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Okay, apologies for the delay. Um I'm in my hotel room today and the wifi is a bit dodgy. Um Thank you very much for coming. Can somebody please let me know, shout at me or something? Uh So that if I become to correctly again, um we'll decide what we're going to do at that point. Okay. Uh Okay. So I've got the meeting chat on so you can always pop things in the meeting chat if you prefer. Thank you very much, especially those of you who've come back for a second dose. Those of you who have been in my presentations before know that there is no Power Point. Uh I might occasionally attach a document into the chat for you to download, look at and use in your own time. However, you want the other thing to say to you is that psychiatry and especially talking about difficult topics like depression can be very triggering for some people. And if you feel you need to leave the session because you're getting uncomfortable with the content, then please do so. If you want to talk to me about it, you can find me on Facebook. It's my full name Phyllida Row. Okay. Um, don't send me a send, don't send me a friend request. I never look at those, um, send me a message and I'll get back to you within a day or two. Okay. So last time we were talking about depression about the fact that it's the most common thing as a psychiatrist that you treat. The estimate is that one in four people at some point in their lives will need help um, to manage a mental health condition. And by far the most common of those, his depression. And it's also, in my opinion, by far, the hardest thing we treat and some of the reasons for that are what we're discussing here. Okay. So there'll be lots of questions. I'll be pushing stuff back to you. Try not to feel nervous or shy in psychiatry. There are differing opinions but it's very rare that there's, there's a, just a plain wrong opinion. Okay. So we talked about how you might identify depression before. Um, what kinds of factors? And I'm expecting you all to either shout out or type something in the chat, please. What kind of factors increase your risk of developing depression? No silence, cold. Say that again. Alcohol, alcohol. Yep. Especially dependence, alcohol. Think people think of alcohol, particularly in the west does something that, that makes you happy, that it's a positive thing. But actually you're quite right. It's actually a depressant, well done somebody else. Family trauma, family trauma. Yes, absolutely response to trauma, sometimes called react diff depression. Physical status itself can be a cause of depression. Physical health. Absolutely. Physical health, any chronic disease carries an increased risk of depression. Any chronic pain condition carries an increased risk of depression and those depressions are often quite hard to treat. And also there are some diseases that are specifically associated with an increased risk of depression. Um Parkinson's disease. So not only do they have the increased risk from having a chronic life altering disease, but they have an additional risk simply due to the fact that they have Parkinson's okay. And multiple sclerosis is another one where there's an increased risk over and above the risk in chronic disease and some, some acute problems as well. Um Heart attack probably about a third of patient's who have a heart attack will develop depression even if they make a really good recovery from their heart attack. And similarly stroke patient's again, it doesn't seem to be associated with uh what quality of recovery they get. They are at increased risk of depression over and above the chronic disease thing. So, yes, physical health is a very important factor. There isn't a Tatiana, there isn't a slideshow. I don't use power points. Sorry about that. Yes, but I can't see the slideshow. The presentation is absent. Only your name is on the screen. I can see. Yeah, Tatianna, I, I don't use slides but if you do. Excuse me? I'm sorry. Excuse me? Excuse? No, no, that's okay. That's okay. I know it's unusual. Um, in my sessions. Um, your, what, you know, please, you know, feel free to ask questions in my sessions. We talk around the topic. I don't usually give people the kinds of lists of things that you can just copy out of the textbook, your adult learners. And so when I'm teaching it's very much more around thinking about the relationships, thinking about how things might be working, how things link up rather than just giving you a list of stuff to copy down. Okay. But there will be some, I use mind maps a lot and because of the poor quality of the transmission, possibly not today. Um but I will arrange for copies of my mind maps um to um so that you can look at those and see how, see how I've gone about thinking about the topics. Okay. So that you're right. This is a very different experience from, from the standard Power Point based teaching and learning experience, Dr Farida, it's Sharman and maybe Dr Sharman and hi to everyone. I don't usually uh come in and, and quite part, but I think maybe because there are no slides and there are difficulties with having your camera. I wonder if people might want to put their cameras on just so it's a bit more kind of interactive for people and you feel, you know, each other's presence a bit more. So maybe if people are able to, they could put their cameras on. Yeah, that would be a good idea. Some people are a bit shy. That's okay. But if you put your camera on, I think there's more of a, more of a collegiate feel, a feeling that, that you're not just sitting listening to a radio talk, but I leave that up to you. Nice to see you assad. Okay. We'll carry on a little bit. A Chandon is also got a nice picture there. Okay. We've got one or two people feeling a little bit braver. Um, and apologies if I pronounce your names incorrectly. Okay. So we talked about trauma. We've talked about physical health conditions. What other factors? Uh, just said alcohol. Uh, oh, yeah. So any questions, um, you're likely to find a pediatric problem or, uh, regent managed psychiatric e uh, could we categorize alcohol or drugs in a substance abuse or? They're two different categories? Um, alcohol and used for ways be part of your, um, drug. So least no one ask every patient always ask when you've done the, you know what you get in prescription? What do you buy over counter? Do you use in the alternative? For general therapies? Are you a smoker? Do you take alcohol? Do you take any other kind of recreational or illegal drugs? Yeah. And most patient's are, um, they're, they're a little bit cagey about the alcohol, but they're usually very open about any illegal drugs they might be taking. They know that we're not asking so that we can report them to the police. But that it's important for us to know exactly what they're taking, what they've got on board