Fig 2. Have you felt this way? Signs of burnout: \200 Stress and depression \200 Fatigue \200 Non-restorative sleep6 7 \200 Emotional exhaustion \200 Motivation \200\201; apathy \200\200 \200 Libido \200\201 \200 Insomnia \200 Guilt or denial \200 Paranoia/isolated \200 Demoralizat ion \200 Amnesia \200 Indecision \200 Temper tantrums \200 Low personal accom- y r t a i h c y s P 6 6 . l u o s d e t c r a f n i plishment Depersonalization \200 Vicarious traumatization \200 Irritability/impatience r u o y r o f y d e m e r y l n o e h t s i e u g o l a i d \200\207 r e t a l t u o Return meaning and purpose to life via dialog, self-transcendence and a sense of connectedn ess with others (meaning-centered psychotherapy).77 \200 Learn new professional skills \200\224or consider early retirement. \200 Set achievable goals in work and leisure (eg p rotected time with family). Prevention Strategies such as career counseling are said to be eff ective but really do no more than point a lollipop at a furnace.78 n=171 Reducing stres s is one (unproven) way of avoiding burnout. Psychiatrists have found their own \200\230st ress busting \200\231 groups helpful \200\224these entail problem-solving with air- ing of stresses \200\224ideally accompanied by talking to colleagues for support and catharsis. Ha ving outside interests helps, as does getting support from family and friends, time managem ent, and exercise.79 On a more universal plane, \200\207we are all responsible for each ot her \200\231s burnout. By being attentive to our own and others \200\231 feelings of troubl ed conscience we all have a role in preventing the burnout of our colleagues. We need oppor tunities to re \202 ect on our troubled consciences. Appraisals (p508) and less formal rou tes to this awareness are becoming more accepted by professionals.72 n r u b d n a n i e v i g l l i w u o y r o w o n p u k a e p S \200\207 Patients in disgrace: the fat-folder syndrome The sorrow that has no vent in tears may make other organs weep.80 Francis J Braceland One role of the psychiatrist/GP is to act as the terminus for patients who have been shunted from hospital department to department. The aim is to reframe symptom-off ering into problems that need solving. Start by accepting that t he patient is troubled and looking for helpful responses from you that are yet to be de \201 ned. After establishing rapport, agree a contract with the patient, that we will give regular consultations for listening to how the patient feels and will try to off er help, i f she acknowledges that past investigations haven \200\231t helped, that psychological fact ors play a part (somatization, p640), and that she agrees not to consult other doctors unti l a \201 xed number of sessions have elapsed.81 Also, cognitive therapy (p374) examining the way that conscious thoughts and beliefs perpetuate disability, can lead to symptom redu ction.82 334 Autosuggestion/dissociation (formerly \200\230hysteria \200\231) Our stream of consciousne ss doesn \200\231t progress from cradle to grave as a sin- gle line: there are separations (disso- ciations) and con \202 uences, for example, when we daydream, or drive to Porlock with no recollection of the scenery along the way, only of our inner land- scape. Dissociat ion may be adaptive, eg by annihilating pain in near-death events ( \201 g 1). Another exa mple: a man who was homosexually raped had no conscious memory of this, but felt irre- sist ible urges to write insulting letters about the perpetrator. Types of dissociation Amnesia is the commonest type: see BOX. Depersonali- zation: Feeling of being detached from one \200\231s body or ideas, as if one were an outsider, observing the self; \200\234I \200 \231m in a dream \200\235 or \200\234I \200\231m an automaton \200\235 (unre- lated to dru gs/alcohol) eg from stress. Dissociative identity disorder: The pa- tient has multiple pers onalities which interact in complex ways. It is present in 3% of acute psychiatric inpatien ts. Fugue: Inability to recall one \200\231s past loss of identity or formation of a new identity, associated with unexpected, purposeful travel (lasts hours to months, and for wh ich there is no me). Follow-up ( 6yrs) shows that 5% of those referred to a CNS hospital w ho had hysteria/dissociation diagnosed turned out to have organic illness. Treatment Explor ing life stresses may help. Be ready to recognize psychologi- cal components of physical il lness, and get expert psychiatric help, while leav- ing the door open for new diagnoses. y r t a h c y s P i Fig 1. This lady has the knack of dissociating her body and replacing it with the airy noth - ingness of a summer sky. Roland Penrose, the artist, intuited this adaptive response to e xtreme events in her past: he did not know when he painted this that at aged 7 that Lee Mil ler, whose portrait this is, was raped, and had suff ered traumatic douches to deal with th e ensuing gonorrhea. Nor could he have known that in 1945 she would be the \201 rst photo grapher to document the over \202 owing ovens of Nazi concentration camps, no doubt using her dissociative skills to keep her camera steady. How did she end up as the leading fashio n photographer of her day? The nested funnels at the foot of the picture suggest an answer: the mind has an in \201 nite capacity to distill one experience through another, and to c hannel experi- ences in new, creative ways. Night & day, Roland Penrose, reproduced by permission of The Penrose Collection. 