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 Nature of the intervention STEP 4: Severe and complex1 depression; risk to life; severe self-neglect Medication, high-intensity psychological interventions, electroconvulsive therapy, crisis service, combined treatments, multiprofessional and inpatient care STEP 3: Persistent subthreshold depressive symptoms or mild to moderate depression with inadequate response to initial interventions; moderate and severe depression Medication, high-intensity psychological interventions, combined treatments, collaborative care2, and referral for further assessment and interventions STEP 2: Persistent subthreshold depressive symptoms; mild to moderate depression Low-intensity psychosocial interventions, psychological interventions, medication and referral for further assessment and interventions NOTES FOR PRESENTERS: Key points to raise: This is not a key priority for implementation, however it is an important feature for holistic care for people with chronic physical health problems and depression. Colour code denotes intensity of intervention, with orange (Step 4) being the most intense, and light yellow (Step 1) being the least. Additional information from section 1.2 of NICE guideline: The stepped-care model provides a framework in which to organise the provision of services, and supports patients, carers and practitioners in identifying and accessing the most effective interventions (see figure 1). In stepped care the least intrusive, most effective intervention is provided first; if a patient does not benefit from the intervention initially offered, or declines an intervention, they should be offered an appropriate intervention from the next step. 1 Complex depression includes depression that shows an inadequate response to multiple treatments, is complicated by psychotic symptoms, and/or is associated with significant psychiatric comorbidity or psychosocial factors. 2 Only for depression where the patient also has a chronic physical health problem and associated functional impairment. STEP 1: All known and suspected presentations of depression 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 review between 10 and 56 days inclusive after the date of diagnosis. For some patients this may not be their first review as they will have been reviewed initially within a week of the diagnosis. Unless a Practitioners are reminded of the importance of regular follow-up in this group of patients to monitor response to treatment, identify any adherence issues and provide on-going support. This review could address the following:  a review of depressive symptoms  a review of social support  a review of alternative treatment options where indicated  follow-up on progress of external referrals  an enquiry about suicidal ideation  highlighting the importance of continuing with medication to reduce the risk of relapse  the side-effects and efficacy of medication. In the USA, 40 per cent of patients prescribed an antidepressant will discontinue its use within one month. Analysis of the GPRD108 from 1993 to 2005 found that more than half of patients treated with antidepressants had only received prescriptions for one or two months of treatment and that this pattern had not changed over the 13-year period. Additionally, clinicians may wish to use formal assessment questionnaires such as PHQ9, HADS and BDI-II to monitor response to treatment. In most clinical circumstances, the review would be performed during a face-to-face consultation so that body language and non-verbal cues may be observed. However, there is some evidence that telephone review may be appropriate for patients 108 Moore

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?