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Mental Health in Primary Care: Management of Depression  Overview of MH in Primary Care  Recognition and Management of Depression.

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Presentation on theme: "Mental Health in Primary Care: Management of Depression  Overview of MH in Primary Care  Recognition and Management of Depression."— Presentation transcript:

1 Mental Health in Primary Care: Management of Depression  Overview of MH in Primary Care  Recognition and Management of Depression

2 Te Rau Hinengaro – the NZ Mental Health Survey  46.6% - Estimated lifetime risk for developing any mental health disorder  24.9% - Lifetime prevalence for the development of any anxiety disorder  20.2% - Lifetime prevalence for the development of any mood disorder  12.3% - Lifetime prevalence for the development of any substance-use disorder  20.7 % - Prevalence of mental disorder in past year - Te Rau Hinengaro: The New Zealand Mental Health Survey (2006)

3 Te Rau Hinengaro – Mental Health of Maori  12 month rates Maori – 29.5%Other -19.3%  12 month mood disorder (depression, BPAD) rates Maori – 11.6%Other – 7.5%  Corrected for age and socioeconomic factors Gap reduced but still increased rates  Higher rates of severe conditions among Maori  Higher rates of suicidal thinking and behaviour  Lower rates of access to health services

4 Te Rau Hinengaro – Mental Health of Pacific Peoples  12 month rates Pacific – 24.4%Other -19.3% NZ Born Pacific – 31.4%Migrated after age 18 – 15.0%! Higher rates in PI groups with longest history of “colonisation”!  12 month mood disorder (depression, BPAD) rates Pacific – 8.3%Other – 7.5%  Corrected for age and socioeconomic factors Gap disappears, same overall rates BUT lower depression rates!!  Sl. higher rates of severe conditions among Pacific  Higher rates of suicidal thinking and behaviour  Much lower rates of access to health services

5 Mental Health Treatment – Unmet Need  Only 38.9% of all 12 month cases of mental disorders visited a health or non-health provider  28.3% to a GP  16.4% to a mental health specialist  4.8% to a social services professional  6.9% to a complementary or alternative medical practitioner  Of those who sought help, most visited a GP for help with a mental disorder  Rates of help-seeking/access to healthcare lowest for PI, lower for Maori - Te Rau Hinengaro: The New Zealand Mental Health Survey (2006)

6 How common are mental health problems – the scale of the problem…all classes and cultures Our children 1 in 5 under the age of 15 Only 25% can access care 50% bullied, leading to: Depression Low self- esteem Suicide 1: 10 have unrecognised dyslexia, dyspraxia The workforce 1 in 5 adults at any time 1: 10 have depression Suicide is the greatest cause of male deaths < 35 yrs Work related stress affects 25-30%, ? > 1 million work days lost a year Senior citizens Dementia effects 5% over 65’s 10- 20% over 80 1 in 6 over 65 suffer from depression Major factors: Social isolation Physical ill- health 30% of >65s in med/surg beds have dementia All communities Many spoken languages in NZ; many cultural beliefs & mental health issues Over-representation of Maori & Pacific people in MH acute inpatient & forensic care

7 Causes of MH Problems – not only a health issue Life cycle time Divorce Retirement Redundancy Menopause Life cycle time Divorce Retirement Redundancy Menopause Isolated Women with small children Victims of domestic violence Employment stress Bullying Harassment Employment stress Bullying Harassment Long term physically ill Elderly isolated men Socio-economic Disadvantage – poverty, housing, unemployment Socio-economic Disadvantage – poverty, housing, unemployment Alcohol & Drug misuse

8 Treatment of Common MH Conditions in the Real World  Too often…  Presenting physical symptoms are the main focus of assessment and intervention  When a MH condition is diagnosed people do not access evidence-based interventions:  An SSRI is started at 20 mg and continued unchanged despite partial or non-response  There is no practice-nurse phone support/follow-up (despite compelling evidence of significant effectiveness)  Very limited access to effective talking therapies  …though the PHO primary care programmes have all slowly improved this situation.

