Depression guidelines sample chapter

Management of Depression in Primary and Secondary Care
By the National collaborating centre for mental health (Nccmh) co-published by the royal college of psychiatrists and the British (one of a series of complete NIce mental health Guidelines) This guideline is concerned with the treatment and management of people withdepression in primary and secondary care. Although the terminology and diagnosticcriteria used for this heterogeneous group of related disorders has changed over theyears, this guidance relates only to those identified by The ICD-10 Classification ofMental and Behavioural Disorders (ICD-10) (WHO, 1992), namely, depressive episode(F32), recurrent depressive episode (F33) and mixed anxiety and depressive disorder(F41.2). It should be noted that a sizeable quantity of the research forming the evidencebase from which much of this guideline is drawn has used a similar classificatory system– the fourth edition of the Diagnostic and Statistical Manual of Mental Disorders of theAmerican Psychiatric Association (DSM-IV) (APA, 1994). The guideline does not addressthe management of related affective disorders such as bipolar disorder or dysthymia, nor does it provide specific guidance for post-natal depression.
2.1.1 Symptoms, presentation and pattern of illness Depression refers to a wide range of mental health problems characterised by theabsence of a positive affect (a loss of interest and enjoyment in ordinary things andexperiences), low mood and a range of associated emotional, cognitive, physical andbehavioural symptoms. Distinguishing the mood changes between major depression andthose occurring ‘normally’ remains problematic: persistence, severity, the presence ofother symptoms and the degree of functional and social impairment form the basis ofthat distinction.
Commonly, mood and affect in a major depressive illness are unreactive to circumstance,remaining low throughout the course of each day, although for some people moodvaries diurnally, with gradual improvement throughout the day only to return to a lowmood on waking. Arguably as common, a person’s mood may be reactive to positiveexperiences and events, although these elevations in mood are not sustained, withdepressive feelings re-emerging, often quickly (Andrews & Jenkins, 1999).
Behavioural and physical symptoms typically include tearfulness, irritability, socialwithdrawal, reduced sleep, an exacerbation of pre-existing pains, and pains secondary toincreased muscle tension and other pains (Gerber et al., 1992), lowered appetite (sometimesleading to significant weight loss), a lack of libido, fatigue and diminished activity, althoughagitation is common and marked anxiety frequent. Along with a loss of interest andenjoyment in everyday life, feelings of guilt, worthlessness and deserved punishment arecommon, as are lowered self-esteem, loss of confidence, feelings of helplessness, suicidalideation and attempts at self-harm or suicide. Cognitive changes include poor concentrationand reduced attention, pessimistic and recurrently negative thoughts about oneself, one’spast and the future, mental slowing and rumination (Cassano & Fava, 2002).
Depression is often accompanied by anxiety, and in these circumstances one of threediagnoses can be made: (1) depression, (2) anxiety, or (3) mixed depression and anxiety,dependent upon which constellation of symptoms dominates the clinical picture. In addition, the presentation of depression varies with age, the young showing morebehavioural symptoms and older adults more somatic symptoms and fewer complaintsof low mood (Serby & Yu, 2003).
Major depression is generally diagnosed when a persistent and unreactive low moodand an absence of positive affect are accompanied by a range of symptoms, the numberand combination needed to make a diagnosis being operationally defined (ICD-10, WHO, 1992; DSM-IV, APA, 1994), although some people show an atypical presentationwith reactive mood, increased appetite, weight gain and excessive sleepiness (Quitkin et al., 1991). In addition, those with a more severe and typical presentation, including markedphysical slowness (or marked agitation) and a range of somatic symptoms, are oftenreferred to as melancholic depressions, or depression with melancholia.
People with severe depressions may also develop psychotic symptoms (hallucinationsand/or delusions), most commonly thematically consistent with the negative, self-blaming cognitions and low mood typically encountered in major depression, althoughothers may develop psychotic symptoms unrelated to the patient’s mood (Andrews &Jenkins, 1999). In the latter case, these mood-incongruent psychotic symptoms can behard to distinguish from those that occur in other psychoses such as schizophrenia.
