3.2A

CLINICAL PATHWAYS: DEPRESSION

Dr Marc Lester Deputy Medical Director BEHMHT

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 pain  Tiredness  Language issues / use of words / stigma  Better to use interpreter than a family member when interviewing patient

How common is it?

 Very common  1 week prevalence 2007 was 2.3%  4-10% lifetime prevalence of Major depression  2.5-5% lifetime prevalence of Dysthymia  90% treated in Primary Care  Large numbers un-diagnosed Ref. NICE guidance

What makes a clinical diagnosis?

 Duration – over 2 weeks  Persistence – little variation each day  Distressed by symptoms – varying degree  Difficulty in functioning normally  Presence 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 critical  Start 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 illness  Deliberate self harm not always a “cry for help”

When to treat

 Discuss with the patient  Some want to wait longer than others – also depends on risk  If in doubt, better to treat  Type of treatment depends on severity and patient choice

What treatments are available?

 NICE guidance recommends STEPPED CARE approach  Severity graded Steps 1 – 4  Different options and recommendations for different steps:

NICE Stepped-Care Model Focus of the intervention STEP 4:

Severe and complex 1 depression; risk to life; severe self neglect

STEP 3:

Persistent subthreshold depressive symptoms or mild to moderate depression with inadequate response to initial interventions; moderate and severe depression

Nature of the intervention

Medication, high-intensity psychological interventions, electroconvulsive therapy, crisis service, combined treatments, multiprofessional and inpatient care Medication, high-intensity psychological interventions, combined treatments, collaborative care 2 , and referral for further assessment and interventions

STEP 2:

Persistent subthreshold depressive symptoms; mild to moderate depression

STEP 1:

All known and suspected presentations of depression Low-intensity psychosocial interventions, psychological interventions, medication and referral for further assessment and interventions Assessment, support, psycho-education, active monitoring and referral for further assessment and interventions 1,2 see slide notes

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 + monitoring  Refer to IAPT or practice counsellor  Start 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

Medication

 NICE 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 this  Try to avoid night sedation

Common side effects

 Nausea most common  Dizziness  Sometimes anxiety  Serotonin syndrome  SIADH  Sleep disturbance  Sexual dysfunction  Recent ECG concerns with Citalopram

Other good antidepressants (1)

 Mirtazapine (NaSSA) good if poor sleep and appetite  Few interactions  Can cause weight gain  Dose 15-45mg nocte  Sedation 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 Triptans  Mirtazapine safer in above situations

Other good antidepressants (2)

 Venlafaxine is allegedly SNRI – but only at higher doses  Best used in secondary care  Less safe in OD  Good as combination therapy  Lofepramine 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

When to refer

 Concerns about risk  Inadequate response to psychological interventions  Inadequate response to 1 or 2 antidepressants  Atypical / 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 development  NICE Guidance  RCPsych website

Any Questions?