when we're thinking about prescribing. So most experienced for one of a better term psychiatric patient's, um, will, uh, will be quite open. They, they will still, um, minimize their alcohol consumption. They may not know how much alcohol they're taking. Yeah, it makes more sense to ask them how many bottles. So if they say I, I have a glass of red wine every night. So it makes more sense to say to them, how many bottles of wine are you buying a week? You'll get a better picture of what they're actually drinking. Most people who take alcohol because of, of this dis inhibiting effect. Actually don't know how much they're drinking. Okay. I have a list just off the top of my head. That's got 15 items on it and I'm sure it's not a complete list. So somebody else have ago think about what might affect your risks of depression because these are all going to be important in your history. How about Taiwan? I was going to say about sexual history because I might be amused physically. They might not open up. Yep. So history of abuse or currently being in an abusive relationship, um estimates for frequency of child abuse are distressingly high. And in some countries, very early marriage is considered appropriate, very, I say very early, but it's very early by kind of Northern European standards. And all of these things are have the potential because they're about loss of control. And don't forget that men can be abused uh by their partners as much as women can be abused by their partners, whether they're in a heterosexual or homosexual or lesbian relationship. Okay. Any relationship can turn sour. What else, Dave? No, Dave is only here in Spirit Tatiana. But is there anybody situations? Good situation, stress can also cause like stress at work, getting a deadline, work related stress. Yeah, work related stress. And don't forget the workplace can be a place where bullying happens as much as in the school playground. So an adult can be bullied by other adults and that can be very stressful, very distressing and and may well lead people to the point where they feel that they need to, to kill themselves. So bullying very, very serious. So questions included in your history assuming that you don't know the patient or to have in your mind if you know the patient. Very simple question, what was school like for you? How did you get on at school? Did you have friends? And that's when people might tell you they will believe at school work status in itself is uh so if you're out of work because of the stress is associated with that and also the fact that work is a social activity. And so if you're not at work, there's a, there's a gap in your social life. And so, um uh not, not being in work can be one of those factors that increase risk of depression and indeed increased risk of suicide. Your job affects your risk of depression and your risk of completed suicide. Anybody suggests jobs that make you particularly prone to depression and or completed suicide. What, what are you all aiming to do in life? You all want to be, you know, which is usually to get certified doctors. Yeah, your family. Yeah, doctors increased risk of depression, increased risk out of suicide. So increased risk of depression is particularly noticeable in general practitioners and they have a high risk of attempted suicide. Anesthetists have a slightly lower risk of depression and suicidal ideation, but a higher risk of completed suicide than GPS. Anybody like to think around why that might be because they know the chemical components which look at numbers seats. So access to properties. Yes. Procodol was proper everything. Yeah, they've got the tools. Um nice bit of car or um well known in many cultures as being fatal. And so it's not just about your job situation but it's about access to means. Why do you think GPS have such high rates of depression, anxiety, attempted suicide? It's new to them. The work experience is new to do. We just study. We don't seek missions or pains, questions, uh, job, uh, efficacy demands this job, be efficient. And, uh, GPS are completely going to the situation and a lot of work load is given a very small time. Yeah. Lots of massive workload. Do they work in a team? Some of them, do, some of them have to work a late night shit, like in a trauma symptom. Yeah. A lot of their work is office based 1 to 1 with a patient. Yeah. And if you think back to what I said about not having a job and work as a social event, it's very easy for GPS to become isolated. And then they start on that spiral where they're isolating. So their social life starts to fall away. Their social network, their support network starts to fall away. Okay. They're not the people in northern Europe who are actually at highest occupational risk. I think they come 3rd, 4th, 5th down the queue. What do you think might be at the top of the queue? Farmers hard physical work isolated long hours. Mostly they live on, on a very thin margin and they have access to means lots of the chemicals used on farms will kill you. Okay. So, so have a little bit of uh it's not definitive, but you should have in your mind that some jobs will give extra risk of depression and some jobs because there's access to means most farmers, we'll have a shotgun. For example, they'll have access to farm chemicals as well as all of the usual means for suicide. Okay. Family history is important. There's no obvious genetic link. There are very few obvious genetic links in psychiatry. But if you come from a family with a history of mental health problems, there is perhaps a vulnerability factor in there. So you want to know, does anybody else in your family have problems with their mental health? You want to know uh perhaps those of you who were at the epilepsy session? Remember that one of the most significant risk factors for having uh some kind of epileptic episode is having previously had an epileptic attack. And it's the same for depression. If you have significant depression, even once things are better and and you're calmer and back in charge of your life, there is still um an increased risk that you will have further depressive episodes, your sexed. Um The figures are a bit misleading here because they might be more about reporting the natural experience. So uh women are much more likely to report depression. So we can't really tell whether it's because they get more depression or whether it's because they're better than men at telling someone that they're depressed. And I think in lots of cultures and certainly in the West, we still very much have a culture where there are concepts of, of weakness around men who express emotions, particularly the strong emotions. Okay, we're getting there anything else? Childbirth, don't forget stuff that to an outsider. It looks like it should be a happy thing can actually cause depression. So there's post partum