Depression

The Importance of Depression Diagnosis Recognition of depression Acute Management of Depression Assessing suicide risk Assess severity of the depression and develop action plan Treatment Recommendations Treatment: adverse effects Management tools Making it happen - a summary References Mnemonic for depression diagnosis

Sheffield adult depression guideline or Sheffield adult depression guideline General health questionnaire (GHQ) The MacArthur Initiative on Depression Primary Care   Mastering depression in primary care WHO-Five Well-being Index The Major (ICD-10) Depression Inventory (MDI)

• 1 in 3 GP Attendees Have Significant Psychological Symptoms
• One New Case of Depression Will Present Per GP Surgery Session
• Research has shown that on Average Only 60% of Those Presenting With Depression Will Be Detected

The Importance of Depression

• Depression is the most common chronic condition in primary care, exceeding rates of asthma, diabetes and hypertension. It is the commonest of the mental illnesses seen by a GP. Around half of these are chronic and recurrent, lasting for longer than twelve months.
• Depression in adults is associated with cognitive damage to their children, marital breakdown, sickness absence and labour turnover. In economic terms, depression may account for up to 8% of all sickness absences from work, resulting in the loss of up to 35 million working days per year.
• People with undiagnosed and untreated or inadequately treated depression have more consultations in primary care often over many years.
• The cost of depression in terms of human misery is incalculable.

Why should Depression be treated in Primary Care?

• Depression often involves a mixture of physical, psychological and social factors. It therefore requires a holistic assessment which is best achieved by the GP who has a continuos relationship with patients and their families. An holistic assessment is particularly important for those people who present their depression obliquely, with frequent attendance or somatised pain.
• Depression is already treated in primary care. Only 10% of those diagnosed as suffering from major depression are referred on to specialist services.
• Depression in general practice is common but curable.

Diagnosis

The term depression describes a continuum from a normal lowering of mood that affects everyone from time to time, to a severe disorder. In general practice, we are generally talking about major depression, which can be classified as mild, moderate and severe.

Other forms of depression are also important and include:

• lifelong mild fluctuating depression (dysthymia) on which major depression may be super-imposed;
• postnatal depression;
• manic depressive disorder (bipolar illness);
• severe depressive episode with psychotic features.

Core symptoms of depression

However, if important symptoms such as agitation or retardation are marked, patients may be unwilling or unable to describe some symptoms in detail. The symptoms should have been present for at least two weeks unless they are particularly severe and of very rapid onset.

Severity of depression

Differential diagnosis

• If there is a history of manic episodes (excitement, elevated mood, rapid speech), consider manic depressive disorder.
• If heavy alcohol use is present, consider alcohol and/or drug use disorders.
• Physical illness such as anaemia or hypothyroidism may mimic depression and should be eliminated as causes before treatment begins.
• Some drugs are depressogenic - notably antihypertensives, oral corticosteroids, indomethacin, opiates.

Symptoms of anxiety or nervousness are frequently present along with depressive symptoms. Where depression is significant (as defined above), treat the depression. Specific counselling and advice about self-help may address symptoms of both anxiety and depression.

Recognition of Depression

Which groups are high risk?

• Drug and alcohol abusers.
• Women up to 18 months post childbirth.
• Socially isolated eg mothers with young children, elderly, unemployed, ethnic, minorities, gays and lesbians.
• People with ongoing relationship problems.
• Past history of depression.
• Family history of depression.
• Multiple adverse events.
• Concurrent physical illness.
• Caring for relatives.

Less obvious ways in which depression may present

• Pain.
• "Tired all the time", "not coping".
• Frequent attendees (self or with child)
• Co-morbidity , ie presence of other mental health problems.
• Other somatic presentation particularly in elderly and ethnic patients. • Adolescent problems.

Note: Patients with learning disabilities can suffer from depression and may present with agitation/aggression, irritability, reduction in self care, reduction in quantity of speech. Refer for specialist advice.