335 Is this amnesia dissociative? 1 \200 Has a physical cause been carefully discounted? (Dru gs, epilepsy, etc.) \200 Is the patient young? Beware making the \201 rst diagnosis if >40yrs old. \200 Have the symptoms been provoked by stress? Ask the family. \200 Do rel ated symptoms \200\230make sense \200\231 (eg apho- nia in a news-reader)? What is the pattern of amnesia? If for dis- tant and near memories, then dissociation is mo re likely (vs organic causes) than if the amnesia is for shorter-term memory. Indiff erence to major handicap, la belle in- diff rence, is of little diagnostic use, see \201 g 1. \200 Is malingering likely? The answer is usually \200\230No \200\231, exce pt in prisons and the military (when secondary gain is easy to identify). . \200\235 r e t t e b y r t a i h c y s P Fig 1. This Lady tells us why we must not place weight on la belle indiff rence. She has h er dead Son on her lap, yet her expression is of serene in- diff erence, not overt sorrow. Michelangelo makes no error here, justly recognizing that dissociation is an adaptive re- a ction to calamity, be it \200\230hys- terical \200\231 (21%) or real (29%).84 s i s o r e l c s Is there a dissociative personality? The dis- sociative experiences scale (DES) screens for this: a 28-item visual analog scale about the proportion of time spent on dissociative exp eriences (not those from drugs/alcohol) going from the normal, eg being so absorbed in TV t hat we are unaware of events around us, to severe forms, eg of having no memory of cardinal personal events, or feeling that our body belongs to another. In dissociative disorders, t ypical DES scores are \200\20630; most others score nearer 0.85 e l p i t l u m y m d o o t s r e d n u Detail from Piet by Michel- angelo, San Pietro, Vatican, S Traykov, by permission. y e h t l i t n u \200\224 l a c i r e t s y h \201\201 Calibrating our sensitivity to psychosomatic events Why do some doctors preferent ially diagnose somatic illness? Why, when confronted by unexplained symptoms, do we often s ubconsciously try to \201 t them to a physical ailment? The reason is usually that prescr ibing a pill is easier than changing, or regulating, intrapsychic events. The patient and t he doctor may collude with this approach, and then get angry when it yields nothing. Altern atively, some doctors are so used to diagnosing psychopathol- ogy that they are all too pro ne to launch into treating someone \200\231s depression and malaise, rather than their endo carditis or brucellosis. There is no single correct approach. We all make errors: the point is to \201 nd out in which direc- tion you tend to make errors, then allow for this in y our work. s m o t p m y s y m d e l l a c y e h T \200\234 Some patients are naively keen to name their condition, eg \200\230 \201 bromyalgia \200 \231, or \200\230somatization disorder \200\231. Being able to name a disease or a conditi on is to start to control it. But it \200\231s only a start. In time, having named a condit ion may not prove all that helpful \200\224and neither may seeing a string of experts. This paves the way for a cognitive shift that may allow progress \200\224even heal- ing \200 \224to come about. As one patient said \200\234I stopped focusing on the speci \201 c dia gnoses years ago, and switched to \201 nding the best ways to increase my overall wellnes s. I use what I learned about my \201 bromyalgia to inform my choices, and have \201 gu red out what works best for me \200 Experts are just peo- ple, and are sometimes wrong \200\235.86 3 8 : % 4 n i g n o r w e r a s r o t c o D 1 Hypnotic phenomena share features with conversion (hysterical) symptoms, eg lack of conce rn, invol- untariness with implicit knowledge, and a compliant tone (la belle indifference) . Theories of conscious- ness postulate an altered relationship between self-awareness and the supervisory attentional system in both conditions (fontal and cingulate cortex are impl icated).87 Most subside spontaneously, but if they do not it is important to refer early to a psychiatrist, before associated behavior becomes habitual. NICE88 Depression Each year 40% of us have quite severe feelings of depression, unhappiness , and disappointment. Of these, 20% experience a clinical depression, in which low mood occ urs with sleep diffi culty, change in appetite, hopelessness, pes- simism, or thoughts of s uicide. Diagnosis of major depression: 1 Loss of interest or pleasure \200\224anhedonia in daily life with dysphoric mood (ie \200\230down in the dumps \200\231) plus \211 4 of the following (the \201 rst 5 are \200\230biological \200\231 symptoms) \200\224present nea rly every day for at least 2 weeks: 2 Poor appetite with weight loss (or, rarely, increased appetite). 