What is depression?

So the most common psychiatric condition, which you probably are aware of and the one that our GP’s tend to deal mostly with is depression. Depression, which is more formally referred to as major depressive disorder, is a leading cause of disability in the UK and worldwide. So when we’re looking at depression and anxiety together, almost one in four people at some point in their lives will develop these conditions. And what we also tend to find with depression is that it’s associated with other health conditions as well, and that increases the kind of problematic nature of depression specifically. What we also tend to find is that almost one in ten people in the UK specifically will experience dementia at some point.

So that’s a very, very high number when we consider that it’s almost 10% of the population as a whole. And in addition to that, what we tend to find is that depression has a significant impact on functioning both socially and occupationally, which means that it has an impact on our finances and on the National Health Service as well as the finances of the country more broadly speaking. So the key symptoms of depression, important to consider again as per the DSM 5 and the ICD 11 are initially first low mood. So low mood is the first and important criterion we need to look out for.

And this low mood needs to be present for a period of at least two weeks along with the following. So then the patient presents with a loss of pleasure in interests that they once found pleasurable. So they’re no longer interested in their hobbies or certain pleasurable activities that they used to do perhaps on an a frequent basis. They’re also more fatigued. They have low energy. There’s more disruption to sleep and to appetite. And all of these changes tend to be present for two weeks consecutively, at the very least. But it’s also important to look out for the following criteria or the following signs that may be suggestive of depression.

So we’ve already mentioned that there is disruption to sleep and appetite, but we’re also looking for certain cognitive symptoms, such as a lack of motivation, poor concentration, inability to sustain focus and attention, and indecisiveness. we also see that patients present with feelings of guilt or shame over their experiences, how they’re feeling, and the impact that this is having on others. We also find that they have low self-esteem. They may feel hopeless about certain situations that they find themselves in. And in addition, they may have thoughts of death. So it’s important to ascertain if a patient or loved one is having those kinds of thoughts.

We shouldn’t be afraid to ask, because usually what we tend to find is that patients do tend to have these thoughts. They may hold back in terms of communicating them, but it’s important to actually ask about that because then that tells us something about the degree of severity when we’re looking at depression as a whole. Now, in terms of the causes of depression, what we’re looking at are, again, a number of different factors. So it’s multifactorial in nature because we have biological potential causes. For instance, we know that there is a genetic component here which could account for almost 30 to 50% of cases. And we know this through certain twin studies.

So we know that certain twin studies have highlighted identical twins, an identical twin has an increased risk of depression if their twin develops depression. So we know that there is a genetic component to this, and there is a strong family history of depression in families. We also know that environmental factors play an important role. So early life experiences such as traumatic experiences or adverse early life situations that patients may have experienced do tend to influence the onset of depression, not only at that point in life, but even later in life.

We also know that current stressful life events have an impact on the individual, and chronic adversity has also been found to have a significant impact in terms of the risk of developing depression at any point in the life course. But what’s important to consider is that we’re not just looking at biology versus nature. It’s not an argument of nature versus nurture. We’re looking at both together. It’s nature and nurture. And we know that the gene environment interaction is key in considering causes for not only depression, but most psychiatric condition.

So whilst we know that there is a genetic component to depression, and we also know that environmental factors and life events are key when we’re looking at the onset of the condition and why it happens when it does. So in terms of diagnosis, again, we’re looking at the two main diagnostic manuals that we use, the DSM 10 and the ICD 11. And what we do tend to look out for here are those key signs and symptoms that I touched on previously. The first person to get in touch with, if you suspect that a loved one, a relative, a friend, is presenting with any of those key signs or symptoms, so the first point of contact is the GP.

So where you suspect that a patient may be presenting with certain key signs or symptoms of depression, you may be picking these up in loved ones and friends and family do get in touch with their GP and raise your concerns. The GP will then invite them in for an assessment. They’ll perform physical examinations as well. It’s important to rule certain things out. We know that thyroid problems can also give rise to certain symptoms of depression. So it’s important to rule out, for instance, an underactive thyroid. But they will also ask the patient certain questions to actually ascertain whether this is a picture of depression that they’re looking at.

And again, they’ll rely on the diagnostic criteria as per those manuals to do so. If the GP suspects that it is a picture of depression that we’re looking at here, then the GP can prescribe certain medications. These medications Include SSRIs, antidepressants. Basically these are the first line type of antidepressants and they act on a specific type of neurotransmitter in the brain. Referred to as serotonin. Serotonin is important not only in terms of our mood, it plays an important role in mood, but also with regards to appetite. And sleep. So these antidepressants act specifically on those specific pathways in the brain where the GP may be concerned that this is beyond mild to moderate depression.

If they’re looking at a more severe case of depression, they will refer to a psychiatrist for further assessment and the psychiatrist will then perform a risk assessment. So this is again asking about whether the patient is experiencing any thoughts of harming himself or others. And as such, they need to ascertain what the level of risk is and what the recommended course of action would be dependent on that risk. They also perform what is referred to as a mental state exam.

Mental state examination is sort of like another interview where they ask questions in order to sort of get a better understanding of the degree or the severity of depression that they’re dealing with and what type of intervention and treatment would be best for the specific patient. So, again, it has to be tailored to the patient specifically. So in mild to moderate cases, the GP, as I mentioned, can prescribe certain medications. But first line would be to try counselling or talking therapy if appropriate. So we try talking therapy in the first instance if the patient is able to engage with that. But we also look at what I refer to as the NICE guidelines.

So the NICE guidelines are guidelines when it comes to interventions and treatments that are recommended for certain kinds of conditions. So according to our guidelines, cognitive behavioural therapy is first line. We try this in the first instance. If we’re looking at a more moderate to severe picture of depression, then we use CBT alongside an antidepressant. Where you’re looking at a more severe picture of depression, you’re also looking at certain other kinds of medications that may help as well and certain other treatments that could be administered in in a psychiatric hospital setting.

And what is key here is that the antidepressants and the other treatments aim to alleviate the distress experienced as a result of the symptoms of depression and combination therapy, where we’re looking at CBT plus medication has proven to be very effective as per the literature. But what’s also very, very important is that patients make certain changes to their lifestyles at home. So, for instance, exercise social activity, keeping more active, are very important in terms of helping with keeping depression at bay. For further supporting information, the GP, your GP or the patient’s GP,is always a good place to start.

GP’s are trained to deal with depression and where they suspect that there may be a more severe case of depression that they’re looking at, they will refer the patients as a matter of urgency. Samaritans, if you’re experiencing certain thoughts of harming yourself or if you’re experiencing certain difficulties in life that you’d like to talk to someone about Samaritans is a, is a great place to start as well. They don’t offer advice, they listen, and they can guide if necessary to the relevant services. You can contact the Samaritans, it is a great place to start. Along with Breathing Space, that’s another number that you can contact, which you can see on the slide here.

And there’s also Mental Health helpline or support group with the information provided here via the NHS website. Which provides information for loved ones as well as for individuals experiencing low mood and depression. In case of emergencies, always contact the NHS 999 if it is an emergency which is life threatening or NHS 24 on triple one [111].

In addition to that, you can also consult the NHS website for further information about depression, as well as further support that is available via the NHS and via certain other charities as well.