9 Anxiety, Depression and Substance Use disorders in General Practice (12 months): Total Substance 11.3% 9.7% 6.7% Total Depression 18.1% 2.5% 8.0% 2.0% 5.8% Total Anxiety 22.2% 1.0%

10 Patient Presentation to the GP 169 (43.9%) = physical acute illness. 70 (18.2%) = pain 55 (14.3%) = physical chronic condition. 22 (5.7%) = main reason psychological

11 Barriers to Care – Patient Experience (Recent US/UK research)  5 commonest presentations to Primary Care where no obvious physical pathology:  Headache, low back pain, lethargy, non-spec. GI and CVS Sx  Surveyed community prevalence of these symptoms:  On average significant Sx experienced every 3-4/7  What determined whether these symptoms were taken to the doctor/health centre??  Main factor distinguishing those who went to Primary Care was the presence of stress/distress/mental health condition

12 Barriers to Care: Patient Perception - Disclosure (MaGPIe data)  Not wanting to talk about emotional problems at all  “They’re my private problems and I’m the only one that can deal with it, I don’t see any relevant point in telling a doctor”  Problem not bad enough to talk about to anyone  “Didn’t class them as medical, they weren’t the reason I went to see doctor, they didn’t seem serious”

13 Barriers to Care: Patient Perception - Role of the GP (MaGPIe data)  The GP is not the right person to talk to about mental health problems  “Only there for the flu. If you’re having emotional problems you don’t take that to the doctor”  “He’s there for the physical side of health”  “I went to a counsellor instead”  Worried about the GP's response  “Thought he would presume I was a nutter and prescribe pills, I didn’t think pills were the answer or he might refer me to a psychiatrist and I didn’t want to be stereotyped”  “Afraid of going back into hospital”




17 Co-Morbidity of Medical Illness and Depression Illness% with Depression Cancer40 – 50% Heart Disease18 – 26% Diabetes33% Multi-infarct Dementia27 – 60% Multiple Sclerosis30 – 60% Parkinson’s Disease40% Stroke 30 – 50%

18 Mental/Physical Health Link – Example 1: Diabetes and Depression  Patients with diabetes have double the population incidence of depression – for reasons which are poorly understood  Depressed patients are three times more likely not to comply with medical treatment  Outcome of co-morbid diabetes/depression – poorer diet, more hyperglycaemia, greater disability, higher healthcare costs  BUT… treatment of depression/anxiety in diabetic patients results in dramatically improved mental and physical health outcomes, lower secondary care costs – the treatment pays for itself within 1 year

19 Mental/Physical Health Link – Example 2: Depression and Heart Disease  Depression predicts the incidence of heart disease  Depressed patients have greater than three times the risk of a cardiac event, in particular MI  Depressed patients have reduced post-MI survival, poorer adjustment, slower return to function, increased disability, increased medical costs  Treatment of co-morbid depression results in improved mental and physical health outcomes, and lower secondary care costs – the treatment pays for itself

20 Medically Unexplained Symptoms  20% of GP consultations  50% of outpatient consultations in specialist care  More dissatisfied with GP care  Improve with psychological therapy ++, medications +/-

21 Acute Care … money well spent ?

22 Medically unexplained symptoms CBT is effective in : Irritable bowel syndrome Chronic fatigue Chronic Back pain Somatisation disorders CBT is most effective: Early in the disorder Antidepressants are effective in: Irritable bowel syndrome (a bit) Chronic back pain (a bit) Chronic fatigue (not) CBT could be afforded in primary care by: Reducing acute outpatient clinic referrals Reducing one emergency admission a month would fund 0.75 of a psychologist Provide 4-6 sessions for 150 people a year

23 Patient Presentation to the GP 169(43.9%) = physical acute illness 70 (18.2%) = pain 55 (14.3%) = physical chronic condition 22 ( 5.7%) = main reason psychological (38.2%) cf(35.7%)= DSM Disorder past 12 mths

24 Primary MH Care: The Challenge  Most patients are experiencing physical symptoms and wanting help with these  Stigma, attitudes re GP role/interest, and beliefs re mental illness prevent ready discussion of MH issues even when the patient is aware of them  You only have 15 min to address these issues, and agree a plan of action to address MH issues…

25 Frequency of Consultation and Identification of any Psychological Issue VariableAdjusted for age and sex Number of prior consultations RR95%CI Never before 1 - Once or twice 1.8 1.3 – 2.6 Three or four times 2.3 1.6 – 3.2 Five or more times 2.9 2.1 – 4.1

26 Questions and Discussion

27 Major Depressive Disorder Diagnostic Criteria (DSM – IV) 1.Key Symptoms:  Depressed MOOD  Diminished INTEREST 2.Other Symptoms:  Appetite decrease (or increase) / weight loss (or gain)  Marked sleep disturbance (increase or decrease)  Psychomotor changes (agitation or retardation)  Fatigue or loss of energy  Feelings of worthlessness or guilt  Diminished concentration or indecisiveness  Recurrent thoughts of death or suicide Either Key, and 4+ Other, for 2+weeks – MAJOR DEPRESSION