The average age of the first episode of a major depression occurs in the mid-20s andalthough the first episode may occur at any time, from early childhood through to oldage, a substantial proportion of people have their first depression in childhood oradolescence (Fava & Kendler, 2000). And just as the initial presentation and form of adepressive illness varies considerably, so too does the prodromal period. Someindividuals experience a range of symptoms in the months prior to the full illness,including anxiety, phobias, milder depressive symptoms and panic attacks; others maydevelop a severe major depressive illness fairly rapidly, not uncommonly following amajor stressful life event. Sometimes somatic symptoms dominate the clinical pictureleading the clinician to investigate possible underlying physical illness until moodchanges become more obvious.
Although it is generally thought that depression is usually a time-limited disorder lastingup to six months with complete recovery afterwards, in the WHO study of mentaldisorders in 14 centres across the world, 66% of those suffering from depression werestill found to satisfy criteria for a mental disorder a year later, and for 50% the diagnosiswas depression. It is probable that widely differing rates between the clinics studied inthese countries reflect true differences in prevalence in these clinics rather than differingconcepts of depression between countries (Simon et al., 2002). In the WHO study,episodes of depression that were either untreated by the GP or missed entirely had thesame outlook as treated episodes of depression; however, they were milder at indexconsultation (Goldberg et al., 1998). In a meta-analysis of 12 studies of depressed olderadults, the outcomes for people with depression in the community were on average poor: after two years, 20% had died and nearly 40% were still depressed (Cole et al., 1999).
While around half of those affected by depression will have no further episodes,depressive illnesses, as with many other mental health problems such as schizophrenia,have a strong tendency for recurrence. At least 50% of people following their firstepisode of major depression will go on to have at least one more episode (Kupfer, 1991),with early onset depression (at or before 20 years of age) particularly associated with asignificantly increased vulnerability to relapse (Giles et al., 1989).
After the second and third episodes, the risk of further relapse rises to 70% and 90%respectively (Kupfer, 1991). Thus, while the outlook for a first episode is good, theoutlook for recurrent episodes over the long term can be poor, with many patientssuffering symptoms of depression over many years (Akiskal, 1986). Sometimes, recurrentepisodes of depression will follow a seasonal pattern, receiving the label seasonalaffective disorder.
The term ‘treatment-resistant depression’, used to describe depression that has failed torespond to two or more antidepressants at an adequate dose for an adequate durationgiven sequentially, is not especially helpful. It does not take into account depressivesubtypes, makes no distinction between chronicity, relapse or recurrence, and fails totake into account what psychosocial factors may be preventing recovery or indeedwhether the patient has had an adequate course of an appropriate psychotherapeutictreatment (Andrews & Jenkins, 1999).
Depression is the most common mental disorder in community settings, and is a majorcause of disability across the world. In 1990 it was the fourth most common cause ofloss of disability-adjusted life years in the world, and by 2020 it is projected to becomethe second most common cause (World Bank, 1993). In 1994 it was estimated thatabout 1.5 million disability-adjusted life years were lost each year in the west as a resultof depression (Murray et al., 1994). It is even more common in the developing world (for review, see Institute of Medicine et al., 2001).
Apart from the subjective suffering experienced by people who are depressed, theimpact on social and occupational functioning, physical health and mortality issubstantial. The impact on physical health puts depression on a par with all the majorchronic and disabling physical illnesses such as diabetes, arthritis and hypertension(Cassano & Fava, 2002). Depressive illnesses substantially reduce a person’s ability towork effectively, with losses in personal and family income (and, therefore, taxrevenues), and unemployment (with loss of skills from the workplace). Wider socialeffects include: greater dependence upon welfare and benefits with the inevitableimpact upon self-esteem and self-confidence; social impairments, including reducedability to communicate during the illness; disturbed relationships during and subsequentto an episode; and longer term changes in social functioning, especially for those whohave a recurrent disorder. The stigma associated with mental health problems generally(Sartorius, 2002), and the public view that depression suggests a person is unbalanced,neurotic and irritating (Priest et al., 1996), may account for the reluctance of depressedpeople to seek help (Bridges & Goldberg, 1987).
Mental disorders account for as much of the total disability in the population as physicaldisorders (Ormel & Costa e Silva 1995), and there is a clear dose-response relationshipbetween illness severity and the extent of disability (ibid.). Depression and disabilityshow synchrony of change (Ormel et al., 1993), and onsets of depression are associatedwith onsets of disability, with an approximate doubling of both social and occupationaldisability (Ormel et al., 1999).
