Depression - Primary care presentation NS MOM

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Efforts are made to ensure the accuracy and agreement of these guidelines. However, we cannot guarantee this. This guidance does not override the individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or guardian or carer, in accordance with the mental capacity act, and informed by the summary of product characteristics of any drugs they are considering. Practitioners are required to perform their duties in accordance with the law and their regulators and nothing in this guidance should be interpreted in a way that would be inconsistent with compliance with those duties

Scope:

• assessment and management of depression in adults
• covers primary and secondary care management
• gives special consideration to depression in pregnancy, breastfeeding and the perinatal period

• covers pharmacological and psychosocial treatments

• also covers recommendations regarding physical treatments, including electroconvulsive therapy (ECT)

• gives special consideration to depression in those with a chronic physical condition

Out of scope:

• assessment and management in children and adolescents
• seasonal affective disorder

Definition:

• depression is characterised by:
  • depressed mood and/or loss of pleasure in most activities
  • a range of emotional, cognitive, physical, and behavioural symptoms
• can range in severity from a mild disturbance to a severe illness with a risk of suicide
• severity is determined by:
  • number and severity of symptoms
  • degree of functional impairment
• depression is defined by the:
  • American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorder (DSM-IV); or
  • the tenth revision of the International Classification of Diseases (ICD-10)

Incidence and prevalence of depression:

• in the UK, depression is the third most common reason for consultation in general practice [1]
• mixed anxiety and depression is the most common mental disorder in a community setting [2]
• depression is the fourth leading cause of disability and disease worldwide [1]
• there is a higher incidence of depression in women than men [3]
• on average, the first episode of major depression occurs in the mid-20s [2]

Prognosis of depression:

• the average length of a depressive episode is 6-8 months [1]
• following their first episode of major depression, at least 50% of people will have at least one more episode [2]

• 50% of people diagnosed with depression still have a diagnosis of depression 1 year later [2]

• at least 10% of people have persistent or chronic depression [2]

• after a second episode, the risk of recurrence increases to 70%; after a third episode, the risk increases to 90% [1]

Risk factors for depression:

• co-morbid psychiatric diagnosis, eg:
  • anxiety
  • social phobia
  • panic and various personality disorders
  • post-traumatic stress disorder (PTSD)
  • obsessive compulsive disorder (OCD)
• a previous history of depression in adulthood
• socio-economic factors, including:
  • poverty
  • homelessness
  • unemployment
• chronic physical illness
• chronic pain syndromes
• family history of depression
• catastrophic life event in the previous 6 months [41]
• chronic life difficulty in the absence of adequate social support [41]
• childhood abuse and/or neglect [41]

Postnatal depression:

• definition:
  • postnatal depression is defined as a non-psychotic depressive illness of mild to moderate severity  occurring during the first postnatal year 
• incidence:
  • approximately 13% of women have an episode of depression during pregnancy [4]

Risk factors for postnatal depression:

• moderate to strong associations with postnatal depression:
  • past history of psychopathology and psychological disturbance during pregnancy
  • low social support
  • poor marital relationship
  • recent life events
• weak associations with postnatal depression:
  • history of abuse
  • low family income
  • lower occupational status
• preterm infants

References:

[1] Clinical Knowledge Summaries (CKS). Depression. Version 1.1. Newcastle Upon Tyne: CKS; 2010.

[2] National Institute for Health and Clinical Excellence (NICE). Depression: the treatment and management of depression in adults (update). Clinical guideline 90. London: NICE; 2009. 

[3] Scottish Intercollegiate Guideline Network (SIGN). Non-pharmaceutical management of depression in adults. A national clinical guideline. SIGN publication no. 114. Edinburgh: SIGN; 2010.

[4] New Zealand Guidelines Group (NZGG). Identification of common mental disorders and management of depression on primary care. Evidence based practice guideline. Wellington: NZGG; 2008.

[5] Contributors invited by Map of Medicine; 2010.

[6] Institute for Clinical and Systems Improvement (ICSI). Health care Guidelines: Major depression in adults in primary care. Bloomington: ICSI; 2009.

[7] Map of Medicine (MoM) Clinical and Editorial team and Fellows. London: MoM; 2010.

[8] Scottish Intercollegiate Guidelines Network (SIGN). Postnatal depression and puerperal psychosis. A national clinical guideline. SIGN Publication No. 60. Edinburgh: SIGN; 2002.

[9] Vigod SN, Villegas L, Dennis CL. Prevalence and risk factors for postpartum depression among women with preterm and low-birth-weight infants: a systematic review. BJOG 2010: 117; 540-50.

[10] World Health Organisation (WHO) Guide to Mental and Neurological Health in Primary Care. Depression (diagnostic checklist). London: WHO; 2004.

[41] Contributors invited by Map of Medicine; 2011.

 Bumps

UKTIS has been providing scientific information to health care providers since 1983 on the effects that use of medicines, recreational drugs and chemicals during pregnancy may have on the unborn baby.

Avon and Wiltshire Mental Health Partnership Choice and Medication website

This website provides information for people who use its services, carers and healthcare professionals. It includes questions and answers about a large number of medicines and mental health conditions, printable leaflets and latest news.

Self Injury Support

A UK-wide service supporting people with depression that offers text support and a helpline.

For All Healthy Living Company

Healthy Connections Client Leaflet

Based at the Healthy Living Centre in South Ward, Weston-super-Mare.

