DEPRESSION and
ANXIETY
Dr. Khalid Aziz
Consultant Psychiatrist Dennis Scott Unit,
Edgware Community Hospital
LEARNING OBJECTIVES
 Detection and diagnosis
 Advice on prevention
 Patient’s and carer’s expectations and concerns
 Care plan for treatment, recovery and crisis
 Consent and carer involvement
 Treatment guidelines
 Monitoring progress
 Cultural issues
 BEH trust’s services and clinical support
Depression
 Pervasive low mood lasting two weeks or more
 Depressed mood, loss of interest, enjoyment and
motivation
 Disturbed sleep, appetite, concentration
 Negative about self, world, and future, guilt
 Suicidal ideas, plans, intent, acts.
 Somatisation (more with age and in some
cultures)
 Low energy, irritability, agitation.
Anxiety Disorders
 Exaggerated concern about threat with
avoidance
 Generalised vs episodic
 Panic disorder with/without agoraphobia
 Phobias (agora-, social, and specific)
 OCD
 PTSD
 May occur in the absence or presence of
depression and other psychiatric disorders
 Physical symptoms of anxiety/panic.
Prevalence
 Depression: 1 week prevalence 2007 was 2.3%
 Anxiety point prevalence 2 – 4 %
 4-10% lifetime prevalence of Major depression
 2.5-5% lifetime prevalence of Dysthymia
 90% treated in Primary Care
 Large numbers un-diagnosed
 Cause of much absence from work
 Presumed underlying cause of suicides
 Ref. NICE guidance
When to diagnose
 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
Differential Diagnosis
 Secondary to other physical or mental condition
 Adjustment disorder / Acute stress reaction
 Personality disorder
 Substance misuse
 Somatoform disorders
 Social triggers
 Grief
 If depression is present – treat it!
What tools are helpful?
 PHQ-9 most common tool in Primary Care
 If score >= 10 - 88% chance of Major
Depression
 Easy to administer
 Available
 QOF target
 How useful is it?
Some useful questions
 How are you feeling in yourself?
 Can you rate your mood out of 10? (10 is
“normal for you when you are OK”)
 Are you able to enjoy anything?
 Do you feel tired a lot?
 Ask about sleep and appetite
 How does the future seem to you?
Suicidality
 Is life worth living?
 Do you wish you were no longer here?
 Do you get thoughts of harming or killing
yourself?
 Have you made any plans about what you would
do?
 Are you intending to act on these thoughts?
 Have you tried to harm or kill yourself?
 Is there anything particular that stops you?
 Any thoughts of harm to others?
Suicide
 Best predictor is past risk behaviour
 Increased risk in men
 Increased risk if isolated
 Increased risk in chronic or painful illness
 Deliberate self harm not always a “cry for help”:
1 – 2% of dsh commit suicide in the subsequent
year.
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:
The 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 sub-threshold 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?
-
CBT
Counselling
IAPT, MIND, Samaritans
Local resources
What should I do first?
 Explain your diagnosis
 Explain their symptoms
 Assess severity – use step guide + clinical
impression
 If less severe, consider self-help approaches +
monitoring
 Refer to IAPT or practice counsellor
 Start medication
 Treat any underlying cause(s) / physical health
Primary Care follow up
 Arranging follow up appointment is containing
(for both parties)
 Antidepressant response not usually seen before
2 weeks’ treatment
 Be aware of your reaction to the patient (overreaction, communicable anxiety, dismissing
patient’s or carer’s concerns, only seeing the
physical presentation)
Medication
 NICE recommends SSRI as first line e.g.
citalopram. Fluoxetine in adolescents
 Start with 10-20mg daily – depends on age etc.
 Need at least 6 week trial at treatment dose
 Try to avoid benzodiazepines or Z-drugs.
 If no benefit by 6 weeks increase dose and
optimise to BNF limits before trying another
class and monitor for 6 weeks at treatment dose.
 6-12 months’ treatment after recovery 1st
episode. Longer if recurrent
Common side effects
 Nausea most common
 Dizziness
 Sometimes initial anxiety
 Sleep disturbance
 Sexual dysfunction (ejaculatory failure,
anorgasmia)
 Withdrawal reaction – anx, insomnia, nausea
 Not dependence
 Not suicide (probably)
Other good antidepressants
 Mirtazepine (NaSSA) good if poor sleep and poor
appetite
 Few interactions
 Can cause weight gain
 Dose 15-45mg nocte
 Sedation not increased by increased dose (can
be more sedating at 15mg)
Other good antidepressants (2)
 Venlafaxine is allegedly SNRI – but only at higher
doses
 Best used in secondary care
 Less safe in OD
 Lofepramine is the safest TCA start with 70mg daily, up to 210mg daily
Important interactions
 Avoid SSRI’s with Aspirin or NSAID’s – GI bleeding
risk
 Avoid SSRI’s with Warfarin or Heparin – antiplatelet effect
 Avoid SSRI’s with Triptans
 Mirtazapine safer in above situations
When to refer
 Concerns about risk (suicide, dsh or self-neglect)
 Inadequate response to management in primary
care
 Severe depression (psychomotor retardation,
psychotic symptoms)
 “Gut feeling”
 Patient / carer preference
 Diagnostic question
 GP Advice Line – 020 8702 3997
Clinical Advice for GPs
NEW GENERAL CLINICAL ADVICE LINE
For a ten minute telephone clinical
advice session with a Trust psychiatrist
call the GP Clinical Advice Line 020 8702
3997 Mon-Fri (9am to 5pm) to book an
appointment (same or next working
day) and discuss generic issues relating
to your practice on mental health.
Where can I find out more?
 BEHMHT GP Intranet site – includes our more
detailed treatment guidelines
 Barnet CCG website
 NICE Guidance
 RC Psych. website
Any Questions?