Depression / Suicide

Depression

1. In a patient with a diagnosis of depression:

   1. Assess the patient for the risk of suicide.

   2. Decide on appropriate management (i.e., hospitalization or close follow-up, which will depend, for example, on severity of symptoms, psychotic features, and suicide risk)

2. Identify patients who may be at a higher risk for depression (e.g., certain socio-economic groups, those who suffer from substance abuse, postpartum women, people with chronic pain) and assess appropriately.

3. In patients who have medically unexplained symptoms consider and assess for depression.

4. After a diagnosis of depression is made look for and diagnose other comorbid psychiatric conditions (e.g., anxiety, bipolar disorder, personality disorder).

5. In a patient diagnosed with depression:

• • Manage appropriately (e.g., medications, psychotherapy, supported self-management)

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

  • Reassess the patient’s safety

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

  • Refer as necessary (including community resources)

6. In a patient presenting with symptoms consistent with depression consider and rule out serious organic pathology using a targeted history, physical examination, and investigations (especially in elderly or difficult patients).

7. In patients presenting with depression inquire about abuse:

• • Sexual, physical, and emotional abuse (past and current, witnessed or inflicted)

  • Addictions (e.g., substance use/abuse, gambling)

8. In a patient with symptoms of depression differentiate major depression from adjustment disorder, dysthymia, and a grief reaction.

9. Following failure of an appropriate treatment in a patient with depression consider other diagnoses (e.g., bipolar disorder, schizoaffective disorder, organic disease).

10. In very young and elderly patients presenting with changes in behaviour consider the diagnosis of depression (as they may not present with classic features).

11. When treating a patient with antidepressants use them in a selective and careful manner, adapted to the presentation and the needs of the individual patient, by:

• • Selecting the most appropriate antidepressant and dose for the patient based on patient factors and on pharmacological factors (e.g., possible drug interactions)

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

  • Considering augmentation strategies when appropriate

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

  • Discontinuing medication gradually, monitoring for relapse, recognizing risk, and following response

12. When developing a return-to-work plan for a patient who is being treated for depression:

• • Assess the impact of residual symptoms on work hardiness, performance, and safety

  • Communicate with the patient and the workplace to ensure the plan is realistic and provides clear guidance

Suicide

1. Actively inquire about suicidal and homicidal ideation (e.g., ideas, thoughts, a specific plan), particularly when caring for patients with chronic illness, mental illness, or substance use problems; recent loss or emotional distress; impulsivity; or repeated suicidal ideation or attempts.

2. Given a suicidal patient, assess the degree of risk (e.g., thoughts, specific plans, access to means, impulsivity) to determine an appropriate intervention and follow-up plan.

3. In patients who present with self-injury (e.g., cutting):

   • Assess the risk of suicide, but do not assume that this is a suicidal gesture (not all people who cut are suicidal, but some are)

   • Explore the underlying emotional distress

   • Discuss alternative adaptive coping strategies

4. In patients at low risk of suicide whom you are managing in the community:

   • Provide specific instructions for follow-up

   • Develop an appropriate contingency plan with the patient should their suicidal ideation progress/worsen

5. When assessing and managing a patient at risk of harm to themselves or others that has been reported by proxy, balance the patient’s and the informant’s rights to confidentiality with the risk of harm to the patient, the informant, or others.

6. In suicidal patients presenting at the emergency department with a suspected drug overdose always screen for acetylsalicylic acid and acetaminophen overdoses as these are common, dangerous, and frequently overlooked.

7. In trauma patients consider attempted suicide as the precipitating cause.

General Overview

Screening

• During the last month, have you often been bothered by feeling down, depressed or hopeless? Or by having little interest/pleasure in doing things?

• Non-mood related presentations

  • Multiple visits with unexplained symptoms

  • Work/relationship dysfunction

  • Weight/sleep/energy/memory/cognitive complaints

  • Comorbidity (IBS, obesity, CVA, cancer)

  • Substance abuse

• Depression Risk

  • Comorbid medical disorders (CAD, Hypothyroidism)

  • Comorbid psychiatric disorders (anxiety, substance use)

  • Chronic pain

  • Low SES

  • Postpartum

• Suicide Risk

• Questionnaire (eg. Hamilton, Beck, PHQ-9)

• Functional impairment (occupational, social, educational), QOL

• Abuse (sexual, physical, emotional, substance)

  • Domestic abuse

    • Does your partner put you down or try to control what you can do? 

