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General Practice, Chapter 16
Chapter 16 - Depression
I am ignorant and impotent and yet, somehow or other, here I am, unhappy, no doubt, profoundly dissatisfied
... In spite of everything I survive.
Aldous Huxley (1894-1963)
Depressive illness, which is probably the greatest masquerade of general practice, is one of the commonest
illnesses in medicine and is often confused with other illnesses. It is a very real illness that affects the entire
mind and body. Unfortunately, there is a social stigma associated with depression and many patients tend to
deny that they are depressed.
It is a useful working rule to consider depression as an illness that seriously dampens the five basic
activities of humans:
energy for activity
sex drive
sleep
appetite
ability to cope with life
Many episodes of depression are transient and should be regarded as normal but 10% of the population
have significant depressive illness. The lifetime risk of being treated for depression is approximately 12% for
men and 25% for women. 1
Classifications
Affective or mood disorders refer to those conditions in which there is a disturbance of affect or mood.
The DSM-IV classification divides the disorder into the depressive disorders and bipolar disorders
(both manic and depressive episodes).
The depressive disorders include major depression, adjustment disorders with depressive mood,
and dysthymia.
Major depression includes those disorders with one or more major depressive episodes. 1
Dysthymia refers to long-standing (2 years or more) depression of mild severity ('neurotic
depression'). 1
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.
Major depression
The patient can experience many symptoms, both physical and mental. The DSM-IV diagnostic criteria for
depression are outlined in the following boxed section.
These criteria can be extended to include:
a feeling of not being able to cope with
life continual tiredness
loss of sense of humour
tension and anxiety
irritability, anger or fearfulness
somatic symptoms such as headache, constipation, indigestion, weight loss, dry mouth and unusual
pains or sensations in the chest or abdomen
The symptoms may vary during the day, but are usually worse on waking in the morning. Some patients
have psychotic features, usually only delusions but sometimes also hallucinations, and may be
misdiagnosed as schizophrenic.
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General Practice, Chapter 16
In practice the DSM-IV classification seems too rigid and the experienced doctor has to consider the global
constellation of symptoms. Better management follows early diagnosis and intervention before the formal
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criteria for major depression develop.
DSM-IV diagnostic criteria for major depression
At least five of the following symptoms for 2 weeks (criterion 1 or 2 essential)
1.
2.
3.
4.
5.
6.
7.
8.
9.
Depressed mood
Loss of interest or pleasure
Significant appetite or weight loss or gain (usually poor appetite)
Insomnia or hypersomnia (usually early morning walking)
Psychomotor agitation and retardation
Fatigue or loss of energy
Feelings of worthlessness or excessive guilt
Impaired thinking or concentration; indecisiveness
Suicidal thoughts/thoughts of death
Important points
The essential feature of depression is mood change which can vary in intensity from despondency to
intense despair. 1
The other major feature is loss of interest or pleasure, including loss of interest in family, hobbies,
sexual activity and personal appearance.
Minor depression
Minor depression is basically a condition where fluctuations of symptoms occur with some vague
somatic symptoms and a transient lowering of mood that can respond to environmental influences.
Suicidal feelings are fleeting, and delusions and hallucinations are absent. These patients usually
respond in time to simple psychotherapy, reassurance and support. However, care should be taken lest
they move into major depression.
Masked depression
This is a difficult yet common type of depression in practice and tends to be misdiagnosed. Patients do not
complain of the classic symptoms and tend to deny depression, which is perceived as a social stigma and
a sign of weakness. They usually have multiple minor complaints of the 'ticket of entry' type. Mood
changes may be elicited only after careful questioning.
The classic affective features of depression are masked by a complex of somatic complaints. Such
symptoms include fatigue; anorexia; weight loss; menstrual changes; unusual sensations in the abdomen,
chest or head; bodily aches and pain; dry mouth; and difficulty in breathing.
If depression is not considered many fruitless, expensive and distressing investigations may be performed.