Recognition in more complex cases

• In some patients, depressive illness is obvious; in others it overlaps other conditions, or situations which may make it easy to overlook.
• Life events
• Physical ill-health eg. loss (bereavement or work), eg. disease, disability childbirth
• Stress situation
• Somatisation eg. personal life, eg. physical symptoms not environment explained by disease

If these situations co-exist with depression, the depression may be missed or may be attributed exclusively to the situation. Where depression is significant, it should be treated, regardless of whether it seems understandable in the circumstances.

Screening tests

The use of screening tests increases the recognition of depression in general practice. A number of self administered rating scales are available for patients to fill in. These save on staff time and improve accuracy of diagnosis. It is also useful to repeat the screening tests at intervals through treatment as an assessment of progress. The five most commonly used scales are:

• General health questionnaire (GHQ) - used a great deal in primary care (but quite a crude measure).
• Patient health questionnaire (PHQ-9) (suggested in QOF 2006).
• Hospital Anxiety and Depression Scale (HADS) - gives a rough score for both anxiety and depression (suggested in QOF 2006).
• Geriatric Depression Scale (GDS) (Validated for the elderly)
• Edinburgh Postnatal Depression Scale (standard depression scales produce unreliable results when used in postnatal women)
• Beck Depression Inventory (BDI) - not a diagnostic tool, but can help differentiate, mild, moderate and severe depression (suggested in QOF 2006).
  • Less than 14 - unlikely to be depressed,
  • 14-19 mild,
  • 20-28 moderate,
  • 29+ severe.

How can a practitioner improve his or her recognition skills?

• Open questions.
• Eye contact.
• Unhurried style.
• Flexible consultation length.
• Warm, empathic style.
• Notice non-verbal behaviour and comment.
• Pick up on verbal cues and ask for clarification.
• Summarising.
• Use of screening tests.
• The consultation style.

The therapeutic effect of a medical consultation has been widely accepted following the work of Balint. There may be similar opportunities for a therapeutic consultation effect from a nurse.

• Positive consultations have been shown to be more effective than negative ones.
• Patients appreciate continuity of care and doctors who operate "usual lists" have higher recognition rates for depression.
• Patients with a psychiatric illness have more consultations and consultations with such patients take longer than the average.
• Separate longer consultations allow more detailed consideration of presenting complaint and more accurate diagnosis in physical, psychological and social terms.

Acute Management of Depression

Assess suicide risk

Possible questions to ask are:

• "Have your had any thoughts about harming yourself?"
• "Do you have any plans to carry this out?"
• "Do you feel life isn't worth living anymore?"
• "Do you feel hopeless about the future"

Distinguish between just thoughts and actual intentions, actual plans and previous attempts.

If the patient has no ideas, intentions, plans or previous attempts, then treat depression. If the patient has ideas and vaguely phrased intentions but no definite plans or history, then treat depression and monitor closely. Involve family or carer in monitoring if possible. If the patient has thoughts plus definite intentions, actual plans or previous history, consult specialist.

Other factors associated with suicide risk:

• Family history of suicide/psychiatric diagnosis
  It is important to note if someone within the close family of a patient has:
  • committed suicide/had episodes of parasuicide
  • suffered from depression
  • misused alcohol or other substances
• Personality traits
  There are several ways of thinking which, when persistent, increase the likelihood of the patient attempting or committing suicide:
  • black and white thinking, also called all or nothing thinking
  • rigid thinking, characterised by patterns of thought that are difficult to change
  • excessive perfectionism, high standards that cause the patient or others distress
  • hopelessness, bleak and pessimistic views of the future
  • impulsivity , a tendency to do things on "the spur of the moment"
  • low self esteem, characterised by feelings of worthlessness
  • poor problem solving skills, an inability to think of alternative solutions
• Environmental factors
  Although all of these apply to many people who are not at risk, it is important to bear them in mind when making an assessment of risk:
  • divorced/separated/widowed
  • single (not co-habiting)
  • elderly/retired
  • living alone
  • poor social supports/isolated (it is perceived level of support that is important)
  • unemployed
• Psychiatric Diagnosis
  The three psychiatric disorders that show the strongest correlation with suicide are:
  • depression
  • substance misuse (including alcohol)
  • schizophrenia
  • Other psychiatric disorders that should be taken into account are:
  • personality disorder
  • obsessive compulsive disorder
  • panic attacks ( called panic disorder in severe form)

