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Uh So today I will be given a talk on depression, which is a very, very important topic. Um and a very, very common. Um So before I actually give out what the intended learning outcomes are, I usually like to begin with a little bit of an activity. So if you can all close your eyes, I'm going to basically tell you a scenario and I'd like you to imagine the things that I read out. OK, so I want you to cast your mind onto the last time that you were really sad about something, um something that may have happened in your life, which has caused you to feel really sad. Firstly, think about your sleep. How was your sleep? Were you able to stay sleeping? Did you have moments where you woke up during the night? Did you find it difficult to go to sleep? What about your energy levels? How are your energy levels? Especially when there's an activity going on in your lives? What about your appetite? Did you eat or did you eat less and think about your concentration? So think about either your studies or your work. Did you find it difficult to sustain concentration when you were given a, an important task? Did you feel quite overwhelmed when a new task was introduced to you? Ok. You may open your eyes. The reason why I start off with this is because this will help to understand because in our lives, we all do experience something that makes us sad and does have a small impact in terms of our functional being, be it in terms of our eating habits or our sleeping habits or our um essentially our ability to concentrate on things. And it's about recognizing when that basically becomes patho or depression, which is extremely important. So in terms of the intended learning outcomes, by the end of this talk, I hope you should be able to recall the ICD 11 diagnostic criteria for depression and the DSM five TR criteria, which is the more international criteria is not different at all from the ICD 11 diagnostic criteria. So it's one of the few conditions in which there is basically equivalence in the diagnostic criteria. Um Hopefully you'll be able to identify biological, cognitive and psychosocial risk factors for depression in young adults. Um You'll be able to describe biological and psychological methods to treat depression as well as supply the nice KS guidelines on treating depression as well as managing self harm behaviors and suicidal ideations, especially in a primary care setting. Ok. So with that, why is depression important? Why um is this a topic that gets covered a lot in um medical education and in training, this is because, and I've deliberately chosen some statistics which are mainly preic. Um The Mental Health Foundation found that 3% of the UK population have depression. So three in 100 people basically will have depression at some point in their life. And no matter which specialty you work in, in the future, you will encounter a person who is experiencing depression. So it's unavoidable. It doesn't only end up with the GP and the psychiatrist seeing it. Um All specialties will basically encounter an individual with depression um as well. Unfortunately, and this may resonate um with uh some of the audience today which I do put that out as a disclaimer to um do seek support if you do feel affected by any of the content that we discuss in today's session. Um You would in also be discussing self harm and suicide um that do feel free to step away from your camera. Um Well, from your screens when we go to that particular part of the talk and um do feel free to talk to um either your educational supervisor or your personal tutor as well. Um So, unfortunately, medical students do have a statistically significant higher rate of depression than nonmedical students. And we do have to appreciate that training is conducive to such an environment and it, it does have quite a lot of competition which does act as a risk factor in terms of um wellbeing essentially. So let's talk about the criteria for depression, which is our first intended learning outcome. Um So, just to split into core symptoms and biological symptoms with your core symptoms, you need to experience at least two of the core symptoms to constitute a differential diagnosis or the main diagnosis being depression. Um So, dysphemia is persistent, low mood, um anhedonia is lack of enjoyment or motivation and things that you used to enjoy an anergia is um increased fatigue levels essentially. And you must basically experience this more persistently than not over a two week period in order to therefore get a differential of depression. Um You may, you may also experience some or all of the vagal symptoms which may include early morning waking. So with depression, um it's more so the difficulty staying asleep than the difficulty going to sleep, which is more common in anxiety and therefore, with someone with mixed anxiety and depression, it's quite common to, to hear or I'm struggling to go to sleep as well, stay asleep, but in terms of the early morning waking and this is a question to the audience. Um Does anyone know roughly what time is quite common for people with depression to wake up at or say that they may wake up at? Mhm OK. So I can see in the chart 6 a.m. three AM. Um So yes, it's actually more so 3 a.m. to 4 a.m. which is the usual early morning waking time, which is actually quite consistent as I've seen with uh many patients that I've seen both in the primary care and secondary care setting in terms of depression. Um They may also experience anorexia and in terms of anorexia, I don't mean the differential condition, anorexia, reversa, anorexia can reference to uh loss of appetite. Um That said it has been recognized that some people may actually conflict, eat more so than lack of it in depression. But unfortunately, that hasn't caught up yet in terms of ICD 11. Um but it has basically been added on to DSM five tr which got updated in September 2023. Um So do basically