Support for adults with low to moderate mental health problems such as anxiety and / or depression, and those who feel isolated in the community.

Adults who live in South Ward can be referred by GPs, and other health professionals, other organisation/agencies, or self refer.

• 'Alcohol and depression' (URL) from The Royal College of Psychiatrists at http://www.rcpsych.ac.uk
• ''Antidepressants' (URL) from The Royal College of Psychiatrists at http://www.rcpsych.ac.uk
• 'Cognitive-behavioural Therapy (CBT)' (PDF) from Patient UK at https://patient.info/
• 'Cognitive Behavioural Therapy (CBT)' (URL) from The Royal College of Psychiatrists at http://www.rcpsych.ac.uk
• 'Depression' (PDF) from Patient UK at http://www.patient.info
• 'Depression and low mood - A Self Help Guide' (URL) from Patient UK at http://www.patient.info
• 'Depression and men' (URL) from The Royal College of Psychiatrists at http://www.rcpsych.ac.uk
• 'Depression in Older Adults' (URL) from The Royal College of Psychiatrists at http://www.rcpsych.ac.uk
• 'Depression: Key Facts' (URL) from The Royal College of Psychiatrists at http://www.rcpsych.ac.uk
• 'Diet and depression' (PDF) from British Dietetic Association at http://www.bda.uk.com
• ‘'SSRI Antidepressants' (PDF) from Patient UK at http://www.patient.info
• 'Tricyclic Antidepressants' (URL) from Patient UK at http://www.patient.info

 NSCCG Sign off Form

Date of publication: 29-Jul-2011

Scheduled update:

The care map has been updated in line with the following guidelines:

• [29] British National Formulary (BNF). BNF 61. London: BMJ Group and
  RPS Publishing; 2011.
• [30] World Health Organisation (WHO). Mental health Gap Action Programme (mhGAP) intervention guide for mental, neurological and substance use disorders in non-specialized health settings. Geneva, CH; WHO: 2010.
• [31] American Psychiatric Association (APA). Practice guideline for the treatment of patients with major depressive disorder. Arlington, VA, US: APA; 2011.
• [32] Beyond Blue. Clinical practice guideline: Depression and related disorders - anxiety, bipolar disorder and puerperal psychosis - in the perinatal period. Victoria, AU: Beyond Blue; 2011.
• [40] National Institute for Health and Clinical Excellence (NICE). Vagus nerve stimulation for treatment-resistant depression. Interventional procedure guidance 330. London: NICE; 2009.

Further information was provided by the following references: [33-39,41].

 Voluntary sector services: -

Rethink Mental Illness

Help people affected by mental illness by challenging attitudes, changing lives. Provide expert, accredited advice and information to everyone affected by mental health problems.

Mind - Provide advice and support to anyone experiencing a mental health problem. Local Minds support people across England and Wales. Their services include supported housing, crisis helplines, drop-in centres, employment and training schemes, counselling and befriending.

Samaritans - Available 24 hours a day to provide confidential emotional support for people who are experiencing feelings of distress, despair or suicidal thoughts.

1 in 4 - Their role isn’t to “treat mental illness”. It’s to enable mental wellbeing, to empower people with mental health issues to tackle the challenges they face and move forward with their lives.

Wellspring counselling - Wellspring has a team of dedicated counsellors who come alongside those facing loss and bereavement, relationship difficulties, stress and anxiety, depression and issues resulting from physical, sexual or emotional abuse as well as other distressing situations.

Second Step - A leading mental health charity based in the west of England, with offices in Bristol, Bath and Weston-Super-Mare. They offer housing, support and hope to people with many kinds of mental health problems. They also help people to manage low mood, anxiety and depression by providing psychological therapies and specialist courses in Bristol, South Gloucestershire and through PositiveStep in North Somerset. 

Chapter 1 - A charity which, based on Christian principles, specialises in providing accommodation and support for vulnerable people.

Richmond Fellowship - Provide a range of mental health support services: Residential recovery, Supported living, Wellbeing and Self-directed support.

Personal Recovery Service - Offers a wide range of therapies to help with a diverse range of presenting problems. PRS is specialist in the treatment and recovery of sexual abuse. However, not all their work is about abuse, much of the work they do is about people trying to cope with Divorce, Bereavement, or just everyday Stress.  

Western Counselling - Residential Rehab Treatment For Addictions. Offers a structured, abstinence-based,12 step residential treatment programme that includes detoxification and aftercare, to give clients the best possible chance of achieving and sustaining long-term recovery from addiction.

Nailsea Disability Initiative - Provides free information and advice to the public, relating to disability. Their work involves not only assisting members of the public who call at their drop in centre, but they also keep up with current issues of importance to disabled and elderly people.

Wanted Not Wasted (Reframe Counselling service) - Free counselling to children and young adults aged 5-25yrs old who live in the South of Weston Super Mare (Bournville, Oldmixon, Coronation, Severn Road area, Potteries, Town Centre etc).

Survivors of Bereavement by Suicide

- Weston-Super-Mare support group. See attached for details.

Support Group press release

Survivors of suicide bereavement leaflet

Common questions - suicide bereavement group

  
Positive Step - Wellness Advisors are employed by Second Step and provide initial assessment, facilitate courses and offer 1:1 therapy by telephone or face to face. Therapists are employed by AWP and are trained to deliver cognitive behavioural therapy (CBT) and offer this 1:1 or via therapy groups.