3 Early waking \200\224with diurnal mood variation (worse in mornings). 4 Psych omotor retardation (ie a paucity of spontaneous movement, or slug- 336 \200 gish thought processes), or psychomotor agitation. 5 Decrease in sexual drive and other appetites. 6 Evidence of (or complaints of) reduced ab ility to concentrate. 7 Ideas of worthlessness, inappropriate guilt or self-reproach. 8 Rec urrent thoughts of death and suicide, or suicide attempts. Why is depression often missed? \200 Ignorance \200 Preoccupation with physical disease \200 Psychiatric labels are h ated \200 Doctors & patients collude \200\234not to open that can of worms \200\235 \200 It \200\231s hard to spot depression coexisting with other illness. Classi \201 cati on Classify as: \200 Mild; moderate; severe. \200 With/without bio- logical features. \200 With/without delusions or hallucinations. \200 With/without manic episodes (ie bipo lar not unipolar). These replace the old reactive/en- dogenous labels. \201\231 \201\231 : Cyclothymic disorder; substance-induced mood disorder; schizophrenia, dementia; mood disor der due to a general medical condition. Why we get depressed: some ideas \200 Genetics: i dentical twins reared apart show 60% more concordance for depression than dizygotic twins ( NB: these twin studies are suspect; see Psychiatr Q 2002 7189 for the reasons why). \200 Biochemistry: there are excess 5-hydroxytryptamine (5HT2) receptors in the y r t a h c y s P i frontal cortex of brains taken from suicide victims. See OHCM p442. \200 Endocrinology: \200 : \200 >1 : 1; dexamethasone suppression test (OHCM p217) is abnor- mal in \205\223. 17 \200 -estradiol may help perimenopausal depression; risk rises 2-fold, in proportion to LH & FSH.90 See also ghrelin (p530) & melatonin (SAD, p404). \200 Stressful events (birt hs, job loss, divorce, illness): seen in 60%. \200 Freudian reasons: depression mirrors bereavement, but loss is of a valued \200\230object \200\231, not a person. There is ambivalence with hostility turned inwards. Learned helplessness: if punishment is unrelated to actions, but is perceived as random, th e response is helplessness and depression.91 \200 Vulnerability factors: physical illness , pain, and lack of intimate relationships may allow depression to arise and be perpetuated .92 Management There is no clear distinction between the low moods we all get and illness n eeding vigorous treatment, but the lower the mood and the more marked the slowness, the mor e vigorous the treatment needs to be. \200 Psychological treatment (eg cognitive therapy, p373) is part of the treat- ment of all depression; it may be all that is needed in milder depressions. Presence of biological features or stress predicts a good response to anti- depressants (p3 40) especially if symptoms are severe. Not everyone wants drugs. Discuss all options. Herba lism can work: hypericum (St John \200\231s wort) may be useful in mild to moderately sever e depression.93 NB: omega 3 supple- ments may reduce suicidal behavior.941.2g of eicosapent aenoic acid+ 0.9g decosahexaenoic acid/day \200 Delusions or hallucinations prompt a phys ical treatment: drugs (antidepres- sants antipsychotic drugs, p360) or ECT (p342; beware: mania may result). \200 Treat depression in bipolar illness as above (with SSRI, risk of mania is low95). \200 Lithium or valproate prophylaxis may be needed (p354).96 \200 Re asons to admit: Social circumstances; high suicide drive; isolation. 337 Who is likely to bene \201 t from antidepressant drugs? (see p340) Sometimes antidepressan ts need to be prescribed as a matter of urgency \200\224 eg if suicide is likely (see below ) or, for example, if a mother \200\231s functioning is so impaired so that she cannot look after her family. If you cannot persuade the patient to start therapy, enlist the help of his or her family, and of a colleague. They may be able to persuade the patient where you h ave failed. Those who have had low mood or loss of desire for pleasure (anhedonia) most of the day for at least the last 2 weeks and who show \211 4 of the following 7 markers of se vere depression are at especial risk of suicide. Suicide plan or ideas of self-harm. Unexpl ained guilt or worthlessness. Inability to function (eg psycho- motor retardation or agitat ion). n e m o w l i a m k c a l b o t s y a w e t i n i f n i e v a h s r D ? y p a r e h t y r t a i h c y s P Concentration impaired. Impaired