DEPRESSION Dr Nick Pendleton

Why is this an Important Condition to Consider?

Commonly seen in Primary Care 10% M 25% F, Considerable Morbidity Risk of Mortality Loss of function/Time off work

Why is this an Important Condition to Consider? Manifestation of Chronic Disease We can turn peoples lives around with correct treatment Risk of Drs developing depression is very high: 3.9% at baseline rising to 25% in one US study Arch Gen Psychiatry. Published online April 5, 2010.

What are the Symptoms of Depression?

Cognitive Distortions in Depression All or nothing thinking (1 failure = complete failure) Overgeneralisation (assumptions) Mental filter (noticing –ves, ignoring +ves) Disqualifying the positive Magnification (of –ves) & Minimisation (of +ves) Jumping to (-ve) conclusions Emotional reasoning (assessing by feelings) Should statements (leads to disappointment) Labelling & Mislabelling (I am obviously a Failure because Personalisation (blaming self when –ve events occur) !

How would you explain the cause/s of Depression to a Depressed patient?

What are the effects of being Depressed? Work, Relationships, Finances, Physical Health

What are the risks of not treating or partial treatment of severe depression without complete remission?

SUICIDE

Assessing a patient who may be depressed:

MENTAL STATE EXAMINATION Appearance Rapport & Behaviour Mood & Affect Speech Thought Processes & Thought Content Perceptions, Cognition Insight & Judgement

PHQ-9 PHQ 9 is not a diagnostic tool! Make a clinical diagnosis and then use PHQ- 9 to grade severity You should not use PHQ-9 to make a diagnosis!

PHQ-9 Questionnaire 1. Little interest of Pleasure in doing things 2. Feeling down depressed or hopeless 3. Trouble falling or staying asleep or sleeping too much 4. Feeling tired or having little energy 5. Poor appetite or overeating

PHQ-9 Questionnaire 6. Feeling bad about yourself—or that you are a failure or have let yourself or your family down 7. Trouble concentrating on things 8. Moving or speaking so slowly that other people could have noticed. Or the opposite—being fidgety or restless 9. Thoughts that you would be better off dead or of hurting yourself in some way

PHQ-9 Questionnaire Last 2 week period Each Question is Graded: Not at all = 0 points Several days = 1 point More than ½ the days = 2 points Nearly every day = 3 points Not Depressed = Mild = 5 - 9, Moderate = Moderately Severe = Severe =

PHQ-9 Assessing severity at the time of diagnosis But also monitoring and showing improvement or deterioration PHQ 9 use is currently part of QOF in Primary Care

Who is at risk of Suicide? Male gender (3 times more likely than women) Advancing age, Unemployed Concurrent mental disorders Previous suicide attempt

Who is at risk of Suicide? Alcohol and drug abuse Low socio-economic status Previous psychiatric treatment Certain professions - doctors, students Low social support / living alone Significant life events Institutionalised e.g. prisons, army

What is the risk of completion after an attempt? 1 million people commit suicide globally each year 50% have tried before : x greater risk than general population (estimated general population risk : The overall rate is 11 suicide deaths per 100,000 people. An estimated 11 attempted suicides occur per every suicide death)

What is the risk of completion after an attempt? The prognosis after attempted suicide varies according to method used : poisoning less risk vs hanging more risk 1 in 10 people with schizophrenia will eventually commit suicide Risk in people with ‘mood disorders’ is 1%

Toolkit for assessing Suicide risk : Mental State Examination Patient Characteristics Past History PHQ-9 Direct Questioning Family/Friends Known to Crisis Team? Any other ideas?

Clinical Scenario Richard is a 31 year old Dentist, he is brought to see you by his wife. He has been depressed for years and is currently taking Venlafaxine. His wife says their relationship has broken down, he is not looking after himself, he was sent home from work yesterday, but he won’t explain why….

Clinical Scenario You speak to him, but he just looks at the floor and says that everything is hopeless. He looks unkempt and his personal hygiene is surprisingly poor. His wife says that he has been drinking and smoking more than usual and has said it would be better for everyone if he wasn’t here…….

Clinical Scenario You speak to him, but he just looks at the floor and says that everything is hopeless. He looks unkempt and his personal hygiene is surprisingly poor. His wife says that he has been drinking and smoking more than usual and has said it would be better for everyone if he wasn’t here……. You are running ½ an hour behind and have a full waiting room

What else do you need to know?

What are your management options?

What else do you need to know? What are your management options? What if he was single and you visited him at the request of a concerned neighbour and found that he had been stockpiling Venlafaxine?

How would you go about admitting him under the MHA if he refused to go voluntarily?

What if he was a single parent and had a 11 year old child?

How would you go about admitting him under the MHA if he refused to go voluntarily? What if he was a single parent and had a 11 year old child? What if his elderly mother with dementia was in bed upstairs?

Treatment of Mild Depression Support from GP & review Talk about it May feel better just acknowledging problem Engage with friends and enjoyable activities Lifestyle adjustments/Make changes Live healthily, moderate alcohol NICE CG90 Be aware of physical causes

Treatment of Moderate and Severe Depression Susie has a PHQ9 score of 19 (mod/severe). Has thought ‘is life worth living?’ but no current SI. She has been depressed for 3 months. She has already consulted the internet & made lifestyle changes. You discuss the options and she would like to start an antidepressant. Which one? What do you say to her? When do you see her again?

CURRENT EVIDENCE SUGGESTS: 1.The more episodes of Depression you have had and the more severe they have been, the higher the risk of relapse 2.Treatment should aim for COMPLETE REMISSION 3.The longer the treatment phase in remission the lower the chance of relapse.

Special Circumstances Pregnancy or chance of pregnancy Breastfeeding women Young people (NICE CG28) 1st Fluoxetine 2 nd line Citalopram/Sertraline Previous non-fatal OD Grief: Kübler-Ross Model Health Professionals/Yourself

5 stages of Grief Denial Anger Bargaining Depression Acceptance How long from start to end? What if you get stuck? Elizabeth Kubler-Ross, Death and Dying, 1969

NICE GUIDANCE CG90 Person-Centred Care Recognition of Depression Depression in those with Chronic ill health Stepped Care Options for: Mild, Moderate and Severe Depression Risk Management Relapse Prevention

Depression commonly affects Doctors How can we protect ourselves? Doctors’ Supportline