Depression can also exacerbate the pain and distress associated with physical diseases,as well as adversely affecting outcomes. For example, in people with myocardialinfarction (MI), death rates are significantly greater for those who are depressedfollowing an MI, not only in the immediate post-MI period, but for the subsequent year(Lesperance & Frasure-Smith, 2000). In one community study, patients with cardiacdisease who were depressed had an increased risk of death from cardiac problemscompared with those without depression, and depressed people without cardiac diseasealso had a significantly increased risk of cardiac mortality (Pennix et al., 2001). Similarfindings for a range of physical illnesses also suggest an increased risk of death whencomorbid depression is present (Cassano & Fava, 2002).
Suicide accounts for just under 1% of all deaths, and nearly two-thirds of this figureoccur in depressed people (Sartorius, 2001). Sometimes depression may also lead to actsof violence against others, and may even include homicide. However, more common,and a greater cause of disability for people who are depressed, is the impact ofdepressive illnesses on social and occupational function (Ormel et al., 1999). Marital andfamily relationships are frequently negatively affected, and parental depression may leadto neglect of children and significant disturbances in children (Ramachandani & Stein,2003). The vocational consequences are discussed below.
The estimated point prevalence for major depression among 16- to 65-year-olds in the UKis 21/1000 (males 17, females 25), but, if the less specific and broader category of ‘mixeddepression and anxiety’ (F41.2, ICD-10, WHO, 1992) was included, these figures risedramatically to 98/1000 (males 71, females 124). In mixed depression and anxiety, it canbe seen that the gender ratio is more skewed to females (Meltzer et al., 1995a and b).
Prevalence rates are greatly influenced by gender, age and marital status. In the samesurvey, for example, female preponderance was marked during the reproductive years,but after the age of 55 the sex ratio actually reverses. Prevalence is highest among theseparated (56/1000 female, 111/1000 male), next highest among widowed males(70/1000) and divorced females (46/1000), with the lowest prevalence among themarried (17/1000 and 14/1000 respectively). Female prevalence is higher among thesingle and cohabiting than among the married, but male rates are low for all of these.
Lone parents have higher rates than couples, and couples with children higher ratesthan those without (ibid.).
Ethnic status and gender also interact: prevalence rates for males from minority ethnicgroups were not greatly different from those for white males, but female rates differedremarkably, the highest rates being found amongst Asians and Orientals (51/1000), thenext highest for whites (24/1000) and the lowest rates for West Indians or Africans (6/1000) (Meltzer et al., 1995a). However, these estimates are based on relatively smallsamples of people from minority ethnic groups.
Gender and a number of socio-economic factors also significantly affect prevalence ratesdifferentially: unemployed women have over twice the prevalence of depression ofunemployed men (56/1000 vs 27/1000), whereas the rates are low for both sexes in full-time employment (11/1000 vs 12/1000 respectively), with part-time women workersin between (22/1000). Social classes 3 and below have higher rates than classes 1 and 2for both sexes, and those living in rented accommodation have substantially higher ratesthan those living in their own home. There are clear trends for years of education formales, with those finishing education later having progressively lower rates fordepression; these effects are less for females. Rates are higher in town than country,with ‘semi-rural’ being intermediate (Meltzer, 1995a and b). Rates for the homeless living in leased accommodation and hostels are very high indeed,with prevalence rates of 130/1000 for ICD depression, and 270/1000 for all forms ofdepression (Meltzer, 1995b). Another study, of the roofless homeless, showed that 60% were depressed (Gill et al., 1996). Those who are depressed consume no morealcohol than the non-depressed, but their cigarette consumption is higher (Meltzer etal., 1995b). It should be emphasised that the direction of causality in these associationsis unclear. Depression also affects asylum seekers, with one-third of asylum seekers inNewham being diagnosed with depression (Gammell et al., 1993), considerably higherthan the rate in the population. Further confirmation of the social origins of depression was found in a general practicesurvey in which 7.2% (range: 2.4% to 13.7%, depending upon the practice) ofconsecutive attendees had a depressive disorder. Neighbourhood social deprivationaccounted for 48.3% of the variance among practices, and the variables that accountedfor most of that variance were: the proportion of the population having no or only onecar; and neighbourhood unemployment (Ostler et al., 2001).
The rates for depression considered so far have looked at depression at a point in time.
Annual period prevalence produces much higher figures, with male rates rangingbetween 24 and 34/1000 and females rates between 33 and 71/1000 in Puerto Rico,Edmonton, Canada, and Christchurch, New Zealand (Jenkins et al., 2003). Even higherrates are obtained for one-year prevalence using the International Composite InterviewSchedule in the US of 77/1000 for males, and 129/1000 for females (Kessler et al., 1994).
