Depression and SuicideDepression and Suicide

Andrew MatrunolaAndrew MatrunolaST3 PsychiatryST3 Psychiatry

DepressionDepression Its been around a long time.Its been around a long time. Hippocrates: Hippocrates: Melancholia: Melancholia: a distinct a distinct

disease with particular mental and physical disease with particular mental and physical symptoms, broader than today’s concept of symptoms, broader than today’s concept of depression.depression.

Kraeplin (1921), a German Psychiatrist: Kraeplin (1921), a German Psychiatrist: ‘depressive states’ used term in context of ‘depressive states’ used term in context of ‘manic-depressive’ illness.‘manic-depressive’ illness.Freud (1917): ‘Freud (1917): ‘Mourning and Melancholia’ Mourning and Melancholia’ shifted focus of clinical descriptions from shifted focus of clinical descriptions from objective behavioural signs to subjective objective behavioural signs to subjective symptoms.symptoms.

DepressionDepression Depressive disorders are common, Depressive disorders are common,

prevalence 2-5% (5-10% primary care prevalence 2-5% (5-10% primary care settings). It affects around 121 million settings). It affects around 121 million people worldwide (WHO)people worldwide (WHO)

Associated with significant morbidity and Associated with significant morbidity and mortality. Recently the WHO have mortality. Recently the WHO have announced it is likely to be the single announced it is likely to be the single cause for burden of any disease by 2030 cause for burden of any disease by 2030 due to years lost of life or through severe due to years lost of life or through severe disability.disability.

More prevalent in developing countries More prevalent in developing countries

Sex ratio male: female 1:2Sex ratio male: female 1:2 Lifetime rates 10-20%Lifetime rates 10-20% Risk factors: genetic Risk factors: genetic personality traitspersonality traits Negative childhood experiences Negative childhood experiences Social circumstances (e.g. employment, Social circumstances (e.g. employment,

confiding relationship, adverse life events)confiding relationship, adverse life events) Physical illnessPhysical illness Aetiology: multifactorial!Aetiology: multifactorial!

Core SymptomsCore Symptoms Depressed moodDepressed mood AnhedoniaAnhedonia Weight changeWeight change Disturbed Sleep: insomnia (less commonly Disturbed Sleep: insomnia (less commonly

hypersomnia)hypersomnia) Psychomotor agitation/retardationPsychomotor agitation/retardation FatigueFatigue Reduced concentrationReduced concentration Reduced libidoReduced libido Feelings of worthlessness/guiltFeelings of worthlessness/guilt Thoughts of death/suicideThoughts of death/suicide

Present for at least two weeks and Present for at least two weeks and represent a change from normalrepresent a change from normal

Not secondary to the effects of Not secondary to the effects of drugs/alcohol misuse, medication, drugs/alcohol misuse, medication, medical disorder, bereavementmedical disorder, bereavement

May cause significant distress May cause significant distress and/or impairment of functioningand/or impairment of functioning

Biological/Somatic Biological/Somatic symptomssymptoms

Sleep disturbanceSleep disturbance Diurnal mood variationDiurnal mood variation AnhedoniaAnhedonia Early morning wakeningEarly morning wakening Psychomotor agitation or retardationPsychomotor agitation or retardation Loss of weight/appetiteLoss of weight/appetite Loss of libidoLoss of libido Constipation, amenorrhoeaConstipation, amenorrhoea

SubtypesSubtypes

MildMild ModerateModerate SevereSevere With psychotic symptoms: typically With psychotic symptoms: typically

mood-congruent delusions, mood-congruent delusions, hallucinationshallucinations

Nihilistic delusions e.g. Cotard’s Nihilistic delusions e.g. Cotard’s syndromesyndrome

Atypical depression: depression with increased Atypical depression: depression with increased sleep, appetite and phobic anxietysleep, appetite and phobic anxiety

Dysthymia: chronic long standing low mood not Dysthymia: chronic long standing low mood not meeting criteria for depressionmeeting criteria for depression

Seasonal affective Disorder (SAD)Seasonal affective Disorder (SAD)

Postnatal depressionPostnatal depression

HistoryHistory

Tell me how have you been feeling?Tell me how have you been feeling? Can you still enjoy the things you normally do?Can you still enjoy the things you normally do? How have you been sleeping recently?How have you been sleeping recently? Have you been waking earlier than usual in the Have you been waking earlier than usual in the

mornings?mornings? How’s your appetite been?How’s your appetite been? Do you find it difficult to concentrate on a Do you find it difficult to concentrate on a

book/TV programme?book/TV programme? Do you eve feel life’s not worth living?Do you eve feel life’s not worth living?

MSEMSE

Appearance and behaviourAppearance and behaviour SpeechSpeech MoodMood ThoughtsThoughts PerceptionsPerceptions CognitionCognition InsightInsight

SuicideSuicide

In the UK the third most important In the UK the third most important contributor to life years lost after contributor to life years lost after coronary heart disease and cancercoronary heart disease and cancer

Most common method among men is Most common method among men is hanginghanging

Amongst women the commonest Amongst women the commonest method is drug overdosemethod is drug overdose

Rates are higher in spring/summer vs. Rates are higher in spring/summer vs. autumn/winter autumn/winter

Risk factorsRisk factors

MaleMale Increasing ageIncreasing age Living aloneLiving alone UnemployedUnemployed Recent life crisisRecent life crisis Occupation (e.g. farmers, doctors)Occupation (e.g. farmers, doctors)

Risk factors 2Risk factors 2

Personality disorder esp. borderline Personality disorder esp. borderline typetype