appreciate um that um essentially, some people may comfort each rather than lack of eat also due to the preoccupation of life and basically having a low mood that can have an effect on concentration so much so that sometimes it may have an impact in terms of occupational life or academia or social life as well. And with preoccupation and difficulty that that may have on concentration, it's no wonder that will also have an effect on memory as well because you do need to concentrate on things and be attentive to things in order to process it into um your short term memory and rehearse it into your long term memory. Um Also as well, some people with depression may experience guilt and sort of put a lot of blame on themselves uh for situations which can sometimes be disproportional as well in terms of rate and the severity of depression. The rate and scale that is important to know is the PHQ nine, which is, which I'll show you on the next slide, which has some items that basically checks your severity. And this is out of 27. If you score greater than 16, out of 27 you are considered to have a more severe depression. And if you have 16 or less, that's considered as less severe. So here is the PHQ nine which basically composes of nine items and a few times that I read that gives you 27. And if you look at it, it pretty much correlates to questions you should ask in a psychiatric depressive history pretty much, um which would screen for symptoms of depression and do a sort of mini risk assessment to some small degree as well. So little interest or pleasure in doing things, which is the anhedonia, the feeling down depressed or hopeless, which is a dysphagia, the trouble falling or staying asleep or sleeping too much. So, the sleeping disturbances feeling tired or having little energy, the energy, the poor appetite or overeating, feeling bad about yourself, difficulties, concentration, uh moving or speaking slowly as well, and also feelings that you'd be better off dead or hurt yourself in some way as well. And this is basically rated in terms of frequency which will therefore affect the severity in terms of the score. So the key thing is this is checking over the last two weeks. So with psychiatry, it's really important that you know, what is the time period that you need to show certain symptoms in order to have a differential of that particular condition? So it's I would definitely advise as you go for each um condition in psychiatry go like, ok, what is the threshold, how many weeks or how many months um is, do I need to see the symptoms to have a diagnosis? Ok. So that is the diagnostic criteria and now we'll move on to the risk factors for depression in young adults. Um The reason why I've um specifically chosen young adults is um essentially they are pretty much a common group of people you are going to see in most healthcare settings with um depression and also the audience I assume is all pretty much within the young adult category. Um So therefore, this is highly relevant in terms of reflecting on yourselves as well. Um So I go to my next interactive question which is what do you think are common risk factors um for depression in young adults. So if I can have some suggestions, please, that shall be great. Ok, so socially economical background. Yes, definitely. So um socio economic inequality is pretty much a significant risk factor in terms of the discrepancies we see in um mental wellbeing. Yes, medical school. Yes, pretty much, very much so. Um financial issues. Yes, very much so. If there's financial difficulties that would contribute to having to take up more work in order to make up for the financial issues, social isolation and loneliness. Yes, pretty much so. And when we are in the young adult group, our relationships and friendships have even more paramount importance than it did even in our, in our teenage. Yeah. Um um So if you are experiencing loneliness, it is pretty much a melting pot for experiencing depression. Good, great. So thank you all for your suggestions. They are really good suggestions. Indeed. So, um I've split it into biological, cognitive and psychosocial because whenever you're looking at risk factors in psychiatry, these are usually the domains to look at. I should have added medical school to the list because oh medical school is a test in time of trials and tribulations. And as you've seen in the research, medical school definitely is pretty much a hotpot um waiting to happen in terms of acquiring depression. So, in terms of um biological, we've got our physical health issues. So unfortunately, um as some of you may be 25 or older, you do recognize that your body isn't as great as it used to be. I am definitely feeling it on a daily basis. Um My back is still constantly hurting me at this at this moment. And the paracetamol is a norm rather than a rarity um as your body basically meets 25 and uh goes past that 25 period. Um So when you're basically experiencing your body decline right in front of you, that in itself will make you think a lot about being careful about activities that you do and um things that you may eat or your lifestyle a lot more. Um And that sort of constant watching and monitoring your health can be what tips someone over the edge in terms of depression. Um Also, we can't forget the genetic risk where um there is some genetic contribution in terms of inheritance of um depression, in terms of cognitive personality can have an impact and having a neurotic personality in particular is a risk factor. Does anyone know what is meant by the term neurotic? As I appreciate, it can be interpreted in quite a few ways, any guesses at all. Nope. So, neurotic basically means um a person who worries a lot. So someone who is a persistent worrier but not enough to warrant a sort of anxiety where they basically overthink things, um they are more likely to acquire depression because if they're overthinking situations and attributing blame to