depression, which is a very specialist area. We're not going to talk much about today when women give birth, there is a massive change in the hormones rushing around their bodies. And it's not unusual for women to feel a bit low baby blues at some point. But post postpartum depression is very serious and it can be a psychotic depression. And so it is one of the very few conditions for which we will not try other routes before we go straight to um using electro convulsive therapy. Because if a woman is having delusions and hallucinations that tell her that her baby is possessed by the devil and needs to be killed, you're now responsible for two lives. Okay. It's rare that it's that severe. But if you're dealing with a woman who's had a child in the past year, you do need to think about whether this is postpartum depression. People in prison and the most at risk population in prison are the prisoners who are on remand and I know you're overseas. So you may not be familiar with these terms. Um So on remand means that you've been arrested and that you're not on bail, your, you're in prison being kept in prison until a decision is made about your sentencing. And so these people are in a great state of uncertainty about what the future holds and they get very depressed, especially if it's their first time on remand and they are at very high risk compared to the general population of completed suicide. So again, if you're in a job where you're working with prison populations, that's something you need to be very aware of that. Your highest risk population are the men on remand rather than perhaps intuition might say that the people who are there for very long sentences. Okay. But it's actually, it's the uncertainty there that causes the problems going on holiday. Why might going on holiday increase your risk of depression or indeed any festival that is normally associated with family getting together and things like that because this is the opposite of isolationism. It depends upon what they're thinking at holidays. Some people think opposite of what, uh, holidays, but they think, instead of enjoying it, they think of something else such as work again in that money. Yep. Good. Good start point is when you spend time with your family, isn't that, is that good or can that be disturbing? Should be good? Should be good. But if things aren't quite right in the family and you're spending a lot of time together, it can bring to the front things that perhaps you've been trying to ignore about your relationships about where you are in life compared to where you want to be in life. So these these, these happy events can be triggers for people reviewing their lives, wondering what they've achieved, wondering what they want to achieve things like that. Okay. So are you starting to get a picture for why I say depression is the most difficult thing we handle. If somebody is having hallucinations, that diagnosis is really easy. Understanding what's happening is comparatively really easy. When you're dealing with somebody with depression, you just have so much to think about. Yeah, and you will whatever discipline you go into at some point, you will be working with people whose mental health is impacting on their physical health and vice versa. Okay. So it's very, very common. Lots of people have it. What's your differential diagnosis for depression? You always have to think about. What else could this be? We can see some ideological syndrome but that is too specific to start. Yeah, something in the brain is affecting the thinking of the room. Yeah, that's possible. Yeah, some endocrinological problems uh such as hypothyroidism. Excellent, well done. Uh you mentioned structural changes in the brain. Um So yes, infectious disease, particularly uh mononucleosis, Epstein Barr virus. Um uh mimics depression, dementia, mixed depression, especially as people with dementia when they're in the phase where they're trying to disguise from the world, what the problem is okay. Um will appear to be very vague and pretend they don't know, we're not pretend they don't know the answers to questions. And so they'll, they'll avoid engaging with you, um, normal grieving. Now, this is an important one. Ok. Grief is a form of depression. It's a very particular form of depression. It's a very natural form of depression. And what we know is that if you interfere with the normal grieving process, you increase the risk of it becoming abnormal grieving and becoming pathological. And so if you've got somebody who's depressed, they come to you and they say I lost, I lost my partner three months ago. Still very low in mood. I wonder every day if I should kill myself and go and join them. But on the other hand, I know they want me to be alive. Um, but I sometimes here and see them in the house and I think, you know, I don't know what they're trying to tell me what in that bundle are you going to think about treating? I think that guess we don't treat, uh, if it's a normal dreaming by time they would understand. Yeah, normal grieving. You don't treat okay. The, um, the hearing of voices of people who have passed, seeing them or, or thinking that you've caught a glimpse of them. These are all normal processes of coming to terms with the loss. And so you should avoid, um, interfering in that process. If it goes on for more than a year, then, um, then would be the time where you would start to step in because a year, um, a year. You've, you've done all of the first anniversaries, you know, the first big religious festival, they're not there for the first Christmas. They're not, therefore, things like that, you've done that. So after a year you start to look more deeply. Um Somebody suggested bipolar disorder. Excellent. It may take seven or eight years to be properly diagnosed with bipolar disorder because people don't go to the doctor because they're feeling great and happy and powerful and strong. They go to the doctor because they're feeling so depressed, they're not sure they can get out of bed and so may well be treated for depression. This is a special case bipolar. So one thing that you should try to remember to ask people is especially if this is like a second episode of depression. Um Have you ever had any times where you feel the opposite of this where you're full of energy where you're rushing around doing stuff? Okay? Because it's the hypomanic or manic episodes that defined bipolar. You only need to have one hyper manic or manic episode to have a diagnosis of bipolar. Okay. And the problem with the depression is that most antidepressants, you're a massive risk or flipping that patient into a high and bipolar is a very cruel disease because it's the times when you feel good and positive and energized that destroy your life because that's when you spend money you don't have, when you may well become sexually promiscuous, you