CLINICAL PATHWAYS: DEPRESSION

1. 3.2A 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. 1986 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. 1990. Psychological Medicine, 20, pp 137-146.

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 >= 10 - 88% 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 Medication, high-intensity psychological interventions, electroconvulsive therapy, crisis service, combined treatments, multiprofessional and inpatient care STEP 4: Severe and complex1 depression; risk to life; severe self-neglect 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 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?