3.2A
CLINICAL PATHWAYS:
DEPRESSION
Dr Marc Lester
Deputy Medical Director
BEHMHT
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?
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
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
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
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.
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
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
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
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?
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?”
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?
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”
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
What treatments are
available?
NICE guidance recommends STEPPED
CARE approach
Severity graded Steps 1 – 4
Different options and
recommendations for different steps:
NICE Stepped-Care Model
Focus of the
intervention
STEP 4: Severe and complex1
depression; risk to life; severe selfneglect
STEP 3: Persistent subthreshold depressive
symptoms or mild to moderate depression with
inadequate response to initial interventions;
moderate and severe depression
STEP 2: Persistent subthreshold depressive
symptoms; mild to moderate depression
STEP 1: All known and suspected presentations of
depression
1,2
see slide notes
Nature of the
intervention
Medication, high-intensity psychological
interventions, electroconvulsive therapy,
crisis service, combined treatments,
multiprofessional and inpatient care
Medication, high-intensity psychological
interventions, combined treatments, collaborative
care2, and referral for further assessment and
interventions
Low-intensity psychosocial interventions, psychological
interventions, medication and referral for further
assessment and interventions
Assessment, support, psycho-education, active monitoring
and referral for further assessment and interventions
Psychological interventions
What is available?
 Most now through IAPT – direct referral
- CBT
- IPT
- Counselling
- Also:
- Psychodynamic Therapy
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
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
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
Common side effects
 Nausea most common
 Dizziness
 Sometimes anxiety
 Serotonin syndrome
 SIADH
 Sleep disturbance
 Sexual dysfunction
 Recent ECG concerns with Citalopram
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
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
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
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.
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
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
Any Questions?