28 Depression “Subtypes” Depression is a syndromal description, within which several discrete “subtypes” are identified. Those with important treatment implications are:  Melancholic – prominent early waking, diurnal variation, psychomotor agitation/retardation, guilty thinking Seems to respond better to Venlafaxine, TCA at antidepressant doses, need medication before any psychological intervention  Atypical – increased sleep, increased eating/weight, heightened interpersonal sensitivity, weighed down feeling/”leaden limbs” Poor response to most antidepressants; some response to Paroxetine, better response to Venlafaxine, Phenelzine (MAOI) – best outcome with CBT +/- antidepressants  Psychotic – onset of psychotic symptoms during a depressive episode, often mood congruent Poor response to antidepressants alone – need antipsychotic as well

29 Differential Diagnosis of Anxiety vs Depression 1.Screen for Depression and Anxiety Disorders 2.Given the common presence of symptoms of both, what is the relative predominant cluster of symptoms ? a.Depression – low mood, loss of interest/motivation, anhedonia, early waking, low energy, hopelessness, etc. VERSUS b.Anxiety – anxious mood, initial insomnia, “nervous energy”, etc. 3.What is the relative time course of symptoms of depression vs symptoms of anxiety? a.Are episodes of onset of depression, followed by onset of anxiety symptoms, which resolve as depression recedes; OR b.Has anxiety waxed and waned, with episodes of depression superimposed (most often with worsening of anxiety)

30 Differential Diagnosis of Unipolar vs Bipolar Depression  Bipolar – COMMON cause of poor treatment response, risk of inducing mania  20% patients with depression have some form of Bipolar Disorder – esp early onset, family history  2-Question screen for Bipolar:  Have you had periods where you can get by on less sleep than usual?  Have you had periods of doing things others may think inappropriate eg, spending too much money  Irritable mood common in both hypomania and depression  Outcome typically worse with antidepressants

31 Differential Diagnosis of Depression vs Alcohol Abuse/Dependence  Diagnosis of depression cannot be accurately made in the face of significant alcohol abuse/dependence  Alcohol abuse/dependence can mimic major depression  In the presence of significant alcohol abuse/dependence need to first treat for this, then reassess re presence or not of persisting depressive symptoms

32 Suicide Risk Screening It looks from what you’ve told me that you’ve been feeling pretty bad lately -  Do you see any future for yourself?  Do you feel you would be better off dead?  When you’re at your worst have you thought about ending your life?  Have you thought about how to do it?  Do you want to act on this plan?  Have you got access to (planned means)?  Do you feel others would be better off without you? * Escalating risk with each successive positive answer

33 Suicide Risk Factors (Presence indicates increased risk)  Severity of current depression and hopelessness  Previous attempt(s)  Alcohol/Drug abuse  Social isolation  Family History of suicide  Medical co-morbidity  Agitation  Being an older male  Recent significant loss(es)

34 Questions and Discussion

35 The Stress-Vulnerability Model  Multiple intersecting lines of research strongly suggest that a person’s mental health at any point is determined by the interaction of vulnerability factors, and current stress levels  Vulnerability (risk) factors –  Biological – Genetic factors, brain insults/injury  Psychological – adaptive/coping style  Stress –  Ambient stress – work stress, financial pressure etc.  “Life events” – bereavement, divorce, change, etc.

36 The Stress-Performance Relationship STRESS PERFORMANCE “A little stress is a good thing, too much is not!”

37 Effects of Stress on the Body – The “Sabre-Tooth Tiger” Problem Increase of fatty acids and cholesterol Body Change Tense muscles Restricted flow of blood to skin Increased perspiration Blood clotting Increased production of white blood cells Increased heart rate Increased respiratory rate Digestion depressed Increase of acid in stomach Decrease in saliva Liver releases extra sugar Pupils dilate Action or Short-Term Effect Quick Reaction Blood diverted to other areas, minimises blood loss in injury Cools body Minimises blood loss in injury Fights infection Increase flow of blood carrying oxygen and nutrients Provides more oxygen; eliminate carbon dioxide Blood diverted to other areas where needed Irritates stomach lining Not needed for digestion More energy available Increased visual perception Potential Long-Term Effect Headache; back, neck, shoulder and jaw pain;fatigue Pallor, skin rashes; itching, dryness Loss of fluids; body odour Blood clots; stroke; heart attack Immune system becomes unbalanced High blood pressure irregular heart sounds; rapid heart rate; damage to heart muscle Impaired breathing; hyperventilation Nausea; indigestion; colitis, diarrhoea Ulcers Diabetes Cholesterol build-up in arteries; stroke; heart attack Impaired vision Dry mouth; indigestion; loss of voice