Local administrative information

 Be alert for depression in high-risk groups, such as those with:

• a history of:
  • depression
  • mania or bipolar disorder [41]
  • suicide attempt
• any significant physical illness, especially those which are [41]:
  • endocrinological
  • neurological
  • life-threatening
  • disabling
  • catastrophic
  • stigmatising
  • painful
  • deforming  
• other mental health problems
• family history of depression

Clinical presentation varies depending on a number of factors, including:

• age:
  • younger patients show more behavioural symptoms and irritability 
  • older adults have :
    • more somatic symptoms
    • fewer complaints of low mood
    • more memory problems [41] 
• stage of illness
• severity of illness
• co-morbidities

Presenting symptoms of depression include:

• typical presentation:
  • persistent sense of sadness, anxiety or emptiness
  • lack of motivation and interest [41]
  • feelings of hopelessness
  • feelings of worthlessness and/or guilt
  • marked physical slowness or agitation
  • complete lack of reactivity of mood to positive events
  • range of somatic symptoms, such as:
    • appetite and weight loss
    • reduced sleep (pattern of early waking and being unable to get back to sleep)
    • loss of energy or fatigue [41]
  • depression being substantially worse in the morning (diurnal variation)
  • in severe depression, patients may develop psychotic symptoms, eg hallucinations and/or delusions 
• atypical presentation:
  • weight gain
  • reactive mood
  • increased appetite
  • excessive sleepiness 

Physical symptoms of depression can include:

• pain
• constant tiredness

The following can accompany or conceal depression:

• anxiety:
  • when depression is accompanied by anxiety, the first priority should be to treat the depression
  • when the person has an anxiety disorder and co-morbid depression or depressive symptoms, consult the relevant guidelines:
    • consider treating the anxiety disorder first (if depression is relatively mild compared to anxiety) [41] − effective treatment of the anxiety disorder will often improve the depression or depressive symptoms
• insomnia
• worries about social problems, eg financial difficulties
• increased irritability and hostility [41]
• increased drug or alcohol use
• in a new mother, constant worries about her infant or fear of harming the baby 

Early warning symptoms of depression in a patient with recurrent depression include:

• anxiety
• phobias
• milder depressive symptoms
• panic attacks

This information was drawn from the following references:

[2] National Institute for Health and Clinical Excellence (NICE). Depression: the treatment and management of depression in adults (update). Clinical guideline 90. London: NICE; 2009. 

[3] Clinical Knowledge Summaries (CKS). Depression. Version 1.1. Newcastle Upon Tyne: CKS; 2010.

[5] Contributors invited by Map of Medicine; 2010

[6] Institute for Clinical and Systems Improvement (ICSI). Health care Guidelines: Major depression in adults in primary care. Bloomington: ICSI; 2009.

[7] Map of Medicine (MoM) Clinical and Editorial team and Fellows. London: MoM; 2010.

[10] World Health Organisation (WHO) Guide to Mental and Neurological Health in Primary Care. Depression (diagnostic checklist). London: WHO; 2004.

[41] Contributors invited by Map of Medicine; 2011.

 At a woman’s first contact with services in both the antenatal and the postnatal periods, healthcare professionals (including midwives, obstetricians, health visitors and GPs) should ask questions about:

• past or present severe mental illness including schizophrenia, bipolar disorder, psychosis in the
  postnatal period, and severe depression [11]
• previous treatment by a psychiatrist/mental health specialist [11]
• previous postnatal depression [41] 
• a family history of perinatal mental illness [11]

At a woman’s first contact with primary care, at her booking visit and postnatally (usually at
4-6 weeks and 3-4 months), healthcare professionals should ask the following questions to identify possible depression [11]:

• during the past month, have you often been bothered by feeling down, depressed or hopeless?
• during the past month, have you often been bothered by having little interest or pleasure in doing things?

If the woman answers yes to the previous 2 questions, ask [2]:

• is this something you feel you need or want help with

Discuss the following for all women of childbearing potential who have a mental disorder and/or who are taking psychotropic medication [11]:

• contraception; and
• the risks of pregnancy (including relapse, risks associated with stopping or changing medication, and risk to the fetus)
• pregnancy plans

If the woman has a current or past history of severe mental illness, develop a written care plan, usually in the first trimester, covering [11]:

• pregnancy
• delivery
• postnatal period including breastfeeding

Develop a care plan. The care plan should [11]:

• be developed with the woman, her partner, family members and carers, and relevant healthcare professionals
• include increased contact with specialist mental health services, including, if appropriate, specialist perinatal mental health services
• be recorded in all versions of the woman’s notes (her own records, maternity, primary care and mental health notes) and communicated to the woman and all relevant healthcare professionals

If there are specific concerns, the woman should be referred by her GP for assessment [11].

Women who need inpatient care for a mental disorder within 12 months of childbirth should be admitted to a specialist mother and baby unit unless there are specific reasons for not doing so [11].

References:

[2] National Institute for Health and Clinical Excellence (NICE). Depression: the treatment and management of depression in adults (update). Clinical guideline 90. London: NICE; 2009. 

[11] National Collaborating Centre for Mental Health (NCCMH). Antenatal and postnatal mental health. The NICE guideline on Clinical management and service guidance. Clinical guideline 45. London: The British Psychological Society (BPS) and The Royal College of Psychiatrists (RC-PSYCH); 2007.