It is probable that widely differing rates between the clinics studied in these countriesreflect true differences in prevalence in these clinics rather than differing concepts ofdepression between countries (Simon et al., 2002). In any event, the evidenceoverwhelmingly supports the view that the prevalence of depression, however it isdefined, varies considerably according to gender and a wide range of social, ethnic andeconomic factors.
Diagnostic criteria and methods of classification of depressive illnesses have changedsubstantially over the years, although the advent of operational diagnostic criteria hasimproved the reliability of diagnosis. ICD-10 uses an agreed list of 10 depressivesymptoms, and divides the common form of major depressive episode into four groups:not depressed (fewer than four symptoms), mild (four symptoms), moderately depressed(five to six symptoms), and severe (seven symptoms or more, with or without variouspsychotic symptoms). Symptoms must be present for at least two weeks. Thesedefinitions have been used in the report that follows. The more severe the episode ofdepression, the less likely it is that remission will occur spontaneously. Patients with mildepisodes in primary care settings will frequently remit, but such episodes may well bepersistent, and may also be a transitional state as a more severe illness develops. Milddepression is also a vulnerability factor, rendering patients more likely to develop a moresevere illness in the presence of life stress. However, it is doubtful whether the severity ofa depressive illness can realistically be captured in a single symptom count althoughthere is some evidence for this (Faravelli et al., 1996): clinicians will wish to considerfamily and previous history, as well as the degree of associated disability, in making thisassessment. In addition, some symptoms may have greater weight than others inestablishing severity levels (Faravelli et al., 1996).
Although reliability of diagnosis has improved, there has been no parallel improvementin the validity of diagnosis (Dohrenwend, 1990), partly as a result of the breadth of thediagnostic category – major depression – partly the result of the lack of physical testsavailable to confirm a diagnosis of depression, and partly because our understanding ofthe aetiology and underlying mechanisms of depression remain putative and lacking inspecificity.
The symptom-focused, diagnostic approach adopted in much contemporary research,and which underpins the evidence base for this guideline, will distinguish between typesof depression (e.g. unipolar versus bipolar), severity (mild, moderate and severe),chronicity, recurrence and treatment resistance. However, depressed people also varygreatly in their personalities, premorbid difficulties (e.g. sexual abuse), psychologicalmindedness and current relational and social problems – all of which may significantlyaffect outcomes. It is also common for depressed people to have a comorbid diagnosis,such as anxiety, social phobia, panic and various personality disorders (Brown et al.,2001). As noted above, gender, ethnic and socio-economic factors account for largevariations in the population rates of depression, and few studies of pharmacological,psychological or indeed other treatments for depression control for or examine thesevariations. Indeed, there is increasing concern that ‘depression’ may be tooheterogeneous in biological, psychological and social terms to enable clarity on whichspecific interventions will be effective – for which problem, for which person, and inwhich context.
Differential diagnosis of depression can be difficult; of particular concern are patientswith bipolar disorder presenting with depression. The issue of differential diagnosis inthis area will be dealt with in the forthcoming NICE guideline on bipolar disorder. The enormous variation in the presentation, course and outcomes of depressive illnesses isreflected in the breadth of theoretical explanations for their aetiology, including genetic(Kendler & Prescott, 1999), biochemical and endocrine (Goodwin, 2000), psychological(Freud, 1917), and social (Brown & Harris, 1978) processes and/or factors. No doubt anemphasis upon physical, and especially endocrine, theories of causation has beenencouraged by the observation that some physical illnesses do increase the risk ofdepression, including diabetes, cardiac disease, hyperthyroidism, hypothyroidism, Cushing’ssyndrome, Addison’s disease and hyperprolactinaemic amenorrhea (Cassano & Fava, 2002).
Whatever theories of causation have gained credence none has been convincinglyaccepted. Most now believe that all these factors influence an individual’s vulnerabilityto depression, although it is likely that for different people living in differentcircumstances, precisely how these factors interact and influence that vulnerability willvary between individuals (Harris, 2000). Nevertheless, the factors identified as likely toincrease a person’s vulnerability to depression include gender (see above), genetic andfamily factors, adverse childhood experiences, and personality factors. In the stress-vulnerability model (Nuechterlein & Dawson, 1984), these ‘vulnerability factors’ interactwith current social circumstances, such as poverty and social adversity, with stressful lifeevents acting as the trigger for a depressive episode (Harris, 2000). Physical illness is alsoregarded as an important stressful life event.
