Clinical Knowledge Summaries CKS Depression Screening, assessment, diagnosis, and initial management The management of depression during pregnancy or in breastfeeding is not discussed. Educational slides based on the CKS topic Depression (August 2013) and NICE guidance (2009); Depression: the treatment and management of depression in adults (CG90), and Depression in adults with a chronic physical health problem (CG91).

Key learning points and objectives To be able to: Identify people with depression. Distinguish between subthreshold, persistent subthreshold, mild, moderate, and severe depression. Outline what management or which treatments should be offered for each type of depression. Describe the types of psychological interventions recommended by NICE. Describe which antidepressant should be offered. Based on the CKS topic Depression (August 2013) and NICE guidance (2009); Depression: the treatment and management of depression in adults (CG90), and Depression in adults with a chronic physical health problem (CG91).

Background information Depression is the third most common reason for consultation in primary care. Average length of a depressive episode is 6–8 months. The risk of recurrence is: 50% after a first episode of depression, 70% after a second episode, and 90% after a third episode. Based on the CKS topic Depression (August 2013) and NICE guidance (2009); Depression: the treatment and management of depression in adults (CG90), and Depression in adults with a chronic physical health problem (CG91).

Screening for depression Screen people who are at high risk (e.g. history of depression, significant physical illness). Ask about the two 'core' symptoms of depression. During the last month have you often been bothered by feeling down, depressed, or hopeless? Do you have little interest or pleasure in doing things? Answering yes to one of these questions has: A high specificity (0.95, 95% CI 0.91 to 0.97). Positive test is helpful - low number of false positives. A low sensitivity (0.66, 95% CI 0.55 to 0.76). Negative test not helpful - high number of false negatives. Based on the CKS topic Depression (August 2013) and NICE guidance (2009); Depression: the treatment and management of depression in adults (CG90), and Depression in adults with a chronic physical health problem (CG91).

Diagnosing depression (DSM-5) The person should have at least 5 out of 9 ‘typical’ symptoms (e.g. fatigue/weight loss). ‘Atypical’ symptoms may also be present (e.g. weight gain, reactive mood). Symptoms should be present for at least 2 weeks. At least one must be a ‘core’ symptom. Symptoms must cause: Clinically significant distress, or Impaired functioning (e.g. social, occupational). Based on the CKS topic Depression (August 2013), NICE guidance (2009); Depression: the treatment and management of depression in adults (CG90), and the Diagnostic and Statistical Manual of Mental Disorders, fifth edition (DSM-5).

Symptoms of depression Typical symptoms: Feeling down, depressed, or hopeless (‘core’ symptom). Little interest or pleasure in doing things (‘core’ symptom). Fatigue/loss of energy. Worthlessness/excessive or inappropriate guilt. Recurrent thoughts of death, suicidal thoughts, or actual suicide attempts. Diminished ability to think/concentrate or indecisiveness. Psychomotor agitation or retardation. Insomnia/hypersomnia. Significant appetite and/or weight loss. Atypical symptoms to be aware of: Reactive mood, increased appetite, weight gain, excessive sleepiness and sensitivity to rejection. Based on the CKS topic Depression (August 2013), NICE guidance (2009); Depression: the treatment and management of depression in adults (CG90), and the Diagnostic and Statistical Manual of Mental Disorders, fifth edition (DSM-5).

Severity of depression The severity depends on: The number, duration, and severity of symptoms, and The impact symptoms have socially and functionally. Subthreshold depression More than 2, but less than 5 symptoms. Usually able to cope with everyday life. Persistent subthreshold depression (dysthmia) More than 2, but less than 5 symptoms with at least 2 years of depressed mood for more days than not. Based on the CKS topic Depression (August 2013), NICE guidance (2009); Depression: the treatment and management of depression in adults (CG90), and the Diagnostic and Statistical Manual of Mental Disorders, fifth edition (DSM-5).

Severity of depression Mild depression Few, if any, symptoms in excess of the 5 required to make the diagnosis. Only minor functional impairment. Moderate depression Symptoms or functional impairment between mild and severe. Some symptoms would be expected to be marked. Severe depression Several symptoms in excess of those required to make the diagnosis. Some symptoms are severe and markedly interfere with functioning. Based on the CKS topic Depression (August 2013), NICE guidance (2009); Depression: the treatment and management of depression in adults (CG90), and the Diagnostic and Statistical Manual of Mental Disorders, fifth edition (DSM-5).

