Recognition and Management
Dr Bruce Davies

A Continuum
Normal Mood Lowering
Abnormal Mood Lowering
Abnormal mood lowering and loss of function

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 Pervasive
 Persistent
 Wide range of symptoms

 Range of symptoms
 Negative views
 Worthlessness
 Incapacity
 Guilt
 Sleep disturbance
 Diurnal mood variation
 Loss of energy
 Impaired concentration

 Impaired work ability
 Poor social functioning
 Psychomotor retardation
 Pessimism
 Better off dead
 Thoughts of suicide
 Suicide / action
 Fear / belief of bodily illness

 No longer important.
 Do not alter treatment thresholds.
 Do not alter treatment.
 Reactive / endogenous = confine to bin.

 Losses
 Stressful life events
 Lack of social support
 Physical illness
 Familial factors
 Genetic factors

What Is Depression? Various Criteria.
Defeat Depression Campaign
 Depressed mood or loss of pleasure for at least 2 weeks. Plus 4 or more of:
 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.
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DSM – IV
Duration > 2 weeks Depressed mood or Marked loss of interest or pleasure in normal activities
Plus 4 of: i.
Significant change in weight ii. Significant change in sleep pattern iii. Agitation or retardation iv. 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
 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:

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?

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Mild.
Two criteria from 1-3 and 2 others.
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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.

 Depressive episodes that do not meet the criteria for major depression.
 Lifelong mild fluctuating depression (Dysthymia).
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Mixed states of above two.
Manic depression – bipolar disorder.

100 - major
200 – subclinical
100 - minor
Depression. In 50% of patients it may not be acknowledged.

 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.

 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.

 50% are missed.
 10% subsequently recognised.
 Of the 40% who remain unrecognised:
 Half remit spontaneously.
 Half remain depressed 6 months later.

 Present somatic symptoms.
 Physical problems.
 Stigma.
 Beliefs about GP role and time to listen.
 Longstanding depression.
 Less overt / typical.
 Less insight.

 More accurate doctors.
 Make more eye contact.
 Show less signs of hurry.
 Are good listeners.
 Ask questions with social and psychological content.
 Less accurate doctors.
 Ask many closed questions.
 Ask questions derived from theory rather than what the patient just said.

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Severity
Duration
Social network
Views of self, world and future
Suicidal thoughts
Past history
Factors affecting symptoms
Biological features

 Directive not closed questions
 Picking up on verbal clues
“clarification”
 Picking up on non-verbal clues and using them
 Empathy
 Summarising

 Key skills
 Re-frame symptoms as depression
 Link to life events
 Negotiate antidepressants if necessary
 Problem list and priorities
 Set realistic time scale
 Agree regular review

 Depressive illness is clinically different from the blues and involves chemical changes in the brain.
 Depressive illness has characteristic symptoms and explain them.

 Depression benefits from both drug and non-drug approaches.
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“Pills for symptoms.”
“Talking for problems.”

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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.

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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.

 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.

 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.