A family history of depressive illness accounts for around 39% of the variance ofdepression in both sexes (Kendler et al., 2001), and early life experiences such as a poorparent–child relationship, marital discord and divorce, neglect, physical abuse and sexualabuse almost certainly increase a person’s vulnerability to depression in later life (Fava &Kendler, 2000). Personality traits such as ‘neuroticism’ also increase the risk ofdepression when faced with stressful life events (Fava & Kendler, 2000). However,different personalities have different expectancies of stressful life events, and somepersonalities have different rates of dependent life events, which are directly related totheir personality – such as breaking up a relationship (Hammen et al., 2000).
The role of current social circumstances in increasing the risk of depression, such aspoverty, homelessness, unemployment and chronic physical or mental illness cannot bedoubted even from a brief examination of the epidemiology of depression (see above).
However, in the UK, predictive factors for depression in women in Camberwell, south-east London, include: having three or more children under the age of 14 years living athome; not having a confiding relationship with another person; and having no paidemployment outside the home (Brown & Harris, 1978).
The neatness of this model, in which vulnerabilities interact with stressful life events,such as separation or loss of a loved one, triggering a depressive episode, is not alwayssupported by the ‘facts’: some episodes of depression occur in the absence of a stressfulevent, and conversely many such events are not followed by a depressive disorder.
Having said that, the presence of some factors protects against depression following astressful life event, such as having a supportive confiding relationship with anotherperson (Brown & Harris, 1978), or befriending (Harris et al., 1999).
2.5 Use of health service resources and other costs As the most common psychiatric disorder, and one that has a strong tendency forrecurrence and chronicity, depression is ranked as the fourth leading cause of burdenamong all diseases and is expected to show a rising trend during the coming 20 years(WHO, 2001). One in four women and one in ten men in the UK are likely to suffer aperiod of depression serious enough to require treatment (National DepressionCampaign, 1999). Due to its high prevalence and treatment costs, its role as probablythe most important risk factor for suicide (Knapp & Ilson, 2002), and the cost ofantidepressant drug overdose and its great impact on the productivity of people withthe disease, depression places enormous economic burden not just on the health caresystem but also on the broader society. On average, depressed patients lose 11 days overa six-month period, compared with two to three days for individuals without thiscondition (Lepine et al., 1997). It is also of interest that the cost of health and socialservice utilisation is almost 1.5-fold higher for older adults with depression comparedwith their younger counterparts (Hughes et al., 1997).
A recent review identified three studies that investigated the economic burden ofdepression in the UK (Berto et al., 2000). The study by Jonsson and Bebbington (1993)focused only on the direct costs of depression in the UK without giving detailedbreakdown of the results. They calculated the direct costs of depression to be about£222 million in 1990, but this is likely to be a substantial underestimate. For example,West (1992) estimated the direct costs of depression in the UK to be £333 million at1990 prices, of which £55 million are drug costs, £250 million hospitalisation costs, and£28 million are GP surgery consultation costs based on data from England and Wales.
In the third study reviewed, Kind and Sorensen (1993), using a different methodology,calculated the cost of depression for England and Wales in the year 1990 from a broadersocietal perspective. They estimated the direct care costs at £417 million, of which £47million were drug treatment costs, £143 million were primary healthcare costs, £40million were social services costs, £177 million were inpatient care costs, and outpatientattendances accounted for £9 million. For hospital admissions they included reasonssuch as depression, attempted suicide, poisoning and mental illness. These authors alsowent a step further by attempting to measure productivity forgone due to prematuredeaths and morbidity arising as a consequence of depression. They estimated that 155million working days were lost in 1990 at a cost of £2.97 billion. In a study comparing community-based and hospital-based treatment of anxiousdepression in Manchester (Goldberg et al., 1996), lost productivity costs due tomorbidity were on average £2,574 per patient to be compared with £424 for totalservice costs during six months. This study included lost marketed output as well as lostdomestic output. It is of interest that the indirect costs were six times as great as thedirect costs to the NHS.