Assessment Consider using a depression questionnaire (PHQ, HADS, or BDI-II) Not required by QOF, should not be used on their own, but Gives an indication of the severity of depression and helps assess improvement over time. Perform a bio-psychosocial assessment. Was required by QOF until March 2014. Considers physical, psychological and social aspects of the condition. Can be carried out over more than one consultation. Need to make a record in the notes on the day depression is diagnosed. Based on the CKS topic Depression (August 2013), NICE guidance (2009); Depression: the treatment and management of depression in adults (CG90), and Quality and Outcomes Framework (QOF) guidance for the General Medical Services contract 2013/14.

Bio-psychosocial assessment Should address: Current symptoms including duration and severity. Personal history of depression. Family history of mental illness. The quality of interpersonal relationships with, for example, partner, children and/or parents. Living conditions. Social support. Employment and/or financial worries. Current or previous alcohol and substance use. Suicidal ideation. Discussion of treatment options. Any past experience of, and response to, treatments. There is no defined assessment questionnaire. Based on the Quality and Outcomes Framework (QOF) guidance for the General Medical Services contract 2013/14.

Initial management Manage the risk of suicide, any safeguarding issues and comorbid conditions such as: Alcohol/substance abuse — treat the underlying drinking or substance problem: depressive symptoms frequently resolve following this. Anxiety — where anxiety and depression co-exist decide which is the main problem and treat this first. Psychotic symptoms — seek expert advice. Antidepressants can trigger hypomania/mania in people with bipolar disorder. Eating disorders — seek expert advice. Requires expert assessment as depression is a differential diagnosis for eating disorders (admission may be required). Dementia — treat the underlying depression. Based on the CKS topic Depression (August 2013), NICE guidance (2009); Depression: the treatment and management of depression in adults (CG90), and Depression in adults with a chronic physical health problem (CG91).

Initial management Consider treatment with: A psychological intervention and/or an antidepressant. Choice of treatment depends on the severity of depression. Psychological interventions: Can be accessed through IAPT (improving access to psychological therapies) via referral or self referral. Are grouped into low-intensity and high-intensity interventions. Based on the CKS topic Depression (August 2013), NICE guidance (2009); Depression: the treatment and management of depression in adults (CG90), and Depression in adults with a chronic physical health problem (CG91).

Low-intensity psychological interventions Suitable for people with persistent subthreshold depressive symptoms or mild depression, and include: Individual guided self-help, based on the principles of CBT (includes written material or other media relevant to reading age) — usually consists of 6–8 sessions (face-to-face and via telephone) over 9–12 weeks. Computerized cognitive behavioural therapy (CCBT) — usually takes place over 9–12 weeks. Structured group-based physical activity programme — usually consists of 2–3 sessions per week of moderate duration (45 minutes to 1 hour) over a 3-month period. Group-based peer support — usually consists of one session per week over 8–12 weeks. Low-intensity psychological interventions are recommended based on considerations of effectiveness and cost. Based on the CKS topic Depression (August 2013), NICE guidance (2009); Depression: the treatment and management of depression in adults (CG90), and Depression in adults with a chronic physical health problem (CG91).

High-intensity psychological interventions Reserved for moderate-to-severe depression, and include: Group based CBT – twelve 2-hour sessions over 8–12 weeks. Individual CBT – usually 16–20 sessions over 3–4 months. For people with severe depression, two sessions per week for the first 2–3 weeks of treatment. Interpersonal therapy – duration and number of sessions is similar to CBT. Behavioural activation – duration and number of sessions is similar to CBT. Couples therapy – usually consists of 15–20 sessions over 5–6 months. High-intensity interventions are effective in moderate-to-severe depression (alone and in combination with antidepressants). Based on the CKS topic Depression (August 2013), NICE guidance (2009); Depression: the treatment and management of depression in adults (CG90), and Depression in adults with a chronic physical health problem (CG91).

Antidepressants Antidepressants are reserved for: Moderate to severe depression, or Mild depression with persistent symptoms following other interventions. For moderate to severe depression: If no treatment is given, 20% will recover. If a placebo is given, 30% will respond. If an antidepressant is given, 50% will respond. Based on the CKS topic Depression (August 2013), NICE guidance (2009); Depression: the treatment and management of depression in adults (CG90), and Depression in adults with a chronic physical health problem (CG91).

