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 and treatment. Secondary care doctors will come across patients who are: (a) experiencing depression: and/or(b) 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 or who are undergoing some form of psychotherapy, for whatever indication e.g.mixed anxiety/depressive states, OCD etc.

If anxiety is a feature of the condition then it is vital that this aspect must be under control as a panic attack under water could be just a lethal as a convulsion.

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
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 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 whose condition has resolved but requires antidepressants to maintain that state of well being can probably dive safely.

Medication for mental health problems

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 dysrhythmias and are sedative. Modern antidepressants such as the SSRIs including sertraline, citalopram, escitalopram, fluoxetine and paroxetine have a low seizure rate of <0.1% compared with the general population. They are also less sedating and do not appear to impair cognitive function (1-2).
• A serotonin–norepinephrine reuptake inhibitor such as venlafaxine (at a maximum dose of 150mg – but note point below) may be considered acceptable as this is now more commonly used.
• Some antidepressants such as venlafaxine or citalopram may cause long QT syndrome so an ECG may be considered particularly on higher doses.
• They should only be on one psychotropic medication, of whatever type.
• 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 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. If all goes well this could be increased to 30 metres (see comment below).

There is a small but significant inhibition in coagulation in some patients taking SSRIs (2). 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.

Individuals requiring adjunctive treatment for their depression with drugs such as Quetiapine, Lithium etc are unlikely to be fit to dive.

Severe mental health conditions such as Bipolar 1 and schizophrenia are likely to disbar and a history of these would require specific liaison with the treating psychiatrist and a diving physician with expertise in this area. There are separate guidelines for stable cases of bipolar disorder.

Complex cases managed in secondary care are also unlikely to be fit to dive. However rarely there may be circumstances where the individuals mental health problems could be discussed with the treating specialist, taking into account that specialist is unlikely to be fully aware of the potential problems that individual would face in the diving environment.

Psychological therapies

If the diver is still undergoing some form of psychological therapy their underlying condition may temporarily worsen or have variable effects whilst difficult issues are addressed possible interfering with safe diving procedures. In these circumstances the Medical Referee may wish to obtain a report from the treating psychologist.

Referee Actions

When on medication –

We would expect the Referee having contacted the diver and taken an appropriate history to write to the patient’s GP or other treating physician requesting that the attached questionnaire is filled out. The physician can charge for this. If the physician will not complete the questionnaire, a report or copies of the relevant parts of the medical records may suffice if the same issues as on the questionnaire are covered.

When currently undergoing psychotherapy only –

The questionnaire has been adapted such that it could be used to obtain a report from the treating psychologist in those divers who are undergoing psychological therapies only and not requiring medication or a physician’s input, if there is concern the underlying condition may not be stable due to the stage of therapy.

On this basis the referee may be able to sign the form without seeing the patient but in cases of any doubt the referee may have to see the patient to make a face to face assessment.

THE PATIENT QUESTIONNAIRE CAN BE DOWNLOADED HERE

References

1. R Ramasubbu, “Cerebrovascular effects of selective serotonin reuptake inhibitors: a systematic review”, Clin Psychiatry 2004 65 1642-53
2. R J Goldberg, “Selective serotonin reuptake inhibitors: infrequent medical adverse effects”, Arch Fam Med 1998 7 78-84

Reviewed July 2023