Depression

Recognition and Management

Dr Bruce Davies

What Is Depression?

A Continuum

Normal Mood Lowering

Abnormal Mood Lowering

Abnormal mood lowering and loss of function

What Is Depression?

Depressive disorder Pervasive Persistent Wide range of symptoms

What Is Depression?

Range of symptoms Negative views Worthlessness Incapacity Guilt Sleep disturbance Diurnal mood variation Loss of energy Impaired concentration

What Is Depression?

Impaired work ability Poor social functioning Psychomotor retardation Pessimism Better off dead Thoughts of suicide Suicide / action Fear / belief of bodily illness

Understandability

No longer important. Do not alter treatment

thresholds. Do not alter

treatment. Reactive /

endogenous = confine to bin.

Vulnerabilities

Losses Stressful life events Lack of social support Physical illness Familial factors Genetic factors

What Is Depression? - Various Criteria.

Defeat Depression Campaign Depressed mood or loss of pleasure for at least

2 weeks. Plus 4 or more of: Worthlessness or guilt Impaired concentration Loss of energy and fatigue Thoughts of suicide Loss or increase of appetite or weight Insomnia or hypersomnia Retardation or agitation

What Is Depression? - Various Criteria.

DSM – IV Duration > 2 weeks Depressed mood or Marked loss of interest or

pleasure in normal activities Plus 4 of:

i. Significant change in weight

ii. Significant change in sleep pattern

iii. Agitation or retardation

iv. Fatigue or loss of energy

v. Guilt / worthlessness

vi. Can’t concentrate or make decisions

vii. Thoughts of death or suicide

What Is Depression? - Various Criteria.

ICD – 10

Patient has low mood:

1) How bad is it and how long has it been going on?

2) Have you lost interest in things?

3) Are you more tired than usual?

If the answer is yes to these, then:

ICD – 10 (Continued)

4) Have you lost confidence in yourself?

5) Do you feel guilty about things?

6) Concentration difficulties?

7) Sleeping problems?

8) Change in appetite or weight?

9) Do you feel that life is not worth living any more?

ICD – 10 (Continued)

Mild.Two criteria from 1-3 and 2 others. Moderate.Two criteria from 1-3 and 3-4 others or a yes to

question 5. Severe.Most of the criteria in severe form especially

questions 5 & 9.

Variants

Depressive episodes that do not meet the criteria for major depression.

Lifelong mild fluctuating depression (Dysthymia).

Mixed states of above two.

Manic depression – bipolar disorder.

Incidence Of Depression : 2000 Patients

100 - major

100 - minor

200 – sub-clinical

Depression. In 50% of patients it may not be acknowledged.

Numbers

10% of those diagnosed in primary care are referred to psychiatrists.

1 in 1000 are admitted to hospital. Lifetime incidence rates approach 33%. 5% of consulters have major depression. 5% have milder depression. A further 10% have some depressive

features.

Numbers

At least one patient per surgery will have depressive symptoms of some type.

Commoner in younger people including children than thought in the past.

Men:women = 1:2. Common in the physically ill. 50% recurrence rate. 12% become chronically depressed.

Why Missed?

50% are missed. 10% subsequently

recognised. Of the 40% who

remain unrecognised: Half remit

spontaneously. Half remain depressed

6 months later.

Missed: Patient Factors

Present somatic symptoms. Physical problems. Stigma. Beliefs about GP role and time to listen. Longstanding depression. Less overt / typical. Less insight.

Missed: Doctor Factors

More accurate doctors. Make more eye contact. Show less signs of hurry. Are good listeners. Ask questions with social and psychological content.

Less accurate doctors. Ask many closed questions. Ask questions derived from theory rather than what

the patient just said.

Assessment

Severity Duration Social network Views of self, world and

future Suicidal thoughts Past history Factors affecting

symptoms Biological features

Assessment Skills

Directive not closed questions Picking up on verbal clues “clarification” Picking up on non-verbal clues and using

them Empathy Summarising

Treatment Contract

Key skills Re-frame symptoms as

depression Link to life events Negotiate anti-depressants

if necessary Problem list and priorities Set realistic time scale Agree regular review

Explanations

Depressive illness is clinically different from the blues and involves chemical changes in the brain.

Depressive illness has characteristic symptoms and explain them.

Explanations

Depression benefits from both drug and non-drug approaches. “Pills for symptoms.” “Talking for problems.”

Explanations

Anti-depressants are not addictive or habit forming.

Anti-depressants take 2-3 weeks to begin to work and need to be taken for 4-6 months after the full benefit is obtained to prevent relapse.

Explanations

Side effects occur and are expected – explain.

Drugs enable talking therapy to work better.

Regular review is important and needs to continue for at least 6 months.

Explanations

Talking therapy can help solve problems that are soluble, cope with the insoluble and examine other problems that seem unrealistic to the patient or therapist.

Prevention of further trouble will be considered when the treatment is coming to an end.

References

Defeat Depression Campaign. The Royal College of Psychiatrists. 1994.

Treating People with depression: a practical guide for primary care. G Wilkinson et al. Radcliffe 1998.

Recognition and management of depression in general practice: consensus statement. BMJ 1992;305:1198-202.