Depression

What we are expected to know…

1.4 Ensure that you appropriately explore both physical and psychological symptoms, family, social and cultural factors, in an integrated manner

1.5 Understand the place of instruments in case-finding for depression (the Whooley questions) and for assessment of severity of symptoms (GAD-72 for anxiety and PHQ-93 for depression)

1.6  Understand the primary care management of patients with common mental health problems

1.9  Understand SIGN or NICE guidelines

1.13 Understand how to access local health and social care organisations, both statutory and third sector, that are an essential component of managing people with mental health problems

2.5 Understand the range of psychological therapies available

3.2 Understand the difference between depression and emotional distress, and avoid medicalising distress

In Plain English…Understand significance of Whooley Screening questions

Explore the Biological, Psychological, Social, Family and Cultural factors (BPS tool to assess severity)

Put into practice different appropriate management options for depression

Those with co-morbid chronic illness have subtle screening & management differences

Understand the place of different “talking therapies”

Be aware of/utilize different local agencies that can offer support

Be able to distinguish emotional distress from depression

Video

Symptoms of depression

“Medical” things that supported her

“Social” things that supported her

Empowering the patient to help/educate themselves

Screening for Depression

'During the last month have you often 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?

NB: If patient has a chronic health problem must also ask about Worthlessness, Concentration and Thoughts of death

If any positive responses then go on to take a formal assessment/history

Whooley Questions

Diagnosing Depression

DSM IV used

Symptoms ≥ 2 weeks

Worthlessness/GuiltPoor

ConcentrationRecurrent

thoughts of death/suicidal

ideation

Depressed Mood

Anhedonia

FatigueSignificant

weight/appetite change

Sleep changesPsychomotor

agitation/retardation

Minimum of one core symptom and additional symptoms that bring the total to 5

PHQ-9 (OLD)

Means of recording symptoms of

depression on GP systems

Note how it gives recording of severity

based on score (conflicts with NICE

defining severity)

Biopsychosocial Assessment (NEW)

Biopsychosocial assessment has to be done on the same day the diagnostic code “depression” is used! QOF Points

Current symptoms, including duration and severityPast history and family historyQuality of personal relationships (e.g. with partner, children, parents)Social supportLiving conditionsEmployment or financial worriesCurrent or previous substance or alcohol useSuicidal ideationDiscussion of treatment options, previous treatments and response to these treatments.

Reassess patients 10d-35d after diagnosis

Severity

Severity is based on the severity of symptoms and their impact functional impairment. Not directly based on number of criteria met (though can often be inferred from this)

Management

Remember: Very important to offer patients choices

Empower patients!

Step 2 ManagementMild-Moderate Depression OR Persistent Subthreshold symptoms

Offer active monitoring

Low-intensity psychological & psychosocial interventions 

Do not routinely use antidepressants (because risk–benefit ratio is poor), unless they:.

Have a past history of moderate–severe depression They present with subthreshold symptoms that have been present

for 2 years or more They have subthreshold symptoms for <2yrs but they don't respond to other interventions

If they have mild depression but it is complicating physical health problems they have

Step 3 Management

Step 2 (but poor response) OR Moderate–severe depression

High-intensity psychological interventions

Medication (usually SSRI)

Combined treatment (antidepressants and psychological intervention)

Step 4 ManagementSevere and complex depression OR Risk to life OR Severe self-neglect

Focus on maintaining a safe environment, likely needing secondary care input

Combined, often multifaceted interventions are required

Medication

High-intensity psychological interventions

ECT

Crisis service

Inpatient care

Low Intensity Psychotherapies

Individual self-help based on CBT principles

Computerised CBT

Group CBT

Group Physical Activity Programme

Counselling

High Intensity Psychotherapies

Individual CBT

Interpersonal therapy

Behavioural Couples Therapy(if appropriate)

Psychodynamic therapy

Psychotherapies

Antidepressant Choice

Choose an SSRI first lineIncrease the risk of bleeding. Consider a PPI in older people on

NSAIDs or aspirin.SSRIs can exacerbate hyponatraemia, especially in the elderly.Interacts with antiplatelets

• Under 18’s –• Breastfeedin

g – • Pregnancy – • Elderly –• Cardiopaths -

Fluoxetine (generally under specialist advice)Paroxetine/SertralineFluoxetine/Citalopram/Sertraline (try and avoid in 1st trimester)Citalopram/Sertraline (less drug interactions)Sertraline