According to Davies, 2 nearly half of patients with depressive illness report to the doctor with complaints
that suggest physical illness. The family doctor has to suspect masked depression in a patient with a
multitude of physical complaints or with complaints that do not fit any definite pattern of organic disease.
The differential diagnoses of depression are presented in Table
16.1 . Table 16.1 Differential diagnoses of depression
Psychiatric conditions
anxiety disorder
schizophrenia
drug and alcohol abuse
dementia
Organic disorders
malignancy, e.g. lung, pancreas, lymphoma
hypothyroidism
hyperparathyroidism
other endocrine disorders, e.g. Cushing's, Addison's
anaemia, especially pernicious anaemia
postinfective states, e.g. Epstein-Barr mononucleosis
cerebrovascular disease
Parkinson's disease
congestive cardiac failure
systemic lupus erythematosus
drugs (which may cause depression)
- antihypertensives
- benzodiazepines e.g. diazepam
- antiparkinson drugs
- corticosteroids
- cytotoxic agents
- NSAIDs
- oral contraceptives/progestogen
An Australian study on masked depression concluded: 3
It must be stressed that the mask ing of the depressive state occurs on the doctor's side as well as the
patient's, and an awareness that this may be so leads us to recommend that, once organic lesions have
been excluded, there is a place for the use of an adequate therapeutic trial of antidepressants.
The following additional points were made by a panel of psychiatrists at a symposium entitled 'Depression:
Masked or Missed?' in Dallas, Texas: 4
Some patients dismissed as 'crocks' may go on to suicide if their depression is not treated.
Masked depression would be missed much less frequently if the physician would look beneath
symptoms that do not quite ring true.
The patient with the 'tired blood syndrome' deserves something other than an iron tonic.
Depression frequently accompanies organic diseases that are associated with nausea and other
illness.
A complete work-up may help to rule out organic disease but may result in iatrogenic disease if
pursued overzealously.
Alcoholism should be suspected as a cause of depression.
Depression in the elderly
Severe depression affects 1-2% of the elderly population while 10% have significant depression affecting
their life. Milder depression can affect a further 20%. 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. 1 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. Four key guidelines help diagnosis:
Are you basically satisfied with your
life? Do you feel that your life is empty?
Are you afraid that something bad is going to happen to you?
Do you feel happy most of the time?
A useful clue is a change in sleep pattern; so a request for sleeping tablets may lead to the prescription for
a more sedating antidepressant. Medical illness is an important precipitant of depression in the elderly.
Tricyclic antidepressants have to be used with caution in the elderly and most have some contraindications
to their use. ECT has a useful place in treatment of severe cases.
Depression in children
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. 5
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. 6 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.
It 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 serious suicide
risk. Referral of these patients to an experienced child psychiatrist is advisable.
The diagnostic approach
Depression can be associated with many illnesses but it is important to realise that the somatic symptoms
may be the presentation of depressive illness and thus 'undifferentiated illness' is a feature. The patient
tends to complain of aches and pains, gastrointestinal symptoms and other similar symptoms rather than
emotional problems.
There is a relationship between anxiety and depression so that many depressed patients are agitated and
anxious-a feature that may mask the underlying depression. 7
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%? 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 for children)
Depression scales
Consider the use of depression scales, for example:
Hamilton Depression
Inventory Beck Depression
Scale General Health
Questionnaire
Management
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?
If the symptoms are major and the patient appears in poor health or is a suicide risk, referral is appropriate.
The basic treatments are:
Psychotherapy, including education, reassurance and support. All patients require minor
psychotherapy. More sophisticated techniques such as cognitive or behavioural therapy may be
used for selected patients. Cognitive therapy basically involves teaching patients new ways of
positive
thinking, which have to be relevant and achievable for the patient. Patients need to be able
to recognise their own negative cognitions including their anxieties and worries.
Pharmacological agents.
Electroconvulsive treatment.