Assess severity of the depression and develop action plan

Mild Depression

• Encourage self-help strategies and give written or taped self help materials. (Self help material and information on depression for patients is available from Psychological Therapies Department at St. George's Hospital).
• Use of GP, nurse midwife, health visitor counselling skills particularly cognitive behavioural techniques. Encourage hope of normal recovery. Many people with mild depression will spontaneously remit.
• Where mild symptoms are chronic and or the patient is struggling with multiple practical difficulties in their daily lives, treatment should be based on "talking therapies" and self help, and so referral to a practice counsellor may be appropriate.
• Where mild depression is chronic and self help strategies have failed - consider referral for brief cognitive behavioural therapy.
• Where symptoms are mild, the patient has experienced a stressful or difficult life event, but the symptoms are not chronic and the patient is not struggling with multiple, persistent practical difficulties in their daily life, it is likely that the depression or anxiety are normal features of adjustment.

Moderate to Severe Depression

• Maximise patient coping strategies
• Use of GP, nurse, midwife, health visitor counselling skills
• GP, nurse, midwife, health visitor teaches patient problem solving skills
• Encourage hope of normal recovery, foster social support measures.

Where depression is prolonged or relapse frequent, consider referral for cognitive behavioural therapy and/or problem solving treatment.

Where depression is prolonged or relapses are frequent and it is clear that particular psycho-social issues are relevant - consider referral to a counsellor trained in helping with the particular issues identified.

In addition to addressing social and contextual issues, consider prescribing antidepressants:

• Antidepressants work in about 80% of these patients (70% within 6 weeks) regardless of the cause of depression.
• There is no "correct" choice of drug: it is up to this individual prescriber to find an agent suitable for an individual patient.
• Antidepressant drugs are not addictive or habit-forming.
• Adequate doses must be given for an adequate length of time (probably at least six months).
• The patient must be regularly monitored for progress (initially every two weeks).
• Check compliance with medication.

Severe depression is unlikely to respond to talking therapies and self help strategies until sufficiently improved with drug treatment. Once sufficiently improved, treat as for moderate to severe.

Explain to the patient how the medication should be used:

• Medication must be taken every day.
• The effect may take two or four weeks to develop and four to six months for full benefit to be felt.
• Side-effects do occur with all antidepressants (but usually fade in 7 to 10 days).
• Antidepressants are not addictive or habit forming.
• Continue antidepressants for at least 3 months after symptoms improve.
• All patients should be warned of the dangers of driving and operating machinery while taking any antidepressant. It is wise to advise a period of two to three weeks off driving until the effect of medication can be assessed.

Essential information about depression for the patient and their family

They need to be aware and comfortable with the idea that:

• Depression is common and effective treatments are available.
• Depression is an illness, not weakness or laziness; patients are trying their hardest.
• Stress or worry have many physical and mental effects (where symptoms of anxiety are also present).

Specific counselling for the patient and their family

• Plan short term activities which give enjoyment or build confidence. Resume activities which have been helpful in the past.
• Resist pessimism and self criticism. Do not act on pessimistic ideas (eg. ending a marriage, leaving a job). Do not concentrate on negative or guilty thoughts.
• If physical symptoms are present, discuss the link between physical symptoms and mood.
• After improvement, discuss signs of relapse and plan with the patient action to be taken if signs of relapse occur.

Where significant symptoms of anxiety are also present

• Practice relaxation methods to reduce physical symptoms.
• Plan short term activities which are relaxing, distracting or build confidence.
• Identify exaggerated worries or pessimistic thoughts.
• Discuss ways to challenge these negative thoughts when they occur.
• Encourage exercise.

Continuing Management of Depression

• Around one half of depressive illnesses are chronic. Compliance with antidepressant medication is low.
• Regular monitoring - every fortnight until the patient seems to be improving, then monthly whilst on treatment.
• Review suicide risk.
• Drug maintenance therapy should be a full dosage. • Encourage the patient not to discontinue treatment without consulting - some drugs may need to be tapered slowly. • As people get better, encourage self-help and consider talking treatments. • Ensure talking treatments are focused and do not become a way of life. • Relapse prevention strategy to be agreed with patient before the end of treatment. • Steady recovery can be assessed by planned, repeated use of the screening questionnaires.