Starting Antidepressants

Explain Gradual onset of action

Possible side effects

The importance of continuing once remission achieved

The risk of discontinuation symptoms (especially paroxetine and venlafaxine)

Review the patient after 2 weeks, and then 2–4 weekly for the first 3 monthsMore often if patient young/higher suicide risk

Stop/change antidepressant if getting unacceptable side effectsIf no/minimal response after 3–4w increase dose or switch SSRIIf inadequate response after 6–8w can switch to alternative antidepressant

group

Stopping Antidepressants

If one SSRI has been ineffective, try an alternative SSRIIf that is ineffective, try an alternative class of antidepressants (SNRI, tricyclic,

MAOI).

Post-recovery continue antidepressants for at least 6 months to reduce risk of relapse

For 2 years if there is a history of recurrent depression or significant risk of relapse

Usually reduce slowly over 4weeksAdvise to seek help if significant discontinuation symptoms

If significant, consider reintroducing antidepressant/increasing back to previous dose or swap to a drug with a longer half-life (e.g citalopram) and then reduce

SSRI Interactions

Medication Recommendation

NSAIDS/Aspirin *Avoid this combo, but if are using together then also prescribe PPI

Warfarin/Heparin *Avoid SSRI use

Triptans *Avoid SSRI use

Tamoxifen Avoid Paroxetine and Fluoxetine (inhibit CYP2D6 and therefore pro-drug conversion of tamoxifen)

MAO-B Inhibitors (e.g Selegiline) *Avoid SSRI use

Clozapine/theophylline/Methadone

Only use SSRI Sertraline or Citalopram

Flecainide Only use SSRI Sertraline *Can consider Mirtazapine instead

VenlafaxineSpecialist supervision if >300mg/in hospital/severe depression

Note if for anxiety max dose is 75mg

S/E: Hypertension (monitor regularly) – care in cardiopaths!

MirtazapineTertracyclic antidepressent

As a good rule of thumb is a good 2nd line agent behind SSRI

Faster onset of action to SSRI by 6-12 weeks

Can cause weight gain and somnolence

Local ServicesPrimary Care Liaison Service (Routine advice/referral) 01225 3714808am to 8pm Mon – Fri

Single point of entry: access to appropriate services thereafter

o BANES Intensive Team (OOH/Emergency) 01225 362814Point of contact for all other times(open 24/7)

Home treatments (2-3/day to avoid hospital admission)

Crisis Assessment and Treatment (Emergency Assessment within 4 hours)

o LIFT (IAPT) 01225 675150Offers psychological therapies services

Self and GP Referrals

Initial Face-to-face appointment with patients to assess specific needs

CAMHS 0117 3604040 Mon – Fri 9am to 5pm

Support Groups (for Mental Health)

Mindfulness group

Central Bath Music Therapy Group

Kitchen Creations

Sing and Smile

Writing Space

5-a-side indoor football

The HOPE guide

BANES for contact details and descriptions

Bereavement/Grief (Loss)

“Normal” Grief can include

• disbelief, shock, numbness and feelings of unreality

• anger

• feelings of guilt

• sadness and tearfulness

• preoccupation with the deceased

• disturbed sleep and appetite and, occasionally, weight loss

• seeing or hearing the voice of the deceased.

Increased risk of depression with

• intense feelings of guilt not related to the bereavement

• thoughts of suicide or preoccupation with dying

• feelings of worthlessness

• markedly slow speech and movements

• prolonged or severe functional impairement

• prolonged hallucinations of the deceased/unrelated

Key Points

Whooley Screening questions for diabetes (+ extra if chronic illnesses)

Diagnosis = at least 1 core and 4 other symptoms

Formal BioPsychoSocial Assessment

Stepwise management of treatment

SSRI choice and commonest risks/side effects/interactions

As well as “medical” and “talking” therapies, think of the “social” therapies also

Know about the local organisations that can help

Don’t over-medicalise simple emotional distress (therapeutic consultation and active monitoring may be enough)

Online Resource

http://nsashley.coursesites.com

Online downloadable powerpoint presentation

NICE guidance

Post tutorial quiz

Other depression resources (eg HOPE Guide)

Thanks!

Any Questions?