Transcript Depression - Bradfordvts

Depression
Recognition and Management
Dr Bruce Davies
What Is Depression?
A Continuum
Normal Mood Lowering
Abnormal Mood Lowering
Abnormal mood lowering and loss of function
What Is Depression?
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Depressive disorder
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Pervasive
Persistent
Wide range of symptoms
What Is Depression?
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Range of symptoms
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Negative views
Worthlessness
Incapacity
Guilt
Sleep disturbance
Diurnal mood variation
Loss of energy
Impaired concentration
What Is Depression?
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Impaired work ability
Poor social functioning
Psychomotor retardation
Pessimism
Better off dead
Thoughts of suicide
Suicide / action
Fear / belief of bodily illness
Understandability
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No longer important.
Do not alter treatment
thresholds.
Do not alter
treatment.
Reactive /
endogenous =
confine to bin.
Vulnerabilities
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Losses
Stressful life events
Lack of social support
Physical illness
Familial factors
Genetic factors
What Is Depression? - Various
Criteria.
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Defeat Depression Campaign
Depressed mood or loss of pleasure for at least
2 weeks. Plus 4 or more of:
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Worthlessness or guilt
Impaired concentration
Loss of energy and fatigue
Thoughts of suicide
Loss or increase of appetite or weight
Insomnia or hypersomnia
Retardation or agitation
What Is Depression? - Various
Criteria.
DSM – IV
Duration > 2 weeks Depressed mood or Marked loss of interest or
pleasure in normal activities
Plus 4 of:
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i.
Significant change in weight
ii.
Significant change in sleep pattern
iii.
Agitation or retardation
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Fatigue or loss of energy
v.
Guilt / worthlessness
vi.
Can’t concentrate or make decisions
vii.
Thoughts of death or suicide
What Is Depression? - Various
Criteria.
ICD – 10
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Patient has low mood:
1) How bad is it and how long has it been going on?
2) Have you lost interest in things?
3) Are you more tired than usual?
If the answer is yes to these, then:
ICD – 10 (Continued)
4) Have you lost confidence in yourself?
5) Do you feel guilty about things?
6) Concentration difficulties?
7) Sleeping problems?
8) Change in appetite or weight?
9) Do you feel that life is not worth living any more?
ICD – 10 (Continued)
 Mild.
Two criteria from 1-3 and 2 others.
 Moderate.
Two criteria from 1-3 and 3-4 others or a yes to
question 5.
 Severe.
Most of the criteria in severe form especially
questions 5 & 9.
Variants
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Depressive episodes that
do not meet the criteria
for major depression.
Lifelong mild fluctuating
depression (Dysthymia).
Mixed states of above
two.
Manic depression –
bipolar disorder.
Incidence Of Depression : 2000
Patients
100 - major
100 - minor
200 – subclinical
Depression. In 50% of patients it may
not be acknowledged.
Numbers
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10% of those diagnosed in primary care
are referred to psychiatrists.
1 in 1000 are admitted to hospital.
Lifetime incidence rates approach 33%.
5% of consulters have major depression.
5% have milder depression.
A further 10% have some depressive
features.
Numbers
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At least one patient per surgery will have
depressive symptoms of some type.
Commoner in younger people including
children than thought in the past.
Men:women = 1:2.
Common in the physically ill.
50% recurrence rate.
12% become chronically depressed.
Why Missed?
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50% are missed.
10% subsequently
recognised.
Of the 40% who
remain unrecognised:
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Half remit
spontaneously.
Half remain depressed
6 months later.
Missed: Patient Factors
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Present somatic symptoms.
Physical problems.
Stigma.
Beliefs about GP role and time to listen.
Longstanding depression.
Less overt / typical.
Less insight.
Missed: Doctor Factors
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More accurate doctors.
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Make more eye contact.
Show less signs of hurry.
Are good listeners.
Ask questions with social and psychological content.
Less accurate doctors.
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Ask many closed questions.
Ask questions derived from theory rather than what
the patient just said.
Assessment
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Severity
Duration
Social network
Views of self, world and
future
Suicidal thoughts
Past history
Factors affecting
symptoms
Biological features
Assessment Skills
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Directive not closed questions
Picking up on verbal clues “clarification”
Picking up on non-verbal clues and using
them
Empathy
Summarising
Treatment Contract
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Key skills
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Re-frame symptoms as
depression
Link to life events
Negotiate anti-depressants
if necessary
Problem list and priorities
Set realistic time scale
Agree regular review
Explanations
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Depressive illness is
clinically different
from the blues and
involves chemical
changes in the brain.
Depressive illness
has characteristic
symptoms and
explain them.
Explanations
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Depression benefits
from both drug and
non-drug approaches.
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“Pills for symptoms.”
“Talking for problems.”
Explanations
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Anti-depressants are
not addictive or habit
forming.
Anti-depressants take
2-3 weeks to begin to
work and need to be
taken for 4-6 months
after the full benefit is
obtained to prevent
relapse.
Explanations
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Side effects occur
and are expected –
explain.
Drugs enable talking
therapy to work
better.
Regular review is
important and needs
to continue for at
least 6 months.
Explanations
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Talking therapy can help solve problems
that are soluble, cope with the insoluble
and examine other problems that seem
unrealistic to the patient or therapist.
Prevention of further trouble will be
considered when the treatment is coming
to an end.
References
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Defeat Depression Campaign. The Royal
College of Psychiatrists. 1994.
Treating People with depression: a
practical guide for primary care. G
Wilkinson et al. Radcliffe 1998.
Recognition and management of
depression in general practice: consensus
statement. BMJ 1992;305:1198-202.