Factors which may predict an incomplete response

• If poor response to treatment, review diagnosis.
• Previous history.
• Poor compliance.
• Inadequate doses of medication.
• Family history of recurrent depression.
• Continuing stressful life events, eg, social deprivation, marital disharmony.
• Incomplete understanding or difficulty in accepting the illness.

Relapse prevention

• Encourage patient awareness of depressive symptoms.
• Provide patient information leaflets and encourage self help.
• Ask the patient what they have learnt from the experience of depression.
• Consider how these experiences can be applied to future illness? • Involve carers in early recognition of relapse.

Recurrent depression

This is defined as three episodes of severe depression in five years.

• Maintain therapy for at least three years in recurrent depression.
• Consider Lithium treatment and referral to specialists.
• Consider need for long-term follow up.
• Ensure relapse prevention is dealt with (see above).

Consult specialist when ......

• Serious risk of suicide (definite intentions, actual plans or previous history - phone consultant).
• Failure to respond to adequate doses of medication (check compliance first) - out patients (OP).
• Uncertain diagnosis - OP or referral to Community Mental Health Team (CMHT).
• When there are problems with management or complex issues - OP or CMHT.
• Consider it if the patient or family request referral.

Treatment

As with most psychiatric conditions depression is generally complicated by having a multi-factorial aetiology with a wide range of variables influencing vulnerability, onset, clinical picture course and prognosis; this is reflected in the range of therapeutic interventions which may need to be considered.

Treatment options broadly fall under the following headings:

• Medication
• Supportive psychotherapy
• Behaviour therapy Cognitive therapy Social intervention
• Other physical treatment

This guidance concentrates on the use of medication, but it should be borne in mind that support from any clinical practitioner may be crucially important. Of the psychotherapeutic interventions that have been studied in depression, cognitive therapy has consistently been shown to be the most effective and whilst this may not be used routinely, a referral for assessment should be considered in patients who do not respond to medication and simpler treatments.

Effective treatment depends on accurate diagnosis; the practitioner must first distinguish clinical depression, (sufficiently severe and disabling to require intervention) from sadness or distress which is part of normal life experience. Good response to treatment with antidepressants is seen in patients with more than mild symptoms: Studies have shown that where there are only few or very mild depressive symptoms the evidence of response to drugs is questionable and effort should therefore be concentrated on prescribing for those with more clearly established depressive illness.

It is helpful to think of treatment in three phases:

• Acute treatment has the aim of alleviating all symptoms with a current episode of depression and at the same time restoring full function. Such a remission may occur with or without treatment.
• Continuation treatment is intended to prevent relapse. By convention, when a patient has been asymptomatic for approximately six months following an episode, it is reasonable to assume recovery and continuation treatment may be stopped. During the period of such treatment it is important to review the patient regularly, to monitor progress and to reinforce the need for ongoing treatment. Ensuring ongoing compliance is essential; it is recommended that such reviews should be undertaken monthly.
• Maintenance treatment is aimed at preventing recurrent episodes of depression in those who establish a pattern of more than two episodes of illness. Treatment may be from one year to life.

Once selected, the initial treatment should be provided for a sufficient length of time to permit a reasonable assessment of response (or lack of it). With medication this means a minimum of four to six weeks.

The selection of the initial and subsequent treatments should be a collaborative decision between the practitioner and patient; nevertheless, if the patient shows a partial response to treatment by four to six weeks it is generally reasonable to continue it unchanged for a further similar period. If, however, the patient has not responded at all by six weeks or only partially responds by ten to twelve weeks, other treatment options should be considered. Antidepressants are effective in depressive disorders satisfying the criteria for major depressive episodes and in episodes a little below this threshold, but they have not been found to be effective in the very mild end of the depression range.

They may be effective in the presence of life-stress and should not be withheld purely because the depression seems understandable.

