PSYCHIATRIC DISORDERS

Unipolar depressive Key points

disorders C Depression is frequently undiagnosed and undertreated;
consider depression in hight-risk groups, including those with
Catherine Symonds a chronic physical illness
Ian M Anderson
C Assessment must include determination of suicide risk, any
history of elevated mood and current alcohol or substance
Abstract misuse
Depression is a common relapsing mood disorder that causes signif-
icant distress and impairment in social and occupational functioning.
C Psychosocial approaches should be used first in patients with
It is associated with an increased risk of death, not only through sui- mild depression
cide, but also from physical illnesses such as cardiovascular disease.
It is under-recognized and undertreated and should be considered in
C Specific psychological treatments (e.g. cognitive behaviour
individuals at high risk of depression, for example those suffering therapy) and antidepressants are alternatives for moderate
from chronic physical health problems. Its aetiology is multifactorial, and more severe depression
and co-morbidity with other psychiatric disorders is common.
Assessment of depression requires an assessment of the duration,
C Selective serotonin reuptake inhibitors are first-line
symptom severity, suicide risk and functional impairment of the cur- antidepressants
rent episode, co-morbid diagnoses, past mood and treatment his-
tory, and developmental, social and family history. Treatment is
C Over-the-counter complementary and herbal treatments (e.g.
guided by illness severity, presentation and prior history. It includes St John’s wort) are commonly used and can interact with pre-
scribed medication
psychosocial interventions, medications and their combination,
with antidepressant medication reserved for persistent and moderate
C Treated patients should be assessed regularly for symptom
to severe depression. Prevention of relapse is a priority; risk factors
severity, suicidality and adverse effects, at least every 2 weeks
for this should be assessed and used to guide the choice of prophy-
initially but more often in those with higher suicide risk
lactic drug and psychological treatment.
Keywords Aetiology; antidepressants; assessment; cognitive C Antidepressant drug treatment trials should usually last 6e8
behaviour therapy; diagnosis; dysthymia; major depression; psycho-
weeks before deciding insufficient efficacy, although a dose
therapy; selective serotonin reuptake inhibitors (SSRIs); treatment
increase or change of treatment is indicated if there is no
improvement after 4 weeks

C Use a symptom rating scale such as the Patient Health

How common? Questionnaire-9 or Hospital Anxiety and Depression Scale to
aid assessment of severity and monitor treatment progress
‘Clinical’ depression (major depression in the 5th edition of the
Diagnostic and Statistical Manual of Mental Disorders (DSM-5); C Combined drug and psychosocial treatment should be used in
Table 1) has a point prevalence of 4.4%, with chronic sub-
patients not responding to either alone
threshold depression (dysthymia) adding an additional 2%. 1,2
Unipolar depressive disorders rank ninth in the world, and C Combination drug treatments are useful when there has been
third in Europe, among causes of health-related disability,
partial response to the first drug or a failure to respond to a
making up 2.8% and 3.8%, respectively, of the total disease
number of trials
burden.
C Relapse prevention is a priority following successful treatment
including continuing antidepressant drugs for at least 6e9
months at the full treatment dosage

Catherine Symonds MRCP (UK) is an NIHR Clinical Lecturer in C Patients at risk of recurrent episodes should be offered pro-
Psychiatry and ST6 in Old Age Psychiatry at the Neuroscience and
phylactic (maintenance) medication or psychological treatment
Psychiatry Unit, Manchester University, Manchester, UK. Competing
interests: none declared. to prevent recurrence

Ian M Anderson MD MRCP (UK) FRCPsych is Professor of Psychiatry at the

University of Manchester, Neuroscience and Psychiatry Unit,
Manchester University, UK. Competing interests: Professor
Anderson has been a consultant to, or received grants, honoraria for Definition
speaking and/or support for conference attendance from, Alkermes,
Depression is a heterogenous syndrome consisting of core
Servier, Lundbeck, Janssen-Cilag, Otsuka Pharmaceutical and
Takeda Pharmaceutical. symptoms of pervasive low mood and/or lack of enjoyment

