2. National Institute for Health and Clinical Excellence (NICE) Clinical Guideline on Depression & Anxiety  We understand how much of GP’s time is spent determining the best treatment for each of their patients with Depression & Anxiety  This short Interactive Questionnaire is designed to help you put NICE Guidance into practice, by testing your knowledge of the Key Recommendations for the referral, psychological and pharmacological interventions in the treatment of D&A in Primary Care.  Where you are unsure of the correct answer to a particular question, you will have the option of clicking on an information button that will provide you with a brief summary of the action that NICE recommend you take in that situation.  The Questionnaire takes about 5 minutes to complete, and once you have submitted all your answers we will automatically receive your responses back.  Each question relates back to a specific recommendation from the NICE guideline for the treatment/diagnosis of depression & anxiety in Primary Care, and focuses on the key priorities for implementation both locally and according to NICE.  We understand how much of GP’s time is spent determining the best treatment for each of their patients with Depression & Anxiety  This short Interactive Questionnaire is designed to help you put NICE Guidance into practice, by testing your knowledge of the Key Recommendations for the referral, psychological and pharmacological interventions in the treatment of D&A in Primary Care.  Where you are unsure of the correct answer to a particular question, you will have the option of clicking on an information button that will provide you with a brief summary of the action that NICE recommend you take in that situation.  The Questionnaire takes about 5 minutes to complete, and once you have submitted all your answers we will automatically receive your responses back.  Each question relates back to a specific recommendation from the NICE guideline for the treatment/diagnosis of depression & anxiety in Primary Care, and focuses on the key priorities for implementation both locally and according to NICE. The first 25 responses will be entered into a draw to win this fantastic new iPod Nano. What is the Purpose of the Interactive Learning Tool? Click HERE to begin the Interactive Learning Tool & Quiz This interactive learning tool is CPD certified, and you will receive your certificate upon completion

3. National Institute for Health and Clinical Excellence (NICE) Clinical Guideline on Depression & Anxiety Question 1: When distinguishing Mild, Moderate and Severe depression, how many of the symptoms below would be treated for each type? (assuming that most of these have been present for at least 2 weeks, for most of each day). SUBMIT Mild Depression = Moderate Depression = Severe Depression = Core Symptoms: Depressed Mood Loss of Interest Loss of Energy and Fatigue Core Symptoms: Depressed Mood Loss of Interest Loss of Energy and Fatigue Additional Symptoms: Poor Concentration Changes in Appetite/Weight Disturbed Sleep Reduced Self-esteem and Self-Confidence Agitation/Slowing Pessimism/Hopelessness Suicidal Ideas/Acts Additional Symptoms: Poor Concentration Changes in Appetite/Weight Disturbed Sleep Reduced Self-esteem and Self-Confidence Agitation/Slowing Pessimism/Hopelessness Suicidal Ideas/Acts ? ? ?

4. National Institute for Health and Clinical Excellence (NICE) Clinical Guideline on Depression & Anxiety BACK TO QUIZ (Q1) NICE Guidance Recommendation: Assessment (ICD-10) Clinical Symptoms Core Symptoms depressed mood, and/or loss of interest, and/or loss of energy & fatigue Additional Symptoms poor concentration reduced self-esteem & self- confidence disturbed sleep change in appetite or weight feelings of guilt or worthlessness agitation/slowing pessimism/ hopelessness suicidal thoughts or acts Assessment (ICD-10) Clinical Symptoms Core Symptoms depressed mood, and/or loss of interest, and/or loss of energy & fatigue Additional Symptoms poor concentration reduced self-esteem & self- confidence disturbed sleep change in appetite or weight feelings of guilt or worthlessness agitation/slowing pessimism/ hopelessness suicidal thoughts or acts Mild Depression: At least 2 core symptoms plus at least 2 additional. Person has some difficulty continuing with ordinary activities but does not cease to function. Mild Depression: At least 2 core symptoms plus at least 2 additional. Person has some difficulty continuing with ordinary activities but does not cease to function. Moderate Depression: At least 2 core symptoms plus at least 3/4 additional. Person usually has considerable difficulty in continuing with normal social & work activity. Moderate Depression: At least 2 core symptoms plus at least 3/4 additional. Person usually has considerable difficulty in continuing with normal social & work activity. Severe Depression : All 3 typical symptoms plus at least 4 additional, some of which are severe. Person shows considerable distress & agitation (or retardation) & unlikely to be able to continue with normal activity. Severe Depression : All 3 typical symptoms plus at least 4 additional, some of which are severe. Person shows considerable distress & agitation (or retardation) & unlikely to be able to continue with normal activity. The NICE guideline uses the following descriptions of depression as defined by ICD-10: Mild, Moderate, Severe and Severe with Psychotic symptoms. Symptoms should be present for a month or more and every symptom should be present for most of every day