    • Have you ever been hit, pushed, restrained or choked during an argument?

Management

• Hospitalization vs. close outpatient follow-up

• Persistent subthreshold depressive symptoms or mild-moderate depression

  • CBT, CCBT (computerized), structured group physical activity program

• Drug treatment if

  • Past history of moderate/severe depression

  • Long period (>2y) of subthreshold depressive symptoms

  • Persistent symptoms after other interventions

  • Moderate/severe depression in combination with CBT or IPT 

Definitions

• Major Depressive Disorder

  • ≥ 5 (with depressed or decreased interest) for >2w with change in functioning

    • Depressed mood most of the day

    • Sleep

    • Interest

    • Guilt

    • Energy

    • Concentration

    • Appetite

    • Psychomotor agitation/retardation

    • Suicidal ideation

  • Specifier:

    • Atypical features

    • Anxious features (Mirtazapine, moclobemide, paroxetine, sertraline, venlafaxine )

    • Catatonic features (Benzodiazepines)

    • Cognitive dysfunction (Vortioxetine, Bupropion, Duloxetine, SSRI)

    • Melancholic features (Paroxetine, Venlafaxine)

    • Mixed features (Luprasidone)

    • Peripartum onset (Fluoxetine in pregnancy, Sertraline in breastfeeding)

    • Psychotic (ECT, Antipsychotic and antidepressant cotreatment)

    • Seasonal pattern (Bright-light therapy)

    • Sleep disturbance (Agomelatine, Mirtazapine, Quetiapine, Trazodone)

    • Somatic symptoms (Duloxetine for pain/energy,  Bupropion for fatigue)

DDx

• Psychiatric:

  • Bipolar (≥1w of energy/activity with ≥3 GST PAID)

  • Depressive disorder due to another medical condition

  • Persistent Depressive Disorder (>2y of 2SIGECAPS, with no MDE)

  • Adjustment disorder with depressed mood (stressor <3mo, resolves in <6mo)

  • Grief reaction (loss, usually <3mo)

  • Schizoaffective

  • Anxiety

  • ADHD

• Medical

  • Adrenal insufficiency,  hypercortisolism, hypothyroidism,

  • Mononucleosis,

  • Multiple sclerosis, Huntington disease, Parkinson disease, systemic lupus erythematosus

  • Obstructive sleep apnea

  • Stroke, traumatic brain injury

  • Vitamin B12 insufficiency

• Medication: Corticosteroids, interferon, antiretrovirals

• Substance-induced

Investigations

• Consider

  • CBC (anemia), electrolytes (creat), TSH, B12/folate, LFTs

  • B-hCG

  • UA, urine toxicology

  • EKG (QT)

• Neuroimaging if focal neurological sign or elderly

Suicidal Risk

• • SAD PERSONS

    • Sex (male)

    • Age>60yo

    • Depression

    • Previous attempts

    • Ethanol abuse

    • Rational thinking loss (psychosis)

    • Suicide in family

    • Organize plan

    • No spouse/support

    • Serious illness/pain

  • ASK: Have you had any thoughts of wanting to kill yourself?

    • Passive vs. Active ideation

    • Plan (time/place), Intent (would you actually carry out this plan)

    • Past Attempts (Practiced/Aborted)

    • Access to means

    • Provocative/Protective factors

Management

• Emergency psychiatric consultation and in-patient treatment if unsafe to self/others

  • If low risk of suicide, consider safety plan

    • Keep home environment safe (remove access to weapons)

    • Recognize early warning signs

    • Coming up with ways to cope personally with suicidal thoughts

    • Identify people to contact for help/distraction

    • Identify place to go to for safety (eg. hospital)

• Consider psychiatric referral for substance use disorder or psychiatric comorbidity (bipolar, anxiety, personality)

• Consider framing depression as an adaptation, rather than a disease,  can lead to better patient outcomes