themselves that in itself is leading to the guilt which will lead to depression. And my particular favorite area of interest of mine that I'm very passionate about, which is neurodiversity. Unfortunately. Um due to factors such as stigma, um the rate of poor mental wellbeing is pretty high in the neuro diverse community. That doesn't mean that being neuro diverse is a mental health condition because it is not, it is just that bit of an increased risk so much so that there was a study by Pierson Zal in 2012 where it suggested that being dyspraxic alone basically increases your risk of depression much more than having a genetic risk of depression in itself. And if we look at the life expectancy and suicide rates in the autistic community, which suicide is one of the greatest contributors to um the reduced life expectancy in the autism community. Life expectancy is 14 years less than life expectancy of an average individual in the UK. So that's quite upsetting. And therefore, it's important that there's more awareness about neurodiversity in order to reduce the stigma and the sort of experiences that neurodivergent um individuals experience, um essentially psychosocial relationships do play a part um for reasons that can only be stated due to being human. Um young adulthood is an age where people may explore the very tur turmoil based concept of having relationships and relationships involve a lot of compromise, a lot of negotiation and a lot of challenges. Um So it's not the most smooth sailing ship in the world. And sometimes that ship can basically crash into an iceberg so much um not referencing Titanic in any way at all. Um That basically can basically be the factor that tips someone over the edge, oh, as expressed earlier friendships as well, has increased importance in young adulthood and is very important to form good friendships in young adulthood. Um to basically take us forward in life. Research has shown that the friendships that you actually make in uni or during your young adulthood last longer than your earlier formed relationships that you've had in your lifetime. So therefore, that experience of loneliness is really rife in that period and therefore, would significantly contribute to experiencing depression, essentially um social expectations as well. And as a family expectations, um raise your hand if already there's a conversation in your household about her possible marriage. And um yeah, so basically that is in itself pretty much a factor um that can get someone over the edge because there are expectations, there's also expectations in terms of how your peers see you. So if you have a particular reputation um with your peers, that in itself is essentially going to contribute to you wanting to maintain that particular um perception that people have of you, which in itself, there may be periods where you can't meet that expectation, which in itself will cause to be the thing that will tip you over the edge. Um O SA University comes with pressures and OSA work comes with pressures and in university is a very different style of learning. It's a very different environment. Some of you will be basically living outside of your family life for the very first time. And that basically comes with a lot of self responsibility and a climatize to a new place and also as well because university and life when you become a young adult becomes quite expensive, some of you may be considering essentially work pressures as well and having to balance work with other things in your life, which can tip, basically be the trick factor, which tips someone over the edge. Um Some of you may have family responsibilities, be it in a caring capacity or be it, you may have Children yourselves, uh which will be a responsibility factor. And we can't forget about advanced life events such as trauma that may happen in childhood that may still have an impact um on that individual today essentially. So those are the risk factors for depression in young adults. Ok. So next, we'll talk about the biopsychological methods of treating depression c whenever you're covering um mental wellbeing and the different question. Um different sort of conditions in psychiatry, it's important to appreciate what are the biological methods of treatment? It ie like medication and what are the psychological methods? So what are the therapies that may be useful for treating that condition? And in terms of thinking about biological and medication, you have to think about what neurotransmitters are linked to that condition. So this is a question I'm going to ask you. So what neurotransmitters are associated with depression? And as an extension, is it too much or too little of that, of that particular neurotransmitter, any guesses at all. And you may put your guesses in the chart as well. Ok. Serotonin. Yes. And is it too much serotonin or too little serotonin which may be related to depression? Little? Yes. So that's the main theory that there's too little serotonin and very good. Thank you. Can anyone think of any other, um, particular neurotransmitters? Dopamine? Yes. And is it too much or too little? Too little? Yes, indeed. Yes. Good and no adrenaline. Yes. And is it too much or too little? Too much? Yes, indeed. So acutely, it's too much noradrenaline, which basically, um, can lead to depression although for some reason, chronically, too little, um, noradrenaline can lead to depression as well. And that somewhat, makes sense in both ways. So, with serotonin, serotonin is your happy hormone. So, if you have too little of it, that is going to correlate to your dysthymia that you're essentially experiencing, um, dopamine is your motivation and concentration hormone. So, if you have too little dopamine, that's going to correlate to your anhedonia and your concentration difficulties and no adrenaline. So, too much of it because it's a stress hormone acutely does correlate with depression, but eventually, chronically, too