[41] Contributors invited by Map of Medicine; 2011.

 Assessment:

• conduct a comprehensive assessment, taking into account the:
  • severity of symptoms and degree of functional impairment
  • disability associated with the possible depression
  • duration of the episode
  • precipitating factors
• consider asking the following questions:
  • 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 having little interest or pleasure in doing things? 

• ask the following − during the last month, have you often been bothered by:

  • feeling worthless?
  • poor concentration?
  • thoughts of death?

NB: the World Health Organisation recommends asking about questions relating to low mood, anhedonia and negative thoughts over the past 2 weeks [30].

Review the person's:

• mental state
• associated functions
• interpersonal and social functioning

Consider using a validated measure for symptoms, functions and/or disability.

Further considerations:

• consider the role of the physical health problem
• check optimal treatment for the physical health problem to being provided and adhered to
• seek specialist advice if necessary

This information was drawn from the following references:

[1] Clinical Knowledge Summaries (CKS). Depression. Version 1.1. Newcastle Upon Tyne: CKS; 2010.

[2] National Institute for Health and Clinical Excellence (NICE). Depression: the treatment and management of depression in adults (update). Clinical guideline 90. London: NICE; 2009.

[3] Scottish Intercollegiate Guideline Network (SIGN). Non-pharmaceutical management of depression in adults. A national clinical guideline. SIGN publication no. 114. Edinburgh: SIGN; 2010.

[4] New Zealand Guidelines Group (NZGG). Identification of common mental disorders and management of depression on primary care. Evidence based practice guideline. Wellington: NZGG; 2008.

[6] Institute for Clinical and Systems Improvement (ICSI). Health care Guidelines: Major depression in adults in primary care. Bloomington: ICSI; 2009.

[7] Map of Medicine (MoM) Clinical and Editorial team and Fellows. London: MoM; 2010.

[10] World Health Organisation (WHO) Guide to Mental and Neurological Health in Primary Care. Depression (diagnostic checklist). London: WHO; 2004.

[30] World Health Organisation (WHO). Mental health Gap Action Programme (mhGAP) intervention guide for mental, neurological and substance use disorders in non-specialized health settings. Geneva, CH; WHO: 2010.

 History:

Conduct a full systemic assessment, including [31]:

• a full psychiatric history
• a mental state examination
• a review of systems
• a general medical history
• a social history
• a family history − ask about:
  • mood disorders
  • suicide
• an occupational history
• a personal history including:
  • psychological development
  • responses to major life events

Ask about:

• current symptoms of depression, including ideas of suicide
• historical pattern of current illness
• duration of symptoms
• severity of symptoms
• degree of functional impairment
• response to any previous treatment
• quality of interpersonal relationships
• living conditions and social isolation
• alcohol, illicit substance, or prescribed medication use [31]
• recent losses, including bereavement
• psychosocial stressors, eg loss, conflict, financial difficulties, life change, abuse

Take a full psychiatric history [31] including:

• history of self-harm
• history of suicide attempt/s
• past history of mania or hypomania or mixed episodes [31]
• past history of depression
• response to any treatment for depression in the past [31]

Enquire into past medical history:

• medication history; the following medications may be associated with major depression:
  • corticosteroids
  • interferon
  • methyldopa
  • isotretinoin
  • varenicline
  • hormonal therapy
• substance misuse/dependence:
  • use of alcohol and hypnotics might mimic and/or induce depression
  • withdrawal from cocaine, anxiolytic, and amfetamines may mimic depression
  • idiosyncratic reactions to illicit substances should be considered

Physical examination must be performed at initial presentation to assess for any physical cause of depression and for co-morbid physical illness [31].

This information was drawn from the following references:

[1] Clinical Knowledge Summaries (CKS). Depression. Version 1.1. Newcastle Upon Tyne: CKS; 2010.

[2] National Institute for Health and Clinical Excellence (NICE). Depression: the treatment and management of depression in adults (update). Clinical guideline 90. London: NICE; 2009. 

[4] New Zealand Guidelines Group (NZGG). Identification of common mental disorders and management of depression on primary care. Evidence based practice guideline. Wellington: NZGG; 2008.

[6] Institute for Clinical and Systems Improvement (ICSI). Health care Guidelines: Major depression in adults in primary care. Bloomington: ICSI; 2009.

[7] Map of Medicine (MoM). London: MoM; 2010.

[31] American Psychiatric Association (APA). Practice guideline for the treatment of patients with major depressive disorder. Arlington, VA, US: APA; 2011.

 Investigations for depression:

• investigations to rule out an organic cause are guided by clinical presentation [1,31] − basic investigations that are indicated include:
  • biochemistry [1]:
    • blood glucose
    • creatinine and electrolytes
    • liver function tests (LFTs)
    • thyroid function tests (TFTs)
    • calcium levels
  • haematology:

    • full blood count (FBC) [1]

    • erythrocyte sedimentation rate (ESR) [1] or carbon reactive protein [5]

    • urinary or blood drug screening [1]
• if indicated clinically or by history, consider HIV and syphilis serology [1]

Consider seeking specialist advice on whether investigations such as brain imaging are indicated, if the patient presents with:

• unexplained headache [1]
• personality changes [1]
• possible signs of space-occupying lesion [41]
• possible convulsions [41]
• altered state of alertness [41]

Reliance on laboratory tests should be greater if [6]:

• medical review detects symptoms that are rarely encountered in mood or anxiety disorders
• patient is older
• the first major depressive episode occurs after age 40 years

References:

[1] Clinical Knowledge Summaries (CKS). Depression. Version 1.1. Newcastle Upon Tyne: CKS; 2010.

[5] Contributors invited by Map of Medicine; 2010.

[6] Institute for Clinical and Systems Improvement (ICSI). Health care Guidelines: Major depression in adults in primary care. Bloomington: ICSI; 2009.

[31] American Psychiatric Association (APA). Practice guideline for the treatment of patients with major depressive disorder. Arlington, VA, US: APA; 2011.

[41] Contributors invited by Map of Medicine; 2011.

 Before diagnosing depression, consider alternative explanations including:

• bipolar disorder − people may present with:
  • mania
  • hypomania − ask about  symptoms of hypomania when assessing a patient with depression and overactive, disinhibited behaviour
  • depression
  • history of previous episodes of possible:
    • mania or hypomania
    • mixture of both manic and depressive symptoms
  • psychotic symptoms
•  other psychiatric conditions:
  • generalised anxiety disorder anxiety
  • post-traumatic stress disorder
  • social phobia
  • panic disorder
  • obsessive compulsive disorder
  • personality disorder
  • psychotic disorders
  • adjustment disorder
  • bereavement
  • dementia
• non-psychiatric:
  • alcohol abuse or dependence [41]
  • as a result of illicit substance misuse:
    • anabolic steroids
    • cannabis
    • cocaine
    • narcotics
  • as a result of adverse drug effects:
    • centrally acting antihypertensives
    • lipid-soluble beta blockers
    • central nervous system depressants
    • opioid analgesics
    • isotretinoin
    • benzodiazepines
    • corticosteroids
    • H₂-receptor antagonists 
    • chemotherapy agents (vincristine, vinblastine, procarbazine, L-asparaginase)
    • levodopa 
    • non-steroidal anti-inflammatory drugs (NSAIDs)
    • cholesterol lowering agents 
    • beta blockers
    • oral contraceptives

• as a result of medical conditions:

  • endocrine disorders, such as:
    • hypothyroidism
    • Cushing’s disease
    • adrenal insufficiency
    • hyperparathyroidism
  • cancer, eg brain tumour [41]
  • diabetes
  • cardiac disease
  • Parkinson’s disease 
  • cerebrovascular disease, such as:
    • stroke
    • subarachnoid haemorrhage
    • myocardial infarction (MI)
  • autoimmune diseases
  • post-polio syndrome
  • HIV [41]

This information was drawn from the following references:

[1] Clinical Knowledge Summaries (CKS). Depression. Version 1.1. Newcastle Upon Tyne: CKS; 2010.

[2] National Institute for Health and Clinical Excellence (NICE). Depression: the treatment and management of depression in adults (update). Clinical guideline 90. London: NICE; 2009. 

[7] Map of Medicine (MoM). London: MoM; 2010.

[10] World Health Organisation (WHO) Guide to Mental and Neurological Health in Primary Care. Depression (diagnostic checklist). London: WHO; 2004.

[5] Contributors invited by Map of Medicine; 2010.

[41] Contributors invited by Map of Medicine; 2011.

 Diagnosing depression:

• Depression is diagnosed using the DSM-IV or ICD-10 criteria
  • DSM-IV − requires a minimum of 5 out of 9 symptoms, including depressed mood and/or anhedonia [1,2]:
    • depressed mood by self report or observations by others [1]
    • loss of interest or pleasure [1]
    • feelings of worthlessness/guilt [1]
    • recurrent thoughts of death, suicide thoughts, or actual suicide attempts [1]
    • diminished ability to think, concentration, or indecisiveness [1]
    • psychomotor agitation or retardation [1]
    • insomnia or hypersomnia [1]
    • significant appetite and/or weight loss [1]
    • loss of energy or fatigue [41]
  • ICD-10 − requires 4 out of 10 symptoms, including at least two of depressive mood, anhedonia, and energy loss [2]
• duration of symptoms [1]:
  • in order to make a diagnosis of depression, symptoms should have been present for at least 2 weeks
  • if depression has persisted for more than 2 years, the patient is said to have chronic depression:
    • 2 year cut off is arbitrary and should be considered in the context of severity and the course of the illness

Consider the use of depression questionnaires to detect and assess severity of depression (do not use to determine the need for treatment), such as:

• Patient Health Questionnaire 9 (PHQ-9) [1,4,6,12]:
  • uses DSM-IV criteria [1]
  • maximum score of 27 [1]
  • score of 12 is the recommended threshold for considering intervention [1] - however there is still debate about this value [41]
• Hospital Anxiety and Depression Scale (HADS) [1,12]:
  • self-administered scale, with 14 items in total (covering depression and anxiety) [1]
  • maximum score for each subscale is 21 [1]
  • score of 10 is the recommended threshold for considering intervention [1]
• Beck Depression Inventory-II (BD-II) [1]:
  • uses DSM-IV criteria, self-administered scale
  • maximum score of 63
  • score of 20 is the recommended threshold for considering intervention

Special considerations:

• a meta-analysis of the Geriatric Depression Scale (GDS) recommends the use of GDS(15) but not GDS(30) in the diagnosis of late-life depression in primary care [13]
• for people with significant language or communication problems, consider [2]
  • using the Distress Thermometer 14; and/or
  • asking family or carer about the person's symptoms
• in the postnatal period consider using the Edinburgh Postnatal Depression Scale (EPDS) [8]

NB: Expert opinion suggests that the PHQ-9 may in fact overestimate the severity of depression and should instead be used to contribute to the overall assessment of a patient and monitor their progress [41]. 