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 PSYCHIATRIC DISORDERS

(anhedonia) together with other emotional, cognitive and phys- factors interacts with environmental precipitating and main-
ical symptoms resulting in significant functional impairment taining factors. ‘Secondary’ depression (symptomatically
(Table 1). Unipolar depression (considered here) occurs in the arising directly from a physical illness or treatment) can be
absence of a history of mood elevation (see Bipolar disorder, pp difficult to separate from depression triggered by the physical
661e663 of this issue); however, the boundary between unipolar condition.
depression and bipolar disorder is blurred and controversial. Vulnerability to depression is hereditable, involving multiple
genes interacting with developmental and environmental fac-
Epidemiology tors.5 The monoamine theory postulates a functional decrease in
serotonin (5-hydroxytryptamine) and/or noradrenaline (norepi-
Onset is usually in the mid-20s but can occur at any time. The point
nephrine) neurotransmission leading to depression, which can
prevalence of major depression rises steeply during adolescence,
be reversed by antidepressant drug treatment. However, many
peaks at about 7.5% in the 40s with a slight decline into old age.1 It
other neurochemical and neuroendocrine systems are impli-
is nearly twice as common in women than men across the age
cated, including the hypothalamicepituitaryeadrenal axis and
range, with higher rates associated with social disadvantage. 3
proinflammatory cytokines, as well as altered neurogenesis and
Depression is commonly associated with other psychiatric disor-
synaptic plasticity. Reductions in grey matter volume, most
ders, especially anxiety and substance-use disorders, and chronic
consistently in the hippocampus, may reverse with recovery, but
physical illness;2,4 for example, the incidence is increased two- to
persistence has been reported in long-standing, recurrent
threefold in diabetes mellitus, coronary artery disease, end-stage
depression. Functionally, there is altered processing of emotion-
renal failure and chronic obstructive pulmonary disease.
related stimuli and of the activity and connectivity of mood-
related brain areas such as the amygdala and anterior cingulate
Pathology and pathogenesis
cortex.5 Vulnerability is strongly associated with childhood
In the ‘biopsychosocial’ model of depression, developmental neglect or sexual abuse, personality factors (neuroticism),
vulnerability caused by biological, psychological and social chronic social difficulties and isolation. Adverse life events

Abridged criteria for major depression and persistent depression/dysthymia

DSM-5 (American Psychiatric Association)
Major depressive disorder
Over the previous 2 weeks, five or more of the following have been present most of the time (must include at least one of the first two ‘core’
symptoms):
C depressed mood most of the day (e.g. sad, empty, hopeless)

C loss of interest or pleasure in almost all activities nearly every day

C significant appetite/weight loss or gain

C insomnia or hypersomnia

C psychomotor agitation or retardation (observable by others)

C fatigue or loss of energy

C feelings of worthlessness or excessive guilt

C diminished concentration or indecisiveness

C recurrent thoughts of death, or suicidal thoughts, plans or attempts

The symptoms cause clinically significant distress or impairment in functioning, and are not caused by a medical/organic factor or illness.
Severity: mild (few symptoms beyond minimum, mild functional impairment), moderate (symptoms and functional impairment between mild and
severe), severe (most symptoms present, marked or greater functional impairment).
Classified as single episode or recurrent (at least one previous episode).
Persistent depressive disorder (includes dysthymia)
Depressed mood for most of the day, for more days than not, for at least 2 years, together with two or more of:
C poor appetite or overeating

C insomnia or hypersomnia

C low energy or fatigue

C low self-esteem

C impaired concentration or indecisiveness

C hopelessness

Must not have been symptom free longer than 2 months.

Note: the requirement not to meet criteria for major depression, found in previous editions, has been removed.
ICD-10 (World Health Organization)
Depressive episode e broadly similar to DSM-5, but two out of three ‘typical’ symptoms (depressed mood, decreased interest/enjoyment,
fatiguability) are needed, and mild depression requires four, rather than five, symptoms.
Dysthymia e similar to DSM-5 persistent depressive disorder except must not meet the criteria for a depressive episode.

