Depression Alison Turner-Parry Sam Rosenburg. Aims To have an enjoyable time covering elements of...
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Transcript of Depression Alison Turner-Parry Sam Rosenburg. Aims To have an enjoyable time covering elements of...
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
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 ?
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.
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.