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?
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