Mood disorderMood disorder Alcohol or drug misuseAlcohol or drug misuse SchizophreniaSchizophrenia Past history of deliberate self harmPast history of deliberate self harm Physical ill-health esp. epilepsyPhysical ill-health esp. epilepsy

Mental State FactorsMental State Factors

Depressed moodDepressed mood Expressed wish to dieExpressed wish to die Detailed suicide plansDetailed suicide plans Hopelessness and helplessnessHopelessness and helplessness Lack of reasons to go on livingLack of reasons to go on living

Assessment following Assessment following self harmself harm

Important predictors:Important predictors: Planned attemptPlanned attempt Personal affairs put in order beforehandPersonal affairs put in order beforehand Attempted to avoid discoveryAttempted to avoid discovery Did not seek help afterwardsDid not seek help afterwards Used a method the patient considered Used a method the patient considered

dangerousdangerous Left a suicide noteLeft a suicide note

Deliberate self HarmDeliberate self Harm

Intentional self harm that does not lead to Intentional self harm that does not lead to death and may or may not have been death and may or may not have been motivated by a desire to die.motivated by a desire to die.

Self poisoning, most commonly Self poisoning, most commonly paracetamol and aspirinparacetamol and aspirin

Self injury: most commonly lacerations to Self injury: most commonly lacerations to forearms and wrists.forearms and wrists.

Increased risk of suicide! (100 x greater Increased risk of suicide! (100 x greater than general population in next 12 months than general population in next 12 months and remains high thereafter)and remains high thereafter)

Assessing suicide riskAssessing suicide risk

Have you had thoughts of wanting to Have you had thoughts of wanting to end your life?end your life?

Have you thought about how you Have you thought about how you would do it?would do it?

Have you made any preparations?Have you made any preparations? Have you tried to take your own life Have you tried to take your own life

in the past?in the past?

Treatment of depressionTreatment of depression

Mild depression: watchful waiting, Mild depression: watchful waiting, problem solving, exerciseproblem solving, exercise

Mild/Moderate depression: consider Mild/Moderate depression: consider CBTCBT

Moderate depression: Moderate depression: antidepressants, SSRI generally first antidepressants, SSRI generally first lineline

AntidepressantsAntidepressants Selective serotonin reuptake inhibitors: Selective serotonin reuptake inhibitors:

SSRIsSSRIs 1st line: citalopram, sertraline, fluoxetine, 1st line: citalopram, sertraline, fluoxetine,

paroxetineparoxetine Max effect 4-6 weeksMax effect 4-6 weeks Side effects: commonest GI side effects, Side effects: commonest GI side effects,

headaches, insomniaheadaches, insomnia Fewer anticholinergic side effects, less Fewer anticholinergic side effects, less

cardiotoxic so safer in overdose.cardiotoxic so safer in overdose. Withdrawl effects; worse if stopped suddenly: Withdrawl effects; worse if stopped suddenly:

nausea, dizziness, agitation, insomnianausea, dizziness, agitation, insomnia

Tricyclic AntidepressantsTricyclic Antidepressants

Older: Imipramine, amitriptyline, Older: Imipramine, amitriptyline, ClomipramineClomipramine

Uptake inhibition of Noradrenaline and Uptake inhibition of Noradrenaline and serotoninserotonin

Side effects:Side effects:

weight gain, sedationweight gain, sedation

Anticholinergic effects: dry mouth, Anticholinergic effects: dry mouth, blurred vision, constipation etcblurred vision, constipation etc

Toxicity in overdoseToxicity in overdose

MAOIsMAOIs

Monoamine oxidase inhibitorsMonoamine oxidase inhibitors Isocarboxazid, PhenelzineIsocarboxazid, Phenelzine ““Cheese reaction”: tyramine rich Cheese reaction”: tyramine rich

food can cause a hypertensive crisis: food can cause a hypertensive crisis: need to avoid foods rich in tyramine need to avoid foods rich in tyramine e.g. cheese, red wine, liver, yeast e.g. cheese, red wine, liver, yeast products.products.

RIMA: moclobemideRIMA: moclobemide

Serotonin SyndromeSerotonin Syndrome

Due to excess serotoninDue to excess serotonin Can be due to SSRIs and other antidepressantsCan be due to SSRIs and other antidepressants Causes: overdose, drug Causes: overdose, drug

combinations/interactions, sometimes at combinations/interactions, sometimes at normal dosesnormal doses

Can be fatalCan be fatal Symptoms: Neurological (confusion, agitation, Symptoms: Neurological (confusion, agitation,

coma), Neuromuscular (rigidity, tremors, coma), Neuromuscular (rigidity, tremors, myoclonus, hyperreflexia), Autonomic myoclonus, hyperreflexia), Autonomic (hyperthermia, tachycardia, (hyperthermia, tachycardia, hyper/hypotension, GI upset)hyper/hypotension, GI upset)

ECTECT

A life saving treatment!A life saving treatment! Highly effective in treatment of depressionHighly effective in treatment of depression 6-12 treatments6-12 treatments Indications: severe depression; failure of drug Indications: severe depression; failure of drug

treatments, failure to eat and drink n treatments, failure to eat and drink n depressive stupor, previous good response to depressive stupor, previous good response to ECT, patient choice.ECT, patient choice.

Side effects: memory loss (usually resolves), Side effects: memory loss (usually resolves), headache, temporary confusion, nausea, headache, temporary confusion, nausea, vomiting vomiting

Requires general anaestheticRequires general anaesthetic

Any Questions?Any Questions?