5. National Institute for Health and Clinical Excellence (NICE) Clinical Guideline on Depression & Anxiety Question 2: A patient comes into Dr. X’s surgery and has had a low mood, loss of interest and enjoyment, and reduced energy; however has no feeling of guilt or worthlessness. These symptoms have not been experienced before. Over a period of a few weeks Dr. X monitors this patient, there is a slight but insignificant improvement. What level of depression would you consider this patient as having? SUBMIT Minor Depression Mild Major Depression Moderate Major Depression

6. National Institute for Health and Clinical Excellence (NICE) Clinical Guideline on Depression & Anxiety Question 3: SUBMIT Dr C sees a patient that has mild depression. Her patient expresses a wish to avoid a psychological or pharmacological intervention. A further assessment should be arranged in……. 1 Week 2 Weeks 3 Weeks 4 Weeks 6 Weeks

7. National Institute for Health and Clinical Excellence (NICE) Clinical Guideline on Depression & Anxiety BACK TO QUIZ (Q3) EXAMPLE OF INFORMATION PAGE THAT WILL OPEN UP AFTER CLICKING ON THE INFORMATION BUTTON ON QUESTION 3: NICE Guidance Recommendation: If a patient has been diagnosed with MILD depression, you may be of the opinion that they will recover with no intervention. You may also be faced with a situation where a patient has been diagnosed with MILD depression but does NOT want to have a formal psychological or pharmacological intervention. In these cases, NICE recommends that a further assessment should be arranged in 2 weeks’ time. This is referred to as ‘Watchful Waiting’ In these cases, NICE recommends that a further assessment should be arranged in 2 weeks’ time. This is referred to as ‘Watchful Waiting’ ***Patient preference should be considered when deciding on treatment

8. National Institute for Health and Clinical Excellence (NICE) Clinical Guideline on Depression & Anxiety Question 4: SUBMIT A patient comes into Dr K’s surgery with symptoms of low mood, increased fatigue, irritability, poor concentration and feelings of guilt, suggesting a diagnosis of mild depression. Dr K decides that the best course of action in this particular case is to prescribe her patient with an antidepressant, what should this be? Tricyclic antidepressant An SSRI such as fluoxetine A new SSRI such as venlafaxine or mirtazipine None of the above

9. National Institute for Health and Clinical Excellence (NICE) Clinical Guideline on Depression & Anxiety BACK TO QUIZ (Q4) NICE Guidance Recommendation: In this example, the patients’ symptoms point towards a diagnosis of Mild Depression. This is because they have listed four symptoms from the ICD-10 list, including at least two from the core symptoms list. In this example, the patients’ symptoms point towards a diagnosis of Mild Depression. This is because they have listed four symptoms from the ICD-10 list, including at least two from the core symptoms list. When an antidepressant is to be prescribed in routine care, it should be an SSRI because SSRI’s are as effective as tricyclic antidepressants and are less likely to be discontinued due to side effects When prescribing an SSRI, consideration should be given to using a product in generic form. Fluoxetine is a reasonable choice because it is associated with fewer discontinuation/withdrawal symptoms Venlafaxine treatment should only be initiated/managed by specialist mental health medical practitioners When an antidepressant is to be prescribed in routine care, it should be an SSRI because SSRI’s are as effective as tricyclic antidepressants and are less likely to be discontinued due to side effects When prescribing an SSRI, consideration should be given to using a product in generic form. Fluoxetine is a reasonable choice because it is associated with fewer discontinuation/withdrawal symptoms Venlafaxine treatment should only be initiated/managed by specialist mental health medical practitioners Antidepressants are not recommended for the initial treatment of mild depression because the risk-benefit ratio is poor. However Antidepressants should be considered for patients with mild depression that is persisting after other interventions, and those whose depression is associated with psychosocial and medical problems Antidepressants should also be considered when patients with a past history of moderate or severe depression present with mild depression Antidepressants are not recommended for the initial treatment of mild depression because the risk-benefit ratio is poor. However Antidepressants should be considered for patients with mild depression that is persisting after other interventions, and those whose depression is associated with psychosocial and medical problems Antidepressants should also be considered when patients with a past history of moderate or severe depression present with mild depression

10. National Institute for Health and Clinical Excellence (NICE) Clinical Guideline on Depression & Anxiety Question 5: SUBMIT Dr X sees a patient who has harmed themselves, is having feelings of guilt, worthlessness, hopelessness and is self-critical. Doctor X decides to prescribe her patient with a tricyclic antidepressant. Which drug would be the preferred choice? Lofepramine Imipramine Doxepin Amoxapine

