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CDHB

Major Depressive Disorder

A common condition in the general hospital (prevalence 30-40%).

• Chance association with other disorders.
• Reactively precipitated:
  • Complicated grief.
  • Chronic debilitating illness.
• Organic.
  • Post viral (influenza, hepatitis, infectious mononucleosis).
  • Neurological (Parkinson's, CVA, multiple sclerosis, head injury).
  • Malignancy (pancreas, lung, cerebral, colon).
  • Immunological (SLE).
  • Endocrine (hypothyroidism, Cushing's, Addison's).
  • Medication (steroids, methyldopa, major tranquillizers, NSAIDs).

Symptoms may not be classical. Physiological (vegetative) symptoms can be hidden by co-existing physical illness. Psychological and cognitive symptoms (pessimism, suicidal ideation, hopelessness, anhedonia, depressive delusions) are more discriminative. Medications should be first line only for moderate or severe depression.

Management of Major Depressive Disorder

• Selective serotonin re-uptake inhibitors (SSRIs) are first choice in patients over 25, e.g., citalopram, fluoxetine, paroxetine - 20 mg mane. Use 10 mg initially in the elderly. Citalopram has fewer drug interactions, thus is generally preferred in the medically ill.
• Serotonin noradrenaline re-uptake inhibitors (SNRIs) are second choice in patients over 25. Give venlafaxine 75 mg initial daily dose, max daily dose 300 mg. Check blood pressure.
• Tricyclics are third choice; nortriptyline is the most tolerable of tricyclics. Dosage range 50 -150 mg nocte, but start low and titrate slowly upwards. Caution in elderly. Check serum therapeutic level.

  Note: Caution in patients who are under 25. Fluoxetine is the first choice; paroxetine and venlafaxine should be avoided; citalopram should be used with caution and tricyclics have not been shown to be effective.

• Check serum sodium with SSRI/SNRI drugs as hyponatraemia may occur, especially in older patients.
• Beware of sensitivity to the side effects of antidepressant medications in the medically ill, particularly the tricyclics.
• ECT should not be forgotten as an option (if fit for GA). Discuss with Consultant Psychiatrist.
• Tricyclic antidepressants may have additional analgesic activity. SSRIs do not.
• The physically ill should not be allowed to suffer an untreated depressive disorder.
• SSRIs may render codeine ineffective (exception citalopram).

Topic Code: 1620