A wide choice of antidepressant compounds is available, all of which have advantages and disadvantages. The advantages of the older tricyclic antidepressants are that they are cheap and have a well-known side effect profile. The newer SSRIs are less toxic in overdose and exhibit a different range of side effects.

• Evidence shows that SSRIs and related drugs are slightly better tolerated with regard to side effects than tricyclic antidepressants, reducing the risk of drop out by about 4% during 6 weeks of treatment.
• There is a differing range of toxicity associated with different antidepressants currently used in primary care. The SSRIs and lofepramine are associated with the smallest risk of fatal poisoning.
• It is still common practice in primary care for depressed patients either to be prescribed a sub-therapeutic dose of an antidepressant or for the patient to fail to take the full dose. Consensus statements from the Royal College of Psychiatrists and the Royal College of General Practitioners have stressed the importance of adequate prescribing of antidepressants as several controlled studies have shown that lower doses are ineffective. However it has been recognised that there is increasing use of antidepressants (particularly tricyclics) for indications other than depression such as neuralgia where lower doses are commonly prescribed. In addition low doses are used in milder cases of anxiety for their anxiolytic and sedative properties although there is little clinical trial evidence to support this.
• All antidepressant drugs available in the UK have been shown to be superior to placebo, but no difference in efficacy between drugs has been shown; and choice is therefore largely dependent on factors such as previous response, side effect profile, toxicity and cost.

It is considered reasonable, in a physically healthy patient who is not at high risk of suicide (particularly overdosing) and without vulnerability to cardiotoxic or anticholinergic side effects, to begin treatment with a tricyclic antidepressant. The dose may be started at 75 mg daily of Amitriptyline or equivalent, although it should be recognised that this is likely to be sub-therapeutic. The dose should be increased quite quickly (depending on side effects) to 125 to 150 mg daily which is the recommended treatment dose. The elderly do require smaller doses and a slower dose titration.

Where agitation is prominent it is reasonable to use a more sedative antidepressant such as Amitriptyline or Dothiepin; indeed, such drugs may be useful in some patients where initial insomnia is a significant problem. If, for any reason, these drugs are not used or are ineffective it is reasonable to use another mildly sedative agent such as Thioridazine (in relatively low dose, say 25 mg two or three times a day) for a period until symptoms begin to subside. Benzodiazepines should only be used where anxiety and/or agitation are severe and only then in short courses for a maximum of two weeks; Diazepam would then be the drug of choice with a starting dose of no higher than 10-20mg per day.

If the patient does not respond to an adequate trial (as previously described) then other treatment options may need to be considered. Likewise if a patient is unable to tolerate tricyclic antidepressants, is at risk of overdose or if toxicity is likely to be a problem then appropriate drugs to consider "second line" are serotonin specific re-uptake inhibitors such as fluoxetine, paroxetine, sertraline and citalopram. If these drugs have been used "first line" and have not been tolerated or have proved ineffective, it may be worth (if possible) proceeding to a tricyclic. Lofepramine, whilst being a tricyclic, has fewer problems of side effects and toxicity than many of the older drugs. Lofepramine appears similar in efficacy and tolerability to alternative antidepressants.

If tricyclics or SSRIs have not been effective, the group of drugs often used "third line" are the Monoamine Oxidase Inhibitors. The most commonly prescribed drug in this group is phenelzine and, although these agents entail dietary restrictions and carry greater risks of drug interactions (particularly sympathomimetic), they are effective antidepressants, particularly when phobic, atypical, hypochondriacal or hysterical features are present.

MAOIs, other than moclobemide, have considerable side effects and are unlikely to be appropriate for initiation in general practice. Moclobemide, however, is less prone to dangerous side effects and appears to have similar tolerability and efficacy to other available antidepressants. They should be tried in any patients who are refractory to treatment with other antidepressants as there is sometimes a marked response, but if such drugs are being contemplated it would generally be appropriate to discuss the patient with a consultant psychiatrist or make a referral. MAOIs should not be started until two weeks after an SSRI has been stopped (5 weeks for fluoxetine.)