little of it correlates even better because noradrenaline gives you that sympathetic drive, that drive to basically give you the energy to do things. So, if you chronically have too little of it that will correlate to anergia because you chronically don't have that sympathetic drive to basically give you the fuel to essentially do things that you need to essentially do. So that's how the neurotransmitters correlate. And now in terms of the medications. So I appreciate that in terms of antidepressants, there is technically five classes including tricyclic antidepressants and um, mao inhibitors. I will not be focusing on Mao inhibitors and TCA S today because essentially those are no longer routinely prescribed for depression due to its um associated um interactions with certain foods and certain medications that would be quite not suitable to make them first line um antidepressant anymore, essentially. So I'll be focusing on SSRI Ss and S and Mertazapine. So firstly, in terms of SRI S, this works on um essentially serotonin and works by essentially working on um the reuptake of serotonin. So we increase the um level of serotonin in the system essentially. Um So examples of SSRI s include sertraline, which is commonly prescribed in the 18 and above population and FLUoxetine, which is prescribed in my area of interest, which is the CAM S population. So, the child and adolescent mental health uh population, the side effects are very key to know and that includes essentially diarrhea agitation, it can slow your heart rate. So, bradycardia, it can cause you postural hypertension, which is therefore important that you are checking the cardiovascular history before you're prescribing SSRI S due to the bradycardia and the postural hypertension. And if you work in old age psychiatry, you therefore see why the doses are titrated a more um than the other populations as well. And they may experience increased suicidal ideations. And this is has been found by research to be including anyone below, below and including the age of 25. So this is why it's really important that you do a risk assessment before you throw SSRI S like smarties at patients. Um because we do throw SSRI S quite a lot, so much so that we are almost set in the SSRI crisis. Um because of the amount of times we are basically given SSRI. Um So do check the suicidal ideations because the last thing you want is someone who is actively planning to commit suicide and you've given them their energy from theories that they need to basically go and commit um suicide. Um Essentially. So this is why you have follow up appointments um every 2 to 4 weeks when you're on SSRI S especially in the first eight weeks to make sure, um especially to monitor not only the physical side effects, but the suicidal ideations. And that's why you need to do a risk assessment in every review. Ok. So next is S MRI S. So S MRI basically not only affects serotonin reuptake, but also affects noradrenaline where we also want to bring um some normal levels of noradrenaline in the system as well. Common medications include venlafaxine and DULoxetine and similar to, they do share the side effects of headaches and dry mouth and dizziness and nausea and postural hypertension. But there is also a risk in terms of sexual dysfunction, um be it erectile or in terms of libido. And uh so therefore, we definitely want to check on um what is important to them because the last thing you want is to create relationship issues and exacerbate those relationship issues by dysfunctioning them with your S MRI s. So do bear that in mind before you give S MRI S in the syp. Next, we move on to Mirtazapine. So, Mirtazapine is quite an interesting medication. Pharmacologically, it is the only NASA medication. Um that is, it's basically its own unique class of antidepressant and its method of action is quite different to some of the other um antidepressants where it two alpha two receptors and two of the seven main classes of receptors for depression, therefore increase in the serotonin and the noradrenaline levels. The reason why Mirtazapine sometimes gets prescribed over SSRI is because of a side effect of weight gain. So especially in patients who um are experiencing depression to the extent that they're eating, um they have a significant loss of appetite which may be affecting their weight. Um You may see doctors choose to prescribe Mirtazapine over an SSRI for that benefit of alone of knowing that their appetite will increase, they will therefore gain some weight um which is healthier for that particular patient and those severe sleep is disturbed. Mirtazapine is good at sedating them um much more than sertraline and um other ESR and ESR and other antidepressants as well. Nice guidelines don't recommend this as first line, but this is to explain why you may have seen or may have personally experienced um being prescribed the Mirtazapine first um over an SSRI I just in case. Um So if you think about the fact that you are gaining weight and your appetite is increasing, if your source of fuel is going to be essentially those that contain higher levels of fat, it will make sense. Therefore, that you are going to have a higher level of cholesterol and higher levels of triglycerides. And it will make sense with an increased weight gain um that it's going to affect your bowel habits in the, in the direction of constipation. Um with Mirtazapine as well, it can cause thrombocytopenia as well. So it's really important you do check for any existing clotting disorders because that is a relative contraindication for prescribing Mirtazapine essentially. OK. So that is Mirtazapine. And now next up, we move on to the psychological treatments of depression. So this can be divided into mindfulness, CBT, and psychotherapy or counseling. So with mindfulness, mindfulness focuses on the present in a holistic way. So this changes the relationships between you and your thoughts. Unlike CBT, this