and monitoring for this period.

• Follow-up outcome of assessment.

After safety is established (and this will need to be continually reassessed at each consultation), the two other aspects that need to be developed early in the process (and also continue on through the long-term management of the patient) are educating the patient about his or her condition and individual situation, and establishing a therapeutic relationship.

Assessment includes:

• characterising the symptom profile

• calibrating the severity and chronicity—rating scales can be employed here

• corroborating (if possible and appropriate) medical and psychiatric comorbidities and context. Significant psychiatric, physical and social comorbidities of depression are common. These include 49% suffering an anxiety disorder, 40% reporting child sexual abuse, 57% child physical abuse, 42% having been at some stage afraid of their partner and 72% reporting a chronic physical condition.¹⁶ Putting the patient’s condition into his or her individual psychosocial and medical context will improve the assessment

• considering coping styles, and the social, financial and occupational consequences of the patient’s condition and situation

This assessment is often spread over multiple consultations.

The basic treatments are outlined by the acronym PACE (which purposefully places priority on the psychological treatments—see FIG. 19.1). These are:

• Psychological, including basic psychological treatments, such as advice on lifestyle changes, problem solving, guided self-help, structured supervised exercise and supportive counselling.^1,6 All patients with depression should be offered these types of support.^1,14 More sophisticated techniques, such as cognitive behaviour therapy (CBT) or interpersonal therapy (IPT) may be used for selected patients⁷ and should be undertaken only by appropriately trained doctors or therapists.⁶ Another option that some patients may prefer is computer-based cognitive behaviour therapy (CBT) programs.¹¹ CBT involves teaching patients new ways of positive thinking, which have to be relevant and achievable for the patient (see CHAPTER 5). Patients need to be able to recognise their own negative cognitions, including their anxieties and worries.

• Antidepressants: antidepressant medication is useful in moderate to severe depression (TABLE 19.1), or when depression has an anxiety disorder codiagnosis.¹¹ Antidepressant therapy should be avoided if bipolar disorder is suspected, and screening should be actively conducted for symptoms of past or previous mania.¹¹

  • – In terms of which drug to use, there is no single drug that is preferred. However, selective serotonin reuptake inhibitors (SSRIs) are considered to have the most favourable balance of benefit to harm in moderate to severe depression.¹¹ Sexual dysfunction and gastrointestinal side effects are common.⁷ Other suitable first-line agents are reboxetine (common side effects include hypersomnia, fatigue and nausea) and mirtazepine (which can cause weight gain and drowsiness).⁷ SSRIs have a relatively flat dose response curve, but dose increase within the recommended range is reasonable if there is a partial response at a lower dose and no troublesome side effects.

  • – Combining different antidepressants or augmentation with lithium or antipsychotics should be done with psychiatrist supervision.⁷

  • – Seretonin and noradrenaline reuptake inhibitors (SNRIs) appear to be more effective in treating severe depression symptoms (and may be a suitable first-line option here) but otherwise adverse effects may limit them to second-line treatment.⁷ Tricyclic antidepressants (TCAs) and monoamine oxidase inhibitors (MAOIs) are considered second-line because of their side effect profiles.¹³

The benefit of medication in moderate depression is equivalent to psychological therapies such as CBT/IPT and both of them are around 20% more likely to achieve remission than placebo.¹ In severe depression, medication is more effective than psychological therapies (see FIG. 19.2), though the latter in addition may help reduce relapse rates once remission is achieved by medication.^1,6

Source: Adapted from Fournier et al. Antidepressant drug effect and depression severity: a patient-level meta-analysis. JAMA, 2010; 303: 47–53

The aim of treatment of depression is to achieve and maintain remission (see FIG. 19.3).¹ Remission is defined as having minimal or no symptoms of depression,⁷ and a good way of asking patients about this is to ask ‘Do you think you are back to your normal self?’.

When using antidepressants, if a response is not evident in the first 2 weeks or there is an inadequate response in 6 weeks, then it is unlikely that this medication will work for this patient, and a treatment change is recommended.⁷ A washout period will be required before a second medication is tried. Patients need close monitoring early on in the course of treatment, and weekly monitoring may be helpful.¹¹ If remission is not achieved in 3 months, then consider a second opinion and continue active treatment.⁷

• A combination of antidepressants and psychological therapy can be considered if there is an inadequate response to either therapy alone. Combining medication with psychological therapy is more effective than either therapy alone in moderate or severe depression.⁷

• ECT (electroconvulsive therapy) is a relatively safe and effective therapy for severe or resistant depression. There is some risk of transient short-term cognitive impairment and long-term memory impairment, and this therapy is reserved for severe depression when pharmacotherapy has failed;⁷ it is administered under the supervision of a psychiatrist.

Possible indications include:

• – psychotic depression (e.g. delusions, hallucinations)

• – melancholic depression unresponsive to antidepressants

• – severe postnatal depression and psychosis

• – substantial suicide risk

• – ineffective antidepressant medication and/or previous response to ECT

• – severe psychomotor depression: refusal to eat or drink, depressive stupor, severe personal neglect

Immediate referral for hospital admission is necessary in most of these circumstances. The course, which is highly variable and individually tailored, is about 8–12 sessions given at 1–3 sessions a week. The most common initial ECT method is unilateral therapy.¹

Transcranial direct current electro-magnetic stimulation, where no anaesthetic is required, is a procedure being explored as a less invasive alternative to ECT.¹⁷

• Uncertainty about diagnosis

• Inpatient care obviously necessary

• Severe depression

• Inability to cope at home

• Psychotically depressed (with delusions or hallucinations)

• Substantial suicide risk

• Failure of response to routine antidepressant therapy

• Associated psychiatric or physical disorders

• Depression in the elderly can be a difficult problem—where diagnosis including dementia is doubtful

• Children with apparent major depression

The choice of treatment should be determined together by doctor and patient, and the best outcomes are likely when a good therapeutic alliance is formed⁶ and patient preferences are taken into account.¹¹ To quote the RANZCP guidelines: ‘Of greatest benefit is the therapeutic relationship, which enables agreement on treatment selection and continuation.’¹ A strong determining factor on patient preference may be the patient’s own previous experience of treatments, or his or her perceptions of treatment results in other people they know or potential adverse effects of the proposed treatment.¹¹

Whatever treatment is chosen by the doctor and patient working together, the choice is less important than persisting with treatment. As the beyondblue guidelines state, it is ‘not so much what you do but that you keep doing it’.⁶ This is why consistent follow-up and monitoring is so beneficial.

Complementary and alternative therapies are widely used for depression. It is estimated that only 50% of Australians who are depressed receive an evidence-based professional intervention.¹⁸ A large driver for this is the public’s belief in complementary and alternative therapies. One study¹⁹ showed 57% regarded vitamins, minerals, tonics or herbal medicines as likely to be helpful for treating depression, compared with 29% who regarded antidepressants as likely to be helpful.

Despite this, none of these therapies is supported by evidence, though some warrant further evaluation.²⁰ Because of their common usage (nearly half of Australians have used a complementary medicine in the previous 12 months),²⁰ actively enquiring about use of any complementary and alternative therapies in patients with depression is advised.

One of the more commonly used and extensively researched alternative therapies is St John’s wort (Hypericum perforatum), which has had mixed results in the research on its effectiveness. One review of the literature suggests it is effective in mild to moderate depression,²¹ though two others suggest it is not.^22,23

Regardless of its effectiveness (or not), it has a lot of medication interactions. These include HIV medicines, warfarin, digoxin, anticonvulsants, oral contraceptives and triptans. Because of this, care needs to be taken with using St John’s wort, including when switching between different preparations that may contain different amounts of active compound.

• While rare, serotonin syndrome is a serious adverse reaction to the use of SSRIs and other serotonergic medications, including St John’s wort.

• Symptoms must coincide with the introduction or dose increase of a serotonergic agent. Drugs to be considered here include antidepressants, opioids (especially tramadol), stimulant drugs, illicit drugs, anti-emetics, lithium and selegiline.

• Other causes, such as infection, substance abuse or withdrawal, must be excluded.

• At least three of the symptoms or signs attributed to the syndrome must be present, e.g.:

  • – mental status/behaviour changes (e.g. agitation, confusion, hypomania, seizures)

  • – altered muscle tone (e.g. tremor, shivering, myoclonus, hyper-reflexia)

  • – autonomic instability (e.g. hypertension or hypotension, tachycardia, fever, diarrhoea)

The offending agents should be withdrawn immediately and supportive therapy initiated; refer to an emergency department.

If antidepressant medication is used and remission achieved, it is recommended that it be continued for a minimum of 12 months for an initial episode, and for 2–3 years in subsequent episodes or in those at high risk of relapse.^1,11 Risk factors for relapse include:^7,11

• residual depressive symptoms

• 2 or more prior episodes in the past 5 years

• 3 or more prior episodes

• history of severe or prolonged depression (especially with psychosis or attempted suicide)

• comorbid medical problems

• life stressors

When remission is achieved, and the treatment is in the maintenance phase, ongoing monitoring of treatment effectiveness, tolerability and adherence is recommended.⁷ Encouragement to persist with the treatment will improve compliance.¹ When ceasing medication, withdrawal reactions are common, so a gradual withdrawal by halving the dose each week may help reduce these.¹