38 Awareness and Recognition: Symptoms of Chronic Stress Constant worry Racing mind Illogic Can’t concentrate Impatience Depression Loneliness Churning stomach Backache Palpitations Chest tightness Poor sleeping habits Rapid speech Reckless driving Excessive drinking Easily distracted Uncertainty Forgetfulness Poor memory STRESS AND YOUR MIND STRESS AND YOUR FEELINGS STRESS AND YOUR ACTIONS STRESS AND YOUR BODY Irritability Anxiety Anger Low self-esteem Fatigue Headaches Diarrhoea Poor eating habits Drug use Excessive smoking

39 The Link Between Stress and Mental Health/Illness  From time to time, everyone faces things in life that cause stress – we will all move up and down this continuum  Sometimes, people’s normal coping skills are not enough to deal with these stress events, leading to developing symptoms  In any one year, for 20% of the population, 35% of Primary Care attenders, life stressors will be causing a mental health or drug alcohol condition – or in our lifetimes this figure is 50% Increasing intensity of stressors Stress Chronic Stress Emotional Disorders (Depression, anxiety, alcohol and drug problems)

40 The Stress-Vulnerability Model: Vulnerability Threshold Research Vulnerability: Biological Psychological Time Well Unwell Greater Resilience Greater Vulnerability Threshold

41 The Stress-Vulnerability Model: Impact of Life Stress Research Vulnerability: Biological Psychological Stress: Ambient life stress “Life Events” New Job Marital Separation Ambient Stress – e.g. work stress, marital problems, etc. Job Loss Life Events – one-off stressful events/changes Time Well Unwell

42 The Stress-Vulnerability Model: Medication Effect Research Vulnerability: Biological Psychological Well Unwell Medication raises the vulnerability threshold for as long as it is taken Time

43 The Stress-Vulnerability Model: CBT Effect Research Vulnerability: Biological Psychological Well Unwell CBT has a slower onset of action in raising the threshold, but the effect is sustained over time Time

44 Questions and Discussion

45 Evidence-Based Treatments – Overview  General Messages:  Expect full recovery, communicate this to patient, treat vigorously, don’t accept non/poor-response  Non-specific therapeutic factors (rapport, strength of relationship, the person feeling validated and understood) make a significant contribution towards good outcome, and are the largest effect in psychotherapy outcome  Whatever interventions are made, persisting in treatment, and maintaining hope and an optimistic outlook, are the most critical factors

46 Evidence-Based Treatments – Overview  Supportive counseling and education re the condition – what GPs and PNs do every day!  Self-management focus – incl information/educn  Lifestyle factors – Exercise, Sleep, Diet  Activity Scheduling  Brief problem solving  Medications – around 50-60% response rate for any 1 medication (NB – placebo response rate 30%!)  Phone follow-up/support – around 20% response rate (as good as medication!)  Cognitive Behaviour Therapy (also same response rate as medication)

47 “The type of treatment matters less, than ensuring it is done properly, and followed up” Ed Wagner

48 Effective Treatments for Depression Mild Depression (PHQ-9 <15):  Support/advice  Exercise  Activity Scheduling  Problem Solving Moderate/Severe Depression (PHQ-9 >15)  The above plus…  Antidepressant medication  Cognitive Behavioural Therapy

49 Treatment of Depression – Medication vs CBT The Effectiveness of Treatments: Uncomplicated Depression – Acute Treatment RCT’s Meta-Analysis a.CBT58.9% vs 28.2%NNT – 3.27 b.SSRI vs placebo51.3% vs 29.1%NNT – 4.50 c.TCA54.5% vs 34%NNT – 4.86 Depression – Long-Term Treatment RCT’s Meta-Analysis a.CBT vs Antidepressant54.5% vs 35.5%NNT – 5.27 b.CBT vs Placebo65.1% vs 37.0%NNT – 3.56 c.Problem solving vs TCA59.1% vs 55.2%NNT – 25.85 (ie. More or less equal) Source – RANZCP Guideline for Treatment of Major Depression (2002)

