CLINICAL PATHWAYS: DEPRESSION

Dr Marc LesterDeputy Medical DirectorBEHMHT

3.2A

Learning objectives

What is depression? Prevention How to recognise it? Risk assessment When to treat depression How to manage depression When and how to refer What options are available?

Prevention

Poor sleep increases risk of depression – advice on sleep hygiene

Advice on alcohol and substance use Managing long term medical conditions and

chronic pain Be aware of risk factors emerging

Risk factors for depression

3 or more children under 5 Domestic violence Life events Past history Self medication

Stressor, vulnerability and depression: a question of replication. Brown & Harris Psychological Medicine. 1986 Nov;16(4):739–744

What is depression?

Persistent: Reduced attention and concentration Ideas of guilt or unworthiness / reduced self

esteem Depressed mood, loss of interest and reduced

energy Disturbed sleep and appetite Ideas of self harm / suicide Pessimistic re. future

Age-related presentations

Depression more common in older people Recent study showed more somatised symptoms

on older people More libido reduction in younger people Older people may present with less overt lower

mood Trend to more agitation in older people These are not absolutes

The Gospel Oak Study: Livingston, Hawkins et al. 1990. Psychological Medicine,

20, pp 137-146.

Cultural presentations

People from some cultures tend to present with more somatic (physical) symptoms:

Non-specific painTirednessLanguage issues / use of words / stigmaBetter to use interpreter than a family

member when interviewing patient

How common is it?

Very common1 week prevalence 2007 was 2.3%4-10% lifetime prevalence of Major

depression2.5-5% lifetime prevalence of Dysthymia90% treated in Primary CareLarge numbers un-diagnosed

Ref. NICE guidance

What makes a clinical diagnosis?

Duration – over 2 weeksPersistence – little variation each dayDistressed by symptoms – varying degreeDifficulty in functioning normallyPresence of psychotic symptoms Ideas of self harm

Ref. ICD-10

Diagnosis & Progress - What tools are

helpful? PHQ-9 most common tool in Primary Care If score >= 10 - 88% chance of Major Depression Use to track progress at each consultation Easy to administer Available QOF target How useful is it?

Can’t I just ask them some questions?

Of course!“How are you feeling in yourself?”“Can you rate your mood out of 10?”“Are you able to enjoy anything?”“Do you feel tired a lot?”Ask about sleep/appetite/libido“Do you feel life is worth living?”

Risk Assessment

This is criticalStart gently Is life worth living?Any thoughts of actual self harm?Any active plans?Any past history?Any thoughts of harm to others?

Risk Assessment (2)

Best predictor is past risk behaviour Increased risk in men Increased risk in older people Increased risk if isolated Increased risk in chronic or painful illnessDeliberate self harm not always a “cry for

help”

When to treat

Discuss with the patientSome want to wait longer than others –

also depends on risk If in doubt, better to treatType of treatment depends on severity

and patient choice

What treatments are available?

NICE guidance recommends STEPPED CARE approach

Severity graded Steps 1 – 4Different options and

recommendations for different steps:

STEP 1: All known and suspected presentations of depression

STEP 2: Persistent subthreshold depressive symptoms; mild to moderate depression

STEP 3: Persistent subthreshold depressive symptoms or mild to moderate depression with inadequate response to initial interventions; moderate and severe depression

STEP 4: Severe and complex1 depression; risk to life; severe self-neglect

Low-intensity psychosocial interventions, psychological interventions, medication and referral for further assessment and interventions

Medication, high-intensity psychological interventions, combined treatments, collaborative care2, and referral for further assessment and interventions

Medication, high-intensity psychological interventions, electroconvulsive therapy, crisis service, combined treatments, multiprofessional and inpatient care

Focus of the intervention

Nature of the intervention

Assessment, support, psycho-education, active monitoring and referral for further assessment and interventions

1,2 see slide notes

NICE Stepped-Care Model

Psychological interventions

What is available?

Most now through IAPT – direct referral- CBT- IPT- Counselling- Also:

- Psychodynamic Therapy

What should I do first?

Assess severity – use step guide + clinical impression

Discuss with the patient what they want If less severe, consider self-help

approaches + monitoringRefer to IAPT or practice counsellorStart medication, if biological symptoms or

more severe

Primary Care follow up

Arranging follow up appointment is containing

2 weeks probably best, unless very concerned

Antidepressant response not usually seen within 2 weeks

Depends on W/L for other input

MedicationNICE recommends generic SSRI as first line

– personal preference is Citalopram, but most CCG formularies suggest Fluoxetine

Start with 10-20mg daily – depends on age etc.

Need at least 6 week trial at therapeutic dose – normally 20mg daily

Normally better not to exceed thisTry to avoid night sedation

Common side effectsNausea most commonDizzinessSometimes anxietySerotonin syndromeSIADHSleep disturbanceSexual dysfunctionRecent ECG concerns with Citalopram

Other good antidepressants (1)

Mirtazapine (NaSSA) good if poor sleep and appetite

Few interactionsCan cause weight gainDose 15-45mg nocteSedation not increased by increased dose

Important interactions

Avoid SSRI’s with Aspirin or NSAID’s – GI bleeding risk

Avoid SSRI’s with Warfarin or Heparin – anti-platelet effect

Avoid SSRI’s with TriptansMirtazapine safer in above situations

Other good antidepressants (2)

Venlafaxine is allegedly SNRI – but only at higher doses

Best used in secondary careLess safe in ODGood as combination therapyLofepramine safest TCA, if S/E’s with SSRI –

start with 70mg daily, up to 210mg daily

QOF 2014/15 BMA GUIDANCE

CG90 recommends that patients with mild or moderate depression who start

antidepressants are reviewed after one week if they are considered to present an

increased risk of suicide or after two weeks if they are not considered at increased

risk of suicide. Patients are then re-assessed at regular intervals determined by

their response to treatment and whether or not they are considered to be at an

increased risk of suicide. This indicator promotes a single depression

review between 10 and 56 days inclusive after the date of diagnosis. For some patients

this may not be their first review as they will have been reviewed initially within a

week of the diagnosis. Unless a Practitioners are reminded of the importance of

regular follow-up in this group of patients to monitor response to treatment,

identify any adherence issues and provide on-going support. This review could address the

following: a review of depressive symptoms a review of social support a review of alternative treatment options

where indicated follow-up on progress of external referrals an enquiry about suicidal ideation highlighting the importance of continuing with

medication to reduce the risk of relapse the side-effects and efficacy of medication. In

the USA, 40 per cent of patients prescribed an antidepressant will discontinue its

use within one month. Analysis of the GPRD108 from 1993 to 2005 found that

more than half of patients treated with antidepressants had only received

prescriptions for one or two months of treatment and that this pattern had not changed

over the 13-year period. Additionally, clinicians may wish to use formal

assessment questionnaires such as PHQ9, HADS and BDI-II to monitor response to

treatment. In most clinical circumstances, the review would

be performed during a face-to-face consultation so that body language and non-

verbal cues may be observed. However, there is some evidence that telephone review

may be appropriate for patients 108 Moore

When to refer

Concerns about risk Inadequate response to psychological

interventions Inadequate response to 1 or 2

antidepressantsAtypical / complicated presentation“Gut feeling”Severity and risk will determine urgent or

routine referral

Where can I find out more?

Pack for good practice and recovery information

BEHMHT GP Intranet site – includes our more detailed treatment guidelines

PCA web resources – in developmentNICE GuidanceRCPsych website

Any Questions?