1. Depression and Suicide
Andrew Matrunola ST3 Psychiatry

2. 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.

3. 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

4. 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!

5. 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

6. 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

7. 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

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

9. 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

10. History

11. 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?

12. MSE Appearance and behaviour Speech Mood Thoughts Perceptions
Cognition
Insight

13. 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

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

15. 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

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

17. 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

18. 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)

19. Assessing suicide risk

20. 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?

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

22. 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

23. 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

24. 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

25. 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)

26. 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

28. Any Questions?