CCFP Topic: Depression

    Always assess and address safety in patients presenting with a mental health issue. And be sure to actively inquire – this does not increase the risk of the patient committing suicide and if you dont ask then you wont know. This also gives you an opportunity to make a plan of action for potential crisis situations (eg: calling a friend/family member, access to crisis lines, etc)

 This is fairly straightforward- assess the acute safety risk (to self or others), for features of psychosis, and ability to care for oneself, in order to determine the most appropriate setting for care, namely in hospital versus outpatient setting. When there are safety concerns it is always important (where possible) to obtain collateral information to assess appropriateness for discharge with supports versus need for hospitalization.ii.      For example in patients with active suicidal ideation, an ER assessment with a form 1 (Ontario specific) is needed to maintain patient safety and expedite/facilitate in-patient psychiatric care.

  It is important to be aware of these groups in order to have this diagnosis on your radar; if you’re not thinking about it then it won’t get picked up.

■      Generally, higher risk groups include: individuals aged 15-45yo, females, low socioeconomic status, poor social support, abuse, adverse childhood events, trauma, stress, substance use, chronic medical conditions (eg: chronic pain, post MI/ post stroke, HIV), postpartum.

Note that these RF for depression differ from the RF for suicide (SADPERSONS mnemonic might be useful to add here or above on SI screen)

  Especially consider this in elderly patients – they may present with physical symptoms of depression as opposed to the symptoms of low mood or anhedonia. Atypical depression may be diagnosed if there are physical symptoms in the absence of mood/cognitive symptoms.

■      Also ask about mood and anhedonia in patients presenting with (potentially) vague symptoms of fatigue, sleep disturbance, weight change

  Let’s quickly review the diagnostic criteria. The DSM-5 states that in order to diagnose depression there must be at least a 2 week period of low mood or anhedonia for most of the day and 4 or more of the following symptoms (and that these symptoms are not attributable to another medical condition):

• Sleep disturbance – insomnia or hypersomnolence
• Feelings of guilt or worthlessness
• Fatigue
• Impaired concentration
• Significant unintentional weight loss, or a change in appetite (this can be an increase or decrease)
• Psychomotor slowing or agitation
• Suicidal ideation or thoughts of death

■      Comorbid conditions include anxiety disorder, personality disorder, bipolar disorder, eating disorder. *These are reviewed elsewhere■      The psychiatric differential for depression includes dysthymia (now called Persistent Depressive Disorder in DSM 5) (chronic low mood for most of the day for a 2 year period), adjustment reaction, bipolar disorder, schizoaffective disorder

 The Medical differential includes but is not limited to: anemia, parkinson’s disease, dementia, hepatitis, stroke, lupus, OSA, and certain medication use (b blocker, steroids, antiretrovirals)

Manage appropriately (e.g., medications, psychotherapy, supported self-management)i.       It is important to think of the management plan as a multi-pronged approach. Medication is important, but so are counselling/therapy and a supportive environment. In most cases, an SSRI/SNRI is considered first line when there is moderate-severe depression. With Mild-moderate depression, psychotherapy may be more appropriate.

   Monitor their response to therapy and modify appropriately (e.g., augmentation, dose changes, medication changes)

• Be sure to follow patients closely when starting and titrating medication. It can take 1-3 weeks for physical symptoms to improve, but a full 4-6 weeks after a moderate dose is established for mood/cognitive symptoms. It’s important to let your patient know about this, and for you to check in every few weeks to re-assess.  

Many patients will stop medications after 2-3 weeks stating no improvement as the cause so educating on the length of time required to see a full response is very important.   

Use the PHQ9 or another validated scale to help gauge medication response, as it may be difficult for a patient to identify this themselves. The PHQ9 can be done at baseline (before starting medications), and at follow up visits. 

Another useful thing to document is a patients mood on a scale of 1-10 (with ten being the highest). Describing that most people, when well, are a 7/10, getting a sense of where they are at currently, and on subsequent re-evaluations can be useful, time-saving and motivates

the patient to integrate mindfully tuning into and being aware of their moods. 

It is also important to make note of a potential “unmasking” of bipolar disorder when titrating antidepressants – ie: if the patient is developing symptoms of mania or “overresponding” to the antidepressant.