Note: Reassurance and support are needed for all depressed patients.
Useful guidelines
Mild depression: psychotherapy alone may suffice but keep medication in mind.
Moderate to severe depression: psychotherapy plus antidepressants is recommended.
Reassurance and support are needed for all depressed patients.
Explanatory supportive notes for patients and relatives 8
Most people feel unhappy or depressed every now and again, but there is a difference between this feeling
and the illness of depression.
Depression is a very real illness that affects the entire mind and body. People cannot seem to lift
themselves out of their misery or 'fight it themselves'. Superficial advice like 'snap out of it' is unhelpful,
because the person has no control over it.
What is the cause?
The cause is somewhat mysterious, but it has been found that an important chemical is present in smaller
amounts than usual in the nervous system. It is rather like a person low in iron becoming anaemic.
Depression can follow a severe loss, such as the death of a loved one, a marital separation or financial
loss. On the other hand it can develop for no apparent reason, although it may follow an illness such as
glandular fever or influenza, an operation or childbirth. Depression is seen more commonly in late
adolescence, middle age (both men and women), retirement age and in the elderly.
What is the treatment?
The basis of treatment is to replace the missing chemicals with antidepressant medication.
Antidepressants are not drugs of addiction and are very effective but take about two weeks before an
improvement is noticed. Alcohol can interact with the tablets; so it is important not to drink and drive. If the
person is very seriously depressed and there is a risk of suicide, admission to hospital will most likely be
advised. Other more effective treatments can be used if needed. The depressed person needs a lot of
understanding, support and therapy. Once treatment is started, the outlook is very good (an 80% cure
rate).
Important points
Depression is an illness.
It is more common than realised.
It just happens; no one is to blame.
It affects the basic functions of energy, sex, appetite and
sleep. It can be lethal if untreated.
It can destroy relationships.
The missing chemical needs to be replaced.
It responds well to treatment.
Recommended reading
Paul Hauck, Overcoming depression. The Westminster Press, London, 1987.
Antidepressant medication
The initial choice of an antidepressant depends on the age and sex of the patient, prior response to
medication, safety in overdosage and the sideeffect profile. All antidepressants are equally efficacious. The
tricyclics and tetracyclics have been the first-line drugs but the newer drugs, the selective serotonin
reuptake inhibitors and moclobemide (a reversible monoamine oxidase inhibitor (MAOI) antidepressant) are
equally effective, are better tolerated, have a wider safety margin 6 and are now considered first-line drugs.
Tricyclic antidepressants 6
1. amitriptyline and imipramine
the first generation tricyclics
the most sedating: valuable if marked anxiety and insomnia
strongest anticholinergic side effects, e.g. constipation, blurred vision, prostatism
2. clomipramine, desipramine, dothiepin, doxepin,
nortriptyline less sedating and anticholinergic
activity
nortriptyline is the least hypotensive of the tricyclics
Dosage: 50-75 mg (o) nocte, increasing every 2 to 3 days to 150 mg (o) nocte by day 7.
If no response after 2 to 3 weeks, increase by 25-50 mg daily at 2 to 3 week intervals
(depending on adverse effects) to 200-250 mg (o) nocte. Trial for 6 weeks.
General adverse effects
dry mouth, weight gain, constipation, sedation
glaucoma, urinary retention, tremor
confusion and delirium in the elderly (caution in the
elderly) sexual dysfunction
postural hypotension
cardiac conduction impairment (caution in heart disease)
lowered seizure threshold
Tetracyclic antidepressants 6
Mianserin 30-60 mg (o) nocte increasing to 60-120 mg (o) nocte by day 7
Adverse effects
sedation, lethargy, dizziness, polyarthritis, dry mouth, headache
neutropenia (reversible) especially > 65 years (uncommon)
less anticholinergic effects than tricyclics
fewer cardiovascular side effects
Selective serotonin reuptake inhibitors
e.g. fluoxetine, paroxetine, sertraline, fluvoxamine, citalopram
Fluoxetine and paroxetine 20 mg (o) mane
This dose is usually sufficient for most patients. If no response after 2 to 3 weeks, increase by 20 mg at 2
to 4 week intervals to 40-80 mg (o) daily in divided doses.