11. National Institute for Health and Clinical Excellence (NICE) Clinical Guideline on Depression & Anxiety BACK TO QUIZ (Q5) NICE Guidance Recommendation: When an antidepressant is to be prescribed in routine care, it should be an SSRI because SSRI’s are as effective as tricyclic antidepressants and are less likely to be discontinued due to side effects When prescribing an SSRI, consideration should be given to using a product in generic form. Fluoxetine is a reasonable choice because it is associated with fewer discontinuation/withdrawal symptoms Venlafaxine treatment should only be initiated/managed by specialist mental health medical practitioners When an antidepressant is to be prescribed in routine care, it should be an SSRI because SSRI’s are as effective as tricyclic antidepressants and are less likely to be discontinued due to side effects When prescribing an SSRI, consideration should be given to using a product in generic form. Fluoxetine is a reasonable choice because it is associated with fewer discontinuation/withdrawal symptoms Venlafaxine treatment should only be initiated/managed by specialist mental health medical practitioners NICE issues the following guidance on prescribing Tricyclic Antidepressants:

12. National Institute for Health and Clinical Excellence (NICE) Clinical Guideline on Depression & Anxiety Question 6: SUBMIT SSRI’s Tricyclic antidepressants CBT A combination of antidepressants and CBT Another psychological therapy Other primary care services e.g. Graduate Mental Health Care Workers When patients present initially with severe depression, what course of treatment should ideally be offered to them?

13. National Institute for Health and Clinical Excellence (NICE) Clinical Guideline on Depression & Anxiety EXAMPLE OF INFORMATION PAGE THAT WILL OPEN UP FOR Q6 BACK TO QUIZ (Q6) NICE Guidance Recommendation: Does your patient initially present with SEVERE Depression? Patients with Severe Depression should have SEVEN or more of the agreed ICD-10 listed symptoms, including the 3 core symptoms A combination of Antidepressants and Individual CBT is recommended by NICE as this combination is more cost-effective than either treatment on its own YES

14. National Institute for Health and Clinical Excellence (NICE) Clinical Guideline on Depression & Anxiety Question 7: SUBMIT Mirtazapine Paroxetine Venlafaxine Sertraline Tricyclic antidepressant Dr Y sees a patient and has diagnosed her with moderate depression; this patient also has pre-existing heart disease. Which of the following SSRI’s would be the drug of choice? (Question may be too specific with no supporting evidence??)

15. National Institute for Health and Clinical Excellence (NICE) Clinical Guideline on Depression & Anxiety Question 8: SUBMIT A patient comes to see Dr X, on his third visit, Dr X prescribes him with an SSRI. The patient is apprehensive and asks about the withdrawal symptoms of SSRI’s. What are the most common withdrawal symptoms of SSRI’s? Dizziness Nausea Numbness and Tingling Craving Paraesthesia Gastrointestinal Disturbances Anxiety Irritability Sleep Disturbances

16. National Institute for Health and Clinical Excellence (NICE) Clinical Guideline on Depression & Anxiety Question 9: SUBMIT Dr P diagnoses one of his patients with severe depression. The patient is concerned about the side effects and withdrawal symptoms associated with antidepressants. Dr P informs the patient about possible side effects and the patient then tries an antidepressant. Unfortunately, this particular antidepressant was not successful. What would be the next course of action? Offer an antidepressant that has fewer side effects Offer CBT Offer psychodynamic therapy Refer to a community Mental Health Team

17. National Institute for Health and Clinical Excellence (NICE) Clinical Guideline on Depression & Anxiety Question 10: SUBMIT Dr Z prescribed his patient paroxetine for 6 months and he is now well. Dr Z decides to taper the dose over a period of time. Over what period of time should he taper the dose? 2 weeks 4 weeks 2 months 6 months 1 year

18. National Institute for Health and Clinical Excellence (NICE) Clinical Guideline on Depression & Anxiety Question 11: SUBMIT A patient comes to Dr Z’s surgery and has symptoms of both anxiety and depression, with underlying low mood, loss of interest, poor concentration and low energy. How do you think Dr Z should treat this patient? Treat the anxiety first Treat the depression first Treat both depression and anxiety at the same time Watchful waiting until one of the conditions remits

19. National Institute for Health and Clinical Excellence (NICE) Clinical Guideline on Depression & Anxiety FINISH END OF QUIZ Thank you for sparing some time to complete the questionnaire, please provide your details and click on the ‘FINISH’ button below and we will automatically receive your responses. If you have scored over 70% we will issue you with your certificate, otherwise we will notify you of your score so that you can re-take the quiz if necessary. For further information please contact Anna Cobb xxxx.xxxx@xxxxx.xxx.xxxxxx.xxxx@xxxxx.xxx.xx Name: Email: Work Address: