1. Depression Alison Turner-Parry Sam Rosenburg

2. Aims  To have an enjoyable time covering elements of the GP mental health curriculum.

3. Objectives  GP’s should be able to recognize depression and assess its severity.  All depressed patients should be screened for suicidal intent.  Treatment options.  Conservative management  Referral to other agencies  Simple Drug treatments

4. Not touching upon…..  Pathogenesis of depression  In depth detail on medication – BNF / SIGN  Treatment resistant depression - refer  Children and Adolescents - CAMHS

5. Quiz …..

6. Depression  WHO defines depression:  “A common mental health disorder that presents with depressed mood, loss of interest or pleasure, feelings of guilt or low self-worth, disturbed sleep or appetite, low energy and poor concentration.”

7. How common is depression ?  121 million people affected worldwide.  850,000 lives are lost worldwide per year  In the UK, 2-3% of population experience depression  Cost of mental health problems £77 billion / year  Lost earnings due to depression - £9 billion / year  Cost of anti-depressant medication - £300 million  In the UK, depression is 3 rd most common reason for consultation in general practice.  The leading cause of disability in developed countries.

8. Challenges facing the GP  Inconsistencies in the doctor-patient relationship  Limited consultation time  Non-specific presentations  ‘one other thing doctor’.

9. High-Risk Groups  Elderly  Chronic illness  Young men  Alcohol  Substance abuse  Victims of abuse  Significant negative life events  Existing psychiatric disorders  Postnatal  History of depression

10. Screening for Depression  QoF rewards practices that screen patients with diabetes and CHD with 2 depression screening questions.  During the last month have you been bothered by feeling down, depressed or hopeless ?  During the last month, have you been bothered by having little interest or pleasure in doing things ?

11. How would you diagnose depression ?  What are the signs and symptoms of depression ?

12. ICD 10 or DSM IV criteria  “a patient should experience at least one of the following, on most days, for at least 2 weeks.”  Persistent low mood  Anhedonia  Fatigue or low energy

13. Other symptoms.  Disturbed sleep  Poor concentration  Poor or increased appetite  Suicidal thoughts or acts  Agitation or motor retardation  Low energy  Guilt or self-blame  Low self-esteem  Feelings of hopelessness

14. Severity of depression  Sub-threshold depression<4 symptoms  Mild-moderate4 symptoms  Moderate to severe 5-6 symptoms  Severe depression > 7 symptoms  Also need to consider functional impairment.

15. Diagnosis of Depression  History  PC,  Past psychiatric History,  Family history,  personal history,  Medical history, drug, alcohol history  Occupation,  home situation,  social support,  attitudes and beliefs.

16. Diagnosis of Depression  Mental state examination  Appearance and behaviour  Speech  Mood  Hallucinations, delusions  Insight

17. Risk Assessment  Current thoughts of self harm or suicide  If no, Previous thoughts and attempts  Act on these thoughts  Is there a plan and establish details  Is there a will, have they written letters, attempts in the past.

18. Differential Diagnosis  Dementia  Hypothyroidism  Anaemia  Stroke  Drug effects – substance abuse, NSAIDs, OCP, steroids  Bipolar disorder  Psychosis  Other psychiatric disorders, adjustment disorder, bereavement

19. PHQ-9  Assessment tool to look at the severity of depression  Not used to determine the need for treatment  9 question self-report  Maximum score is 27  Score of 12 - threshold for considering intervention  QoF  Within 28 days of diagnosis of depression.  5-12 weeks after the initial recording of severity.

20. Depressed…… what next ?  Immediate referral to IHTT.  GP follow up.  Referral to secondary care services

21. Immediate Referral  Immediate risk to themselves or others  Actively suicidal  Has psychotic symptoms  Has severe agitation accompanying severe symptoms  Has deteriorating personal circumstances exacerbating their mental illness  Severe depression who cannot be managed outside hospital

22. IHTT  In York, IHTT are the gatekeepers to Hospital Admissions.  Available 24 hours a day, 7 days a week.  Offer face to face assessment within 4 hours of receiving an appropriate referral.  Ensure that people experiencing acute, severe mental health difficulties are treated in the least restrictive environment as close to home as possible.

23. Who can refer ?  GP  AMHP  Community alcohol team  Consultant psychiatrists  CMHW  Outpatient clinics

24. How do I contact them ?  Hospital switch board

25. Treatment  Aim is to induce remission and to return the patient to their baseline level of functioning.  NICE recommends a stepped approach  Non-Pharmacological  Medication  Depends on the patient and their circumstances, severity, underlying cause, past history of depression, previous response to treatments, local availability of services and patient choice.

26. GP Non-Pharmacological Treatments Lifestyle Measures  Sleep hygiene  Establish regular sleep / wake times  Create a proper environment for sleep  Exercise  Stop smoking  Healthy diet  Decrease alcohol consumption  Avoid substance misuse  Maintain social networks

27. Sub-threshold or mild depression  Active monitoring  Lifestyle advice  Integrate structure into the day  Provide information about depression  Discuss the presenting problem  Review in 2 weeks to assess progress.

28. Non-Pharmacological Treatments Mild to moderate and sub- threshold depression  Problem Solving Strategies  Computerised CBT  Beating the Blues  Living life to the full  The Mood Gym  Self-help Guides  Newcastle, North Tyneside & Northumberland Mental Health NHS trust  http://www.ntw.nhs.uk

29. Other Therapies  Counselling  Outside agencies  Women’s counselling service  See hand-out  IAPT (Improved Access to Psychological Therapies)  Low intensity  High intensity  St. Andrew’s Counselling & Psychotherapy Unit

30. Persistent Milder Depression +  Consider anti-depressant medication  Try not to prescribe at first visit as symptoms may improve during 1-3 weeks  Give patients information on the reasons for prescribing  Time scale of action  Likely side effects  May be increased anxiety, suicidal thoughts & agitation in the initial stages of treatment  Seek help promptly

31. Medications  SSRI – citalopram, fluoxetine, sertraline  S/E gastrointestinal upset, dry mouth, headache, rash, generally weight neutral  SNRI - Venlafaxine  Mirtazapine –  more sedation, increased appetite and weight gain.

32. Follow up  Review the patient every 1-2 weeks until stable  Assess response, compliance, side effects, suicidal risk  Then assess monthly  Continue treatment for at least 6 months.

33. Inadequate response to initial intervention  Check compliance  Check for side effects  If no side effects, increase the dose,  Increase support,  Consider switching to another antidepressant

34. Discontinuation Reactions  Occur once drugs have been used for >8 weeks  Discontinue drugs by tapering over 4 weeks  Withdrawal of SSRI’s – headache, dizziness & anxiety.  Switching medications – SIGN guidelines

35. Pregnancy  Antidepressant medication should be avoided – try non- pharmacological therapies.  Amitriptyline 100mg od  Fluoxetine  Sertraline if breast feeding.  NICE guidance

36. Summary  Be open minded and welcome patients to discuss any problems  Keep high risk groups in mind and monitor for depression  If depression suspected, diagnose using ICD-10 criteria and record the severity with PHQ-9  When a diagnosis is established, complete a risk assessment.  Discuss treatment options with the patient.

37.  Active monitoring is useful for mild or sub-threshold depression.  Strategies used in GP include lifestyle changes and CCBT, problem solving techniques.  Psychological therapies for depression are recommended by NICE both alone and as treatment for mild-mod depression and in combination with drug therapy for more severe depression.

38.  More severe depression, treatment resistant  REFER to SECONDARY CARE SERVICES / CMHT  CMHT will only take on moderate – severe mental illness.

39. Questions ?