References:

[1] Clinical Knowledge Summaries (CKS). Depression. Version 1.1. Newcastle Upon Tyne: CKS; 2010.

[2] National Institute for Health and Clinical Excellence (NICE). Depression: the treatment and management of depression in adults (update). Clinical guideline 90. London: NICE; 2009.

[4] New Zealand Guidelines Group (NZGG). Identification of common mental disorders and management of depression on primary care. Evidence based practice guideline. Wellington: NZGG; 2008.

[6] Institute for Clinical and Systems Improvement (ICSI). Health care Guidelines: Major depression in adults in primary care. Bloomington: ICSI; 2009.

[8] Scottish Intercollegiate Guidelines Network (SIGN). Postnatal depression and puerperal psychosis. A national clinical guideline. SIGN Publication No. 60. Edinburgh: SIGN; 2002.

[12] National Institute for Health and Clinical Excellence (NICE). Depression in adults with a chronic physical health problem: Treatment and management. London: NICE; 2009.

[13] Mitchell AJ, Bird V, Rizzo M et al. Diagnostic validity and added value of the geriatric depression scale for depression in primary care: A meta-analysis of GDS(30) and GDS(15). J Affect Disorder 2009 [Epub ahead of print].

[41] Contributors invited by Map of Medicine; 2011.

 The severity of depression can be defined as follows [14]:

• subthreshold depression:
  • significant depressive symptoms below the threshold for DSM-IV depression
• mild depression:
  • symptoms barely meet the minimum criteria; and
  • there is mild functional impairment
• moderate depression:
  • more than the minimum number of symptoms are present; and
  • there is moderate functional impairment
• severe depression:
  • most symptoms are present; and
  • there is a marked or greater functional impairment

Reference:

[14] Anderson IM, Ferrier IN, Baldwin RC. Evidence-based guideline for treatment depressive disorders with antidepressants: A revision of the 2000 British Association of Psychopharmacology guidelines. J Psychopharmacol 2008; 22: 343-96.

 Always ask directly about suicidal ideation and intent [1-3,6,10,31]:

• asking about suicide or self-harm is important and does not increase the risk of suicide or self-harm episodes [5]
• questions to consider include:
  • do you ever think about suicide? [1,6]
  • have you made plans for ending your life? [1,4]
  • have you thought about how you would end your life? [6] If the person with suspected depression answers yes to this question, ask about specific methods considered, eg gun, overdose [6]
  • do you have the means for doing this available to you? [1,4,6]
  • what has kept you from acting on these thoughts? [1,6]
  • do you feel that life is worth living? [6,10]
  • do you wish you were dead? [6]
  • have you ever thought about harming yourself in anyway? [10]

Risk factors for suicide include [1]:

• social characteristics:
  • male gender
  • young age (less than age 30 years)
  • advanced age
  • single or living alone
• history:
  • prior suicide attempt [31]
  • family history of suicide or mental illness [31]
  • history of substance abuse [31]
  • recently started antidepressants
  • history of impulsive acts and/or violence [41]
• clinical features:
  • hopelessness [4] 
  • psychosis [31]
  • severe anxiety [31], agitation, panic attacks
  • concurrent physical illness
  • severe depression
• life stressors [31]  
• lack of protective factors [4,31] 

If there is a risk of self-harm or suicide:

• assess whether the person has adequate and reliable social support [1,2]
• arrange appropriate help [1]
• advise the person to seek further help if the situation deteriorates [1,2]
• consider toxicity in overdose of prescribed medications [1]

Advise family and carers to be vigilant of [1,12]:

• mood changes
• negativity
• hopelessness
• suicidal ideation and plans

Also assess the patient's level of:

• self-care
• hydration
• nutrition

Consider risk to others − in particular [31]:

• risk to dependants through neglect
• risk of violence − enquire about:
  • history of violence
  • homicidal ideas, plans, or intentions 

References:

[1] Clinical Knowledge Summaries (CKS). Depression. Version 1.1. Newcastle Upon Tyne: CKS; 2010.

[2] National Institute for Health and Clinical Excellence (NICE). Depression: the treatment and management of depression in adults (update). Clinical guideline 90. London: NICE; 2009.

[3] Scottish Intercollegiate Guideline Network (SIGN). Non-pharmaceutical management of depression in adults. A national clinical guideline. SIGN publication no. 114. Edinburgh: SIGN; 2010.

[4] New Zealand Guidelines Group (NZGG). Identification of common mental disorders and management of depression on primary care. Evidence based practice guideline. Wellington: NZGG; 2008.

[5] Contributors invited by Map of Medicine; 2010.

[6] Institute for Clinical and Systems Improvement (ICSI). Health care Guidelines: Major depression in adults in primary care. Bloomington: ICSI; 2009.

[10] World Health Organisation (WHO) Guide to Mental and Neurological Health in Primary Care. Depression (diagnostic checklist). London: WHO; 2004.

[12] National Institute for Health and Clinical Excellence (NICE). Depression in adults with a chronic physical health problem: Treatment and management. London: NICE; 2009.

[31] American Psychiatric Association (APA). Practice guideline for the treatment of patients with major depressive disorder. Arlington, VA, US: APA; 2011.

[41] Contributors invited by Map of Medicine; 2011.

 Refer to specialist mental health services if the person with depression:

• is considered to an immediate risk to themselves or others [1,2,12,14,31]
• is actively suicidal, has a current suicide plan, is at risk of self-harm [1,4]
• has psychotic symptoms [1,4], eg hallucinations, delusions [1]
• has severe agitation accompanying severe symptoms [1]
• presents with severe self-neglect [4]
• has deteriorating personal circumstances exacerbating their mental illness [1]
• is a risk to other people [41]

If the person needs to be admitted to hospital, every attempt should be made to persuade them to go voluntarily [7].

If the person refuses to go to hospital, compulsory admission may be necessary if the person [7,31]:

• requires assessment and/or treatment in a hospital, and
• needs to be admitted in the interests of their own health or safety, and/or for the protection of other people

Consider assessment for compulsory admission − Mental Health Act 2007 (MHA; in England and Wales):

• section 2 of MHA:
  • allows for compulsory admission for assessment of mental state for up to 28 days [15]
  • it requires an application from an Approved Mental Health Professional (AMHP; formerly an Approved Social Worker) [15]
  • rarely, the person's nearest relative, and recommendations from two doctors [15]:
    • usually a psychiatrist [5] or Section 12 approved doctor [5]; and
    • usually the person's GP if at all practicable [15]
  • ideally the person should be examined jointly by the two doctors with the AMHP also present. Where this is not possible, each doctor may carry out a separate examination. If the AMHP is not present it is essential that at least one of the doctors discusses the person with the AMHP [15]
• section 3 of MHA [15]:
  • allows compulsory admission for assessment and treatment of mental illness for up to 6 months
  • only used if diagnosis is previously known [5]
• section 4 of MHA [15]:
  • allows for compulsory admission for up to 72 hours if there is 'urgent necessity', and 'undesirable delay' would occur while trying to arrange admission is allowed:
    • it requires an application from an AMHP (or, rarely, the person's nearest relative) and just one medical recommendation, preferably from a doctor with previous acquaintance (usually the GP)
• section 136 of MHA:
  • allows for compulsory admission with the assistance of the police for detainment in a place of safety for further assessment [15]
  • can only be used in a public place [5]

Admission to mental health services may also be indicated for severely ill patients who [31]:

• lack adequate support outside of a hospital setting
• have complicated psychiatric or general medical conditions

References:

[1] Clinical Knowledge Summaries (CKS). Depression. Version 1.1. Newcastle Upon Tyne: CKS; 2010.

[2] National Institute for Health and Clinical Excellence (NICE). Depression: the treatment and management of depression in adults (update). Clinical guideline 90. London: NICE; 2009.

[4] New Zealand Guidelines Group (NZGG). Identification of common mental disorders and management of depression on primary care. Evidence based practice guideline. Wellington: NZGG; 2008.

[5] Contributors invited by Map of Medicine; 2010.

[7] Map of Medicine (MoM) Clinical and Editorial team and Fellows. London: MoM; 2010.

[12] National Institute for Health and Clinical Excellence (NICE). Depression in adults with a chronic physical health problem: Treatment and management. London: NICE; 2009.

[14] Anderson IM, Ferrier IN, Baldwin RC. Evidence-based guideline for treatment depressive disorders with antidepressants: A revision of the 2000 British Association of Psychopharmacology guidelines. J Psychopharmacol 2008; 22: 343-96.

[15] Department of Health (DH). Mental Health Act 2007. London: DH; 2007.

[31] American Psychiatric Association (APA). Practice guideline for the treatment of patients with major depressive disorder. Arlington, VA, US: APA; 2011.

[41] Contributors invited by Map of Medicine; 2011.

  The PCLS referral form is available as an EMIS Template

 Severe depression:

• consists of symptoms that cause a marked interference with functioning [2,6]
• may be with or without psychotic symptoms [4]
• is defined as Patient Health Questionnaire 9 (PHQ-9) score equal to or greater than 20 [4,41]

Admission to mental health services may be indicated for severely ill patients who:

• lack adequate support outside of a hospital setting [31]
• have complicated psychiatric or general medical conditions [31]
• carry significant risk to themselves or others but cannot be managed safely outside a hospital setting [41]

NB: Expert opinion suggests that the PHQ-9 may in fact overestimate the severity of depression and should instead be used to contribute to the overall assessment of a patient and monitor their progress [41]. 

References:

[2] National Institute for Health and Clinical Excellence (NICE). Depression: the treatment and management of depression in adults (update). Clinical guideline 90. London: NICE; 2009.

[4] New Zealand Guidelines Group (NZGG). Identification of common mental disorders and management of depression on primary care. Evidence based practice guideline. Wellington: NZGG; 2008.

[6] Institute for Clinical and Systems Improvement (ICSI). Health care Guidelines: Major depression in adults in primary care. Bloomington: ICSI; 2009.

[31] American Psychiatric Association (APA). Practice guideline for the treatment of patients with major depressive disorder. Arlington, VA, US: APA; 2011.