• Lifestyle

  • Regular exercise, adequate food, housing, sleep

  • Stress management (mindfulness-based stress reduction, engaging in ≥1 pleasurable activity per day)

  • Avoiding substance abuse

• Psychology

  • Cognitive behavioural therapy

  • Interpersonal psychotherapy

  • Behavioural activation

  • Group (less effective than individual but lower costs)

• Pharmacotherapy - Acute (Consider EKG for prolonged QT)

  • Choose based on comorbid, previously used antidepressants, interactions (consider CFP support tool)

    • Citalopram 20mg PO daily (cheapest)

    • Escitalopram, Mirtazapine, Sertraline, Venlafaxine (modest superiority 5-6% in network meta-analysis)

      • Side effects: Nausea (21%), xerostomia (20%), diaphoresis (20%), drowsiness (18%), insomnia (15%), sexual dysfunction (up to 50%), weight gain, headache

        • Dangerous: Serotonin syndrome, suicidality, upper GI bleed, osteoporosis, hyponatremia, prolonged QT

  • Use objective scales (eg. PHQ-9) to monitor improvement

    • If >20% improvement at 2-4w continue treatment and reassess at 6-8w

    • If <20% improvement at 2-4w

      • Increase dose

      • Switch to another medication

        • Consider Escitalopram, Mirtazapine, Sertraline, Venlafaxine

      • Adjunct/Augment (if ≥ 2 antidepressant trials, well tolerated, partial response, specific symptoms to target, less time to wait (severe, functional impairment), patient preference)

        • Consider Aripripazole, Quetiapine, Risperidone

        • Other options may include lithium, thyroid hormone

  • Maintenance until 6-9 months minimum after remission

    • Consider 2y minimum especially if high risk (frequent/recurrent episodes, severe, chronic, comorbid,  residual symptoms, difficult to treat)

  • Discontinuation by slow taper over weeks

    • Symptoms include FINISH (Flu-like symptoms, Insomnia, Nausea, Imbalance, Sensory disturbance, Hyperarousal)

    • Typically resolves in 1-2 weeks

• Neurostimulation

  • Repetitive transcranial magnetic stimulation (rTMS) if failed ≥1 antidepressant

  • Electroconvulsive Therapy (ECT) if severe (active suicidal ideation), psychotic, treatment-resistant

    • Consider in medication intolerance, catatonic features, rapidly deteriorating physical status (eg. malnutrition due to food refusal)

• Complementary

  • Light therapy (phototherapy) 

    • 10,000 lux for 30 minutes per day during early morning up to 6 weeks (response usually within 3 weeks)

    • Consider especially in seasonal, shift work, sleep dysregulation

  • Acupuncture

  • Sleep deprivation (total for 40h or partial allowing 3-4h of sleep per night, employed 2-4 times over one week)

  • Natural health products

    • St John's Wort (care for medication interactions)

    • Omega-3 fatty acids (3-9g/day) or 1-2g of EPA + 1-2g of DHA per day

    • SAM-e

    • Zinc

• Social skills training, vocational rehabilitation

Special populations

• Children/Adolescents

  • First line

    • CBT/IPT or internet-based psychotherapy

  • Second line

    • Level 1 evidence: Fluoxetine

    • Level 2 evidence: Escitalopram, sertraline, citalopram

• Pregnancy/Breastfeeding

  • First line

    • CBT/IPT

  • Second line

    • Citalopram, escitalopram, sertraline

  • Note: 

    • Most antidepressants not linked to major congenital malformations

      • Paroxetine: CV malformations (OR 1.5)

      • Fluoxetine: Small increase in congenital malformations

      • Very modest link for spontaneous abortion (OR 1.5) , 4-day shortened gestational duration and reduced birth weight (74g)

    • Exposure to antidepressants in breastfed infant is 5-10 times lower than in utero

      • Sertraline has lowest relative infant dose (milk-to plasma ratio)

• Perimenopausal

  • First line

    • Desvenlafaxine

    • CBT

• Late-Life (≥60yo)

  • First line

    • Level 1 evidence: Duloxetine, mirtazapine, nortriptyline

    • Level 2 evidence: Buproprion, citalopram/escitalopram, desvenlafaxine, sertraline, venlafaxine, vortioxetine