Depression Lawrence Pike

Depression Detection Diagnosis Treatment Suicide Referral Recurrence

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

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

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%

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?

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

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

Depression - Treatments General Drug Treatment Psychological Treatments Other Treatments

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

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

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 - 4-6 months after normal St John’s Wort as effective as TCA Stopping treatment- discontinuation syndrome possible

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

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

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)

Depression - Suicide Risk Factors

Depression - Suicide Risk Factors

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

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

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

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

Depression www.psychiatry.ox.ac.uk/