[41] Contributors invited by Map of Medicine; 2011.

  
The PCLS referral form is available as an EMIS template

 DSM-IV criteria for a diagnosis of moderate to severe depression requires five or more depressive symptoms [14].

Moderately severe depression is defined as a Patient Health Questionnaire for Major Depression (PHQ-9) score between 15 and 19 [41].

NB: Expert opinion suggests that the PHQ-9 may in fact overestimate the severity of depression and should instead be used to contribute to the overall assessment of a patient and monitor their progress [41]. 

References:

[14] Anderson IM, Ferrier IN, Baldwin RC. Evidence-based guideline for treatment depressive disorders with antidepressants: A revision of the 2000 British Association of Psychopharmacology guidelines. J Psychopharmacol 2008; 22: 343-96.

[41] Contributors invited by Map of Medicine; 2011.

 Voluntary sector services: -

Rethink Mental Illness

Help people affected by mental illness by challenging attitudes, changing lives. Provide expert, accredited advice and information to everyone affected by mental health problems.

Mind - Provide advice and support to anyone experiencing a mental health problem. Local Minds support people across England and Wales. Their services include supported housing, crisis helplines, drop-in centres, employment and training schemes, counselling and befriending.

Samaritans - Available 24 hours a day to provide confidential emotional support for people who are experiencing feelings of distress, despair or suicidal thoughts.

1 in 4 - Their role isn’t to “treat mental illness”. It’s to enable mental wellbeing, to empower people with mental health issues to tackle the challenges they face and move forward with their lives.

Wellspring counselling - Wellspring has a team of dedicated counsellors who come alongside those facing loss and bereavement, relationship difficulties, stress and anxiety, depression and issues resulting from physical, sexual or emotional abuse as well as other distressing situations.

Second Step - A leading mental health charity based in the west of England, with offices in Bristol, Bath and Weston-Super-Mare. They offer housing, support and hope to people with many kinds of mental health problems. They also help people to manage low mood, anxiety and depression by providing psychological therapies and specialist courses in Bristol, South Gloucestershire and through PositiveStep in North Somerset. 

Chapter 1 - A charity which, based on Christian principles, specialises in providing accommodation and support for vulnerable people.

Richmond Fellowship - Provide a range of mental health support services: Residential recovery, Supported living, Wellbeing and Self-directed support.

Personal Recovery Service - Offers a wide range of therapies to help with a diverse range of presenting problems. PRS is specialist in the treatment and recovery of sexual abuse. However, not all their work is about abuse, much of the work they do is about people trying to cope with Divorce, Bereavement, or just everyday Stress.  

Western Counselling - Residential Rehab Treatment For Addictions. Offers a structured, abstinence-based,12 step residential treatment programme that includes detoxification and aftercare, to give clients the best possible chance of achieving and sustaining long-term recovery from addiction.

Nailsea Disability Initiative - Provides free information and advice to the public, relating to disability. Their work involves not only assisting members of the public who call at their drop in centre, but they also keep up with current issues of importance to disabled and elderly people.

Wanted Not Wasted (Reframe Counselling service) - Free counselling to children and young adults aged 5-25yrs old who live in the South of Weston Super Mare (Bournville, Oldmixon, Coronation, Severn Road area, Potteries, Town Centre etc).

Survivors of Bereavement by Suicide

  
Positive Step - Wellness Advisors are employed by Second Step and provide initial assessment, facilitate courses and offer 1:1 therapy by telephone or face to face. Therapists are employed by AWP and are trained to deliver cognitive behavioural therapy (CBT) and offer this 1:1 or via therapy groups.

Local administrative information

  
The Positive Step referral form is available as an EMIS template

 Mild depression symptoms is defined as:

• few symptoms in excess of the 5 required to make a diagnosis and only minor functional impairment [1,2,6]
• Patient Health Questionnaire for Major Depression (PHQ-9) score between 5 and 9 [41]

Moderate depression is defined as:

• symptoms or functional impairment between mild and severe depression [1,2,6]
• Patient Health Questionnaire for Major Depression (PHQ-9) score between 10 and 14 [41]

NB: Expert opinion suggests that the PHQ-9 may in fact overestimate the severity of depression and should instead be used to contribute to the overall assessment of a patient and monitor their progress [41]. 

References:

[1] Clinical Knowledge Summaries (CKS). Depression. Version 1.1. Newcastle Upon Tyne: CKS; 2010.

[2] National Institute for Health and Clinical Excellence (NICE). Depression: the treatment and management of depression in adults (update). Clinical guideline 90. London: NICE; 2009.

[6] Institute for Clinical and Systems Improvement (ICSI). Health care Guidelines: Major depression in adults in primary care. Bloomington: ICSI; 2009.

[41] Contributors invited by Map of Medicine; 2011

 Subthreshold depression symptoms:

• is defined as fewer than five depressive symptoms [1,2]
• does not meet the DSM-IV criteria for depression [2]
• persistent symptoms (normally for 2 years) is referred to as dysthymia [2]:
  • diagnosis of dysthymia requires at least two symptoms but less than five

References:

[1] Clinical Knowledge Summaries (CKS). Depression. Version 1.1. Newcastle Upon Tyne: CKS; 2010.

[2] National Institute for Health and Clinical Excellence (NICE). Depression: the treatment and management of depression in adults (update). Clinical guideline 90. London: NICE; 2009.