It is extremely important
to screen for suicide risk
at every encounter
with a patient.
Because the suicide risk
assessment is so important,
I want you to pay particular
attention to this slide.
So the chronic risk factors, a few
of them include patient’s age
previous suicide attempts,
ownership of guns or weapons,
race or ethnicity, family
history of suicide attempts.
Some modifiable risk factors
are patients’ mental illness,
physical illness, substance abuse, connection
to treatment and their support network.
And then also consider protective factors.
They may be finances, education, religion,
family or friends,
employment, pets, et cetera.
So I want to ask you what percentage
of patients with major depression
will go on to experience a
second episode of depression?
Here’s what we think.
About half of people who’ve had
one episode of major depression
will experience a second.
We think that 70% of those of who
have experienced two episodes
will have a third episode of depression
and we tend to think that about 90%
of those people who have experienced
three or more lifetime episodes of
depression are going to have another event.
So this is very important
as you consider treatment
recommendations and management
plans for your patient.
Children are an interesting subset and
they’re also susceptible to depression.
It’s important to note that a child may
not come to the doctor or their parent
complaining of a low mood or depression,
they can’t quite put words
to what they’re feeling.
So instead, they may just
seem very irritable or angry
and that’s an important thing
to look out for in a child
who comes to the office visit.
So any child who’s looking irritable
might actually be a sign of depression.
And the elderly are another subset
that need particular attention
because major depression is actually
very common and it affects them, too.
The elderly are twice as likely to commit
suicide than the general population
and depressed symptoms have been found
in about 15% of nursing home residents.
So it’s pretty pervasive.
These symptoms of depression will often in
the elderly look a little bit different.
So, here, the presenting complaint
may be a memory problem
or a new onset
Therefore, they are at risk for being
written off as having dementia.
So any elderly patient who presents
with poor concentration or focus
or any changes in their cognition really
needs to be screened for depression.
And the term for this is
There are a lot of different
treatment options for depression.
One of the first things
you have to consider
is the level of care that a patient needs.
So we think about hospitalization as being
the safest place for the
patient who is unable
to safely take care of
themselves in the community
because their depression has gotten so bad.
So any patient at risk of
harm to themselves or others
or a patient who can’t meet their day to
day needs may need to be hospitalized.
Otherwise, you might opt to treat your
patient in the outpatient setting.
Pharmacotherapy is also
We’re going to touch on that
briefly in this lecture
and then you can followup
with another lecture
specifically dedicated to
pharmacotherapy and depression.
It includes everything from
antidepressants to stimulants
to even antipsychotic medications,
anxiolytics and mood stabilizers.
A little bit more about hospitalization.
There are a couple of options.
So we talked before about
patients needing to
go to the hospital because
of a safety risk.
That’s called involuntary admission.
And the involuntary admission is
permitted only when an individual
poses a serious risk of threat
to harm to themselves or others.
And the goal there is the acute safety
and stabilization of the patient.
There’s always an option for somebody
to go into the hospital voluntarily.
And that’s where a patient will
recognize they need a lot more help
and they ask to go in so
they can receive treatment
from doctors, nurses and social workers,
maybe in an effort to help establish
a good outpatient care plan.
Otherwise most patients with
depression are actually managed
in the outpatient care setting.
A quick overview of the
pharmacotherapy for depression.
It can include antidepressants
such as selective serotonin
reuptake inhibitors or SSRIs,
monoamine oxidase inhibitors.
There can also be other
medications like stimulants,
and these are often helpful
especially in people
who are elderly or
the terminally ill.
Think of that group who have very
low energy and low motivation.
That’s where a stimulant might actually
help to perk them up a little bit.
Antipsychotics can be helpful
in some cases of depression,
especially in people who have psychotic
features or features of catatonia
and there are other
options as well.
You want to make sure general medical
treatments are being addressed,
even a little extra thyroid
treatment can go a long way
in terms of helping
someone with depression.
All antidepressant medications are
pretty much equally effective
but they differ in terms of
their side effect profile
and that’s usually what you need to
consider when making a recommendation.
Also, it’s important to tell your patient
that these medicines can take about
four to six weeks before
they actually start to work.
So that way, your patient won’t
just give up on the medicine
and they’ll persist
in taking it.
A side effect that can be very serious
from antidepressant medications
that’s worth noting is something
called serotonin syndrome.
And this is marked by autonomic
instability, hyperthermia, and seizures.
It can actually result in coma or death.
So serotonin syndrome can
result when somebody’s on,
say too high of a dose of an SSRI
or they’re on multiple
SSRIs at one time.
It can also result from combining
medications like an SSRI
with a monoamine
or an SNRI, another medication that
boosts serotonin and norepinephrine.
If you combine that with a
monoamine oxidase inhibitor,
there’s also a very high
risk for serotonin syndrome.
So it’s important when
prescribing medication to
always share with your
patient risks and benefits
and make sure that
you’re being attentive
to how their physically
tolerating the medicine.
There’s also psychotherapy,
which is extremely helpful especially
in combination with pharmacotherapy.
There’s a wide array of psychotherapies
that can help your patient.
These range from behavioral to
cognitive, supportive, family therapy,
and again in combination with medication
management is extremely valuable.
ECT otherwise known as
is also a very useful
treatment in depression.
This is specifically used for people who
have treatment resistant depression,
so somebody who’s maybe
tried three antidepressants
and hasn’t had a positive
effect from them.
There are other indications
for ECT as well such as
catatonic features and
sometimes mixed episodes.
ECT is actually quite safe,
it’s done under general anesthesia in
an operating room or surgical suite.
And while a small controlled seizure
is delivered to the patient,
it’s done in a very controlled setting
where their blood pressure
and heart rate is monitored
and an anaesthesiologist is actually
putting the patient to sleep
and very temporarily
paralysing their muscles.
So when that seizure occurs, the patient
doesn’t have a huge grand mal seizure,
but rather their
body doesn’t move
and all the activity
is really limited
to the region of the brain
that we’re hoping to target.
Usually , a patient will go through a
course of about eight to ten ECT treatments
and then sometimes have
maintenance beyond that,
meaning once monthly ECT to help
sustain the positive benefits.
A common side effect of ECT
is retrograde amnesia,
something very important to remember
and inform your patients about.
So we summarized here a little bit about
depression, the various types of it,
the diagnosis, and some