1. DEPRESSION and ANXIETY
Dr. Khalid Aziz
Consultant Psychiatrist Dennis Scott Unit, Edgware Community Hospital

2. 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

3. 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.

4. 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.

5. 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

6. 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

7. 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!

8. What tools are helpful? PHQ-9 most common tool in Primary Care
If score >= % chance of Major Depression
Easy to administer
Available
QOF target
How useful is it?
PHQ>10 has a sensitivity and specificity of 88% for MDD
5= mild, 10=mod, 15=mod severe, 20=severe

9. 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?

10. 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?

11. 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.

12. 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

13. What treatments are available?
NICE guidance recommends STEPPED CARE approach
Severity graded Steps 1 – 4
Different options and recommendations for different steps:

14. The stepped-care model
Focus of the intervention
Nature of the intervention
STEP 4: Severe and complex1 depression; risk to life; severe self-neglect
Medication, high-intensity psychological interventions, electroconvulsive therapy, crisis service, combined treatments, multiprofessional and inpatient care
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 sub-threshold depressive symptoms; mild to moderate depression
Low-intensity psychosocial interventions, psychological interventions, medication and referral for further assessment and interventions
NOTES FOR PRESENTERS:
Key points to raise:
This is not a key priority for implementation, however it is an important feature for holistic care for people with chronic physical health problems and depression.
Colour code denotes intensity of intervention, with orange (Step 4) being the most intense, and light yellow (Step 1) being the least.
Additional information from section 1.2 of NICE guideline:
The stepped-care model provides a framework in which to organise the provision of services, and supports patients, carers and practitioners in identifying and accessing the most effective interventions (see figure 1). In stepped care the least intrusive, most effective intervention is provided first; if a patient does not benefit from the intervention initially offered, or declines an intervention, they should be offered an appropriate intervention from the next step.
1 Complex depression includes depression that shows an inadequate response to multiple treatments, is complicated by psychotic symptoms, and/or is associated with significant psychiatric comorbidity or psychosocial factors.
2 Only for depression where the patient also has a chronic physical health problem and associated functional impairment.
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

15. Psychological interventions
What is available?
CBT
Counselling
IAPT, MIND, Samaritans
Local resources

16. 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

17. 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 (over-reaction, communicable anxiety, dismissing patient’s or carer’s concerns, only seeing the physical presentation)

18. 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

19. 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)

20. 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)
noradrenergic and specific serotonergic antidepressant (NaSSA)

21. 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

22. 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

23. 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 –

24. 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 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.

25. Where can I find out more?
BEHMHT GP Intranet site – includes our more detailed treatment guidelines
Barnet CCG website
NICE Guidance
RC Psych. website

26. Any Questions?