Depression

• The diagnosis of depression requires at least 2 weeks of at least 5 of the following issues:

Core (at least one of these is present)

1. Depressed/Low Mood
2. Anhedonia

Biological

1. Anergia (fatigue)
2. Appetite/Weight changes
3. Insomnia or Hypersomnia
4. Psychomotor agitation or retardation

Cognitive

1. Beck’s Triad
   • Hopelessness
   • Helplessness
   • Worthlessness
2. Cognitive dysfunction (concentration, memory)
   • Often referred to as pseudo dementia
3. Recurrent thoughts of death

DSM-5 Diagnosis of Depression

Here are the DSM-5 diagnostic criteria for major depressive disorder (MDD), commonly referred to as depression:

A. Symptoms

A. Five (or more) of the following symptoms have been present during the same 2-week period and represent a change from previous functioning; at least one of the symptoms is either (1) depressed mood or (2) loss of interest or pleasure.

Note: Do not include symptoms that are clearly attributable to another medical condition.

1. Depressed mood most of the day, nearly every day, as indicated by either subjective report (e.g., feels sad, empty, hopeless) or observation made by others (e.g., appears tearful). (Note: In children and adolescents, can be irritable mood.)
2. Anhedonia ie Markedly diminished interest or pleasure in all, or almost all, activities most of the day, nearly every day (as indicated by either subjective account or observation).
3. Fatigue or loss of energy nearly every day.
4. Significant weight loss when not dieting or weight gain (e.g., a change of more than 5% of body weight in a month), or decrease or increase in appetite nearly every day.
   1. Note: In children, consider failure to make expected weight gain.
5. Insomnia or hypersomnia nearly every day.
6. Psychomotor agitation or retardation nearly every day (observable by others; not merely subjective feelings of restlessness or being slowed down).
7. Feelings of worthlessness or excessive or inappropriate guilt (which may be delusional) nearly every day (not merely self-reproach or guilt about being sick).
8. Diminished ability to think or concentrate, or indecisiveness, nearly every day (either by subjective account or as observed by others).
9. Recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation without a specific plan, or a suicide attempt or a specific plan for committing suicide.

B. Significant distress

B. The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.

C. Not attributable to other causes

C. The episode is not attributable to the physiological effects of drugs or another medical condition.

D. Not better explained by another disorder

D. The occurrence of the major depressive episode is not better explained by schizoaffective disorder, schizophrenia, schizophreniform disorder, delusional disorder, or other specified and unspecified schizophrenia spectrum and other psychotic disorders.

E. Never been a manic or hypomanic episode

E. There has never been a manic episode or a hypomanic episode (Required to distinguish between major depressive disorder and bipolar disorders.)

Treatment

Depression is a multifaceted disorder, and its treatment is tailored to the individual, often involving a combination of interventions. As for all mental illness a BIO-PSYCHO-SOCIAL approach should be used.

Bio-Psycho-Social Approach

• Bio – refers to primarily to medication, but also things like ECT and TMS
• Psycho – refers to the talking therapies (psychiatry, psychology and counselling)
• Social – refers to lifestyle and other supports for the patient

Pharmacotherapy

• Antidepressants:
  • These are the most commonly prescribed medications for depression. There are various classes, including:
    • Selective Serotonin Reuptake Inhibitors (SSRIs): e.g., fluoxetine (Prozac), sertraline (Zoloft), escitalopram (Lexapro).
    • Serotonin-Norepinephrine Reuptake Inhibitors (SNRIs): e.g., venlafaxine (Effexor XR), duloxetine (Cymbalta), desvenlafaxine (Pristiq).
    • Tricyclic Antidepressants (TCAs): e.g., amitriptyline, nortriptyline, imipramine (Tofranil).
    • Monoamine Oxidase Inhibitors (MAOIs): e.g., tranylcypromine (Parnate), phenelzine (Nardil).
      • These are less commonly used due to significant dietary restrictions and potential drug interactions.
• Atypical Antidepressants:
  • These don’t fit into other classes:
    • Bupropion (Zyban) and
    • Mirtazapine (Avanza).
• Antipsychotics:
  • Sometimes used as adjunctive treatment, especially when there are psychotic features or treatment resistance.
  • Examples include quetiapine (Seroquel) and aripiprazole (Abilify).
• Mood Stabilizers:
  • Such as lithium might be used, especially if there’s a suspicion of bipolar depression.

