1. Depression for GPs Dr Rob Waller Consultant Psychiatrist
Bradford District Care Trust

2. Outline What are you saying to the client?
Is a diagnosis the best way to meet their needs?
Getting more assistance:
Antidepressant medication
Secondary care
Counselling
Are questionnaires any use?
How not to get depressed yourself!

3. Clinical Depression ICD-10 Depressive Episode
Lowering of mood, reduction of energy, and decrease in activity
Little variation
Two-weeks
Somatic Symptoms – dictates severity

4. Other types of depression
Brainstorm: think of as many forms of depression as you can
Non-medical depressions:
Dysthymia/Cyclothymia/Personality
Baby-blues
Economic depression
Psychodynamic depression
The Great Depression

5. Responses to a diagnosis
Relief – help is at hand
Stigma – people will think…
Regression – I am a failure after all
Attribution – how can I change things?
Anger – how can you know?
Anti-medical – I don’t want pills
Dependant – It’s up to you now
Reductionism – so that’s what it is…

6. Seven levels of understanding
One-line Diagnosis – ICD-10
Differential Diagnosis
Bio-psycho-social formulation
3x3 Aetiological Grid
Cross-sectional formulation:5-Areas
Longitudinal formulation: Beliefs/Rules
Why has this person developed this illness at this point in their lives?

7. Aetiological Grid
Bio
Psycho
Social
Antecedents
Behaviour
Consequences

8. Cross-sectional Formulation
ENVIRONMENT
Mood
Behaviour
Biology
Thoughts
Trigger

9. Longitudinal Formulation
Mood
ENVIRONMENT
Behaviour
Biology
Thoughts
Trigger
Cognitive Biases
Activating Events
Core Beliefs
Early Events

10. This person, This illness, This time
Genes
IUE
Perinatal
Tabla Rasa?
Demands
Resources
Oral
Anal
Genital
Life
Latent

11. The eighth level

12. Do we need a diagnosis? Problem-focussed Solution-focussed
Bio: medication, diet, exercise
Socio: debt, CAB, community groups
Psycho: counselling, guided self help
Solution-focussed
Where do you want to be in six months?
What steps are needed to get there?
Can you do one before I see you next week?

13. NICE management

14. NICE GPs Watchful Waiting Computerised CBT Guided Self Help
Brief Psychological Interventions
Two of these !

15. Secondary Care Options
Counselling [may well be PCT based]
Psychiatry
Out-patient - complexity
In-patient - risk
Therapy
Psychotherapy – dynamic factors
Psychology – circular factors
One Stop Shop?

16. When to Refer Complexity Risk Needs longer than seven minutes
Needs more than Counselling
Needs careful diagnosis & formulation
Risk
Risk-spotting [hunches]
Risk-assessment [dynamic/static]
Risk-management [self + others + residual]

17. Questionnaires - QOF vs Usefulness
Group Work
In threes:
Which ones do you use?
How do you use them?
Why do you use them?
Five mins

18. Feedback

19. Making Questionnaires Work
Time: They fill them in
Diagnosis vs Change Measure
Copyright: the PHQ
Discussion: eg BDI item 9
Symptom Targeting: eg sleep

20. Depressed GPs
Doctors on the Edge: General Practitioners, Health and Learning in the Inner-City
Linden West
“Gritty realism, observational style, vastly helpful but also depressing”

21. How not to become depressed
Groups of five
What ways do you personally use to stop yourself from becoming depressed?
Do these work?
What can we learn from this how we talk to clients?

22. Feedback What is mental HEALTH? Work-life balance?
And what can we do to increase it?
Work-life balance?
Or should we go for integration?
Research findings for mental health
Static: supportive upbringing, education, etc
Dynamic:
Marriage / confiding relationship
Intrinsic faith
Personal development opportunities

23. The Primary-Secondary Care Interface
Dr Rob Waller
Consultant Psychiatrist
Bradford District Care Trust