Sertraline, 50 mg (o) daily, starting dose; can increase to 200 mg daily.
Fluvoxamine, 50 mg (o) bd, starting dose; can increase to 200 mg daily.
Citalopram 20 mg (o) daily, up to 60 mg (max).
These new drugs have a similar efficacy profile to the tricyclics. They do not appear to cause weight gain,
interact with alcohol or cause serious cardiovascular effects.
Adverse effects
Nausea, nervousness, fatigue, agitation, diarrhoea, headaches, insomnia. Possible effects include sexual
dysfunction, mainly ejaculatory disturbances, allergic reactions and hypomania (in some manic
depressives). They should not be used with MAOIs or the tricyclics.
Moclobemide
Moclobemide 150 mg (o) bd. If no response after 2 to 3 weeks, increase by 50 mg daily to maximum 300 mg
(o) bd.
This is a reversible MAOI, which is less toxic than the irreversible MAOIs.
It has minimal interaction with tyramine-containing foodstuffs, so that no dietary restrictions are
necessary.
Adverse effects include nausea, headache, agitation, dizziness and insomnia.
The irreversible MAOIs, which should be reserved for second-line MAOI therapy, include phenelzine
and tranylcypromine.
Serotonin noradrenaline reuptake inhibitors
The first of the SNRIs to be released is venlafaxine. It is recommended for major depression where
other therapy is inappropriate. The starting dose is 37.5 mg (o) bd increasing to 75 mg bd after 2
weeks if necessary.
Side effects appear to include nausea, dizziness, insomnia and sexual dysfunction, giving the drug a
similar side-effect profile to the SSRIs. It should not be used concomitantly with MAOIs and various 'washout periods' from other antidepressants are required.
5-HT2 receptor blockers
Nefazodone is the first of the serotonin type 2 (5-HT2) receptor blockers. It is recommended for the
treatment of major depressive disorders and is effective for depression associated with anxiety. The usual
dose is 300- 600 mg (o) daily in two equally divided doses. The starting dose is 50 mg bd for 1 week and
then 100 mg bd for week 2.
Reported adverse effects include asthenia, dry mouth, nausea, constipation, somnolence and dizziness.
Notes about antidepressants
Tricyclics can be given once daily (usually in the evening).
There is a delay in onset of action of 1-2 weeks after a therapeutic dose (equivalent to 150 mg
imipramine at least) is reached.
Each drug should have a clinical trial at an adequate dose for at least 4-6 weeks before treatment is
changed.
The SSRIs are probably now the first-line drugs of choice and the tricyclics second-line.
Consider referral if there is a failed (adequate) trial.
Full recovery may take up to 6 weeks or longer (in those who respond).
Continue treatment at maintenance levels for at least 6 to 9 months. 1 There is a high risk of relapse.
For a second episode use antidepressants for 3 to 5 years.
MAOIs are often the drugs of choice for neurotic depression or atypical depression. 1
The serotonin syndrome 9
This is a dangerous adverse reaction related to the use of the SSRIs and is most likely to occur with the
combined use of MAOI drugs and other agents. The diagnosis is based on three criteria:
Symptoms must coincide with the introduction or dose increase of a serotonergic agent.
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, i.e.
mental status/behaviour changes, e.g. agitation, confusion, hypomania, seizures
altered muscle tone, e.g. tremor, shivering, myoclonus
autonomic instability, e.g. hypertension, tachycardia, fever, diarrhoea
The offending agents should be withdrawn immediately and supportive therapy initiated.