appetite. Decreased sleep/early waking. Energy low/unaccou ntable fatigue \200\207Enquire about these whenever depression is possible. NB: treatment may still be needed if these criteria are not met: listen to the story. People often don \200\231t accept that they are depressed as \200\234There is nothing to make me depressed \200\235. It helps to suggest that they could still be depressed, and that treatment could be very helpful. Give them time to go away and think about it, perhaps discussing it with s omeone they know (get consent). Try \200\234Would your wife (or partner) say you were depr essed? Please could you ask and let me know? \200\235 Such patients often return enriched b y dialog and re \202 ection, and are successfully treated. This may not be over-medicalizi ng a patient \200\231s symptoms .There is evidence that such patients are simply inexperi- enced in understanding their depression: when they next become depressed, their views much more nearly match those of their doctor. Over-diagnosing severe depression This is undesira ble as patients lives are medicalized and drugs with signi \201 cant side eff ects are nee dlessly given \200\224 as has been happening in the UK following NICE and QOF recommendatio n of use of the PHQ-9 diagnostic tool.97 f o s k s i r Fig 1. Has he planned the time?1 Has he planned the method? d n a d e e p s e h t e t a t c i d n e r d l i h c r e h f o s d e e n e h t o d : s r e h t o m d e s s e r p e D In some areas prescriptions for antidepressants have tripled from 1992 \200\2233 to 2006 \200\2237 without clear bene \201 ts. Antidepressants for adjustment disorder and bereavement? Adjustment disorder is one of the ways that stress causes psychopathology (oth er mechanisms re \202 ect extraordinarily severe responses \200\224acute stress reaction a nd post-traumatic stress disorder, p347). In adjustment disorder there is \200\230marked d istress that is in excess of what would be expected given the nature of the stressor \200 \231 (DSM-IV). In normal adaptive reactions to stress, functioning is less impaired. If the re is an adjustment disorder and there are <5 signs of a major depression (above) antidepre ssants may not help much.98 \201\2011 Poets, medical students (such as John Keats) and other harmless or immortal roma ntics tend to favor midnight as the proposed time for self-destruction: see p553 for Keats \200\231 midnight death wish \200\234to cease upon the midnight with no pain. \200\235 For once, Keats was wrong: just before lunch is in fact the favored time for suicide (11am) in some communities.99 The safest time is 4 \200\2238am. We should pay no attention to the ph ase of the moon: day of the week is much more important (Mondays are fatal).100 NICE101 Suicide and attempted suicide Distinguish suicide from non-suicidal self-harm (eg a cry for help \200\224common, but every non-fatal event may be fatal next time,1 hence trea ting both here; it is most prevalent in teenage girls; >1%/yr). Suicide is commoner in isla nds and east Europe, and rarer in Islamic peoples. Incidence: 106/yr ( 1/1000uk).102 Risk \200\200 if:103 bipolar disorder; depression; borderline personality disorder (p366); anore xia; substance abuse; past self-harm; farmers; vets; doctors and all other prisoners; poor problem-solving; recession/unemployment; serious illness; spring sunshine (aff ects seroton in neurotransmission and impulsivity).104 Understanding suicide Suicide can be a form of pr otest,2 or a way of avoiding pain or shame, and of keeping honor/autonomy,105 the noble Ro- man in us preferring suicide to humiliation. 2 Other themes \200\234Giving up an un- equa l struggle \200\235; \200\234I \200\231m worthless \200\235; \200\234I \200\231m invisibl e, disconnected from society \200\235.106 Self-harm may be a way of: Communicating a messag e, or gaining power by escalating con \202 ict, often after an argument with a partner. Im maturity, inability to cope with stress, weak religious ties, and availability of drugs (ps ychotropics and alcohol are popular poisons) are also important, as is \200\230copy-cat \200\231 behavior: when celebrities try suicide, others follow. Antecedents of suicide: Dis ease, depression, bankruptcy; anything engender- ing rumination and hopelessness. 