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

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Presentation on theme: "DEPRESSION and ANXIETY Dr. Khalid Aziz Consultant Psychiatrist Dennis Scott Unit, Edgware Community Hospital."— Presentation transcript:

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?

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 STEP 1: All known and suspected presentations of depression STEP 2: Persistent sub-threshold depressive symptoms; mild to moderate depression STEP 3: Persistent subthreshold depressive symptoms or mild to moderate depression with inadequate response to initial interventions; moderate and severe depression STEP 4: Severe and complex 1 depression; risk to life; severe self- neglect Low-intensity psychosocial interventions, psychological interventions, medication and referral for further assessment and interventions Medication, high-intensity psychological interventions, combined treatments, collaborative care 2, and referral for further assessment and interventions Medication, high-intensity psychological interventions, electroconvulsive therapy, crisis service, combined treatments, multiprofessional and inpatient care Focus of the intervention Nature of the intervention Assessment, support, psycho-education, active monitoring and referral for further assessment and interventions 1,2 see slide notes The stepped-care model

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 1 st 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)

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?

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