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Depression

Specialties > General practice

Background knowledge 🧠

Definition

  • Depression is a common mental health disorder characterized by persistent low mood and loss of interest or pleasure in most activities.
  • It is often associated with other symptoms, such as feelings of guilt, hopelessness, poor concentration, and disturbed sleep or appetite.
  • The diagnosis requires the presence of symptoms for at least two weeks.

Epidemiology

  • Depression affects approximately 4-5% of the UK population each year.
  • It is more common in women, with a female-to-male ratio of about 2:1.
  • Peak age of onset is in the late 20s to early 30s.
  • Higher prevalence is seen in those with chronic physical illnesses and those who are unemployed.

Aetiology and Pathophysiology

  • Multifactorial causes include genetic, biological, psychological, and environmental factors.
  • Imbalance in neurotransmitters such as serotonin, norepinephrine, and dopamine plays a key role.
  • Chronic stress and inflammation may contribute to the development of depression.
  • Psychosocial stressors such as trauma, loss, and isolation are significant contributing factors.
  • Genetic predisposition increases the risk, with heritability estimates around 40-50%.

Types

  • Major depressive disorder (MDD) – characterized by one or more major depressive episodes.
  • Persistent depressive disorder (dysthymia) – chronic low-grade depression lasting at least 2 years.
  • Bipolar disorder – involves episodes of depression alternating with mania or hypomania.
  • Atypical depression – features include mood reactivity, increased appetite, and hypersomnia.
  • Seasonal affective disorder (SAD) – depression occurring during certain seasons, usually winter.

Clinical Features 🌡️

Symptoms

  • Low mood, most of the day, nearly every day.
  • Anhedonia – loss of interest or pleasure in most activities.
  • Fatigue or low energy.
  • Feelings of worthlessness or excessive guilt.
  • Recurrent thoughts of death or suicide.
  • Difficulty concentrating or making decisions.
  • Sleep disturbances – insomnia or hypersomnia.
  • Appetite changes – usually reduced appetite and weight loss, but sometimes increased appetite and weight gain.

Signs

  • Psychomotor retardation or agitation.
  • Flattened or sad facial expression.
  • Poor eye contact.
  • Tearfulness during the interview.
  • Neglect of personal appearance or hygiene.
  • Speech changes – slow, monotonous, or reduced volume.

Investigations 🧪

Tests

  • Clinical diagnosis based on history and examination, following DSM-5 or ICD-10 criteria.
  • Full blood count, thyroid function tests, and electrolytes to rule out medical causes of depressive symptoms.
  • Consider imaging (MRI or CT) if there are neurological signs or a suspicion of a space-occupying lesion.
  • Use of screening tools such as PHQ-9 or HADS for initial assessment and monitoring.
  • Psychological assessment may be needed for complex cases or when coexisting psychiatric conditions are suspected.

Management 🥼

Management

  • Biopsychosocial approach is essential for effective management.
  • First-line treatment typically involves psychological therapy (e.g., CBT, IPT).
  • Antidepressant medications, such as SSRIs, are commonly prescribed.
  • In severe cases, ECT may be considered, particularly if there is a high risk of suicide or lack of response to treatment.
  • Lifestyle modifications including regular exercise, sleep hygiene, and reducing alcohol or drug use are recommended.
  • Regular follow-up is crucial to monitor treatment response and adjust the management plan.
  • Collaborative care models can be effective, especially in primary care settings.

Complications

  • Increased risk of suicide and self-harm.
  • Development of chronic depression or treatment-resistant depression.
  • Higher risk of comorbid anxiety disorders and substance misuse.
  • Impaired social and occupational functioning.
  • Increased risk of physical health problems, such as cardiovascular disease.

Prognosis

  • Prognosis varies; approximately 50% of patients experience a recurrent episode within 10 years.
  • Early treatment improves outcomes and reduces the risk of relapse.
  • Chronic depression is associated with a poorer prognosis.
  • Patients with good social support and effective treatment adherence have better outcomes.
  • Risk of recurrence is higher in those with multiple previous episodes.

Key Points

  • Depression is a common, multifactorial disorder requiring a holistic management approach.
  • Early recognition and treatment are crucial to improve outcomes.
  • Management should be tailored to the individual, considering the severity and presence of comorbidities.
  • Collaboration between primary care, mental health services, and social support networks enhances care.
  • Ongoing monitoring and support are essential to prevent relapse and manage chronic depression.

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General practice