doesn't ask you to challenge your thoughts. Instead, it asks you to make peace and accept and acknowledge your thoughts. And not only are you being one with your thoughts, but also with your feelings and your sensations and your surroundings as well. Um So there is more to mindfulness than just meditation. There are also exercises like being mindful of your breathing. Um How many of you have heard of square breathing and feel free to use the raised hand function? Um If there is a raised hand function um to show you may have heard of square breathing before. Mm OK. So square breathing essentially, we will all basically go for it now. So if you can close your eyes and if you can take a deep breath in for three seconds, hold for three seconds, release, breathe out through your mouth for three seconds and hold again for three seconds. Mhm So this is a technique that we offer to people who are experiencing a crisis episode. So when things are basically becoming a bit overwhelming, uh square breathing is useful for taking someone out of the crisis episode. Um So that's the purpose of it. Um Also basically being heightened, be aware and mindful of your daily activities is a great form of practice and mindfulness. So lots of times when people recommend mindfulness, they worry about when are they going to factor it in in your day. But even for example, so I practice mindfulness walking where I am really attentive um to basically what I can see in my surroundings and what I can hear in my surroundings. Um That's a form of um basically mindfulness that I've introduced into my daily routine. So it's something that you can really embed in quite well to your daily routine. Next is CBT. So when mindfulness asks you to basically make peace with your thoughts, CBT asks you to challenge your thoughts. So CBT is on the notion of that, our thoughts basically affects our feelings, which in turn affect our behaviors, both physical and psychosocial in a way that it can basically act as a vicious cycle. Um And with CBT, it essentially looks at breaking this by looking at the negative automatic thoughts that you may experience, that is causing you to basically feel depressed essentially and CBT sessions work to challenge them. Um Does anyone know in terms of a regular course of CBT? Um as per the NHS, how many sessions someone may on average have of CBT? Yeah. So 6 to 12 is the average number of sessions for the CAM S population. It's been found that eight has been the, the most common beneficial number and with adults, it's usually 16, that's quite beneficial and that's mainly because of the frontal lobe development. So when you become 25 years of age, your brain would have matured in that your reason. Uh reasoning part of your brain has fully matured under the age of 25 your Amygdala is more active than your frontal lobe. Um So therefore, you're more likely to accept what CBT is aiming to do. Whereas once you become older, you may start to challenge the challenger. Um in terms of the CBT, hence why you need more sessions as you become an adult in terms of relapse prevention. Um mindfulness based cognitive therapy is what is recommended in terms of uh relapse prevention. This is a third wave type of CBT, which basically works to um essentially not only challenge but make peace with some of your thoughts as well. So it's a relationship between CBT and mindfulness, which is the only one you would basically recommend in terms of relapse prevention. OK. So next up is psycho um therapy and counseling. So these are more focused towards the past where CBT and um essentially uh mindfulness focus on the present. Psychotherapy and counseling works on the past. And even more. So it's the relationship that you have with your therapist, which basically is more of importance than in CBT and mindfulness where it's more the technique rather than the therapist. And that's because in both of these types of modalities, the therapist has an, has an explaining role. So they actually make sense of your thoughts for you. So it's more hands on rather than CBT, which is a bit hands off where you come into the solution. And the therapist just sort of facilitates your journey to come into the solution where psychotic psychotherapy and counseling, explain it for you and makes sense of your experiences. So, psych psychotherapy basically works on emotions and behaviors and on the conscious and unconscious level. Whereas counseling works on your situations and creating growth thinking essentially through decision making essentially. So those are those therapies? Cool. So now that we've covered the different modalities, we'll now look at the nice C KS guidelines for treating depression. So if unless you are severe, the first line is essentially self help. So ideally, you'd recommend things such as mood diaries or headspace or other similar apps um which act as a mood diary, especially if a if the person is a document, if it not a document, um mindfulness could be useful um on its own instead. And you would basically have a 2 to 3 weekly review of the GP whilst awaiting psychological therapies in terms of psychological therapies. The main one that IC Ks guidelines suggest is first line is CBT. That doesn't mean counseling and psychotherapy don't have a place, especially for example, if relationship issues is the problem, then you want to basically have relationships counseling. If there is family dynamic difficulties, then you'd want family dynamic um therapy essentially. So it's ideal to be flexible um around this. But in terms of basically purposes of UK MLA CBT is basically you'll go to uh first line therapy if these two steps have failed. And um and or essentially your symptoms of depression is severe enough to have a significant impact on your um occupational, academic or social life. Then medication SSRI S is basically the first line you want to prescribe. Um That's not the same in your life. You don't see some doctors who prescribe