These studies highlight the important facts that drug costs account for onlyapproximately 11 to 19% of the direct costs and that the cost of lost productivity due todepression far outweighs the health service costs. Although no recent economic burden estimates exist for the UK, it is likely that theoverall economic impact of depression has increased substantially over the last decade:statistics reveal that the age-standardised prevalence of treated depression in primary care grew from 19.9/1000 males and 50.5/1000 females in 1994 to 29.0/1000 males and70.1/1000 females in 1998 (Office for National Statistics, 2000) and that the number ofGP consultations for depressive disorders more than doubled from four million to ninemillion during these years (National Depression Campaign Survey, 1999). Also thenumber of prescriptions for antidepressants increased by 11.2% between 1998 and 1999(Compufile Ltd, 1999). This may reflect increasing trends in the prevalence and/or in therecognition and treatment of major depressive disorder.
In 1993, Henry reported that the majority of cases of major depression were diagnosedby general practitioners, who issued 95% of all prescriptions for antidepressants (Henry,1993). Freemantle & Mason (1995) and Freemantle (1998) calculated that 76.5% of theGP antidepressant prescribing volume was for TCAs and related drugs, which accountedfor 36.7% of the total cost of prescription for depression in primary care in England inthe year 1993/94. In the same period, SSRIs accounted for 23.2% of the total volume ofprescribing at 62.6% of the total cost. Both the sale and cost shares of MAOIs were lessthan 1%. In 1996, GPs prescribed 160 million pounds’ worth of antidepressants. Thisfigure has further increased as newer and more expensive antidepressants have becomeavailable (Eccles et al., 1999).
Without doubt, depression places a major direct economic burden on patients, carersand the healthcare system, and its indirect economic consequences are shown to beeven greater. Furthermore, its healthcare costs continue to increase substantially.
Efficient service provision could greatly reduce this burden and ensure that best care isdelivered within the budget constraint.
Treatment for depressive illnesses in the NHS is hampered by the unwillingness of manypeople to seek help for depression and the failure to recognise depression, especially inprimary care. The improved recognition and treatment of depression in primary care iscentral to the WHO strategy for mental health (WHO, 2001).
2.6.1 Detection, recognition and referral in primary care Of the 130 cases of depression (including mild cases) per 1000 population only 80 willconsult their GP. The most common reasons given for reluctance to contact the familydoctor were: did not think anyone could help (28%); a problem one should be able tocope with (28%); did not think it was necessary to contact a doctor (17%); thoughtproblem would get better by itself (15%); too embarrassed to discuss it with anyone(13%); afraid of the consequences (e.g. treatment, tests, hospitalisation, being sectioned– 10%) (Meltzer et al., 2000). The stigma associated with depression cannot be ignoredin this context (Priest et al., 1996).
Of the 80 depressed people per 1000 population who do consult their GP, 49 are notrecognised as depressed, mainly because most such patients are consulting for a somaticsymptom, and do not consider themselves mentally unwell, despite the presence ofsymptoms of depression (Kisely et al., 1995). This group also have milder illnesses(Goldberg et al., 1998; Thompson et al., 2001). And of those that are recognised as depressed, most are treated in primary care and about one in four or five are referred tosecondary mental health services. There is considerable variation between individual GPsin their referral rates to the mental illness services, but those seen by the mental illnessservice are a highly selected group – they are skewed towards those who do notrespond to antidepressants, more severe illnesses, single women and those below theage of 35 (Goldberg & Huxley, 1980).
General practitioners are immensely variable in their ability to recognise depressiveillnesses, with some recognising virtually all the patients found to be depressed atindependent research interview, and others recognising very few (Goldberg & Huxley,1992; Üstün & Sartorius, 1995). The communication skills of the GP make a vitalcontribution to determining their ability to detect emotional distress, and those withsuperior skills allow their patients to show more evidence of distress during theirinterviews, thus making detection easy. Those doctors with poor communication skillsare more likely to collude with their patients, who may not themselves wish to complainof their distress unless they are asked directly about it (Goldberg & Bridges, 1988a;Goldberg et al., 1993).
Attempts to improve the rate of recognition of depression by GPs using guidelines,lectures and discussion groups have not improved recognition or outcomes (Thompsonet al., 2000), although similar interventions combined with skills training may improvedetection and outcomes in terms of symptoms and level of functioning (Tiemens et al.,1999; Ostler et al., 2001). The inference that these health gains are the result ofimproved detection and better access to specific treatments, while having face validity,has been contested. For example, Ormel et al. (1990) suggested that the benefits ofrecognition of common mental disorders could not be attributed entirely to specificmental health treatments. Other factors like acknowledgement of distress,reinterpretation of symptoms, providing hope and social support were suggested tocontribute to better patient outcomes.
