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Ask the specialist: Depression

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Consultant psychiatrist and author Dr Conor Farren answers questions on managing depression in the community

 

Q: What factors can help predict the likelihood of developing depression?

A: The easiest answer is that depression is often multifactorial, and many factors may lead to the accumulation of biological events and psychological feelings that is depression. A biological predisposition is a major factor. Depression is about 40 per cent genetic, and female gender is also predisposing; depression is twice as common in women.

Other factors include: A recent traumatic/life event (depression often occurs in the six months after a major life event such as a bereavement/financial stress); a vulnerable childhood (those who lose parents early or suffer abuse or neglect as children are more likely to develop depression); those who have a substance abuse problem, particularly alcohol misuse, are more likely to develop depression; about 10 per cent of women who have recently given birth can develop depression; those who have taken mood altering medication such as steroids can develop depression; those who have had major physical events such as stroke and myocardial infarction are more likely to develop depression; and finally, those who have had no recent events and no background factors are also vulnerable. Frequently, depression occurs in patients who have no predisposing or precipitating factors.

Q: Should GPs screen for depression in certain patients to increase detection?

A: Yes, not only do GPs see the majority of depression, the presentation to GPs is very varied, often being masked in physical symptomatology. Screening for depression would allow for a vast amount of psychosomatic disorders to end up being appropriately treated, instead of being partially diagnosed and partially treated.

Q: Should major depressive disorder (MDD) be managed differently in patients with addiction problems, such as alcoholism, and can these patients be given pharmacotherapy?

A: If a patient presents with any hint of an addiction problem, even second hand via a spouse, failure to address that addiction problem will inhibit the treatment response to the depression treatment, such as an antidepressant. If there are two issues present, both should be treated. A large majority of alcohol misusers are more accepting of an addiction diagnosis if their very real depression is also acknowledged. It is possible, even advisable, to treat the comorbid depression with an antidepressant such as an SSRI, and for it to be partially successful. If both issues are addressed, both really respond.

Q: Should GPs screen for suicidality in patients with depression?

A: Yes suicidality should always be asked for, even in the mildest most trivial sounding set of symptoms. In 20 years of psychiatry I have never met a patient who was embarrassed to answer the question of suicidality, but I have met many who answered in the affirmative when I simply did not expect it from the rest of their presentation.

Q: Reports have shown that bipolar disorder is sometimes mistaken for depression in primary care: Is there a quick way to distinguish the two?

A: Bipolar disorder is one of the great underdiagnosed psychiatric disorders. Recent reports suggest that the lifetime incidence of some sort of bipolar disorder is about four per cent. In clear cases such as bipolar 1 disorder, with a clear description of a major episode of elation, it is not a difficult diagnosis to make. In bipolar 2 disorder, with hypomania being present, or in mixed mood disorder with mixed depressive and manic features, it can be a much missed diagnosis. Of all the features of elation, it is the components of agitation, restlessness, and racing thoughts that point the way to bipolar disorder rather than a pure depressive diagnosis.

Q: For how long should patients with depression be followed up in primary care?

A: Unfortunately for a very long time. Patients with an index episode of depression need to be treated and followed up for at least one year. Some long-term research suggests that if followed up for 20 years, almost everyone with one episode of depression will have a relapse sometime during that period. Basic education of what a patient needs to look for in a relapse can allow the patient to return to care quickly in this situation.

Q: When should a GP refer to psychiatric services?

A: Most depressive disorders can be safely, quickly and effectively treated in primary care. GPs should think of referral in situations where there is a failure to respond to one or perhaps two appropriately dosed antidepressants for at least six weeks each; in situations where the depression persists to the level of threats of self harm at any stage; and if there are significant complications such as alcohol misuse that render the patient difficult to treat, or more likely to fail to respond to treatment. In situations of doubt, a quick phone call to a psychiatrist can answer the borderline cases one way or the other.

Q: Can you offer a quick guide to treatment selection in patients with MDD?

A: The short answer is no, but there are a few guidelines. Most antidepressants are safe and effective, and thus there are few bad choices as first-line. If there are patient safety issues, then the use of a potentially “dangerous in overdose” medication, such as a tricyclic antidepressant, are not advisable first-line. If the patient has responded effectively to a particular antidepressant in the past, then it should probably be the first-line for a subsequent episode.

An attempt can be made to match particular side effect profiles of antidepressants with particular presenting profiles of patients: For example, if a patient presents with hypersomnia, then more activating antidepressants such as venlafaxine can be considered over more sedating antidepressants such as mirtazapine. Finally, some meta analyses have suggested that some antidepressants, including escitalopram, venlafaxine and clomipramine, may have a very small added benefit in efficacy relative to some others.

However, it has to be said that meta analyses tend to favour older antidepressants simply because there are more studies carried out on them. Of course, if there is a major complicating factor, e.g., addiction or a recent bereavement, then these may need to be addressed through appropriate therapeutic intervention at the same time.

Q: Is relapse common in depressed patients and is there a way to combat it?

A: Relapse is very common in depressed patients, and the key to success is early identification. Studies tend to show that relapse is more common in those with high baseline severity, and those with only a partial response to antidepressant intervention.

Thus being aggressive with seemingly mild symptoms, such as a comorbid anxiety or a long standing marital disharmony or indeed an addiction issue, may significantly increase the chances of relapse to full depression. Patient education about the importance of paying attention to prodromal symptoms, particularly insomnia, can bring them back to their GP earlier and prevent the onset of full depression.

Q: Is depression usually a cause or a symptom of an addiction problem?

A: Depression is very common in addictive disorders (about 50 per cent), and addiction is very common in depressive disorders (about 25 per cent). Patients often blame depression as being the cause of the onset of their addictive disorders, and for some that is true, but in fact alcohol misuse predates the onset of depression in dually diagnosed patients by a factor of two-to-one.

Patients with a depression secondary to alcohol misuse can get a major lift in their mood with simple abstinence over the course of a few weeks. Of course, depression in the setting of an addiction can be very dangerous, as it can be of sudden, severe onset and can be associated with suicidal ideas. Patients who are intoxicated can act impulsively on suicidal ideas, and sometimes succeed. If both issues are present, then both need attention and treatment.  n

Dr Conor Farren is an addiction psychiatrist at St Patrick’s University Hospital, Dublin, and author of the new book “Overcoming Alcohol Misuse”. More information is available online at www.conorfarren.com


 

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