Table 1

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 PSYCHIATRIC DISORDERS

commonly trigger depression and add to continuing social Important symptom patterns are as follows:
adversity. Psychological factors include low self-esteem and a ● Melancholic depression is often seen in elderly or more
bias to appraise things negatively and ruminate, reinforced by severely ill patients. Low mood is experienced as distinct
withdrawal from pleasurable activities. 3 from sadness, worse in the morning and unreactive to
positive events; there is appetite and weight loss, reduced
Diagnosis sleep with early morning waking and inability to get back
to sleep, and marked physical slowness (or agitation).
The two international diagnostic systems, DSM-5 and the Inter-
● Atypical pattern depression shows temporary mood
national Classification of Diseases 10th revision (ICD-10), are
improvement to positive events, lack of melancholic fea-
broadly similar (Table 1), with the former (in its preceding
tures with increased appetite (often for carbohydrates),
version, DSM-IV) preferred in the 2009 National Institute for
weight gain and hypersomnia.
Health and Care (previously Clinical) Excellence (NICE) clinical
● Depression with psychotic symptoms (commonly mood-
practice guidelines. 3 Depressive symptoms occur on a continuum
congruent, such as derogatory auditory hallucinations
of severity and duration, making threshold cases common. Major
and/or delusions of poverty) is usually associated with
depression occurs at a threshold of severity and impairment at
severe and melancholic depression.
which specific clinical treatment is indicated; persistent depres-
● Persistent (chronic) depression, with continuing symptoms
sion, even when milder (dysthymia) is also disabling and bene-
for at least 2 years, with a low likelihood of spontaneous,
fits from treatment.
sustained, improvement. Patients with dysthymia may have
Screening questions/questionnaires such as the two ‘Whoo-
had life-long low mood, commonly with superimposed
ley’ questions and Patient Health Questionnaire-2 (PHQ-2; Table
episodes of major depression (‘double depression’).
2) tend to be sensitive but not specific, making them useful as a
Depression can also be classified by whether it is seasonal
first-stage screening for identifying a low likelihood of depression
(usually winter and associated with an atypical pattern) or occurs
in those at high risk; false-positive results are, however,
after childbirth (postnatal depression). The presence of significant
common.
coexisting anxiety symptoms, or disorder, is associated with
Diagnosis requires clinical assessment. Systematic enquiry
poorer response to treatment and can warrant treatment in its own
should be made to identify depressive symptoms, their severity
right. In the elderly, agitation and complaints about physical (so-
and duration, potential psychiatric and physical co-morbidities
matic) symptoms often predominate, and reversible cognitive
(Table 3), current medication and suicide risk. History of past
impairment (depressive pseudodementia) may be seen. In chil-
episodes should include mania/hypomania, triggering factors,
dren and adolescents, irritability or withdrawal, behavioural
severity, including psychosis, suicidality, treatment and
problems and poor school performance can be prominent.
response. Also review the family psychiatric history, personal
development and social history, especially of trauma, social
Investigations
adjustment and relationships, significant and precipitating life
events and continuing social difficulties. In the mental state ex- There is no specific diagnostic test for depression, and in-
amination, note apparent mood and reactivity, speech rate and vestigations are directed at the exclusion of possible physical
motor activity, agitation, hopelessness and psychotic signs and causes (Table 3) or factors that might worsen depression or affect
symptoms. Differential or co-morbid diagnoses (Table 3) should treatment. Routine screening usually includes haematology,
be explored by relevant cognitive and physical examination, biochemistry including thyroid and liver function tests, and in
guided by history and presentation. some cases a chest X-ray and electrocardiogram.

Two commonly used brief tests for depression

Two-question test for depression (Whooley questions)
1. During the last month, have you often been bothered by feeling down, depressed or hopeless?
2. During the last month, have you often been bothered by little interest or pleasure in doing things?
Yes to at least one question has 95% sensitivity at picking up depression but only 65% specificity (pooled analysis of 10 studies, with low
heterogeneity between studies).
PHQ-2
Over the past 2 weeks, how often have you Not at all Several days More than half the days Nearly every day
been bothered by any of the following
problems?

1. Little interest or pleasure in doing things 0 1 2 3

2. Feeling down, depressed or hopeless 0 1 2 3

A score of 2 or more has 89% sensitivity at picking up depression and 76% specificity (pooled analysis of nine primary care studies, with high heterogeneity between
studies).