Mirtazapine for the reasons I described earlier. But for the purposes of UK, MLA SSRI S are basically um the go to first line in terms of treating depression. Um If you do have patients who are of higher suicide or risk, then essentially, it's important to prescribe a shorter course and review earlier rather than having four week reviews, essentially. So more so two week reviews. Ok. So that is the guidelines for treating depression. So now we'll move on to self harm and suicidal ideations in primary care. And this is a bit that I do put a disclaimer that if um things do resonate with, you do feel free to um take a step back and whilst we um go through this, ok? So in terms of self harm, what would surprise you is that not everyone who self harms will end up being referred, needing to be referred to mental health team. Um which is something that usually surprises people. And this is why it's important to know the guidelines of when you basically refer people um to a mental health team. The important things that you have to do as a clinician is if they've recently self harmed to assess the severity of the injury basically is the injury infected. So therefore you need to basically give, um, treatment for, um, the site to being infected. Um, have they lost a significant amount of blood that may warrant them to basically need to go to A&E, um, to be treated for it. Um, have you noticed any other symptoms in terms of the site, um, of where they've basically, um, solved harmed? Um, so that's the most primary thing you have to do when someone so harms. That's the first line thing you have to do. Um You also have to assess your mental state and level of distress as well because that does play a feature in terms of constituting a referral and essentially assess for any immediate concern to be safety or safeguarding essentially. Um Again, don't assume everyone who self harms basically, therefore warrant a safeguarding concern. Um because that's not necessarily the case and also assess whether they need a referral essentially. And these are the things that constitute a requirement for a referral to mental health team. So every level of concern is either increasing or high or sustained or if the frequency or the degree of the self harm is intent is increasing. So, despite your efforts, they still are of an increased mind of wanting to self harm if it's done once and they don't want to do it again. Um That is a reason not to refer essentially um because they feel remorse for their actions, essentially. Um if you, the, the provider is basically worried, then that also is a suitable grounds to referral. And um if the patient asks for it, then you have to basically respect for your autonomy and basically um refer them. And if family members are also distressed as well, despite attempts to help, that also is a good grounds for a referral as well. And in terms of what the primary care physician or the GP can essentially do, um, it's important to ensure regular appointments for review of self harm, especially ideally with the GP they disclose to because mental wellbeing is something that takes a lot to tell someone and have the confidence to tell someone about it and self harm and suicidal intent even more. So, so if they've already built that trust to disclose that to you, it's unlikely we're going to go through the whole process of telling another person again. So it's better you follow them up as much as possible to basically keep an eye on them and um, continuously assess because they're more likely to open up to you um, than a new clinician and start the whole process again. Also a review of your medications, not only the SSRI S but also other medications that could be used as a means for self harm as well. And do provide um, information of relevant uh, services to sign post to and manage any particular other uh mental wellbeing conditions which may be affecting them and referred to mental health. Something that I have been asked a lot whenever II do give teaching, especially about self harm is um given self-harm substitutes, what I will say is unless you are a qualified mental health first aider, please please please do not give self harm substitute advice. Um The training that we as mental health first aiders basically get on offering it and monitoring it is is done in a way to make sure that as little harm from a self harm substitute comes as much as possible because some of the self harm substitutes are a different form of danger basically. Um So it if you've not got a mental health first aid license, please please please do not in your practice um recommend any self harm substitutes. And if you are mental health first aid and you've got a license do document that you are often advised on the basis of your mental health first aid training. So that's also protective for you as well. Um I would not be disclosing any self harm substitutes. Um Yes, I knew I was going to be asked that as a question. Um I it it it's difficult for me to disclose any because I do worry about the risk in terms of um advising um in terms of self harm substitutes. But thing. So how can I answer the question about giving him one away? But yes, basically think of when you're when someone is self harm and asking them, um, what, why are they doing the particular mechanism of self harm? Is it for the sight of the blood? Or is it basically for the quick pain relief? Is it the sort of sensation? And essentially the self harm substitute works to basically give a substitute for that particular reason, that face of harm? Um So if it's the blood, given a substitute form for, for the blood, that they can still get a similar sort of sensation. Um Or if it's basically a pain, it's basically thinking about the particular nociceptor um that you're activating through var mechanism and given a different form of agent, which will basically satisfy that very same nociceptor essentially. Um So yes, that's as much as I can say in