Depression in the UK is very common. Most cases are managed in primary care with only the most severe requiring specialist assessment and 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 and worthlessness, poor concentration and decision making, occasionally thoughts of self harm and suicide. These symptoms are also observed by close friends and 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 at: http://www.who.int/whosis/en/
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 and decision making, or the irrational decision to use diving as form of suicide. This would put the sufferer and his buddy at risk.
There are also concerns about theoretical risks of diving whilst taking antidepressants.
However a patient who’s depression has lifted and 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 and are sedative. Modern antidepressants such as the SSRIs citalopram, fluoxetine and paroxetine have a low seizure rate of <0.1% compared with the general population. They are also none sedating and 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 and anxiety.
- The condition for which they were prescribed should have resolved and treatment should be in the maintenance phase. This means that they should have returned to work and normal daily life.
- There must be no history of upward mood swings associated with lose 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.
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 and the slight theoretic risk that they might increase narcosis.
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 patients medical form and all correspondence should be sent to Dr’s Farrell and Beer at Townsend House, Harepath Rd, Seaton, Devon EX12 2RY.
This is so we can audit any problems with the new guideline. The patient must be asked for their consent for this to happen and be advised that we will be contacting them in one year.
Download patient questionnaire (29KB .doc)
Arch Fam Med 1998 7 78-84
J.Clin Psychiatry 2004 65 1642-53