Table 2

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 PSYCHIATRIC DISORDERS

Differential diagnosis
C Bipolar disorder e bipolar and unipolar depressive episodes cannot be distinguished clinically, and the diagnosis is made on a history of hy-
pomania or mania. There is controversy about the degree of overlap between unipolar depression and milder forms of bipolar disorder
C Psychiatric disorders that can share features of depression but where depression is also frequently present as a co-morbid diagnosis. A careful

symptomatic and chronological history may be needed to identify the primary or pre-existing disorder. Examples include:
○ Anxiety disorders, post-traumatic stress disorder and obsessiveecompulsive disorder: decreased enjoyment, sleep disturbance and social
withdrawal are common
○ Eating disorders: appetite disturbance and social withdrawal are seen.
○ Alcohol and other drug use disorders: persistent dysphoria and sleep disturbance occur
○ Personality disorder: dysphoria and mood disturbance are common
○ Schizophrenia: prodromal symptoms can resemble depression, and negative symptoms including apathy can mimic depression. The course of
illness, presence of mood-incongruent psychotic symptoms and thought disorder strongly suggest non-affective cause of the symptoms
○ Dementia: loss of interest and affect that can be mistaken for depression. But note that depression is common in the early stages of dementia
and, conversely, depression in the elderly can present with cognitive impairment (‘pseudodementia’)
C Chronic fatigue syndrome e persistent fatigue, somatic symptoms and mood disturbance can be mistaken for depression, but co-morbid

depression also occurs commonly

C Chronic pain syndromes e the coexistence of pain and mood symptoms is common in depression, but co-morbid depression is also common

with chronic pain

C Medical causes of depression, including:

○ Endocrine disturbance, e.g. hypothyroidism, Cushing’s disease, Addison’s disease, hypo- and hypercalcaemia
○ Nutritional deficiency, e.g. low body weight of any cause, deficiencies of iron and vitamin B 12, D, thiamine or niacin
○ Neurological causes, e.g. normal-pressure hydrocephalus, multiple sclerosis, cerebrovascular disease
○ Medication, e.g. b-adrenoceptor blockers, g-interferon

Table 3

Management coordination of multidisciplinary input and long-term follow-

up.4
Most cases of depression can be managed in primary and general
Monitoring of treatment response is aided by symptom rating
medical care. Criteria for referral to psychiatric services are given
scales and recommended by NICE. 3 Longer-term management
in Table 4. NICE recommends a ‘stepped care’ approach to match
involves strategies to maximize improvement, maintain remis-
the presentation with the appropriate treatment (Figure 1).3 Pa-
sion and prevent relapse.2,3
tients with mild, recent-onset depression may improve after
discussion of their concerns, provision of information and
Psychosocial and psychological treatments: Table 5 lists
scheduled follow-up (active monitoring). Lifestyle (e.g. alcohol,
evidence-based psychological treatments. These are first-line
physical exercise) and sleep hygiene advice should be given.
treatments for mild and moderately severe depression
Psychosocial treatment, antidepressant medication or both is the
(Figure 1)2,3 and should be combined with antidepressants if
mainstay of treatment. The use of medication should be based on
there is poor response, or from the start for more severe
the balance of risks (higher in the physically ill) and benefits
depression. Commonly used non-directive counselling lacks
(lower efficacy in milder severity).
good evidence of efficacy. Psychological therapy is first-line for
Poor or incomplete response to initial treatment occurs in 30
children and adolescents, and prescribing antidepressants for this
e50% of patients, approaching 90% after three or four trials.
group should only be undertaken by a specialist.
Next-step treatment approaches are to increase the dosage,
switch therapy, combine medication with psychological treat-
Medication: selective serotonin reuptake inhibitors (SSRIs) are
ment and incorporate electroconvulsive therapy (ECT).2,3
first-line treatment, based on efficacy and tolerability; sertraline
Moderate and severe depression with chronic physical illness
and escitalopram have a slight efficacy advantage and are the
not responding to treatment warrants collaborative care with

Referral to specialist services

Refer to specialist care if:
C There is significant risk of harm to self or others

C There has been failure to respond to treatment, usually with at least two antidepressants and psychological treatment in primary care

C There is the possibility of bipolar disorder

C There are complex problems or significant co-morbidity (e.g. psychosis, psychiatric co-morbidity, severe psychosocial difficulties)

Table 4

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 PSYCHIATRIC DISORDERS

NICE stepped care model

Focus of the intervention Nature of the intervention

STEP 4: Severe and complex Medication, high-intensity

depression; risk to life; severe psychological interventions,
self neglect electroconvulsive therapy, crisis
service, combined treatments,
multiprofessional and inpatient
care