50 Getting maximum “bang for your buck” – practice nurse phone follow-up and support  2-4 x 5 min phone calls over the first 2-4 weeks following diagnosis/initiating treatment – most often by practice nurse  Provide support, encouragement, enquire re medication adherence, address any questions, reinforce key messages (incl time taken to respond to antidepressants)  Treatment effect is as strong as that of SSRI – is an extremely cost-effective intervention

51 Self-Management  Key to improved outcomes in depression as in all chronic conditions  Use of information resources, care plans – negotiate agreed plan, follow-up re progress with this  Start small/achievable and build from there  Expect it will require fine tuning over time

52 Six Principles of Self-Management 1.Activities that protect & promote health (Live a healthier lifestyle) 2.Monitor signs/symptoms of illness and take appropriate action to respond 3.Know and understand your health condition 4. Be actively involved in decision making 5.Manage the social / emotional and physical impact 6.Follow a care plan that is agreed with your health professionals (Battersby, 2005)

53 Key Components of SMS 1.Build patient’s self- efficacy (confidence) 2.Improve health literacy 3.Use behaviour change techniques 4.Share decision making 5.Collaborative, planned care with regular F/up  Share responsibility and decision making so patients feel in control and realise how important their actions are

54 Exercise in Depression  Evidence that in elderly (over 60) exercise programme has same efficacy as antidepressants  Must be vigorous exercise (for age/fitness)  Some evidence that balance of aerobic and resistance exercise ideal  Integrate into Activity Scehduling

55 Activity Scheduling  Use of structured activity scheduling tool Key aspect of “Behavioural Management”  See handout  Reverses cycle of low mood/despondency – reduced activity – more time to dwell on negative thoughts – lower mood  Important to include rating of sense of pleasure and mastery from activity

56 Activity Scheduling Tool

57 Brief Problem Solving  Proven effective in mild-mod depression  Focus is in mobilising the patient’s coping and problem-solving capacity, to overcome the issues that are causing stress/inducing depression  Uses structured approach, increases sense of mastery and reverses “helplessness – hopelessness”

58 NDI Phase 2 – “The Journal” an online self-management tool  Advertising campaign starts June 2010  Can be self-directed access OR via GP  Uses K-10 to monitor progress  People set goals re activity, exercise, diet  Get txt/email encouragement from “JK”  Includes a section on Problem Solving  Will be a great aide to managing depression in primary care!

59 Cognitive Behaviour Therapy (CBT)  Structured, time-limited, ‘here and now’  Specific skills for now and future  Five components to problem (“Five-Part Model”)  Cognitive model  Evidence  Balanced thinking

60 CBT - 5-Part Model Thoughts or Cognitions Physiology, Sensations Behaviours, Actions Feelings, Emotions Environment (Past & Present), Situation


62 Classes of “Warpy Thoughts” – Automatic, absolute, unbalanced  Mind reading (“He thinks I’m a loser”)  Fortune telling (“I won’t get the job even if I apply”)  Catastrophising (“This plane is going to crash”)  Unrealistic expectations of self (“Shoulds… musts…”)  Personalising(“Everything is my fault”)  Perfectionism (“no matter what I do it’s never good enough”)  Overgeneralising (“I always muck everything up”)  Black-White thinking (“I didn’t win, I’m useless”)  Looking on the dark side (“The world is a bad place”)

63 Pharmacotherapy of Typical Depression  First line Rx in most instances is SSRI  Severe/Agitated Depression – Dual action Ads (Venlafaxine, Mirtazapine, TCA) more effective  Non- or partial-treatment response – strong evidence for both Nortriptyline and new dual action ADs (Venlafaxine, Mirtazapine – NB: Voc. Reg. GP can apply for SA)  Nortriptyline in therapeutic doses – usually 75-100 mg  Venlafaxine dose v. variable 75 mg to 450 mg NB – monitor for incr BP at higher doses  Mirtazapine dose 30-45 mg nocte

64 Treatment with SSRI  Initiate at 20 mg mane (if sedative effect change to nocte)  Significant anxiety - ??initiate with low-dose BZP or Quetiapine  Significant S/E – change to alternate SSRI  No or minimal response 2-3 weeks, increase to 40 mg  Persisting poor response 4-6 weeks, change to alternate SSRI progress as above

65 Pharmacotherapy of Other Depression Subtypes  Melancholic Depression – TCA/Dual action ADs more effective  Atypical Depression – Only Phenelzine has strong evidence of effectiveness; some evidence Paroxetine and Venlafaxine  Psychotic Depression – MUST treat with antipsychotic (eg, low dose Risperidone) plus antidepressant