107,108 ( esp. if psychiatric care is reduced).109 Bullying, sexuality, intolerable stress to succeed , and falling behind in home- work are also factors. If this mirrors your own state after t rudging through endless handbook pages, shut this book, and take an immediate holiday. Asse ssment3 Think of a target with 3 concentric rings. The inner ring is the circumstances of t he attempt: what happened that day; were things normal to start with? When did the feelings and events leading up to the act start? Get descriptions of these in detail. Was there any last act (eg a suicide note)? What happened after the event? Was this what he/she expected ? The middle ring is the background to the attempt: how things have been over the preceding months. Might the attempt have been made at any time over the last months? What relationsh ips were important over this time? The outer ring is the family and personal history (p322) . Now come to the bulls eye, the intention lying behind the act, and the present feelings and intentions. Does the attempt re \202 ect a wish to die (a grave, not-to- be-ignored s ign); a wish to send a message to someone; or to change circum- stances? Ask: \200\234If y ou were to leave hospital today, how would you cope? \200\235 Ex- amine the mental state (p 324; is there is any mental illness?) Summary: \200 Any plan? What? When? Where? \200 A re the means available? \200 Ever tried before? How seriously? \200 Preparations (makin g a will, giving things away). 338 \200 n=16,673 y r t a h c y s P i Before arranging hospital admission, ask what this is for. Is it only to make you feel happ ier? \200\224or to gain something that cannot be gained outside hospi- tal. Ask: Why will d ischarge be safer in a few weeks rather than now? After the assessment, there are 3 stages in trying to help survivors \200 Agree a contract off ering help (p339), by negotiation. Discuss con \201 dentiality, then talk with family as to how problems are to be tackled. T reat depression. \200 Problem-solving therapy helps by pointing out how she coped with pa st problems.110 N=1094 The aim is to engender a greater ability to cope in the future and t o help with immediate personal or social problems. \200 Follow-up, either alone or with t he family, with preventive strategies:111 \200\200Access to: Samaritans & doctors; on-line help (Facebook is addressing this). \200\201Access to: Guns/poisons.112 Less: Poverty & d ead-end work; alcohol/drugs; isolation; sexual coercion; suicide website availability. More : God;113 family caring; shared meals;114 justice; sexual equality;115 poetry.116 1 Once a person has self-harmed, the risk of death by suicide rises by a factor of 50 \200\223100. B MJ 2011 1167 2 Suicide is powerful: Mohammed Bouazizi (a poor street vendor in Sidi Bouzid, Tunisia) set himself alight after humiliation by an offi cial wanting a bribe, on Dec 17 2 010, so sparking the demise of 4 Arab dictators. 3 Use clinical judgment and assessment too ls: medscape.com/viewarticle/730857_5?src=emailthis 339 Nuclear confrontations \200\234I \200\231ll kill myself if you leave me \200\235 The be st approach is probably not to encourage patients to counter with \200\234I hate you: if y ou go on threatening, it \200\231s me who \200\231ll commit suicide \200\235. To avoid m utually assured destruction, explain that it \200\231s worth acknowledging close feelings ( including negatives ones), emphasizing that a healthy relationship cannot be based on threa ts, and that there should be more to life than a sin- gle relationship, especially one base d on coercion. It may be good to re \202 ect aloud on past times when there was more range of things which made life worth living, and to explain that it \200\231s possible to get b ack to a balanced state through dialog and giving and receiving pleasure.Ellis & Newman, Ch oosing to Live 7 1 1 \200\235 y d o b y m n w o d The psychiatrist may become enmeshed in these webs of suicide threats, and may wrongly assu me that because someone threatens suicide, they should be admitted to hospital (compulsoril y if necessary) so that they can be kept under constant surveillance, and suicide prevented . This reasoning has 3 faults. The \201 rst is the idea that it is possible to prevent su icide by admis- sion. There is no such thing as constant surveillance. Second, admission ma y achieve nothing if it removes us from the circumstances we need to learn to cope with. Th ird, we must distinguish between suicide gestures, which have the object of in \202 uencin g others \200\231 behavior, and a genuine wish to die.3 g n i m a e r t s y r t a i h c y s P d o o l b f o e l k c i r t t s r i f Before death, many suicide victims see a GP, and it is wise to be alert to undercurrents of suicide which only sometimes surface during consultations. Ask unambiguously about suicide plans (p322). On deciding that a threat is more manipulative than genuine, very experience d therapists may in \202 uence the person \200\231s use of suicide behavior by forcing him to face the reality of his suicide talk, eg by asking: \200\234When will you kill yoursel f? \200\235 \200\234How will you do it? \200\235 \200\234Who will discover the corpse? \200\235 \200\234What sort of funeral do you want? Crema- tion, burial, with or without \202 owers? \200\235 \200\234Who will come? \200\235 e h t d e h c t a w d n a n i k s See opposite for risk factors for suicide; they may be of no help in individual cases, so a im to think dynamically of risks