STEP 3: Persistent subthreshold Medication, high-intensity

depressive symptoms or mild to psychological interventions,
moderate depression with combined treatments, collaborative
inadequate response to initial care and referral for further
interventions; moderate and assessment and interventions
severe depression

STEP 2: Persistent subthreshold Low-intensity psychosocial

depressive symptoms; mild to interventions, psychological
moderate depression interventions, medication and
referral for further assessment
and interventions

STEP 1: All known and suspected Assessment, support, psychoeducation,

presentations of depression active monitoring and referral for further
assessment and interventions

a
Complex refers to inadequate response to multiple treatments/with psychosis/significant
comorbidity or psychosocial factors
b
For depression complicating a chronic physical illness (see text)
National Institute for Health and Clinical Excellence (2009) CG90 Depression: treatment and
management of depression in adults, including adults with a chronic physical health. problem. London: NICE.
Available from www.nice.org.uk/guidance/CG90 Reproduced with permission.

Figure 1

least likely SSRIs, along with citalopram, to cause drugedrug maximum 200 mg), citalopram 20 mg (increasing to 40 mg) or
interactions.2 However, citalopram and its active enantiomer, escitalopram 10 mg (increasing to 20 mg). Fluoxetine’s long
escitalopram, can increase the QT c interval, leading to cautions half-life (1 week) after chronic use minimizes discontinuation
or contraindications (see Pharmacological management of symptoms (see Pharmacological management of depressive
depressive disorders in Psychiatry II, Medicine 2016, December), disorders in Psychiatry II, Medicine 2016, December) but can
especially in the elderly. First-choice SSRIs are sertraline 50 mg complicate drugedrug interactions. Paroxetine is a reserved
once daily (increasing to 100 mg if response is inadequate, to a choice given its drugedrug interaction potential and association

Psychological treatments
Low-intensity (subthreshold and mild depression)
C Guided self-help based on CBT principles

C Computerized CBT

C Structured group physical exercise.

High-intensity (persistent milder depression, moderate to severe depression)

Individual therapy
C CBT (addressing negative thoughts and associated behavioural patterns)

C Behavioural activation (addressing unrewarding behavioural patterns and withdrawal)

C Interpersonal psychotherapy (addressing relationship and role difficulties)

Group therapy
C Individual therapies delivered in a group setting

C Couples therapy (focussing on partner interactions and conflicts)

C Mindfulness-based cognitive therapy for relapse prevention (includes meditation techniques, bodily awareness and self-acceptance)

CBT, cognitive behavioural therapy.