might lose your job because you're just so peculiar. So, so it is a horrible disease. Okay. So bipolar good. A newcomer on the scene is long COVID. Yeah, we have a significant population of people who appear to be experiencing symptoms of COVID long long after it would seem that the body is clear of the virus. Um and obviously chronic disease, there are increased risk of depression and, and difficult to treat. Actually, it's very hard to, to get an improvement for them. B 12 deficiency will mimic depression. It makes you feel exhausted, achy, unable to, you know, too tired to manage any kind of social life. Um It can also cause hallucinations, um iron deficiency. So in any condition really, that that kind of gives the pattern of, of tired all the time symptoms. Yeah. So it may well be depression and you need to check, but you also need to think about does this person have a vitamin D deficiency? Um In Britain, we're a very Gray Little Island. It's quite common amongst um populations with darker skins, but it's also uh common and shouldn't be discarded just because somebody has a white skin. I think I'm just about the whitest person. I know in terms of skin color and I still managed to get vitamin D deficiency when I was living in Cornwall, which is our sunniest um area of the country. So routinely think about checking that you're not missing anything physical. Okay. And so if they've not had bloods for a while, think about, are they anemic, what sort of anemia might they have? Are they vitamin deficient? Are they having problems with their thyroid? So, you know, a good, good spread just to make sure you're not missing anything. It may not be the whole story of how they're feeling, but it will certainly not be helping. And in my own practice here in the UK, whoever you are, whatever color you are, you get a full panel of blood from me. Um including um renal liver, thyroid, uh CRP. So looking for signs of inflammation or infection, full blood count, um specific asking for folate iron B 12 vitamin D as well. Okay. Another important population who commonly present with depressive symptoms and will tell you that they're suicidal are some of the personality disorders. Okay. And one of the mysteries or of the psychiatric universe is that even where people with a personality disorder have a genuine depression running alongside their personality disorder, antidepressants don't work very well for them. So they are a very much a difficult to treat group. For most of them. They're not depressed and they're not suicidal. Um They're trying to find help, but this does not mean that you should dismiss their risks. Um Even if you're certain that somebody is not suicidal, there is always a risk of what in Britain we call death by misadventure. So they have a plan to make it look like they've attempted suicide to get help. And that plan will include a rescue plan. And for some reason that rescue plan fails, so they expect to be found by a friend, for example, and that friend meets somebody in town and they go off and have a coffee instead of coming straight home. So increasingly in Europe, we have specialist units to, to work with people with personality disorders because they are so complex and because their risks are not superficially how they might appear. Okay. So what makes it complicated? It's common. The symptoms are also common in lots of physical and physiological diseases. The triggers can be enormously wide ranging including things that superficially looked like they should be happy stuff. Yeah. Um So it is, and then you need to think about what am I going to do about it? Okay. What's the first and most important thing in managing any patient for any condition? It's not a trick question and it's something doctors are bad at. Listen. I just interrupted someone say it again. Whoever you are. I was going to say to ask them, how are they, how they're feeling? Okay. Listen is a perfect, perfect summarize. Yeah. Okay. As doctors for all sorts of really excellent reasons, okay, I'm not arguing against it, but we're taught to be thinking about the next question. Kindness and compassion. Yeah. Even the most annoying patient in the world um deserves your compassion. Okay. Most of the biggest compliment you can get from a patient again, whatever discipline urine is for the patient to say, I feel like you listened to me. And it's because most of the time when they see a doctor, the doctor isn't actually listening to them. You're listening for one or two key words and phrases so that you can formulate your next question. Yeah. And certainly as a medical doctor that, that was, that was how I practiced as a psychiatrist and, and with lots of experience behind me, I'm now confident to say to a patient, okay, I just need a minute or two to think. It's not even a minute or two. But, but when you're just sitting there in silence, it feels like a very long time, even if it's only a small number of seconds to the patient. Okay. So I just, so, so I'm, I'm confident to say okay, I didn't want to make any decisions before I met you and heard from you what's going on? I'm just going to have a little bit of a think about what we should do next and just give yourself that little bit of time and how we get that balance between asking a question, listening to the answer and formulating. Our next question is something that that becomes for each of us are individual style of work and it's just something to bear in mind. And when you see your friends and your colleagues and you say hi. How are you doing today? Listen to the answer. I used to have a boss that we mutually disliked each other. Um, and he would ask me every day, how are you doing today? Phyllida. And most of the time I would say, yeah, fine. And then he'd carry on with telling me what he wanted done that day. And, um, but about once a fortnight I used to say, oh, terrible, hardly slept very low in mood. He never responded to that at all. He just went straight on to tell me what it made. No difference to the conversation. Try not to become that person when you ask your friends how they're doing. How are you doing? Listen to the answer. Ask yourself, how am I doing? Am I okay and listen to what you have to say about yourself? Okay. So that's a very important thing that you can do to help protect your own. Well, being to listen to yourself as well as to your patient's okay. So we finally decided that our patient probably does have a good going depression. We've listened to them, we've heard their anxieties and concerns. The more you listen, the more people will tell you because you're listening. Okay. So what are you gonna do about it? I don't know whether we should tell the patient that they are in a state of depression because some people might not take it uh uh in a good way some might take that as an insult. Mhm. But they know there's a problem, they've