and protective factors (eg family support), with suicide o ccurring after key events that accumulate risk. \200\207Take all suicide threats seriously \200\224but emphasis diff ers depending into which group the patient falls. Aim to form a contract with the patient, eg: \200 The therapist will listen and help if the patient agr ees to be frank, and y m s s o r c a e d a l b a t h g u o r b to tell the therapist of any suicide thoughts or plans. Agreement about which problems are to be tackled is made explicit. \200 Agree the type of change to aim for and who will be involved in treat- ment (eg family, friends, GP). Agree the timing and place of sessions. \200 An agreement to collaborate with the therapist, an d to do any homework. Not all self-harm is suicidal Cutting can relieve stress; in helping people re- duce the need to self-harm they may \201 nd addressing these questions helpful : 1 Have I got a solid support system I can call on if I feel like cutting? 2 Have I got 2 \200\2233 people I feel comfortable to talk to about cutting with? 3 Have I got a list of t hings I can do as an alternative to cutting? 4 Have I got a place to go if I need to leave home so as not to hurt myself? 5 Can I get rid of everything I might use to harm myself, wi thout panicking? 6 Am I prepared to feel scared, frustrated while cutting down my cutting? I e m i t t s r i f e h t d l o s r a e y 7 s a w I \200\234 \201\2011 If in doubt about the energy with which we may pursue our own destruction,let us call to mind a notable Japanese pilot who, during World War II, persistently volunteered to be a Kamikaz i pilot to run suicide missions against US ships, in the defense of Okinawa. The authoritie s just as persis- tently refused his request \200\224he had a wife and 3 daughters. He kept on reapplying, determinedly. Not wanting to risk her husband \200\231s failure again, and not wanting to stand in Destiny \200\231s way, his wife killed their 3 daughters, and then herself, so removing the obstacle to her husband \200\231s mission \200\224and on May 28, 1 945, he \201 nally took to the air, and achieved his end. 2 NICE says: \200\230the decis ion to discharge a person without follow-up after an act of self-harm shouldn \200\231t be based solely on the presence of low risk of repetition of self-harm and the absence of a me ntal illness, because many such people may have a range of other social and personal proble ms that may later increase risk. These problems may be amenable to interventions \200\231.1 18 Which antidepressant? Sample regimens Drugs improve mood and \200\200synaptic availability of noradrenaline or 5HT. Your own personal qualities and psychotherapy (p370) are as impor tant as drugs. Encourage socializing, exercising, and countering negative thoughts (p372). \200 Uncomplicated depression in middle age \200\224little suicide risk: If a cheap agent is essential, try dosulepin, \211 150mg at night (start with 25mg; max 225mg/day, in hosp ital).119 Explain side eff ects (below); warn about driving/ machinery use. Explain that be ne \201 ts take weeks to develop. Avoid if arrhyth- mia risk (eg post MI). SSRI alternativ e: citalopram 20mg/day, unless QT is long (works fastest120); only use max dose of 40mg if LFT OK and <65yrs old; consid- er sertraline 50mg/day (if not responding in 2wks, switching to paroxetine 20 \200\22340mg/day is better than continuing sertraline). 121 \200 Depre ssion with intellectual disability: Try SSRIs eg \202 uoxetine, 20mg/24h PO (doubled afte r 3wks if needed). t \211\210 3 days. If \200 , consider combining with 0.5mg/ day foli c acid: folate is low in major depression, and supplements may help.121 N=127 \200 Past h istory of good response to tricyclics, now suicidal: Try lofepramine, 70mg/12h (less likely to be fatal in overdose; less risk of fatal arrhythmias). \200 Depression in an adolesce nt: See p390; tricyclics/SSRI have problems. Unlic- ensed \200 Depression if elderly: ?Av oid SSRI; halve dose of tricyclic (SEs may be worse). \200 Depression + psychosis: ECT (p 342) antipsychotics (p360) may be needed. \200 Bipolar child: Get help; aripiprazole, olanzapine & risperidone have a role. 123 \200 Depression in those insisting on driving: Paroxetine (20mg each morning, increased by 10mg increments; max: 50mg/24h) is safer than t ricyclics. It is the SSRI most associated with the unpleasant dystonias on withdrawal. 