Table 5

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 PSYCHIATRIC DISORDERS

with greater adverse effects, effect on sexual function and weight gain. Combining antidepressants (especially mirtazapine
discontinuation symptoms. Next-step drug treatment options with an SSRI) can also be effective.
after insufficient response include dosage increase, and All patients treated with antidepressants require 6e9 months
switching to another SSRI, or to a serotoninenoradrenaline of continuation treatment following symptom resolution to pre-
reuptake inhibitor or other antidepressant (Table 6). Tricyclic vent early relapse. Longer, sometimes indefinite, treatment is
antidepressants are third line because of their lower tolerability required if there is a high risk of relapse (e.g. persisting symp-
and toxicity in overdose, apart from lofepramine, which is safer toms, severe or recurrent depression, co-morbidity, family his-
in overdose. Irreversible inhibitors of monoamine oxidase are tory of depression, persistence of social adversity). 2
specialist drugs, but moclobemide, a reversible inhibitor of In the elderly, the principle of ‘start low, go slow’ applies.
monoamine oxidase A, is well tolerated and safer, although Polypharmacy and physical co-morbidity should be taken into
rarely used. account when prescribing antidepressants, and elderly people are
Lithium, the longest established augmenter of antidepres- more prone to adverse effects than working-age adults. In
sants, requires regular monitoring of serum concentration particular, syndrome of inappropriate antidiuretic hormone
because of its low therapeutic index and narrow target range. secretion secondary to antidepressants, especially SSRIs, is more
Augmentation of SSRIs with second-generation antipsychotics, common, as is a prolonged QT c interval and anticholinergic
especially quetiapine (see Pharmacological management of adverse effects from tricyclic agents. Co-prescribing antidepres-
depressive disorders in Psychiatry II, Medicine 2016, December), sants that inhibit serotonin uptake (e.g. SSRIs, venlafaxine) with
has good evidence for efficacy, but at the cost of sedation and antiplatelet agents and anticoagulants can lead to gastrointestinal
bleeding, so gastroprotection should be considered. 2
The use of antidepressants in children and adolescents is
Drug treatments controversial because of lower efficacy (fluoxetine has the best
evidence) and an increased risk of self-harm behaviour, making
Antidepressants them second-line agents after psychological treatment. They
C SSRIs require specialist prescription and a careful balance of risks and
○ Sertraline, citalopram, escitalopram (first-line; see text) potential benefits.
○ Fluoxetine, fluvoxamine, paroxetine Specialist advice should be sought when prescribing in preg-
C Other newer antidepressants (usually second- or third-line) nancy, and pre-conception counselling is advised. Fluoxetine and
○ Venlafaxine, duloxetine (serotonin and noradrenaline reuptake tricyclic antidepressants appear relatively safe if an antidepres-
inhibitors) sant is indicated, and sertraline is safe in breast-feeding. Parox-
○ Reboxetine (noradrenaline reuptake inhibitor) but efficacy etine appears associated with cardiac malformations and is not
questioned recommended.
○ Mirtazapine (serotonin and noradrenaline receptor antagonist)
○ Bupropion (noradrenalineedopamine reuptake inhibitor) Other treatments: ECT is an extremely effective acute antide-
○ Agomelatine (melatonin agonist and serotonin receptor pressant but, given concerns about its cognitive adverse effects,
antagonist)
is mostly used for severe depression when a rapid effect is
○ Vortioxetine (serotonin reuptake inhibitor and receptor needed or there is lack of response to other treatments. 2,3 It is
antagonist)
administered in specialist centres under general anaesthetic and
C Older receptor antagonists (now rarely used) is safe in pregnancy. Other experimental brain stimulation
○ Mianserin, trazodone (serotonin and noradrenaline receptor techniques are not widely available clinically.
antagonists) Intravenous ketamine (a glutamate antagonist) has been
C
Tricyclic antidepressants (non-selective noradrenaline T seroto- shown experimentally to be rapidly effective (an unlicensed use),
nin reuptake inhibitors) but its place in treatment has yet to be established because of
○ Lofepramine (newer and safer in overdose) concerns about adverse effects, abuse risk, magnitude and
○ Amitriptyline, clomipramine, imipramine (third-line and duration of effect in clinical practice, as well as practicalities of
decreasing in use) administration. Other drugs with glutamatergic effects are under
C Monoamine oxidase inhibitors clinical development.
○ Phenelzine, tranylcypromine (irreversible, specialist use only)
○ Moclobemide (reversible inhibitor of monoamine oxidase A)
Prognosis and explanation to the patient
Drugs used to augment antidepressants (usually specialist-initiated)
C Second-generation (atypical) antipsychotics Outcome varies by setting and severity. The median episode
○ Quetiapine, aripiprazole, risperidone, olanzapine duration is 4e12 months, with 10% of patients having an unre-
C Addition of a second antidepressant (especially mirtazapine to an mitting course and many others experiencing fluctuating symp-
SSRI) tom levels. At least 50% of people experience a subsequent
C Lithium (requires monitoring, specialist initiation only)
relapse, increasing to 90% after the third episode, with a median
C Tri-iodothyronine (rarely used, poor evidence-base, specialist use
of four lifetime episodes. 2,3 Poorer outcome is associated with
only) earlier age of onset, increased episode number, duration, severity
SSRI, selective serotonin reuptake inhibitor.
and treatment resistance, psychosis, cognitive impairment, phys-
ical and psychiatric co-morbidity and continuing social adversity.
Table 6 Around 10% of patients, especially after early onset, are

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 PSYCHIATRIC DISORDERS

subsequently found to have bipolar disorder. 2,3 Eventual death 4 National Institute for Health and Clinical Excellence. Clinical Guide-
through suicide is increased fourfold, to 2%, in community line 91. Depression in adults with a chronic health problem: full
samples, rising to 9% in the most severely ill. 2 Depression in- guideline. 2009, https://www.nice.org.uk/guidance/cg91/evidence/
creases the morbidity and mortality in a range of physical ill- full-guideline-243876061 (A shorter NICE guideline is available at:
nesses, including a threefold increase in risk of dementia in those https://www.nice.org.uk/guidance/CG91.) (accessed 28 Apr 2016).
whose first episode of depression occurs >65 years of age.4 A 5 Fakhoury M. New insights into the neurobiological mechanisms of
major depressive disorders. Gen Hosp Psychiatry 2015; 37: 172e7.