terms of self harm substitutes. I was ready for that question because it's one that I always get asked a lot. Um So yes, I was ready for it. So on to the next question, which is, when would you refer someone to mental health services or crisis team for suicidal ideations? Um Please feel free to uh place your answers in the chat. Yes. So if they've made a plan to act or harm themselves or someone else. Yes, very much indeed. Yes. Um So it's essentially about the plan or if they've actually done it, those are the two main constituents which basically warrant um a referral. So yes, if they've fought out a plan or have attempted it, then they need referring. And essentially, I've made this as colorful as, as possible to make this easier, to process as much as possible, um, to help, you know, basically what is first line in each different situation. Um, because in your UK MLA, they may vary, um, the, the sort of risk in terms of the particular person you, you have in front of you, um either in terms of your clinical exams or the re exams. So, um firstly, you want to do a risk assessment and if they have general suicidal ideations with no plan, then you basically want to manage the coexisting wellbeing difficulties essentially. So for example, if they tell you, yes, I've had thoughts of not wanting to be here anymore. And if you ask them, have you thought about methods to do? So they go like, no, not really. I've just been having thoughts then essentially you don't really need to refer them. Um because suicidal ideas are actually much more common than people think they are essentially. So you don't want to refer everyone who does have the occasional thought of not wanting to be here anymore. Um The next one is if having suicidal ideations with a plan, um but not ready to act on it or thought to do it. Um So if they say yes, I've had a plan, but I haven't been given the drive to carry it out any time soon. Um Then ideally, they need a non urgent assessment by either the crisis team or the mental health services or wellbeing team within 14 days. So within two weeks, essentially, if they do have intentions to act on it, so if they tell you, yes, I thought of a plan and I do plan to carry it out either tomorrow or tonight or some specified time period. Um Then they need an immediate same day referral to crisis team essentially. And if they acted on it, think of it like self harm, you want to assess the um the um to see any sort of physical things that you as a doctor, um need to es essentially manage and you want to send to A&E as um if required. Um So for example, if it's like paracetamol overdose or medication overdose that does warrant um an A&E send in and assessment and you also want to get crisis team involved immediately as well. Um Or if this is in the hospital setting, liaison psychiatry um involved as soon as possible. So that's basically this triage like system of managing suicidal ideations, ok? So now that we've near the end, I'm going to give you a plenary case and there are two questions that are associated with this plenary that I would like you to give your answers to um in the chat. Um So Mr JJ is a 32 year old man who has come into your primary care clinic after experiencing four weeks of low mood, he has now been finding it to be really difficult to be focusing on work as a salesman and his cells have been going down at home. He has a wife who has an unplanned pregnancy and she does not work. Mr JJ comes to you breaking down during the appointment. So if you can give some suggestions of how you would approach this particular patient. Yeah. Is there something specific causing a low mood? Yes, indeed. So, looking for potential triggers. Yes, good. Any more suggestions? Um Other additional sym symptoms. Yes, they doing a for um depression screen. Yes, good. And what about management? So what management plan would you have for this patient? Yep, you will do a PHQ nine. Yes, indeed. So to screen for the severity. Yes, good. Um Anything else mindfulness? Yes, very much. So. So you'll offer mindfulness in the very first step. Good. So let's basically um go through um the recommended answer. So the approach is you'll take a full history screening for core symptoms and biological symptoms of depression as well as do a PHQ nine to screen for um the severity of it. Um you'll screen for anxiety because anxiety and depression usually happen in tandem um rather than mutually exclusively. Um So it's always worth when you're taking your depression histories to OSA screen for an anxiety history and sometimes those work screening for mania as well. Um because sometimes you may have a patient who may be in the hypomanic phase um in the low mood phase rather than in um the sort of elated phase of the mania. Um You would want to do a risk assessment as well and validate any stressors that um he brings and actively listen as well. And in terms of management, yes, you definitely want to start off with mindfulness uh for this particular individual, some self help uh whilst you're awaiting a referral to CBT, um because your symptoms are not of the threshold of going to free essentially straight off. If the first two don't work, then you may want to offer SSRI S essentially great. So with that, that brings uh my talk to an end. I usually at the end of my presentations like to ask um uh for, to put one thing you've learned in the session. Um So if one of you could please put in the chat, one thing you've learned in the session. Yes. You use the PHQ nine to assess severity. Yes. And the question I have is can depression go away on its own without treatment? And the answer is yes. Um So if it's not severe enough and the person, so with depression, it's all about your coping mechanisms and your strategies with depression, it's difficult to come out of it in a crisis. So if the stimulus that the trigger that is there, that is causing you to, to be depressed is still there and it still rife and