Transcript Depression and Suicide

Depression and Suicide
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Andrew Matrunola
ST3 Psychiatry
Depression
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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.
Depression
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Depressive disorders are common, prevalence 25% (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
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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!
Core Symptoms
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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
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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
Biological/Somatic symptoms
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Sleep disturbance
Diurnal mood variation
Anhedonia
Early morning wakening
Psychomotor agitation or retardation
Loss of weight/appetite
Loss of libido
Constipation, amenorrhoea
Subtypes
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Mild
Moderate
Severe
With psychotic symptoms: typically moodcongruent delusions, hallucinations
Nihilistic delusions e.g. Cotard’s syndrome
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
History
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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?
MSE
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Appearance and behaviour
Speech
Mood
Thoughts
Perceptions
Cognition
Insight
Suicide
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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
Risk factors
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Male
Increasing age
Living alone
Unemployed
Recent life crisis
Occupation (e.g. farmers, doctors)
Risk factors 2
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Personality disorder esp. borderline type
Mood disorder
Alcohol or drug misuse
Schizophrenia
Past history of deliberate self harm
Physical ill-health esp. epilepsy
Mental State Factors
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Depressed mood
Expressed wish to die
Detailed suicide plans
Hopelessness and helplessness
Lack of reasons to go on living
Assessment following self harm
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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
Deliberate self Harm
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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)
Assessing suicide risk
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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?
Treatment of depression
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Mild depression: watchful waiting, problem
solving, exercise
Mild/Moderate depression: consider CBT
Moderate depression: antidepressants, SSRI
generally first line
Antidepressants
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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
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
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MAOIs
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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
Serotonin Syndrome
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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)
ECT
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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
Any Questions?