340 NICE \200 N=132 y r t a h c y s P i Depression + disordered sleep pattern: Tricyclic, eg dosulepin, as above. If suicidal mirta zapine (blocks 5HT2, H1, and 5HT3 \200\22415mg at bedtime, max 45mg) may have a role. Warn not to rely on the \200\230fact \200\231 that daytime sleepiness usu- ally wears off after a few weeks. NB: ordinary SSRIs can aggravate insomnia. Sleep is such a restorative for so me patients, so give them the best chance. have a role.124 Depression not responding to SSRI: Venlafaxine (SNRI1) may \200 Pregnancy/breastfeeding: Tricyclics may be best; p408; get expert help. \200 Depression with obsessive \200\223com pulsive features: Clomipramine or an SSRI. \200 Depression with Parkinson \200\231s disea se: SSRI (nortriptyline 2nd choice). \200 Post-stroke depression: Nortriptyline is ?bette r than \202 uoxetine.125 \200 Depression at menopause: HRT may help but \200\200 breas t cancer risk, p256. \200 Depression+sexual dysfunction: Mirtazapine or bupropion. \200 Depression + obesity: Fluoxetine sometimes leads to weight \200\201.126 \200 Worried abo ut drug interactions: Citalopram and sertraline have lowest risk. Most SSRIs inhibit CYP450 enzymes so can \200\200levels of many drugs. \200 Depression in psychiatrists: In a sur vey of psychiatrists, most said \200\234I \200\231d want citalopram, \202 uoxetine, or v enlafaxine; in severe depression I \200\231d want ECT. \200\235127 Side eff ects \200\224SS RI: Citalopram & sertraline: \200 Nausea, vomiting, dyspepsia, diarrhea, abdominal pain \200\224also rash, sweats, agitation, headache, insomnia, tremor, anorgasmia \200 + \200 /e rectile dysfunction (sildena \201 l helps),128 Na+ \200\201, GI bleed- ing.129 Fluoxetine as above (insomnia & agitation commoner). Fluvoxamine as for citalopram but nausea more com mon. Paroxetine as for citalopram except more antimuscarinic eff ects and sedation, also ex trapyramidal symptoms (rare). Sertraline may attenuate happiness, rapture, and love.130 n=1 Tricyclics: Amitriptyline \200\224common SE: sedation, dry mouth, urine retention, blurred vision, postural hypotension, tachycardia, constipation. Other SE: ar- rhythmias; convulsi ons (dose-related). Clomipramine, dosulepin, doxepin as for amitriptyline. Imipramine and l ofepramine less sedating than amitripty- line. Trimipramine more sedating than amitriptylin e. 1 SNRI = serotinin and noradrenaline reuptake inhibitor. Avoid if BP \200\200, U&E \200\200 \200\201, or heart disease. Specialist use only if >300mg; monitor BP if on >200mg/day. St arting dose: 37.5mg/12h PO. SE: Constipation; nau- sea; dizziness; dry mouth; BP \200\200; ADH \200\200; Na \200\201; T \200\200; dyspnoea, hallucinations, arthralgia etc: see BNF. 341 SSRI issues SSRIs are under a cloud as a 2008 meta-analysis shows their eff ects in depres- sion may be no greater than placebo.131 Also, in one cohort study in the elderly (n=60,746 ) SSRIs had the highest hazard ratios for falls (1.66) and hyponatrae- mia (1.52). All-caus e mortality was also higher vs tricyclics.132 There is also the question of suicidal behavi or. In adults, research using the UK GP research database for 1993 \200\2239 found risk of suicidal behavior wasn \200\231t signi \201 cantly greater with SSRIs than vs tricyclics ( but strong suicidal drive is reported).133 Venlafaxine is also problematic.134 In teenagers , the position is complex, and prescribing bodies tend to recommend that no antidepressants be used \200\224but this is unworkable for those many teenagers with formidable mental hea lth problems where there is lack of availability of cognitive therapies, or they are not wo rking. Here the small risk of suicide ( \200\2051 : 4000 ) may be the least bad option.135 Before prescribing: get informed consent from the teenager and the parent/carer. Ensure met iculous follow-up, and ensure that it really is a major depression you are treating, using detailed questionnaires to aid diagnosis. A patient-centered approach to depression We can feel perplexed with antidepressants; it can feel like trial and error when prescribing them . What works well in one person may not help another. There seems to be an ever increasing choice of drugs and con \202 icting information on safety. In this context, the following may be helpful: Advice to give a patient when treating depression \200 Discuss choice of drug and non-pharmacological therapy. Cognitive thera- py is known to be as eff ective as a ntidepressants in mild to moderate de- pression.136 Combined use is better than either trea tment alone. 137,138 \200 Discuss side eff ects, not all side eff ects are undesirable (S SRIs may help pre- mature ejaculation). Warn that there may be an initial worsening of symp - toms in the \201 rst weeks so persevere before therapeutic eff ects are seen. \200 As sess after 4 \200\2236 weeks. If eff ective continue for at least 4 \200\2236 months after recovery, if stopped too soon 50% relapse. 139 If no eff ect, increase dose and review in 2 weeks. If still no response, increase dose if it is safe to do so (un- less poorly tolerat ed), review in 2 weeks. If no response or poor tolerability, switch to an alternative class of antidepressant (special method, p369). y r t a i h c y s P Recurrent depression: of those who have one episode of major depression 50 \200\22385% will have further episodes. Continuing antidepressants lowers the odds of relapse by 65%, whic h is about half the absolute risk. 140 Theories of antidepressant action 8 pharmacological actions are known, and over 20 antidepr essants exist. How do all they lead to a similar response? Why is there a delay? 