Antidepressants Mild depression Little clinically-relevant difference between treatment with an antidepressant and placebo. Persistent subthreshold depressive symptoms (dysthymia) Evidence suggests that antidepressants may be effective. Recent onset subthreshold depressive symptoms Antidepressants no more effective than placebo. Based on the CKS topic Depression (August 2013), NICE guidance (2009); Depression: the treatment and management of depression in adults (CG90), and Depression in adults with a chronic physical health problem (CG91).

Managing mild depression or subthreshold depressive symptoms Consider a period of active monitoring, and: Provide information about the nature and course of depression. Arrange follow up, within 2 weeks (consider contacting the person if they do not attend follow-up appointments). If still unwell after 2 weeks Consider referral for a low-intensity psychological intervention. Based on the CKS topic Depression (August 2013), NICE guidance (2009); Depression: the treatment and management of depression in adults (CG90), and Depression in adults with a chronic physical health problem (CG91).

Managing persistent subthreshold depressive symptoms or mild-to-moderate depression Consider referral for one or more low-intensity psychological interventions. If chronic physical health problem – group-based peer support programme may be considered. Avoid the routine use of antidepressants, but consider for people with: A history of moderate or severe depression. Subthreshold depressive symptoms that have persisted for a long period (typically at least 2 years). Mild depression that is complicating the care of a chronic physical health problem. Based on the CKS topic Depression (August 2013), NICE guidance (2009); Depression: the treatment and management of depression in adults (CG90), and Depression in adults with a chronic physical health problem (CG91).

Moderate or severe depression Offer: An antidepressant, and Referral for a high-intensity psychological intervention. Based on the CKS topic Depression (August 2013), NICE guidance (2009); Depression: the treatment and management of depression in adults (CG90), and Depression in adults with a chronic physical health problem (CG91).

Which antidepressant? The efficacy of antidepressants is largely equivalent. The choice is based on: The person's preference. Adverse effect profile (e.g. sedation, sexual adverse effects, weight gain). Safety in overdose - avoid TCAs or venlafaxine. Previous response to therapy. Presence of a chronic physical health problem. Based on the CKS topic Depression (August 2013), NICE guidance (2009); Depression: the treatment and management of depression in adults (CG90), and Depression in adults with a chronic physical health problem (CG91).

Which antidepressant? First episode: Recurrent episode of depression Generic SSRIs preferred – better tolerated, safer in overdose. Citalopram, fluoxetine, paroxetine, or sertraline. Recurrent episode of depression Consider an antidepressant the person has responded well to in the past. Chronic physical health problem Sertraline preferred (lower risk of drug interactions). Dosulepin should only be started by a specialist Increased cardiac risk and toxicity in overdose. Based on the CKS topic Depression (August 2013), NICE guidance (2009); Depression: the treatment and management of depression in adults (CG90), and Depression in adults with a chronic physical health problem (CG91).

Follow up Arrange frequent, regular review to assess: Suicide risk. Safeguarding concerns. Response to treatment. Adherence to treatment and adverse effects. Antidepressant effect is usually seen within 2 weeks. Consider changing antidepressant after 4 weeks if poor response. Continue antidepressant for at least 6 months following remission – greatly reduces the risk of relapse. Longer duration (up to 2 years or longer) may be needed (e.g. if the risk of relapse is high). Based on the CKS topic Depression (August 2013), NICE guidance (2009); Depression: the treatment and management of depression in adults (CG90), and Depression in adults with a chronic physical health problem (CG91).

Summary Screen people at high of depression - ask about the two 'core' symptoms of depression. To make a diagnosis there should be at least 5 out of 9 symptoms (at least one core) present for at least 2 weeks. Treatment options include psychological interventions or antidepressants, but Managing co-morbidities such as alcohol or substance abuse first will often improve symptoms with out the need for further treatment. Psychological interventions are preferred for mild depression and persistent subthreshold depressive symptoms. Antidepressants are usually reserved for people with: A history of moderate or severe depression. Subthreshold depressive symptoms that have persisted for a long period (typically at least 2 years). Mild depression that is complicating the care of a chronic physical health problem. For milder types of depression antidepressants are no more effective than placebo.