come to you because they know there's a problem. So we might tell them first, we had to ask them what is the main reason that you're feeling like this and tackle that? Is it work? Is it some, some situations besides, uh, you're going to want to eliminate all of that obvious physical stuff because all of it may, it may not be the sole cause of the problem, but it's so pretty easy stuff to fix. Yeah. And so especially if they don't often come to see a doctor, it's a good opportunity to get a baseline, even if all of those things are fine. So you're going to say to them and I do, I do think you're depressed and we're gonna do something to help you about it. First thing I'd like to do is I'd like to get some bloods just to make sure we're not missing anything obvious. I don't think we are, but let's just have a bit of a check and see how you're doing physically and it may be that you've picked up something in your history that makes you think. Actually, I wonder if this is something rather okay because you've been listening to your history. So you're gonna listen, you're going to eliminate obvious physical causes, then what you're going to do, you're going to treat them, might, might give something, uh, mood enhancement. Yeah, we might think about 20 depressant antidepressant. It's good. That's the word we're after. So we might think about an antidepressant in a perfect world. Actually, the best management for mild and moderate depression is talking therapy. But that's expensive because it's very time consuming. And certainly in northern Europe we, we have limited access to, to qualified therapists on the NHS. So a lot of people are not in a position to pay NHS waiting list for therapy tend to be very long. So even though that's going to be the thing that's really going to make the difference in the long term for most people, we also need to get in there with some medication to see what we can do to help. And that is usually antidepressants. Okay. So I've done a lot of talking, some of you have done a lot of talking. Let's take a five minute break while you just think about some of the topics and issues. Think about questions that you've got, um, I need to get some more water. So let's meet back here. Don't switch your machines off. You just um uh leave it running, let's give it five minutes. So back to start talking again at 10 past 12. Mhm. Uh Oh, hello. Can people hear me? Yes, we can hear you. Brilliant. Thank you very much. So, thank you for questions that have come up in the chat. Um I've put a couple of bits of reading in there for you. Um The, the fact sheet is very short to the point but useful reading and uh summary of recent findings about the impact of war on depression. Okay. I've also attached a copy of my worksheet that I used when I was thinking about what to talk to you about. Uh it's not perfect. Um but perhaps it's a starting point for you to build your own mind map. Um I do tend to work in, in mind maps because they help me see how stuff fits together rather than just making lists of stuff. Okay. So um there will be another mind map for antidepressants themselves probably has more information on it than, than you need uh at most of you at your level. Um But there'll be, there are certain antidepressants that you need to know about because you will come across them very commonly. OK. Somebody asked very sensible question. They dave, I think when anxiety and depression coexist, how does it present? And this is a very important question. You, the patient may well come to you with one or the other and it's like anxiety and depression are best friends, they always go out together, but like best friends, there tends to be one dominating at any one time. And so what you need to do is explore with the patient, which one they think is dominating. And I sometimes use an analogy like, you know, best friends, they go out, but there's usually one in charge. What do you think is driving? Who do you think the driver here? Is it the anxiety that stops you from going out? So you become depressed because you're isolated or is it the depression that's making you anxious about going out? And the patient may need a few seconds to think about that, but most of them will be able to, to unpick for themselves and then tell you what's in charge, what you do about it then affects what decisions you might make about their medication. Okay. And so that's what we're going to come on to talk about next. And I really apologize. I, I usually try to at least have a spider started for you. Um, and that just hasn't happened today because of pressure of work. Um I might try to get a photograph that I can at least upload for you. Um It will be difficult to read and then later on I'll arrange for, for a proper diagram to, to be made available for you. Okay. So downsides of antidepressants, there's one very, very big downside that is a big contributor to what makes depression difficult to manage. Does anybody have any ideas? What that might be? Because it's something most people, especially non psychiatrists um, tend not to think about. So, here's a tricky question and it's the fact that we have no antidepressants that will have a significant impact on symptoms for at least three weeks and for many patient's won't reach full therapeutic benefit for five or six weeks. Why is that a problem? By the time it shows the fact, it might be just focusing on the changing the mood rather than the other effects. Just see the patient is getting better than we still hoping. Fine. Yeah, some patient's I do actually improve quite quickly and I would suggest that that's more around um suggestibility. However, what you do find is that where you've got a lot of anxiety in the mix that the anxiety will often um start to settle quite quickly. Okay. And so within a small number of days, the patient may well be feeling better simply because they're a bit less anxious. Okay. So that's the first thing you have to talk to your patient about. They, you've decided you're gonna give them some medication, you tell them about that and explain that it may take a little bit of time to work. Okay. What's another very important thing that you must warn patient's about when you start them on an antidepressant uh addiction. Somebody started to say something, I was going to say addiction, but I've never heard any, you know, some addiction. Now you're, you're, you're slightly barking up the wrong tree there. Some, some anxiolytics, you're, you're right, there is a risk of addiction. So if you're going to start somebody on a benzodiazepine, for example, you would think about that. Um But, but patient's will ask you about addiction. There is something that does worry. Some patient's okay. Um, so you can reassure them on that point. They've all heard horror stories of people becoming addicted. Your biggest worry for your patient. Your