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Quick Summary of Depression and Insomnia - GP Management
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Structured summary of depression and insomnia investigations and management in a GP setting - structured for OSCES
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DEPRESSION● Investigations: FBC, TSH, B12, rapid plasma reagin (RPR), HIV, electrolytes, BUN,
UEC, FLTs, BAC, ABG, dexamethasone suppression test (cushing disease also
positive in depression), neuroimaging, ACTH stimulation test
● Types: major depressive disorder, with anxiety, with melancholic features, with
catatonia, atypical, postpartum, seasonal affective disorder, with psychotic features,
metabolic
● Assessment: what sort of depression, eliminate/identify suicidality, identify major
illness, identify environmental influences
● Screening: DASS, K10
● Severity differentiation:
○ depressed mood most reliable to discriminate moderate from non-depression
○ Somatic factors useful for differentiating moderate from nondepression
○ Non-somatic DSM-5 criteria distinguish moderate from severe
○ Severe from moderate most reliable symptom is suicidality →
anhedonia, worthlessness, depressed mood
● Overall Mx:
1. Comprehensive assessmentss
2. Ongoing safety evaluations
3. Setting treatment goals
4. Agreed upon treatment plan to meet goal
5. Good support network
6. Mood charting
7. Systematic, meaningful appointments: review suicidality, triggers, adherence,
side effects, general health measures, substance, progress towards goal
○ Refer to psychologist, psychiatrist for complex issues requiring additional
treatment/complex medication
○ Refer to physio/massage
● Mx:
○ 1st line: lifestyle - avoid alcohol, exercise, stress reduction, diet, sleep, social
support, hobbies, nature
○ 2nd line: psychological (mild depression) - counselling with clinical
psychologist (mental health treatment plan 20 sessions), online (thiswayup,
moodgym, CBT courses), mindfulness medication (smiling minds)
○ 3rd line: medications - moderate-severe depression
■ 1st line: any SSRI or escitalopram, agomelatine
■ 2nd line: another SSRI or SNRI or mirtazapine, venlafaxine
■ Start low-mod dose of 1st line - ½ dose for 1st 3 days
■ Review at 3-4 weeks - good response → continue; partial
response → increase dose until max dose/SE; no response →
alternative from either same/different class
■ After try 2 drugs + no response refer to psychiatrist who will
→
■ Add 2nd agent: 2nd antidepressant, 2nd generation antipsychotic
(olanzapine, risperidone), lithium
● Don’t mix MAOIs with other antidepressants
● Don’t give paroxetine to young women who want to carry child
● Don’t combine bupropion and venlafaxine
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