1. Depression
Lawrence Pike

2. Depression
Detection
Diagnosis
Treatment
Suicide
Referral
Recurrence

3. Depression - Detection
50% missed, especially in patients with chronic physical disease
Consulting styles makes a difference
Screening tools can help

4. Depression - Detection
Consulting styles
open questions
more time
more eye contact
less interuptions

5. Depression - Detection
Screening Tools:
consider for those at high risk as improve detection
Hospital Anxiety and Depression Scale
more sensitive than GPs (90% vs. 49%)
less specific than GPs (86% vs. 96%)
Two question test
sensitivity 96% but specificity 57%

6. Depression - Detection
Two Question Test:
During the last month, have you often been bothered by feeling down, depressed or hopeless?
During the last month, have you often been bothered by little interest or pleasure in doing things?

7. Depression - Diagnosis
DSM-IV Criteria for Major Depression:
Over the last 2 weeks five of the following features should be present of which one or more should be:
1/ depressed mood
2/ loss of interest or pleasure
continued

8. Depression - Diagnosis
3/ significant weight loss or gain or a change in appetite
4/ insomnia or hypersomnia
5/ psychomotor agitation or retardation
6/ fatigue or loss of energy
7/ feelings or worthlessness or excessive guilt
8/ diminshed ability to think or concentrate
9/ recurrent thoughts of death (not just fear of dying) or suicidal ideas

9. Depression - Treatments
General
Drug Treatment
Psychological Treatments
Other Treatments

10. Depression - Treatments
General
whichever treatment is agreed and offered, patients have a better outcome if given good clear information, especially a leaflet

11. Depression - Treatment - Drugs
Antidepressants are all equally efficacious
They have similar drop-out rates
Costs vary considerably
Trazodone and lofepramine are cost effective and safe in overdose
Patients anxious addictive and need information and reassurance

12. Depression - Treatment - Drugs
When using tricyclics - use 100mg or 140mg for Lofepramine
Trial of 6 weeks
If fails use a different class of drug
Duration months after normal
St John’s Wort as effective as TCA
Stopping treatment- discontinuation syndrome possible

13. Depression - Psychological Treatments
Problem solving - can be performed by GP with some training but takes time
Cognitive Therapy
of value in those who respond to concept, prefer psychological treatment or have not responded to drugs. “Beating the Blues”
Counselling - not shown to be more effective than GP although patients may prefer

14. Depression - Other Treatments
Written information
can improve mild to moderate
Exercise

15. Depression - Suicide Ask about known risk factors
most important is how depressed the patient is and whether they have made any suicidal plans (as opposed to passive thoughts)

16. Depression - Suicide Risk Factors

17. Depression - Suicide Risk Factors

18. Depression - Referral Serious suicidal intention Failure of treatment
2 courses of anti-depressant at full doses
Difficulty with diagnosis
For specific treatments (CBT)
Severe psychomotor retardation

19. Depression - Referral Referral letters should contain:
Considered diagnosis
Why referral is being made
Degree of urgency
Treatment tried - including doses, duration etc

20. Depression - Recurrence
Recurrence Rate
50% after one episode, 70% after two, 90% after three.
15% in first year after 6 months treatment, 40% after less than 4 months treatment
Relapses reduced by long term antidepressants

21. Depression - Recurrence
Cognitive behaviour therapy
some evidence reduces relapses but no satisfactory long term trials
Discussion with patient
Balance between long term medication and risks of recurrence will need careful consideration

22. Depression