biggest worry is that round about day 10 today, 14, some patient's a significant proportion of patient's, well, actually have increased. Um, they're, um, their risk of suicide. It can actually make things worse, okay. Um, and they become, um, they become much higher risk of suicide. If they're having suicidal impulses, they will find it easier to respond to, to those. Um, sorry, I just had a message pop up on my screen that I had to answer. Um, so that is something you must warn patient's about that. It might make them feel a little bit worse. So you got a patient, you're giving them a medication that in five weeks time you'll know whether or not it's helping and you're telling your patient that in two weeks time they might actually feel worse. That's quite a difficult conversation, isn't it? So, what are you going to do to safety net that patient in case they get this worsening problem? We might say that they might need to be under an observation. If you think the patient is very high risk of attempted or completed suicide and they can't reassure them, they can't reassure you that they can keep themselves safe, then yes, you will hospitalize them. If you're in the NHS, you will hospitalize them, assuming that there's a bed. Okay. But, yes, you will think about, should this person be out in the community? What sorts of things might be protective? If the medication is not helping, then we might have to stop. Yeah. But that's going to be a long, long wait, isn't it to find out whether or not the medication is helping? What about family? Who do they, someone, someone to observe them, like, within the family? Yeah. More useful in some ways. Yeah. Is, if you start to get impulses that are really overwhelming you, who could you tell like a child it could be a better, uh, a partner. Yeah. Parent partner. Adult child, best friend. Yeah. And what facilities, uh, pets, pets can also be useful in the prevention of your business. Uh, sorry, a pet, scan a pet, pet? Like a dog, a pet? Yes. Yes. Absolutely. That, that unconditional love. And that's what we all seek all the time. That's a normal impulse and animals are particularly good at, at giving that unconditional love. Yeah. And some animals are, are very sensitive to the mood of their humans. Um, and you hear lots of stories about, um, you know, I'm, when I'm not. Well, my dog, my cat and so on. So, yeah, having a pet is a strong protective factor. What if you're patient tells you without really talking about being depressed that they've decided to give away their pet, that they've written a will, um, that they've made sure that, you know, they've picked all their taxes, all their tax affairs are in order and so on. Should that ring any alarm bells? Like the bat being a music, uh, companion of the person. Yeah. These are somebody tidying up their life. These are very worrying signs. This is somebody who is planning on leaving. Yeah. And so it's very important that you pick up on that. Yeah. And that you respond to them, what is the best way or finding out if somebody is depressed the most accurate? This is not a trick question. Well, how have you been talking, like, in what way they have been doing? Yeah. Well, one question can you ask that will tell you what you need to know. It's not a trick question. It's as obvious as it sounds. I was just ask, how are you feeling, how are you feeling? You can specifically ask, are you feeling depressed? Yeah. And sometimes patient's will be say, able to say to you. Well, I am a bit unhappy. I don't think I'm really depressed. Okay. So that gives you a start point. Say, well, they might say, yeah, I think I'm really depressed. I'm just not coping with anything and then you can start to explore what triggered it. How is it? Is this the first episode? Is it getting better? Is it getting worse? All of your usual questions? Okay. So good. Well done. So we've warned them that they might feel a bit worse. We've checked with safety netted as best as we can. We started the patient on an antidepressant and we're talking a minute about which antidepressants we might try. Um, but what else? So, when are we going to check in with this patient? How long are we going to wait before we see them again? You bet you don't waste. Sorry. It would be better if we don't wait. We start as soon as possible as soon as possible. Yeah. How long, how long till we know whether or not we've benefited the patient? Um, by um, by starting them on medication? Two weeks, maybe how many weeks? Two weeks, two weeks, maximum 10 days with me. If the medication was wealthy enough to work that 10 days will be left. Yeah. So we want to check in in about 10 days time, 10 days, fortnight. That kind of time. Yeah, but we want to check in because that's the high risk period. We want to check in to make sure that nobody uh, that they're not getting any side effects that they can't tolerate. Yeah. Um Are we expecting to see any particular benefit at 10 days to a fortnight? That's just a slight better answer than we ask. Okay. Are you feeling depressed? Yeah. So, but we're not expecting to get any difference in their mood at that point. This is a safety check that we're doing at 10 days to a fortnight. Yeah, some patient's may tell you that their anxiety has improved and has reduced, but that will be about all you'll get. So really at that point, you're checking, am I causing physical problems that you're not tolerating? Because we've got choices of what we give we need to think about. Um Are they, are they now higher risk than when I started treating? And you need to check that, that safety net is still in place and you, for some patient's, you may need to think about. Does this patient actually need to be in hospital if they get this increase in suicidal ideation, it usually only lasts three or four days at most. So if they can tough it out with the right kind of support, then that will, that will, they will soon start to feel better. It's almost for some patient's a sign that the drug is actually getting into their system. Okay. So, do anybody know of any particularly useful, um, drugs? Have any of you come across? Anything that you've seen work? Well, anything that you find that you've perhaps heard or seen other people doing well with? Yeah, I've never come to my, someone was used medication because in our country, depression is not, they were taken seriously. Yeah. And where, where from? I'm in India. Mental health is not taken seriously an X around the point. And that, that is actually a global problem. It's more or less in different places. Um, but it is, it is still a global problem that somehow there's a sense of shame, there's a sense of stigma attached to mental health. Okay. I'm just trying to get uh, um, the spider map for antidepressants up for you. Okay. Um, I've been trying to, to upload it, but somehow my laptop doesn't