This view has gained confirmation from a Dutch study in which providing skills trainingfor GPs did not improve detection but did improve outcomes. Moreover, about half ofthe observed improvement in patient outcomes was mediated by the combinedimprovements in process of care. In combination with the strong mediating effect ofempathy and psycho-education they suggest that other, probably also non-specific,aspects of the process of care must be responsible for the training effect on symptomsand disability (Van Os et al., 2002). In addition, the communication skills needed by GPscan be learned and incorporated into routine practice with evident improvement inpatient outcomes (Gask et al., 1988; Roter et al., 1995).
In summary, those with more severe disorders, and those presenting psychologicalsymptoms to their doctor, are especially likely to be recognised as depressed, while thosepresenting with somatic symptoms for which no cause can be found are less likely to berecognised. The evidence suggests that this very undesirable state of affairs, in whichlarge numbers of people each year suffer depression, with all the personal and socialconsequences and suffering involved, could be changed. With 50% of people withdepression never consulting a doctor, 95% never entering secondary mental healthservices, and many more having their depression going unrecognised and untreated, thisis clearly a problem for primary care.
2.6.2 Assessment and co-ordination of care Given the low detection and recognition rates, it is essential that primary care andmental health practitioners have the required skills to assess the patients withdepression, their social circumstances and relationships, and the risk they may pose tothemselves and to others. This is especially important in view of the fact that depressionis associated with an increased suicide rate, a strong tendency for recurrence and highpersonal and social costs. The effective assessment of a patient, including riskassessment and the subsequent co-ordination of their care (through the use of the CareProgramme Approach in secondary care services), is highly likely to improve outcomes,and should, therefore, be comprehensive.
All healthcare professionals involved in diagnosis and management shouldhave a demonstrably high standard of consultation skills, so that a structuredapproach can be taken to the diagnosis and subsequent management ofdepression. (GPP) In older adults with depression, their physical state, living conditions, andsocial isolation should be assessed. The involvement of more than oneagency is recommended where appropriate. (GPP) When depressive symptoms are accompanied by anxious symptoms, the firstpriority should usually be to treat the depression. Psychological treatment fordepression often reduces anxiety, and many antidepressants also havesedative/anxiolytic effects. When the patient has anxiety without depression,the NICE guideline on management of anxiety should be followed. (GPP) In deciding on a treatment for a depressed patient, the healthcareprofessional should discuss alternatives with the patient, taking into accountother factors such as past or family history of depression, response of anyprevious episodes to intervention, and the presence of associated problemsin social or interpersonal relationships. (GPP) Healthcare professionals should always ask patients with depression directlyabout suicidal ideas and intent. (GPP) When a patient with depression is assessed to be at high risk of suicide, theuse of additional support such as more frequent direct contacts with primarycare staff or telephone contacts should be considered. (C) Healthcare professionals should advise patients and carers to be vigilant forchanges in mood, negativity and hopelessness, and suicidal ideas, particularlyduring high-risk periods, such as during initiation of and changes tomedication and increased personal stress. Patients and carers should beadvised to contact the appropriate healthcare practitioner if concerned. (GPP) Healthcare professionals should assess whether patients with suicidal ideashave adequate social support and are aware of sources of help. They shouldadvise them to seek appropriate help if the situation deteriorates. (GPP) Where a patient presents considerable immediate risk to self or others,urgent referral to a specialist mental health service should be arranged. (GPP) When a patients’ depression has failed to respond to various strategies foraugmentation and combination treatments, referral to a clinician with aspecialist interest in treating depression should be considered. (GPP) The assessment of patients with depression referred to specialist mentalhealth services should include a full assessment of their symptom profile andsuicide risk and, where appropriate, previous treatment history. Assessmentof psychosocial stressors, personality factors and significant relationshipdifficulties should also be undertaken, particularly where the depression ischronic or recurrent. (GPP) In specialist mental health services, after a thorough review of previoustreatments for depression has been undertaken, consideration should begiven to re-introducing previous treatments that have been inadequatelydelivered or adhered to. (GPP) Medication in secondary-care mental health services should be initiatedunder the supervision of a consultant psychiatrist. (GPP) Inpatient treatment should be considered for people with depression whoare at significant risk of suicide or self-harm. (C) Where a patients’ depression has resulted in loss of work or disengagementfrom other social activities over a longer term, a rehabilitation programmeaddressing these difficulties should be considered. (C) The nature and course of depression is significantly affected by psychological, social andphysical characteristics of the patient and their circumstances. These factors have asignificant impact upon both the initial choice of treatment and the probability of apatient benefiting from that intervention.