•  Augmentation agents can be added when there is partial but suboptimal effect with routine antidepressant treatment. We generally consider augmenting agents when there is failed trial of 2 anti-depressants from two different classes (such as an SSRI and an SNRI/NDRI
  
  • Examples include:

1.     Aripriprazole, quetiapine, Risperidone which are considered first line

2.     T3, lithium; bupropion/modafinil/mirtazapine which are considered second line3.     Note that only Aripiprazole, quetiapine, T3 and lithium have evidence to support patient benefit compared to placebo.

■  Reassess the patient’s safety

i.       Re-assess this at every visit, even if you’ve seen the patient before or even if you anticipate that there are no safety concerns. Things can change and it’s important to check in with our patients as they may not be forthcoming about safety concerns.

■  Set goals, including a return-to-work plan

i.       patients may need to have time off from work while dealing with crisis situations and adjusting their treatment plan, including starting medication and getting access to counselling. In these scenarios, setting up a return to work date (and follow up appointments to re-assess) is important as we know that going to work and maintaining routines are important for overall mental health. You may also consider a gradual return-to-work or reduced work load pending patient preference and employment circumstances.

■  Refer as necessary (including community resources)i.       Consider referring to outpatient psychiatry if multiple trials of medication, comorbidity, or diagnostic uncertainty. Also consider additional resources such as GP psychotherapy, support groups or situational specific sources (eg: Alzheimer’s society for caregiver support).

On history we may want to ask about or assess for

• Endocrine disorders: hypothyroid, hypercortisol, adrenal insufficiency, diabetes mellitus
• Infectious disorders: mononucleosis, HIV
• Neurologic disorders: post stroke, MS, parkinsons disease, Huntingtons disease, sleep apnea, dementia
• OSA
• Lupus, hepatitis
• Anemia – iron, folate, B12 deficiency
• Medication – steroids, B blocker, interferon, antiretrovirals, OCP/IUD
• Substance induced
•  Inquire about abuse: substance, sexual, physical, mental, childhood, addictions

A Physical exam would include a general assessment of vitals, cardiac, resp, neuro exams, and other focal exams based on the patient’s medical history.

Baseline Investigations include (but not limited to)

• CBC, folate, iron, B12
• LFT, creat, lytes, TSH
• bHCG
• Urinalysis, urine toxicology
• ECG (which is also important for assessing the QT interval prior to starting medication, particularly for elderly patients and in patients with augmenting anti-psychotics)
• We can also Consider neuroimaging based on history, physical

This objective is fairly straightforward; if you don’t ask, the patient may not voluntarily tell you. It’s also important to highlight that if there is risk of harm to a minor, that this will need to be reported in most jurisdictions to childrens’ aid or equivalent. 

The person who acquires this history is the person most responsible for reporting (ie don’t have nursing report it if you’ve elicited it on interview)■      Thus on history, you should inquire about Sexual, physical, and emotional abuse (past and current, witnessed or inflicted), and addictions (e.g., substance use/abuse, gambling)

These distinctions can be made mostly based on timeline and duration of symptoms. So, in order from shortest to longest duration:

1) grief reaction or acute stress disorder: this is typically a reaction to a loss (eg bereavement) or stressful event. The timeline for this is 3 days – 3 months

2) adjustment disorder: this is typically a reaction to a stressor, and can present as low mood or anxiety that is negatively impacting function. Timeline: <3 months duration but resolves by 6 months after resolution of the stressor3) dysthymia(Persistent depressive disorder):
this is defined as a chronically depressed mood for 2 or more years, for most of the day, with no more than 2 months without these symptoms. The patient must also have 2 or more of the “SIGECAPS” symptoms from the DSM. In adolescents the timeline is depressed or irritable mood for 1 year.

–        Depressive symptoms may be part of the presentation of other psychiatric illnesses, namely bipolar and schizoaffective disorder. It is important to keep this in mind when considering a possible diagnosis of depression. This also highlights the importance of conducting a functional inquiry for other psychiatric illness (commonly summarized as “MOAPS”, which was reviewed in a previous episode).

–        Antidepressant use could “unmask” bipolar disorder, which is concerning if the patient was incorrectly diagnosed with major depressive disorder and is not on a mood stabilizer. The “unmasking” could present as an overresponse to antidepressants (for example responding faster and with an increased intensity than expected). 