Psychotherapy

• Cognitive-Behavioral Therapy (CBT):
  • Focuses on identifying and challenging negative thought patterns and behaviors.
• Interpersonal Therapy (IPT):
  • Focuses on improving interpersonal relationships and communication patterns.
• Dialectical Behavior Therapy (DBT):
  • Originally developed for borderline personality disorder, it’s also effective for treating depression, especially in those with suicidal tendencies.
• Psychodynamic Therapy:
  • Explores unconscious processes and past experiences to understand current feelings.
• Problem-Solving Therapy:
  • Focuses on the practical approach to solving current problems causing distress.

Electroconvulsive Therapy (ECT)

Electroconvulsive Therapy (ECT) is often used for severe, treatment-resistant depression or when rapid response is required (e.g., high suicide risk). It involves electrical stimulation of the brain while the patient is under anesthesia.

Transcranial Magnetic Stimulation (TMS)

Transcranial Magnetic Stimulation (TMS) is a non-invasive procedure that uses magnetic fields to stimulate nerve cells in the brain. It’s used for people with treatment-resistant depression.

Lifestyle Therapies

• Physical Activity:
  • Regular exercise has demonstrated antidepressant effects.
• Dietary and Nutritional Strategies:
  • A balanced diet can support mental health, and some supplements like omega-3 fatty acids and S-adenosylmethionine (SAMe) have shown potential benefits.
• Mindfulness and Meditation:
  • Techniques like mindfulness and meditation can be effective for some.
• Support Groups:
  • Peer support can offer understanding, advice, and encouragement.
• Light Therapy:
  • Especially useful for Seasonal Affective Disorder (SAD).

Other Therapies

• Vagus Nerve Stimulation (VNS):
  • An implanted device similar to a pacemaker that sends regular, mild pulses of electrical energy to the brain via the vagus nerve.
  • It’s used for long-term treatment-resistant depression.
• Ketamine and Esketamine:
  • These are newer treatments being used for treatment-resistant depression.
  • Esketamine, the S-enantiomer of racemic ketamine, is TGA & FDA approved as a nasal spray under the brand name Spravato.

Hospitalization

Sometimes, depression can be so severe that hospitalization is required, especially if there’s significant self-harm or suicide risk.

When treating depression, it’s crucial to monitor for potential side effects of treatments and to adjust as necessary. Close collaboration between the patient, their family, and their medical team is essential for optimal outcomes.

Postpartum Depression

Treating postpartum depression, also known as postnatal depression, involves several special considerations to ensure the health and well-being of both the mother and the baby. Here are some key points:

1. Early Identification and Screening:
   • It’s important to identify postnatal depression early.
   • GPs often screen for depression during and after pregnancy.
2. Holistic Approach:
   • Treatment should consider the physical, emotional, and social aspects of a new mother’s life.
   • This includes acknowledging the challenges of motherhood, changes in relationships, and the need for support.
3. Medication:
   • If medication is required, it must be chosen carefully, especially if the mother is breastfeeding.
   • Some antidepressants are safer for use during breastfeeding, but it’s important to weigh the benefits against any potential risks to the baby.
     1. Sertraline (Zoloft) is often preferred because it has low levels in breast milk.
     2. Amitriptyline and Nortriptyline are also considered relatively safe, with low levels found in breast milk.
4. Counselling and Psychotherapy:
   • Psychological therapies, like cognitive-behavioral therapy (CBT) or interpersonal therapy (IPT), are effective treatments.
   • These therapies can provide coping strategies and address issues like anxiety, relationship challenges, and adjustment to motherhood.
5. Support Groups:
   • Joining a support group can provide emotional support and practical advice from other mothers experiencing similar challenges.
6. Self-Care:
   • Encouraging self-care is crucial. Adequate rest, nutrition, exercise, and time for self can greatly improve mental health.
7. Family and Partner Involvement:
   • Involving family members, especially partners, in the treatment process can be beneficial. Education about postnatal depression helps them understand and provide better support.
8. Monitoring Infant Well-being:
   • It’s also essential to monitor the baby’s development and well-being, as maternal depression can impact infant care.
9. Safety Planning:
   • In severe cases, it’s important to assess the risk of harm to the mother or the baby and to make safety plans if needed.
10. Cultural Sensitivity:
    • Treatment should be culturally sensitive and consider the mother’s background, beliefs, and values.
11. Long-term Monitoring:
    • Postnatal depression can sometimes lead to chronic depression. Long-term follow-up and support may be necessary.
12. Access to Resources:
    • Providing access to resources like childcare, financial aid, and housing support can reduce stressors that may contribute to depression.

It’s important for any treatment plan to be individualized, taking into account the mother’s personal circumstances, medical history, and specific needs.