1. CLINICAL PATHWAYS: DEPRESSION
Dr Marc Lester
Deputy Medical Director
BEHMHT

2. 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?

3. 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

4. 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 Nov;16(4):739–744

5. 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

6. 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 Psychological Medicine, 20, pp

7. 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

8. 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

9. 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

10. Diagnosis & Progress - What tools are helpful?
PHQ-9 most common tool in Primary Care
If score >= % chance of Major Depression
Use to track progress at each consultation
Easy to administer
Available
QOF target
How useful is it?

11. 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?”

12. 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?

13. 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”

14. 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

15. What treatments are available?
NICE guidance recommends STEPPED CARE approach
Severity graded Steps 1 – 4
Different options and recommendations for different steps:

16. 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

17. Psychological interventions
What is available?
Most now through IAPT – direct referral
CBT
IPT
Counselling
Also:
- Psychodynamic Therapy

18. 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

19. 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

20. 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

21. Common side effects Nausea most common Dizziness Sometimes anxiety
Serotonin syndrome
SIADH
Sleep disturbance
Sexual dysfunction
Recent ECG concerns with Citalopram

22. 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

23. 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

24. 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

25. 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

26. 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

27. 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

28. Any Questions?