It is important to screen for possible manic/hypomanic episodes, especially if there is a family history of bipolar disorder, before starting medication. Bipolar disorder is characterized by episodes of depression and/ or mania and hypomania. As per the DSM-5, at least 3 of the following symptoms would need to be present to diagnose a manic or hypomanic episode:

Distractibility.
Inhibition lost
Grandiosity/inflated self esteem, decreased need for
Flight of Ideas,
Activity (goal directed activity),
Sleep,
Talkative

The above symptoms must not be secondary to another medical condition or substances. A helpful mnemonic to remember these symptoms is “GSTPAID”.

–        Manic episodes last >7 days and disrupt functioning or require hospitalization, whereas hypomanic episodes last 4-7 days and may not disrupt one’s function and would not require hospitalization.

–        A patient can also have a mixed episode, where they concurrently experience manic and depressive symptoms.-        Bipolar disorder 1 can be diagnosed with at least one manic or mixed episode, whereas bipolar disorder 2 is diagnosed with at least one hypomanic episode (but no manic or mixed episodes) and 1 or more depressive episode.

–        When considering a possible diagnosis of schizoaffective disorder, we are looking for symptoms of psychosis. Specifically, the DSM-5 criteria for schizoaffective disorder is:

–        Concurrent mood episode (mania or depression) and two or more of the following criteria of schizophrenia (and at least one of the first three) which must be present for the majority of a 1 month period:

Delusions
Hallucinations
Disorganized speech
Disorganized or catatonic behaviour
Negative symptoms (eg avolition, apathy)

–        Mood symptoms must be present during the majority of the illness

–        Delusions or hallucinations must be present at least 2 weeks without mood symptoms during the patient’s lifetime

–        The above symptoms must not be secondary to another medical condition or substances.

–        The diagnosis of schizoaffective is often difficult to elicit on the first interview, as it requires a reliable historian to understand the timeline of events. It is not uncommon for a patient’s diagnosis to be refined to schizoaffective disorder after many years of and alternative diagnosis such as schizophrenia, bipolar or MDD with psychotic features.-        Aside from having an incorrect psychiatric diagnosis, also consider if the patient’s symptoms are being caused by another medical condition, for example or severe diseases inclu

    As noted previously, elderly patients may present with changes in physical symptoms

–        Depressive symptoms may be a prodrome to dementia in patients >65yo, especially if this is their first presentation of depression. Thus it is important to monitor cognition over time

–        Elderly patients are also thought to have an Increased risk of suicidal ideation due to chronic illness, and social isolation-        CHildren and adolescents with depression may present with hypersomnolence instead of insomnia, and with an irritable mood instead of a low mood

 often this irritability will be mislabeled as “defiant” by parents, or “anxious” by other practitioners. Its important to consider depression, especially if irritability is the presenting complaint.

i.       The CanMAT guidelines have an entire section for recommendations on pharmacological treatment (section 3). Generally, SSRIs are considered first line for most patients. The guidelines also include suggestions for medications based on specifiers and other symptoms, including:

•  anxious distress (SSRI/SNRI used for generalized anxiety),
• cognitive dysfunction (vortioxetine, bupropion), 
• sleep disturbance (mirtazapine, quetiapine).

Note that some SNRIs (duloxetine, venlafaxine) and TCAs (nortriptyline) have the added benefit of pain control, specifically for neuropathic pain.

■  Monitoring medication effectiveness, including adherence and the patient’s possible self-medication using other substances (e.g., herbal and naturopathic remedies, alcohol, cannabis)

i.       The general recommendation is close follow up once a patient is started on a medication. One may notice changes in physical symptoms by the 2 week mark so this can be a good time to check in. Generally if there is some response at this time, there is a higher chance of having further therapeutic benefit with continuing this medication at higher doses as well.

ii.      We usually consider an early response:   A 20-25%% reduction in symptoms in the first 2 weeksiii.    If no, or very little, response after a full 4-6 weeks on an adequate dose, consider switch to an alternative first line agent in a different class or if this is the second “failed trial” consider an augmentative agent