2 theories : The neurotransmitter receptor hypothesis: Postulates that a change in receptor sensitivit y by desensitization and down- regulation of diff erent receptors (not just \200\200neurot ransmitter at the synapse) leads to clinical eff ects after a few weeks. The monoamine hypo thesis of antidepressants on gene expression: This suggests the eff ect of increased neurot ransmitter at the synapse initiates a sequence of events to give the anti- depressant respo nse. This includes up and down regulation of various genes with subsequent varying expressi on of receptors and critical proteins. 141 Have a non-pharmacological arm to every treatmen t plan Exercise (in wild Nature, eg on or near water ), tai chi (p753), Yoga, social int eraction, psychotherapy (p370), counseling (p380), reading clubs, medita- tion, poetry (rea ding/writing). Join a club, eg Ramblers. Rest from work. People may not want drugs, equatin g them with moral failure? If still unconvinced, an alternative therapy, eg St John \200 \231s wort, may be acceptable? 142 Electroconvulsive therapy (ECT) Mechanism There is MRI evidence for the idea that ECT inter rupts the hyper- connectivity between the various areas of the brain that maintain depressi on.143 Indications NICE recommends ECT is used only to gain rapid (if short-term) improveme nt of severe symptoms after an adequate trial of other treatments has proven ineff ective a nd/or when the condition is considered to be poten- tially life-threatening, in individuals with: \200 Severe depression \200 Catatonia (eg associated with schizophrenia. 144) \200 A prolonged or severe manic episode. Emergency ECT is possible, eg in some elderly pa tients, but rarely used (but the success rate is good, eg 80%).145 Carry on antidepressants when ECT ends: this may prevent recurrences.146 Typical course length: 6 sessions (2 per w eek). Contraindications Recent subdural/subarachnoid bleed; no consent (p402; in- volve rel atives, but they cannot consent for an adult). Cautions Recent stroke MI, arrhythmia, CNS v ascular anomalies. SE: Anesthetic problems; amnesia; delirium/agitation (may respond to don epezil).147 Parkinsonism may improve. 148 Technique Check the patient \200\231s identity an d that \200\230nil by mouth \200\231 for >8h. \200 Ensure a detailed medical history and physical examination has been done, and any illnesses investigated and treated as far as p ossible. High anaes- thetic risk? \200\224See p614; seizure threshold \200\200 if on concu rrent benzodiazepines or anticonvulsants; also \200\200risk of heart complications if on t ricyclics. Liaise between psychiatric and anesthetic staff . Do bene \201 ts outweigh risk s? 342 y r t a h c y s P i ECT is frightening; give calm reassurance away from the site where ECT is go- ing on. (Patients should not witness other patients having ECT.1) Are the consent forms in order (p402; see below)? In the rare instances in the UK where ECT is given without consent, a second opinion from the Mental Health Commission must state th at the treatment is necessary (p402). Ensure that fully equipped resuscitation trolleys are present including a functioning de \201 brillator, suction apparatus, and pulse oximeter. \200 Ensure anesth etist (senior & ECT trained) knows of allergies drugs inter- fering with GA. For counter ing ECT-induced vagal stimulation, she may use at- ropine before using an ultra-short-actin g anesthetic agent with muscle re- laxation (eg suxamethonium) to minimize the seizure \200 \231s muscular component. \200 The ECT machine: checked recently? Reserve machine to hand ? What charge/ energy is to be given? Which waveform will be used (bidirectional or modi- \201 ed sinusoidal, or unidirectional)? See manufacturer \200\231s information. Put jelly on the electrode sites (not enough to allow shorting). See \201 g 1. \200 Whe n the anesthetist gives the word, give the shock. Be prepared to re- strain the patient if paralysis is incomplete. While the current passes, the muscles will contract. This will cea se as the current ceases. After 10sec, further clonic spasms occur, lasting 1min. The onl y sign may be lid \202 utter- ing. Clonus is probably needed for ECT to be fully eff ecti ve. Then coma position and BP/pulse, etc until conscious. Ask the anesthetist to try IV midazol am for those (few) who get very agitated during recovery. Consent for today \200\231s shock is suspect if yesterday \200\231s ECT has made you unable to remember your basic biography (am I divorced?).149 Re \202 ect on the blogs OP- POSITE, and on Hay \200\231s paradox: t he organ giving consent is the organ affected. As in all metaphysical paradoxes, don \200