Transcript depression pp HDR 07.09.11.

Depression
Alison Turner-Parry
Sam Rosenburg
Aims
 To have an enjoyable time covering elements of the GP
mental health curriculum.
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
Not touching upon…..
 Pathogenesis of depression
 In depth detail on medication – BNF / SIGN
 Treatment resistant depression - refer
 Children and Adolescents - CAMHS
Quiz …..
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.”
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 3rd most common reason for
consultation in general practice.
 The leading cause of disability in developed countries.
Challenges facing the GP
 Inconsistencies in the doctor-patient relationship
 Limited consultation time
 Non-specific presentations
 ‘one other thing doctor’.
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
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 ?
How would you diagnose
depression ?
 What are the signs and symptoms of depression ?
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
Other symptoms.
 Disturbed sleep
 Poor concentration
 Low energy
 Poor or increased
appetite
 Guilt or self-blame
 Suicidal thoughts or acts
 Agitation or motor
retardation
 Low self-esteem
 Feelings of hopelessness
Severity of depression
 Sub-threshold depression
<4 symptoms
 Mild-moderate
4
 Moderate to severe
5-6 symptoms
 Severe depression
> 7 symptoms
symptoms
 Also need to consider functional impairment.
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.
Diagnosis of Depression
 Mental state examination
 Appearance and behaviour
 Speech
 Mood
 Hallucinations, delusions
 Insight
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.
Differential Diagnosis
 Dementia
 Hypothyroidism
 Anaemia
 Stroke
 Drug effects – substance abuse, NSAIDs, OCP, steroids
 Bipolar disorder
 Psychosis
 Other psychiatric disorders, adjustment disorder,
bereavement
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.
Depressed…… what next ?
 Immediate referral to IHTT.
 GP follow up.
 Referral to secondary care services
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
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.
Who can refer ?
 GP
 AMHP
 Community alcohol team
 Consultant psychiatrists
 CMHW
 Outpatient clinics
How do I contact them ?
 Hospital switch board
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.
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
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.
Non-Pharmacological Treatments
Mild to moderate and subthreshold 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
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
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
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.
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.
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
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
Pregnancy
 Antidepressant medication should be avoided – try nonpharmacological therapies.
 Amitriptyline 100mg od
 Fluoxetine
 Sertraline if breast feeding.
 NICE guidance
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.
 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.
 More severe depression, treatment resistant
 REFER to SECONDARY CARE SERVICES / CMHT
 CMHT will only take on moderate – severe mental
illness.
Questions ?