FAQ for Depression

Who is this FAQ meant for?

This FAQ is meant for General Practitioners.  It is not meant for the layperson.  It is a simple FAQ and it is not meant to be a comprehensive chapter on depression.  It cannot replace drug information, medical journals or guidelines on depression.  Medical information provided here has to be combined with the clinical judgement of the doctor and considered in the unique context of the patient.

How do you diagnose Depression?

These are symptoms of depression:

  • Low mood 

  • Loss of interest 

  • Tiredness

  • Poor concentration

  • Reduced or increased sleep

  • Reduced or increased appetite

  • Slowness (observed by doctor) 

  • Meaningless of life

  • Suicidal thoughts

To make a diagnosis, there has to be five or more symptoms of at least 2 weeks duration. There should be at least one core symptom: low mood or loss of interest.

What else to look out for in the history?

There may be a stressor that triggered the depression (e.g. relationship difficulties, work or school problems, financial problems).  

However, depression is a multi-factorial condition just like diabetes mellitus. Look out for predisposing and perpetuating factors like:  

  • Female gender 

  • Family history of mental health issues

  • Childhood difficulties (e.g. separation of parents, childhood trauma)  

  • Lower socioeconomic status

  • Chronic medical conditions

  • Adverse social circumstances

What other symptoms may depressed patients present with?

Sometimes, a depressed patient may present with pain, tiredness or other non-specific somatic symptoms. They may also have anxiety symptoms such as excessive worries and panic attacks. Some may hear voices that have negative contents (mood-congruent auditory hallucinations) or have abnormal beliefs that they are poor, guilty of a crime, or that part of their body is dead (delusions of poverty, guilt, nihilism respectively). An older patient with depression may present with forgetfulness and other cognitive impairments. This is sometimes called pseudo-dementia.

What would you observe in a depressed person?

You may notice poor eye contact, tearfulness, furrowed brows and slowed movements. You may also notice weight loss.

What are the differentials to consider?

It may be an adjustment disorder. There is a source of stress (e.g. problems with spouse,  bullying at work, financial problems, National Service) and while the distress is more than what we would expect, it does not meet the criteria for depression.

If there were previous episodes of either mania or hypomania (e.g. elevated mood, not requiring sleep for a few days, high energy, excessive spending and other risk-taking behaviours), consider bipolar depression.  In a young adult, low mood can be the first presentation of bipolar disorder and mania may be triggered by antidepressants. It is advisable to refer to a psychiatrist if bipolar disorder is suspected. 

There are medical conditions (e.g. thyroid disorders) and medications (e.g. steroids) which can cause secondary depression, although these are less common.  

Which medication to start?

Consider SSRIs and NaSSA (mirtazapine).  The starting doses are :

  • Fluoxetine 20 mg OM

  • Fluvoxamine 50 mg ON (may improve sleep)

  • Sertraline 50 mg OM

  • Escitalopram 5 mg OM (minimal drug-drug interactions, suitable for those on multiple medications)

  • Mirtazapine 15 mg ON (may improve sleep and appetite)

What are the common side effects of SSRIs?

The common side effects are “SING":

S - sexual side effects (reduced libido, delayed climax)

I - insomnia 

N - nervousness

G - gastrointestinal side effects like nausea, loss of appetite and bloatedness

These side effects are usually short-lived. Most patients report a reduction in side effects after the initial week.

In patients above 65 years old, there is a higher risk of hyponatremia and GI bleed.  You may want to check their sodium level at the next appointment.

For patients younger than 24 years old, there is a black box warning of increased suicidal thoughts although the risk is very, very small. I usually inform the parents and get parental consent if the patient is below 18 years old. 

When do I avoid SSRI?

  • Patient is pregnant 

  • Medications like tamoxifen and warfarin as SSRI inhibits Cytochrome P450

  • Medications that can trigger serotonin syndrome when combined with SSRI (tramadol, other antidepressants)

What other forms of help can I offer?

  • Practical help eg. MC for respite from work, memos to employer

  • Advise healthy diet, exercise and good sleep hygiene

  • Advise against alcohol use

  • It may be helpful to explain the condition to the family and enlist their support if the patient consents to it

Any tips for counselling?

The key ingredient is “Active Listening”.  This means to listen calmly and intently with empathic body language (nodding, leaning in and mirroring). It is often very therapeutic for patients to have their distress validated by the doctor. Active listening also helps to build rapport.

Are there counsellors in the community?

The Family Service Centre in your neighbourhood will be able to provide counselling.  You can locate one here. You can also refer to this list for other counselling centres. 

Is psychological therapy helpful?

Evidence-based psychotherapies for depression include Cognitive Behavioural Therapyj (CBT)  and Mindfulness-Based Cognitive Therapy (MBCT). These are typically done by a psychologist or psychiatrist. The sessions aim to help individuals with depression:

- Gain awareness of their depressive symptoms

- Identify and restructure negative automatic thoughts

- Reduce unhelpful coping and  break behavioural patterns

- Increase engagement in pleasurable and mastery tasks that promotes well-being 

The combination of an antidepressant and psychotherapy is typically regarded as the best approach for treatment of depression. 

What are some risk factors?

  • Past suicide acts 

  • Elderly 

  • Poor social support

  • Multiple medical conditions 

  • Family history of suicidal behaviour

  • Active suicide thoughts and plans (e.g. specific method, date, suicide note)

So how do I assess suicide risk?

A comprehensive explanation on suicide risk assessment is beyond the scope of this FAQ.

When do I refer to a mental health expert?

  • Symptoms are moderate to severe (e.g. poor functioning at work or school, suicidal thoughts, hallucinations, delusions)

  • Complicated circumstances that require help from different agencies 

  • Co-morbid personality issues

  • Patient is not responding despite several weeks of antidepressants and counselling

  • Patient wants to see a psychiatrist

Who can I refer to?

  • Please email, WhatsApp or call Private Space Medical at 69797 886 to make an appointment for your patient.