DepressionAlison Turner-Parry

Sam Rosenburg

Aims

To have an enjoyable time covering elements of the GP mental health curriculum.

Objectives

GP’s should be able to recognize depression and assess its severity.

All depressed patients should be screened for suicidal intent.

Treatment options. Conservative management

Referral to other agencies

Simple Drug treatments

Not touching upon…..

Pathogenesis of depression

In depth detail on medication – BNF / SIGN

Treatment resistant depression - refer

Children and Adolescents - CAMHS

Quiz …..

Depression

WHO defines depression:

“A common mental health disorder that presents with depressed mood, loss of interest or pleasure, feelings of guilt or low self-worth, disturbed sleep or appetite, low energy and poor concentration.”

How common is depression ?

121 million people affected worldwide.

850,000 lives are lost worldwide per year

In the UK, 2-3% of population experience depression

Cost of mental health problems £77 billion / year

Lost earnings due to depression - £9 billion / year

Cost of anti-depressant medication - £300 million

In the UK, depression is 3rd most common reason for consultation in general practice.

The leading cause of disability in developed countries.

Challenges facing the GP

Inconsistencies in the doctor-patient relationship

Limited consultation time

Non-specific presentations

‘one other thing doctor’.

High-Risk Groups

Elderly

Chronic illness

Young men

Alcohol

Substance abuse

Victims of abuse

Significant negative life events

Existing psychiatric disorders

Postnatal

History of depression

Screening for Depression

QoF rewards practices that screen patients with diabetes and CHD with 2 depression screening questions.

During the last month have you been bothered by feeling down, depressed or hopeless ?

During the last month, have you been bothered by having little interest or pleasure in doing things ?

How would you diagnose depression ?

What are the signs and symptoms of depression ?

ICD 10 or DSM IV criteria

“a patient should experience at least one of the following, on most days, for at least 2 weeks.”

Persistent low mood

Anhedonia

Fatigue or low energy

Other symptoms.

Disturbed sleep

Poor concentration

Poor or increased appetite

Suicidal thoughts or acts

Agitation or motor retardation

Low energy

Guilt or self-blame

Low self-esteem

Feelings of hopelessness

Severity of depression

Sub-threshold depression <4 symptoms

Mild-moderate 4 symptoms

Moderate to severe 5-6 symptoms

Severe depression > 7 symptoms

Also need to consider functional impairment.

Diagnosis of Depression

History PC,

Past psychiatric History,

Family history,

personal history,

Medical history, drug, alcohol history

Occupation,

home situation,

social support,

attitudes and beliefs.

Diagnosis of Depression

Mental state examination Appearance and behaviour

Speech

Mood

Hallucinations, delusions

Insight

Risk Assessment

Current thoughts of self harm or suicide If no, Previous thoughts and attempts

Act on these thoughts

Is there a plan and establish details Is there a will, have they written letters, attempts in the

past.

Differential Diagnosis

Dementia

Hypothyroidism

Anaemia

Stroke

Drug effects – substance abuse, NSAIDs, OCP, steroids

Bipolar disorder

Psychosis

Other psychiatric disorders, adjustment disorder, bereavement

PHQ-9

Assessment tool to look at the severity of depression Not used to determine the need for treatment

9 question self-report

Maximum score is 27

Score of 12 - threshold for considering intervention

QoF Within 28 days of diagnosis of depression.

5-12 weeks after the initial recording of severity.

Depressed…… what next ?

Immediate referral to IHTT.

GP follow up.

Referral to secondary care services

Immediate Referral

Immediate risk to themselves or others

Actively suicidal

Has psychotic symptoms

Has severe agitation accompanying severe symptoms

Has deteriorating personal circumstances exacerbating their mental illness

Severe depression who cannot be managed outside hospital

IHTT

In York, IHTT are the gatekeepers to Hospital Admissions.

Available 24 hours a day, 7 days a week.

Offer face to face assessment within 4 hours of receiving an appropriate referral.

Ensure that people experiencing acute, severe mental health difficulties are treated in the least restrictive environment as close to home as possible.

Who can refer ?

GP

AMHP

Community alcohol team

Consultant psychiatrists

CMHW

Outpatient clinics

How do I contact them ?

Hospital switch board

Treatment

Aim is to induce remission and to return the patient to their baseline level of functioning.

NICE recommends a stepped approach

Non-Pharmacological

Medication

Depends on the patient and their circumstances, severity, underlying cause, past history of depression, previous response to treatments, local availability of services and patient choice.

GPNon-Pharmacological TreatmentsLifestyle Measures

Sleep hygiene

Establish regular sleep / wake times

Create a proper environment for sleep

Exercise

Stop smoking

Healthy diet

Decrease alcohol consumption

Avoid substance misuse

Maintain social networks

Sub-threshold or mild depression

Active monitoring

Lifestyle advice

Integrate structure into the day

Provide information about depression

Discuss the presenting problem

Review in 2 weeks to assess progress.

Non-Pharmacological TreatmentsMild to moderate and sub-threshold depression

Problem Solving Strategies

Computerised CBT Beating the Blues

Living life to the full

The Mood Gym

Self-help Guides Newcastle, North Tyneside & Northumberland Mental Health

NHS trust

http://www.ntw.nhs.uk

Other Therapies

Counselling

Outside agencies Women’s counselling service

See hand-out

IAPT (Improved Access to Psychological Therapies) Low intensity

High intensity

St. Andrew’s Counselling & Psychotherapy Unit

Persistent Milder Depression +

Consider anti-depressant medication Try not to prescribe at first visit as symptoms may improve

during 1-3 weeks

Give patients information on the reasons for prescribing

Time scale of action

Likely side effects

May be increased anxiety, suicidal thoughts & agitation in the initial stages of treatment

Seek help promptly

Medications

SSRI – citalopram, fluoxetine, sertraline S/E gastrointestinal upset, dry mouth, headache, rash,

generally weight neutral

SNRI - Venlafaxine

Mirtazapine – more sedation, increased appetite and weight gain.

Follow up

Review the patient every 1-2 weeks until stable Assess response, compliance, side effects, suicidal risk

Then assess monthly

Continue treatment for at least 6 months.

Inadequate response to initialintervention

Check compliance

Check for side effects

If no side effects, increase the dose,

Increase support,

Consider switching to another antidepressant

Discontinuation Reactions

Occur once drugs have been used for >8 weeks

Discontinue drugs by tapering over 4 weeks

Withdrawal of SSRI’s – headache, dizziness & anxiety.

Switching medications – SIGN guidelines

Pregnancy

Antidepressant medication should be avoided – try non-pharmacological therapies.

Amitriptyline 100mg od

Fluoxetine

Sertraline if breast feeding.

NICE guidance

Summary

Be open minded and welcome patients to discuss any problems

Keep high risk groups in mind and monitor for depression

If depression suspected, diagnose using ICD-10 criteria and record the severity with PHQ-9

When a diagnosis is established, complete a risk assessment.

Discuss treatment options with the patient.

Active monitoring is useful for mild or sub-threshold depression.

Strategies used in GP include lifestyle changes and CCBT, problem solving techniques.

Psychological therapies for depression are recommended by NICE both alone and as treatment for mild-mod depression and in combination with drug therapy for more severe depression.

More severe depression, treatment resistant

REFER to SECONDARY CARE SERVICES / CMHT

CMHT will only take on moderate – severe mental illness.

Questions ?