Depression and Medication for Mental Health Conditions

Depression in the UK is very common.  Most cases are managed in primary care with only the most severe requiring specialist assessment & treatment.  Secondary care doctors will come across patients who are taking antidepressants on a regular basis.

The aim of this guideline is to provide a basis for the assessment of divers who wish to dive whilst taking antidepressants.

Depression is a condition where the patient experiences a disorder of mood. They complain of “being down”, unhappy, sad, tearful, poor sleep, feelings of hopelessness & worthlessness, poor concentration & decision making,  occasionally thoughts of self harm & suicide. These symptoms are also observed by close friends & relatives.

The cardinal diagnostic features are
·               Poor sleep
·               A black cloud hanging over the day when they waken
·               An inability to get pleasure from things such as hobbies that formerly provided pleasure

The full diagnostic features are listed in ICD10

http://www3.who.int/icd/vol1htm2003/fr-icd.htm

The concerns are that a diver who is suffering from depression may not be able to function in the water due to anxiety, poor concentration & decision making, or the irrational decision to use diving as form of suicide. This would put the sufferer & his buddy at risk.

There are also concerns about theoretical risks of diving whilst taking antidepressants.

However a patient who’s depression has “lifted “ & is now clinically cured but requires antidepressants to maintain that state of well being can probably dive safely.

Divers who are taking antidepressants must satisfy the following criteria:

• Patients should only dive on the newer antidepressants. The older tricyclics reduce the fit threshold, can cause dysrythmias & are sedative.  Modern antidepressants such as the SSRIs citalopram, fluoxetine & paroxetine have a low seizure rate of <0.1% compared with the general population. They are also non sedating & do not appear to impair cognitive function.
• They should only be on one psychotropic medication.
• They should have been used for a minimum of three months before diving to allow for resolution of side effects e.g. heightened arousal & anxiety.
• The condition for which they were prescribed should have resolved & treatment should be in the maintenance phase.  This means that they should have returned to work & normal daily life.
• There must be no history of upward mood swings associated with loss of judgement.  For upward mood swings to be significant they have to be persistent for at least four days with an unequivocal change in functional mood observed by others.  The symptoms include decreased need for sleep, racing thoughts and excessive involvement in pleasurable activities that have a high potential for painful consequences.  Thus a history indicating loss of judgement with unrestrained buying sprees, sexual indiscretions etc are incompatible with diving.  Antidepressants are known to worsen this condition.
• There is a significant relapse rate when stopping antidepressants.  Following withdrawal, further information regarding the patient’s mental health will need to be obtained from the GP. The patient should also not dive during the withdrawal phase. For short acting antidepressants such as Paroxetine, the suggested period is six weeks.
• Diving on second line antidepressants such as Mirtazepine may be considered provided the diver meets the above criteria. An initial depth restriction of 20m is advised to ensure there are no interactions with the medication and pressure. No decompression limits are also advised to permit direct return to the surface if necessary.

There is a small but significant inhibition in coagulation in some patients taking SSRIs.  This would exacerbate the bleeding phase of DCI.  It may also make the bleeding associated with barotrauma worse.  It is therefore recommended that the maximum depth should be an E.A.D of 30 meters to minimise the risk of DCI & the slight theoretic risk that they might increase narcosis.

Referee Actions 

We would expect the referee having contacted the diver & taken an appropriate history. To write to the patients GP requesting that the questionnaire is filled out.  On this basis the referee may be able to sign the form without seeing the patient if there is any doubt the referee will have to see the patient.

THE PATIENT QUESTIONNAIRE CAN BE DOWNLOADED HERE

References

Arch Fam Med 1998 7 78-84

J.Clin Psychiatry 2004 65 1642-53