national institute for health and clinical excellence (nice) clinical guideline on depression &...

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


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

?

?

?


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


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


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


BACK TO QUIZ (Q3)

EXAMPLE OF INFORMATION PAGE THAT WILL OPEN UP AFTER CLICKING ON THE INFORMATION BUTTON ON QUESTION 3:


If a patient has been diagnosed with MILD depression, you may be of the opinion that they will recover with no intervention.

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.

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


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


BACK TO QUIZ (Q4)


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




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


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


BACK TO QUIZ (Q5)








NICE issues the following guidance on prescribing Tricyclic Antidepressants:NICE issues the following guidance on prescribing Tricyclic Antidepressants:


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?


EXAMPLE OF INFORMATION PAGE THAT WILL OPEN UP FOR Q6

BACK TO QUIZ (Q6)


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

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


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??)


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


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


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


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


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 [email protected]

Name:

Email:

Work Address:

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