66 Antidepressant Prescribing Issues in Particular Populations:  Intention to Treat Meta-analyses of Antidepressant trials  Children/Adolescents – Fluoxetine only AD with any evidence of effectiveness; significant concern re harms with ADs esp. other SSRI  Over 60 – trend-level data to suggest elderly do better with dual action ADs – VF and TCA (BUT TCA S/E issues)  Males – trend-level data to suggest men do better on TCA

67 Antidepressant Prescribing Issues in Pregnancy/Lactation:  Need to balance (uncertain) risks of “safe” medications, with known risks to mother AND child of untreated depression:  Nortriptyline, Fluoxetine considered “safe” during pregancy, MAY cause withdrawal syndrome in neonate  Paroxetine contraindicated 1 st Trimester  Nortriptyline, Paroxetine only ADs with very low levels in breast milk of treated mothers  NB – BZP relative contraindication (esp 1 st Trimester)

68 Managing Side Effects  The art of prescribing – matching medication effect profile to symptoms (e.g., sedating vs activating)  Managing sleep disturbance –  short term hypnosedative eg Zopiclone, OR  If also anxiety/agitation – low-dose Quetiapine  SSRI-related sleep disturbance –  Short half-life SSRI OR change to alternate agent  Sexual dysfunction – a tough one!

69 Monitoring and Follow-up  Need to closely monitor patients receiving antidepressants for worsening and suicidality especially at beginning of treatment and with changes in dosage  Also need to instruct patients and families to be alert for worsening or suicidal thoughts and to immediately report such symptoms  Use practice recall systems

70 Promoting Adherence  Shared decision making  Inquire into prior use of antidepressants  Explain that it may take 2 to 4 weeks for therapeutic response, longer for full effect  Discuss most common side effects  Advise patients to continue medication even if they feel better  Explain risk of stopping too soon  Phone follow-up/support – doubles adherence!!! Is good practice nurse role.

71 Follow Up  Close follow up by telephone and or visits until stable (phone support betw visits impt)  Depression scale (eg,PHQ-9) to assess progress  Titrate dose for total remission  Maintain effective dose for 6 to 12 months (continuation phase)  Monitor for early signs of recurrence  Consider maintenance therapy if there have been more than 2 episodes

72 Antidepressant Continuance  Relapse of depression is COMMON:  After one episode 50%, after 2 episodes 75%, after 3 episodes 90%  Risk reduced if patient accesses CBT  Usual advice re duration of antidepressant treatment (from research re more severe depression):  First episode – 6-12 mths  Second episode – 12-24 mths  Third + episode – 24 mths plus ??long-term Rx

73 Poorly Treatment Responsive Depression  Defined as non- or partial-response to an adequate dose of medication, for an adequate duration, with good adherence  Effectively means 20-40 mg SSRI for 4-6 weeks (NB if no response at 20 mg after 2-3 weeks, trial increase to 40 mg)  Should be seen as a trigger for further assessment re cause of poor response  Needs assertive response – greater duration of depression, poorer chances of recovery

74 Poorly Treatment Responsive Depression  Review diagnosis/presentation –  ?adherence (common…) – ?why - address  ?psychosocial issues/trigger – need CBT  ?bipolar depression – need mood stabiliser  ?atypical depression – need effective ADs/CBT  ?comorbid A+D – need A+D Intervention  ?other comorbidity - anxiety disorder, ADHD, etc  Intervention for these as appropriate

75 Poorly Treatment Responsive Depression – STAR*D Trial  If above factors excluded, evidence- based treatment options for treatment non-responsive depression are:  Substitute option 1 – Alternate SSRI*  Substitute option 2 - Venlafaxine or TCA  Augment option – Lithium, T3  Addition option – CBT  Continued non-response OR unsure - Indication for Psychiatric Consultation * Note that non-response to 1 SSRI is NOT highly predictive of non-response to a second, so first-line strategy should be trial of a second SSRI.

76 When to Consult/Refer to DHB MHS  Any case with serious suicide risk  Any case with psychotic symptoms or possible evolving psychosis  Complex presentations with serious impairment in function  Includes cases with significant comorbidities  Cases which fail to respond to treatment  Early referral important – duration of illness inversely related to odds of full recovery

77 Other Resources for your Patients  The PHO may have Community Health Coordinator roles to assist with cultural & social issues, linking to community resources, sorting benefits/housing etc  Most PHOs now have access to funded CBT/counselling  Think of the Primary Mental Health NGO’s – Lifeline, James Family, Relationship Services, Presbyterian Support etc.

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