■  Considering augmentation strategies when appropriate

i.       Consider the addition of an augmentative agent if the patient has a partial response to an antidepressant (defined as residual symptoms and failure to achieve full remission by the 4-6 week mark on an adequate dose of an antidepressant) .ii.      There are 4 augmentative agents that have more evidence than placebo which are: T3, quetiapine, lithium and aripiprazole. Note that Lithium and T3 are considered “second line” agents

■  Monitoring side effects carefully when initiating treatment, especially in young and elderly patients

i.       When counselling patients on antidepressant treatment, always provide information about potential side effects, as this would help increase their success with the medication if they are aware of what to expect.

ii.      SSRI side effects include:

1.  QT prolongation – consider an ECG prior to medication initiation in elderly patients
2. SIADH
3. Headache
4. Sweating, agitation
5. Nausea, vomiting, diarrhea, heartburn (theoretical increase risk in GI bleed with use of NSAIDs)
6. Sexual dysfunction – ranges from reduced libido, to delayed ejaculation, to erectile dysfunction. This can be “treated” or managed with a PDE5 inhibitor, or with the addition of bupropion.

Increased risk suicidality in the first few weeks – this is due to physical symptoms improving prior to mood symptoms
a.     In those <21 years of age, there is a black box warning for the increased risk of suicidal thinking but studies DO NOT demonstrate an increased risk of completed suicides. Important to counsel families on this!

iii.    SNRI side effects: the SSRI side effects, and some medication specific ones (duloxetine may be sedating and cause anticholinergic side effects, venlafaxine and desvenlafaxine can cause insomnia, diaphoresis, reduced blood pressure)

iv.    Mirtazapine: increased appetite, sedation; anticholinergic side effects (eg: dizziness, urinary retention). Benefits: no sexual dysfunction

v.     Bupropion: anxiety, insomnia, reduced seizure threshold, weight loss. Benefits, no sexual dysfunction, energy-invoking

vi.    Serotonin syndrome is important to look out for in patients taking antidepressants. This occurs due to blockade of serotonin receptors, thus there is increased risk of this with the use of an SSRI or SNRI. Both of these medication classes should not be combined with an MAOI as this further increases that risk1.     Symptoms of serotonin syndrome include: restlessness, hyperreflexia, gastrointestinal symptoms, dyspnea, seizures

The recommendation is to stay on an antidepressant for 9-12 months after remission of symptoms after the first episode of depression, 2 years if there is a history of previous episodes, and longer if there have been multiple episodes of depression.

i.       Always encourage patients to be forthcoming and transparent if they are considering medication discontinuation. Much better for us to help the patient discontinue safely as opposed to them stopping on their own accord and suffering a relapseii.      Always encourage gradual discontinuation (if patients prefer) during a time of stability for the patient

This objective is straightforward. When a patient needs to be off for work, it is important to consider what that time can be used for: titrating treatment strategies, finding a therapist/counsellor, referrals to additional resources, or setting up social support like childcare.

When discussing time off work, always ensure that a return date is planned where possible, even though this may change with time as you refine their treatment.

Occasionally we can support the patient in a graduated return to work plan (part time to start)

If an adolescent has been hospitalized or missed school because of depression, it can be important to counsel on how to re-integrate into school setting as there will likely be a lot of questions about where they were, which is anxiety provoking and may lead to avoidance altogether.

• DSM-5 for diagnostic criteria.
• Kennedy SH, Lam RW, Morris B [CANMAT depression work group]. Clinical guidelines for depressive disorders: Summary of recommendations relevant to family physicians. Canadian Family Physician. 2003 April; 49: 489-91. https://www.cfp.ca/content/cfp/49/4/489.full.pdf
• Kennedy SH et al [CANMAT depression work group]. Canadian Network for Mood and Anxiety Treatments (CANMAT) 2016 Clinical Guidelines for the Management of Adults with Major Depressive Disorder: Section 3. Pharmacological Treatments. The Canadian Journal of Psychiatry. 2016;1-21. https://www.cmh.org/sites/default/files/page-assets/programs-services/mental-health-services/mental-health-events-health-care-providers/canmat-pharmacological-39247.pdf
• www.bouneback.cmha.ca : self-referral program online with the help of an online health-coach. Patients who are accepted will be granted up to 6 telehealth sessions with a health-coach to work through a specific modules pertaining to their presenting complaint  (depression, anxiety etc).
• The brain of Dr Darby Ewashina