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Depression Lawrence Pike. Depression n Detection n Diagnosis n Treatment n Suicide n Referral n Recurrence.

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Presentation on theme: "Depression Lawrence Pike. Depression n Detection n Diagnosis n Treatment n Suicide n Referral n Recurrence."— Presentation transcript:

1 Depression Lawrence Pike

2 Depression n Detection n Diagnosis n Treatment n Suicide n Referral n Recurrence

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

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

5 Depression - Detection n 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 n 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 n 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 n General n Drug Treatment n Psychological Treatments n Other Treatments

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

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

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

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

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

15 Depression - Suicide n 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


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

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

20 Depression - Recurrence n 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 n Relapses reduced by long term antidepressants

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

22 Depression

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