KEY REFERENCES FURTHER READING

1 Baxter AJ, Scott KM, Ferrari AJ, Norman RE, Vos T, Whiteford HA. Anderson IM. Pharmacological treatment of unipolar depression. Curr
Challenging the myth of an “epidemic” of common mental disor- Top Behav Neurosci 2013; 14: 263e89.
ders: trends in the global prevalence of anxiety and depression Bosanquet K, Bailey D, Gilbody SH, et al. Diagnostic accuracy of the
between 1990 and 2010. Depress Anxiety 2014; 31: 506e16. Whooley questions for the identification of depression: a diagnostic
2 Cleare A, Pariante CM, Young AH, et al. Evidence-based guidelines meta-analysis. BMJ Open 2015; 5: e008913.
for treating depressive disorders with antidepressants: a revision of Kroenke K, Spitzer RL, Williams JB. The PHQ-9: validity of a brief
the 2008 British Association for Psychopharmacology guidelines. depression severity measure. J Gen Intern Med 2001; 16: 606e13.
J Psychopharmacol 2015; 29: 459e525. Mitchell AJ, Yadegarfar M, Gill J, Stubbs B. Case finding and
3 National Institute for Health and Clinical Excellence. Clinical screening clinical utility of the Patient Health Questionnaire (PHQ-9
Guideline 90. Depression in adults (update): full guideline. 2009, and PHQ-2) for depression in primary care: a diagnostic meta-
https://www.nice.org.uk/guidance/cg90/evidence/full-guidance- analysis of 40 studies. Br J Psych Open 2016; 2: 127e38.
243833293 (A shorter NICE guideline is available at: https://www. Snaith RP, Zigmond AS. The hospital anxiety and depression scale. Br
nice.org.uk/guidance/CG90.) (accessed 28 Apr 2016). Med J 1986; 292: 344.

TEST YOURSELF
To test your knowledge based on the article you have just read, please complete the questions below. The answers can be found at the
end of this issue or online here.

Question 1 Which one of the following would be the best initial psycho-
logical therapy at this time?
A 67-year-old man was brought by his wife to see his general
A Cognitive behavioural therapy (addressing negative
practitioner. She was concerned about his symptoms of tired-
thoughts and associated behavioural patterns)
ness, poor sleep and loss of interest in his usual activities. He had
B Behavioural activation (addressing unrewarding behav-
recently been diagnosed with prostate cancer and was facing
ioural patterns and withdrawal)
further treatment for this. He was an accountant who had
C Interpersonal psychotherapy (addressing relationship and
continued to work after this retirement date, because he enjoyed
role difficulties)
it and not because it was financially necessary. He was now
D An individual therapy delivered in a group setting
finding this more difficult. He had never smoked, drank about 3
E Guided self-help based on cognitive behavioural therapy
units of alcohol per week, and had no previous history of mental
principles
illness.
Question 3
Which of the following factors in this presentation is associ-
A 45-year-old woman presented to her general practitioner with
ated with an increased risk of a depressive illness?
early morning waking and inability to get to sleep again. She was
A Male sex
finding it increasingly difficult to go to work each day, and some
B Age over 65 years
days had called in sick. She found that she was no longer able to
C A high-level, responsible job
enjoy things she previously found pleasurable, and this had
D Intercurrent illness
caused marital disharmony. She had started cognitive behav-
E Alcohol consumption
ioural therapy but remained symptomatic.
Question 2
Which of the following is the most appropriate medication for
A 35-year-old woman consulted her general practitioner as she her at this time?
was feeling ‘fed up’. She was sleeping poorly but had difficulty A Venlafaxine
getting up in the mornings. She was managing to look after the B Sertraline
house and her two children, aged 7 and 5 years, but was finding C Phenelzine
it a strain, as was her part-time job. She was able to enjoy herself D Amitriptyline
on occasions that she could get out with friends. E Vortioxetine

MEDICINE 44:11 660 © 2016 Elsevier Ltd. All rights reserved.