Depression Alison 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 Low energy Poor or increased appetite Guilt or self-blame Suicidal thoughts or acts Agitation or motor retardation Low self-esteem Feelings of hopelessness Severity of depression Sub-threshold depression <4 symptoms Mild-moderate 4 Moderate to severe 5-6 symptoms Severe depression > 7 symptoms 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. GP Non-Pharmacological Treatments Lifestyle 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 Treatments Mild to moderate and subthreshold 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 initial intervention 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 nonpharmacological 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 ?