still vicious. It's difficult to come out of it without treatment. However, if you're not in a crisis state, um, and you've got more time to cognitively appraise the situation yourself and reason for it. Um, you can basically come out of depression, um, by yourself without treatment as well. Um, which is one of the reasons why it's important to recommend self step one, the self help as much as possible because more times than not it, you can come out of it without treatment. Um Essentially um which we don't seem to tell patients enough of to be the masters of their own wellbeing. Um Good question and suicidal ideation. Great. I'm glad you learned that and I've learned more useful ways of managing depression without immediately going to pharmacological methods. I'm very happy to hear that because yes, we don't put enough power on um the psychological methods and self help. Yes and square breathing. Great. Thank you very much. Um Does anyone have any questions for me? Um at all? Yes, I think. Yes, Tony. I over to you to ask a question. Um Could you repeat what effects like specifically that the neurotransmitters have in depression again? Like too little serotonin needs to what specific symptom and the same for the other ones, please. Yes, indeed. So too little serotonin correlates to dysthymia. Um So persistent low mood because serotonin is your happy hormone. So, if you have too little of your happy hormone. You're going to be, you're more likely to be persistently low mood. Um, dopamine is your motivation and concentration hormone. So if you have too little dopamine, you're more likely um, to be anhedonic. So lack of motivation of things you used to enjoy and you're more likely going to have concentration difficulties chronically with noradrenaline. If you chronically have too little nor adrenaline, you are basically going to be more tired because you lack that sympathetic drive that you need. So chronically, too little noradrenaline leads to anergia essentially. Um So increased fatigue levels. Um I hope that summarized it. Thank you. You're welcome. Great question. Um Any more questions? Hi. Yeah. Um Thanks so much for the lecture. It was really useful. Um I do have a quick question. Um You know, the mechanisms of the um drugs that you mentioned and the antidepressants. Um I'm just a bit confused slightly about the mechanisms. Could we do like a brief explanation regarding that? So, like serotonin, um not the serotonin. Sorry. The SSRI S Yeah, indeed. So let me go back to the diagrams. So with, so with the medications, the things that you want to achieve is essentially increase in the level of serotonin or nor adrenaline. Um So that's what you want to achieve. That's the main goal because more serotonin means more happiness. So with SSRI S, they essentially um prevent your presynapse. So you've got your pre synapse and your post synapse in depression, your serotonin is basically broken down quickly and taken up back into your presynapse. So if they don't have enough time to basically sit on the receptors and create the happy effects. So with um serotonin selective serotonin reuptake inhibitors, they basically prevent that quick breakdown of serotonin and reuptake. So therefore, serotonin has more time to work on your system, therefore increasing in your happiness levels. So that's SSR with Einar similar mechanism where it doesn't only affect serotonin reuptake, but also noradrenaline reuptake with einer. I, we also want to think about your tiredness levels. So if Nordan has more time to basically act on your postsynaptic receptors, that's giving you more time of higher energy levels and sympathetic activation. If that gets broken down too quickly and reuptake, that's basically not going to lead you to feel more tired. So I not only affects the serotonin but the nor adrenaline side as well. And then Mirtazapine basically blocks um the certain receptors um that are associated with adrenaline and um essentially depression. Um And it's quite interesting because it basically antagonizes those receptors which will therefore cause other receptors to make up for the lost serotonin and noradrenaline and those that making up of the lost serotonin and noradrenaline will basically stimulate more happiness and more energy essentially due to compensation mechanisms. I hope that somewhat makes a bit more sense. Yeah, that was really good. It really makes sense. Thank you so much again for the lecture and the explanation. You're very welcome and you're very welcome. And what about acute low noradrenaline? I have as a question. So in terms of acute low, no noradrenaline, it's sort of not enough to make you constantly tired. Um with acute high noradrenaline that correlates to increased anxiety and increased stress. Um but acute low noradrenaline isn't, hasn't reached the threshold to you to start to feel anergic. So think of anergic as chronically feeling tired or for a long period of time, feeling tired. So that's why we want chronic low noradrenaline levels to essentially correlate to chronically feeling uh persistently tired, essentially. Um You're very welcome. Great. Any more questions? Great questions everyone so far. OK. I think no more questions. Oh, great. Uh Thank you guys so much for coming to this um lecture. Thank you so much Mitchell. I'm sure everyone learned so much uh from this and what I just wanted to say, remember, um if you guys can fill out the feedback form, we'll be sending that out shortly. Um And that way if Mitchell can um I either improve or know where he's uh going in the right direction with uh his future lectures if he does any future lectures. And uh yeah, thank you so much again, Mitchell. It's been a pleasure having you. I always thoroughly enjoy your lectures. Thank you so much for having me. It's been a pleasure delivering uh, the, the, the lecture. All right. Well, I'm going to stop the recording and, um, oh, yeah, I'm going to stop the recording now. Yeah.