want to play. So hopefully somebody can, can get that first draft up for you for you to look at amitriptyline. Somebody's put up as a drug. It's true. Amitriptyline is a tricyclic antidepressant not often used these days, um because it has lots of nasty side effects. Okay. Um It is, it's one of those drugs that we sometimes use in psychiatry, um because it has lots of different uses. So it's very good for managing nerve pain, neuropathic pain. It is very sedating which for some patient's can be an advantage. Um, but it's also um it can be quite uh antihistaminic anti cholinergic. So it's quite dangerous in overdose because of the anticholinergic properties. On the other hand, it has the benefit of being cheap. Um, so it's a useful drug. It has its place. I would rarely use it for psychiatric purposes. Um Okay, you should have a mind map. Now that's just appeared excellent that you can um download, as I say, sorry, it's my first draft. I haven't had time to make a draft that you're going to be able to read easily, but I will do this in the foreseeable future. Um so that it will be there for you to access along with the recording. Oh, of the session. Okay. So amitriptyline, the mainstay of treatment, at least initial treatment and mostly in non specialist hands uh will be the SSRI s the serosous serotonin specific re uptake inhibitors. Okay. And they work well what the name tells you. Uh they work by inhibiting the breakdown and re uptake of serotonin molecules in the synaptic cleft. If so that there's a greater concentration in the synaptic clef. Okay. So serotonin we know has a very significant role in depression. People with depression, it's routine. You found when tested that they have lower levels of serotonin than we would expect. Okay. So, very useful drugs because a lot of them are also anti axa lytic. So, so if you've got a patient who is talking to you about how anxious they're feeling as well as their depression, then you're probably going to be looking at um sertraline or citalopram, both of which have very beneficial effects in terms of increasing serotonin and both of which have good anxiolytics. Okay. The jury's out on which one is better anxiolytic. I think citalopram is better. Other people think sertraline is better, they're both good drugs. What you get is you get a slightly different side effect profile. So basic rule of thumb in psychiatry, the more power a drug has the stronger it is for one of a better term, the greater the risk of unwanted effects. Okay. So sertraline very easy on the system. So Tala prom tends to have slightly more unwanted effects. So common effects that patient's might mention to you would be gi disturbance and this can be anything, they can feel a little bit nauseated, they can have a little bit of runny tummy, um varies from patient to patient. And so I tend to avoid, um, specifying what that unwanted effect would be. I use a vague term. I say, you know, I call it wobbly tummy because different people get different things usually short lived for some people. They can't tolerate it. And so you, you swap them to something else. Okay? Um, Citalopram, as I say, in my opinion, has a little bit more welly than, um, sertraline, but the jury is out on that people tend to get slightly more side effects, slightly higher risk of the gi disturbances. And, um, it can give people vivid dreaming and leaving nightmares. So, not a good choice if you're patient tells you that they get nightmares okay, because you might make that worse. So, Citalopram, as far as I can tell the world is divided into two, um, those that it makes them feel really queasy and sick and those that it gives nightmares too. I've not come across a patient that gets both. And so if you really want to use it, then if the patient tells you that. Yeah, it's kind of okay, but I still feel really sick. Tell them to take it at bedtime and if the patient says to. Yeah. But I think my nightmares have got worse, suggest that they take it in the morning. So it doesn't matter what time of day you take it as long as you take it fairly consistently. Okay. S S R I S, um, another important thing to mention to patient's is that it can affect um sexual function. People may experience significant loss of libido and if their relationship is already under strain, that can be a big problem. And it's certainly something even if they're in a good relationship that they would want to make sure that their partner understands. Okay. Um So sex is important and you have to specifically ask about it slightly more worrying, especially in the elderly population is that it can cause hyponatremia. And that's because it, it um increases the risk of S I A D H syndrome of inappropriate anti diuretic hormone. Yeah. And the other thing is that it has actions at receptor five ht. Don't worry too much about that. But no, that, that's also involved in um uh in platelet depletion. And so there is a risk of bleeding and these are not high risks in the elderly and, and are negligible risks in the young and fit. But if you've got somebody who has already had a hemorrhagic stroke, for example, you probably don't want to be reducing their platelets. Um So again, you just need to think a little bit about um what do I want to achieve for this patient? What do I want to avoid for this patient? And that, that's good prescribing practice. There is also something called serotonin syndrome, which is why you should avoid giving people more than one serotonin increasing drug at a time. Um It's rare but it is potentially fatal. But if you stay within guidelines, don't prescribe um to serotonin uh reuptake inhibitors at a time and so on. So you just have to be aware of what the drugs you're using do because some patient's do end up needing several antidepressants and some patient's may need to try several antidepressants before they find one that suits them and works for them. So, in terms of um sexual function escitalopram, which is a comparative newcomer on the block um is, is probably the best, has the least effect on libido. And paroxitine is, is by far the worst. Okay, very commonly used is FLUoxetine. Um It's quite an old drug by psychiatric standards and it means that general practitioners have had lots of experience with using it and they feel comfortable. It's a, it's a good antidepressant. Um It's comparatively safe. It comes with all of the caveats of all of the SSRI S and then very new to, to the city, not on the SSRI is this one called 40 Oxytocin. It's only been a couple of years since in the UK. It's been taken off specialist prescription only. Um And it's a little bit unusual in that as well as being a re uptake inhibitor. Um So it reduces breakdown of serotonin molecules. It also has a direct effect on serotonin receptors. Um So, uh some people who seem to be a little bit treatment resistant do very well on, on the on