Most treatment options beyond this stage should generally be undertaken by specialist. teams and frequently the next step beyond MAOIs is combination treatment by augmentation with Lithium; combinations of Lithium and tricyclics and Lithium and MAOIs are used and some clinicians favour a combination of a tricyclic and an SSRI in certain circumstances. Literature does contain some studies involving the combination of tricyclic and MAOI drugs, but this should never be prescribed in general practice as there are considerable dangers.

Electroconvulsive therapy, certain anticonvulsants and thyroid hormone are all sometimes used in certain cases which are treatment resistant, but should only usually be initiated with reference to specialist psychiatric teams.

Antidepressant drugs should not be used in isolation in treatment; the aims and intentions of treatment should be made clear to the patient, as should the mechanisms of action and side effects of the drugs. Evidence suggests that patients' lack of knowledge plays a significant part in higher rates at which drug therapy gets abandoned and they should always be warned that initial treatment response is likely to be delayed by two to three weeks.

Continuation treatment should be undertaken for a period of between four and six months after the acute treatment phase and the dose of drug should be continued at or near the initial therapeutic level. Beyond this, decisions about longer-term prophyllaxis should be based on the likelihood of further recurrent episodes and discussion with the patient over the risks and benefits. The total duration of prophyllaxis in those with relapse or recurrence remains a matter of clinical judgement depending on the individual circumstances.

Recommendations

• As they represent the most cost-effective option, tricyclic antidepressants should be used as the routine first line medication for depression in primary care
• The choice of antidepressant should be based on individual patient factors; these would include:
  • the desirability or otherwise of sedation
  • previous response to a particular drug
  • comorbid conditions
  • concurrent drug therapy
• Lower doses should be used initially in older patients
• The dose of tricyclic antidepressants should be titrated up to the doses used in the clinical trials. If patient compliance is a concern tricyclic antidepressants can be given in a once daily dosage.
• If the toxic effects of the older tricyclic antidepressants are perceived to be a problem, for example in a patient who has previously taken a drug overdose, then lofepramine is a more cost-effective choice than an SSRI.
• However, when faced with a patient not responding to first line drug therapy reasonable options are:
  • review the diagnosis
  • check compliance with drug therapy
  • consider a change in drug treatment
  • consider referral

Antidepressants: relative adverse effects

Management tools

Once a diagnosis of depression is made, severity can be measured by

• The Hospital Anxiety and Depression Scale (HADS)
• The Beck Depression Inventory
• Clinical judgement

Making it happen - a summary

• Maintain a high index of suspicion, especially with high risk groups. • Ensure good communication amongst Primary Care Health Teams (PHCT) and with the Community Mental Health Team. • Ensure continuity of care and invite the patient back for regular review. • Use guidelines and have a strategy for relapse prevention. • Provide a patient library with self help literature or encourage patients to acquire this type of information from libraries or bookshops. • Plan training and support for staff. • Consider audit - Consult Medical Audit Advisory Group (MAAG). • Add a mental health element to new patient and other physical screening programmes.

References

1. NFER-Nelson, Darville House, 2 Oxford Road East, Windsor, Berks, SL4 1BU. (General Health Questionnaire and Hospital and Anxiety Depression Scale, available as individual packs of questionnaires or as part of a comprehensive mental health assessment portfolio).
2. Recognition and Management of Depression in Late Life in General Practice: Consensus Statement. Katona C, Freeling P, Hinchcliffe R, Blanchard M and Weight A (1995). Primary Care Psychiatry, Volume 1, p107-113.
3. Perinatal Psychiatry. Use and Misuse of The Edinburgh Postnatal Depression Scale. Cox and Holden (1994). Gaskell London.
4. Psychological Corporation, Foots Cray High Street, Sidcup, Kent, DA14 5HP. (0181-3085750).
5. Suicide Risk: A Guide for Primary Care Teams and Mental Health Staff. MacDonald F, Northumberland Mental Health Trust.
6. Drug Treatment of Depression. Guidelines for General Practitioners in Northumberland. Northumberland Health Authority, September 1998.

Source: Northumberland Mental Health NHS Trust guidelines 1998 and 1999 and Northamptonshire Health Authority Defeat Depression guidelines.

• Brad Cheek: last updated Dec 2006
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