Electroconvulsive therapy
Electroconvulsive therapy (ECT) is safe, effective and rapidly acting. 1 6 10
Indications
psychotic depression, for example delusions,
hallucinations melancholic depression unresponsive to
antidepressants substantial suicide risk
ineffective antidepressant medication
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 usual course
is 6-8 treatments over 3 weeks. All antidepressants can be used in combination with ECT and after ECT
to prevent relapse.
Recurrent depression
Lifelong antidepressant therapy may have to be considered. Lithium is an alternative medication for longterm use.
Suicide
The risk of suicide is a concern in all depressed patients. Between 11% and 17% of people who have
suffered a severe depressive disorder at any time will eventually commit suicide. 10 Referral for hospital
admission should be arranged for patients who are at great risk for suicide. There is a distinction between
patients who are determined to suicide and those who attempt suicide (parasuicide).
Risk factors for suicide include:
male sex
older age > 55
years adolescents
young adults 15-25 years
immigrant status
isolation/living alone
recent divorce, separation or bereavement
recent loss of employment or retirement
family history of psychiatric illness (including suicide)
impulsive, hostile personality
previous suicide
attempt severe
depression financial
difficulties
alcohol or other substance abuse
psychosis
early dementia
physical illness, especially if chronic pain
A useful suicide risk assessment is the SAD PERSONS (mnemonic) index ( Tabl e 16. 2 ). A score
greater than 7 represents a very high risk that demands careful attention including referral to an acute
psychiatric service.
Table 16.2 SAD PERSONS Index: Suicide risk assessment
Risk factor
Criteria
Score
Sex
Male
Age
< 20 years; > 45 years
Depression
Major, e.g. depressed mood
Psychiatric history Previous attempts
Excessive drug use Ethanol or other drug abuse
Rationality loss
Psychosis, severe depression
Separated
Loss of spouse or other single
Organised plan
Determined suicide plan
No supports
No community back-up; generally isolated 1
Sickness
Chronic illness
Score > 7 = high suicide risk
If there is concern about suicide risk and treatment is supervised outside hospital, provide closer
supervision and considerable support, and prescribe drugs that are less toxic in overdosage, e.g.
mianserin or fluoxetine. If tricyclics are prescribed, useful guidelines are that dangerous medical
complications occur with an equivalent dosage of 1000 mg (40 tablets) of imipramine and a high risk of
death with 2000 mg (80 tablets). 6
When to refer
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
Difficult problem in the elderly-where diagnosis including 'dementia' is doubtful
Children with apparent major depression
References
1. Burrows GD. Depressive disorders. In: MIMS Disease Index (2nd edn). Sydney: IMS Publishing,
1996, 139-141.
2. Davies B. An introduction to clinical psychiatry. University of Melbourne, 1977, 76-77.
3. Serry DK, Serry M. Masked depression and the use of antidepressants in general practice. Med
J Aust, 15 February 1969, 35-37.
4. Depression: Masked or missed? Patient Care, Oct 1972, 1(3):6-14.
5. Robinson MJ. Practical paediatrics (2nd edn), Melbourne: Churchill Livingstone, 1990, 552-553.
6. Moulds RFW. Psychotropic drug guidelines (3rd edn), Melbourne: Victorian Medical
Postgraduate Foundation, 1996/7, 107-118.
7. Davis A, Bolin T, Ham J. Symptom analysis and physical diagnosis (2nd edn), London:
Bailliere Tindall, 1990, 983.
8. Murtagh J. Patient education (2nd edn). Sydney: McGraw-Hill, 1996, 146.
9. Keltner N. Serotonin syndrome: A case of fatal SSRI/MAOI interaction. Perspectives in
Psychiatric Care, 1994; 30(4):26-31.
10. Kumar PJ, Clark ML. Clinical medicine (2nd edn), London: Bailliere Tindall, 1990, 983.
11. Rogers I. Guidelines for the management of common emergencies in the emergency department
(2nd edn). Auckland Hospital, 1996, 43.