vortioxetine where they've had a little bit of positive response to the older SSRI s but perhaps not as much as you would hope. Okay. So, amitriptyline, somebody specifically mentioned it's, it's um so amitriptyline new is a tertiary amen um often useful if you've got a patient with chronic neuropathic pain, with sleep problems and so on, but pretty poor in terms of antidepressant um actions. The other important thing to know about the T C A s is that they are really cardiotoxic, okay. They can cause hypertension, tachycardia and Q T C prolongation. Now, who can tell me something about U T C or Q T interval? Some of you must have done some cardiology. Uh Can you shout at me? I'm a bit deaf. Uh It's uh polarizing of the ventricle stone than the giant bare stone. Good. Well done. What happens if that interval gets too long, irregular heart rhythm, irregular heart rhythm. And what does an irregular heart rhythm cause? Uh what's all sorts of things. Yeah, death infraction that, yeah, it's kind of better to not kill your patient's. So anybody with any history of any heart disease at all? You cross the tcs off your list? Okay. The safest antidepressant in terms of cardiotoxicity is certainly. So as soon as a patient tells you or you see from the notes that they've got any kind of heart condition and they've got depression, sertraline is going to be your choice. Okay. We've got a few minutes left. Um So how to calibrate effective dose for different patient's important question. So in psychiatry, don't forget we're screwing around with the brain, the brain is a black box. Okay. So the answer is always start low, go slow. So sertraline you starting dose would be 50. Give the patient four weeks of that with all of the supervision that we've just talked about and assuming that they're feeling a little bit better but still not, well, at four weeks, you can think about going up to 100. So sertraline goes up in steps of 50. Okay. It's the same with any of these drugs. Check with B N F, check with your local guidelines. Start with the lowest available dose and see what happens. And this is one of the factors that makes depression hard to treat because you've got a patient who is going to be unwell for a significant period of time. Psychosis. I can have you feeling better in three days. Yeah. Depression. It may take months. Yeah. Okay. So, so yes. So that's one of the challenges with it. So start low, slow increments. If you really feel the patient can't keep themselves safe, then don't, don't worry about medication, get them into hospital if you can. Okay. Mono oxides inhibitors. They're on the bottom left of the chart that somebody is very kindly uploaded for you. They're rarely used these days. Um Mostly because of very high risk in terms of drug, drug and food, drug interactions. Um They come in two types, reversible and irreversible. Soma clobber might is the most common. I would use them as, as a final option for a patient whose depression seems to be very treatment resistant. And of course, if you've got a patient that you've tried several different antidepressants and nothing's helping, then you do need to ask the question. Um Are they actually depressed? Okay. So always have that at the back of your mind. If a drug isn't working, are they depressed? Yeah. Another drug that I use a lot. I usually give patient's a choice to three. Okay. So the pain I'm handing power over to the patient to make a final decision based on potential benefits versus potential unwanted effects. Okay. So, one of my favorites is much as a pine. And the great thing about Matassa Pine for some people is that it's quite sedating. It's the only one apart from the T C A s that I would recommend taking at bedtime. And the other thing about it is it makes you hungry. And so one of the things that we talked about symptoms of depression are disrupted sleep and disrupted appetites. And so for some patient's Matassa Pine because of its side effects is a really useful drug. And it's very, it's almost unique amongst the antidepressants in that. Instead of having a big effect on one or two points in, in the urological system, it has small effects across several. Okay. So it affects histamines, it affects um alpha receptors, uh all sorts. So again, for some patient's that seems to work a little bit better than the kind of all or nothing of the SSRI. And so do think about unwanted unwanted effects because sometimes for your patient, these are going to be wanted effects. And because of the way Mirtazapine works at low doses, you get the improved sleep and increased appetite. But then as you go up the dose is those, those effects vanish will become much less and you get more of the antidepressant effect. So in lots of ways, it's a very useful drug and I usually include it in my options unless a patient is clearly obese. In which case, you don't want to be giving them a drug that's going to make them hungry. Okay, you can always add in things to help me sleep rather than having the both at the same time and the other big gun drug for people who have tried lots of different antidepressants with little success. My last choice is Venlafaxine that you'll find down towards the bottom right of the chart. Um Very good antidepressant for some people. It is literally a lifesaver but horrible side effects, very difficult to get patient's off it. Not because they're addicted, but because their body habituates to it because one of its unwanted effects is around calcium channels. So, apologies, we don't have time to talk much about calcium channels. Now, think back about all of the things calcium channels do. Patient's find it very difficult to tolerate venue. Fax in some patient's were report feeling like they're getting little electric shocks running through their muscles or even through their brain. And they do find that very difficult. And the other thing that you have to caution patient's on Venlafaxine about is that they must not stop it suddenly, they will feel absolutely dreadful. Um And so to get people off it, it's um it's a slow down hydration because even a small step down, they won't necessarily get a worsening of their mood, but they will get an increase in any unwanted effects that they've experienced when increasing the dose. Okay. So thank you very much for your attention. It's been a long session. Um But I hope you found it interesting, I hope it's given you some ideas to think about and especially the the conflict that we have that are most common disease in mental health is actually the hardest one to treat and manage because it is surprisingly complicated. Okay. So, thank you for your concentration. Thank you for your patience while I was struggling with, with technology. And um I think we've got some sessions on psychosis coming up. Hope you enjoy what's left of your day and I'm sure I'll see some of you again soon.