Presentation on theme: "DEPRESSION and ANXIETY"— Presentation transcript:
1 DEPRESSION and ANXIETY Dr. Khalid AzizConsultant Psychiatrist Dennis Scott Unit, Edgware Community Hospital
2 LEARNING OBJECTIVES Detection and diagnosis Advice on prevention Patient’s and carer’s expectations and concernsCare plan for treatment, recovery and crisisConsent and carer involvementTreatment guidelinesMonitoring progressCultural issuesBEH trust’s services and clinical support
3 Depression Pervasive low mood lasting two weeks or more Depressed mood, loss of interest, enjoyment and motivationDisturbed sleep, appetite, concentrationNegative about self, world, and future, guiltSuicidal 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 episodicPanic disorder with/without agoraphobiaPhobias (agora-, social, and specific)OCDPTSDMay occur in the absence or presence of depression and other psychiatric disordersPhysical 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 depression2.5-5% lifetime prevalence of Dysthymia90% treated in Primary CareLarge numbers un-diagnosedCause of much absence from workPresumed underlying cause of suicidesRef. NICE guidance
6 When to diagnose Duration – over 2 weeks Persistence – little variation each dayDistressed by symptoms – varying degreeDifficulty in functioning normallyPresence of psychotic symptomsIdeas of self harm
7 Differential Diagnosis Secondary to other physical or mental conditionAdjustment disorder / Acute stress reactionPersonality disorderSubstance misuseSomatoform disordersSocial triggersGriefIf depression is present – treat it!
8 What tools are helpful? PHQ-9 most common tool in Primary Care If score >= % chance of Major DepressionEasy to administerAvailableQOF targetHow useful is it?PHQ>10 has a sensitivity and specificity of 88% for MDD5= 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 appetiteHow 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 isolatedIncreased risk in chronic or painful illnessDeliberate 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 riskIf in doubt, better to treatType of treatment depends on severity and patient choice
13 What treatments are available? NICE guidance recommends STEPPED CARE approachSeverity graded Steps 1 – 4Different options and recommendations for different steps:
14 The stepped-care model Focus of the interventionNature of the interventionSTEP 4: Severe and complex1 depression; risk to life; severe self-neglectMedication, high-intensity psychological interventions, electroconvulsive therapy, crisis service, combined treatments, multiprofessional and inpatient careSTEP 3: Persistent subthreshold depressive symptoms or mild to moderate depression with inadequate response to initial interventions; moderate and severe depressionMedication, high-intensity psychological interventions, combined treatments, collaborative care2, and referral for further assessment and interventionsSTEP 2: Persistent sub-threshold depressive symptoms; mild to moderate depressionLow-intensity psychosocial interventions, psychological interventions, medication and referral for further assessment and interventionsNOTES 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 depressionAssessment, support, psycho-education, active monitoring and referral for further assessment and interventions1,2 see slide notes
15 Psychological interventions What is available?CBTCounsellingIAPT, MIND, SamaritansLocal resources
16 What should I do first? Explain your diagnosis Explain their symptoms Assess severity – use step guide + clinical impressionIf less severe, consider self-help approaches + monitoringRefer to IAPT or practice counsellorStart medicationTreat any underlying cause(s) / physical health
17 Primary Care follow upArranging follow up appointment is containing (for both parties)Antidepressant response not usually seen before 2 weeks’ treatmentBe aware of your reaction to the patient (over-reaction, communicable anxiety, dismissing patient’s or carer’s concerns, only seeing the physical presentation)
18 MedicationNICE recommends SSRI as first line e.g. citalopram. Fluoxetine in adolescentsStart with 10-20mg daily – depends on age etc.Need at least 6 week trial at treatment doseTry 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 anxietySleep disturbanceSexual dysfunction (ejaculatory failure, anorgasmia)Withdrawal reaction – anx, insomnia, nauseaNot dependenceNot suicide (probably)
20 Other good antidepressants Mirtazepine (NaSSA) good if poor sleep and poor appetiteFew interactionsCan cause weight gainDose 15-45mg nocteSedation 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 dosesBest used in secondary careLess safe in ODLofepramine 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 riskAvoid SSRI’s with Warfarin or Heparin – anti-platelet effectAvoid SSRI’s with TriptansMirtazapine safer in above situations
23 When to refer Concerns about risk (suicide, dsh or self-neglect) Inadequate response to management in primary careSevere depression (psychomotor retardation, psychotic symptoms)“Gut feeling”Patient / carer preferenceDiagnostic questionGP 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 guidelinesBarnet CCG websiteNICE GuidanceRC Psych. website