When assessing a person with depression, healthcare professionals shouldconsider the psychological, social, cultural and physical characteristics of thepatient and the quality of interpersonal relationships. They should considerthe impact of these on the depression and the implications for choice oftreatment and its subsequent monitoring. (GPP) The need for more effective assessments for people who are depressed also requires thathealthcare professionals must have the requisite level of skill and ensure continuedcompetence in the use of those skills.
Healthcare professionals should ensure they maintain their competence inrisk assessment and management. (GPP) This is particularly important if an individual receives help and treatment in both primaryand secondary care. Where a patient’s management is shared between primary and secondarycare, there should be clear agreement between individual healthcareprofessionals on the responsibility for the monitoring and treatment of thatpatient, and the treatment plan should be shared with the patient and,where appropriate, families and carers. (GPP) 2.6.3 Non-specific effects of treatment and the placebo Among those seeking care with depression, those put on waiting lists do improvesteadily with time. Posternak & Miller (2001) studied 221 patients assigned to waitinglists in 19 treatment trials of specific interventions, and found that 20% improved inbetween four and eight weeks, and 50% improved in six months. They estimate that60% of placebo responders, and 30% of responders to antidepressants, may experiencespontaneous resolution of symptoms (if untreated). An earlier study by Coryell et al.
(1994) followed up 114 patients with untreated depression for six months: the meanduration of episode was six months, with 50% remission in 25 weeks. It should be notedthat there is a high relapse rate associated with depression (see Section 2.1.2 above).
Despite their greater severity and other differences, Furukawa et al. (2000) showed thatpatients treated by psychiatrists with antidepressants did better than this: the mediantime to recovery was three months, with 26% recovering in one month, 63% in sixmonths; 85% in one year, and 88% in two years.
Although there is insufficient space to allow proper discussion, the placebo effect in trials ofpsychiatric drugs is often so large that specific pharmacological effects can be hard toidentify, especially when given to people who fall into one of the larger, more heterogeneousdiagnostic categories. The treatment of depression is a clear example of this (Kirsch et al.,2002a). Drug, and some other, treatments for depression, when compared with wait listcontrols in the treatment of mild to moderate depression, all produce a substantial androughly equal fall in depressive symptoms. But, when antidepressants are compared withplacebo for this diagnostic group, the clinical improvements resulting from antidepressantsover and above that for placebo is not clinically significant (Kirsch et al., 2002b). Given therecent focus upon publication bias, especially with regard to drug company funded trials(Lexchin et al., 2003; Melander et al., 2003) there is the possibility that some drug (or other)treatments for depression may offer no advantage, on average, over placebo, for patientswith mild depression. Nevertheless, it is likely that with greater definition of subgroups ofpeople with depression, benefits over placebo may well be demonstrable. Further discussionof the placebo effect in the treatment of depression can be found in the evidence chapters.
The mainstay of the pharmacological treatment of depression for the last 40 or moreyears has been antidepressants. Tricyclic antidepressants (TCAs) were introduced in the1950s, the first being imipramine (Kuhn, 1958). The mode of action of this class ofdrugs thought to be responsible for their mood-elevating properties is their ability to block the synaptic reuptake of monoamines, including noradrenaline (NA), 5-hydroxytryptymine (5HT) and dopamine (DA). In fact the TCAs predominantly affectthe reuptake of NA and 5HT rather than DA (Mindham, 1982). The antidepressantproperties of MAOIs were discovered by chance in the 1950s in parallel with TCAs.
Although the introduction of the TCAs was welcome, given the lack of specifictreatments for people with depression, the side effects resulting from their ability toinfluence anticholinergics, histaminergic and other receptor systems reduced theiracceptability. Moreover, overdose with TCAs (with the exception of lofepramine) carries ahigh mortality and morbidity, particularly problematic in the treatment of people withsuicidal intentions.
In response to the side effect profile and the toxicity of TCAs in overdose, new classes ofantidepressants have been developed, including: the specific serotonin reuptakeinhibitors (SSRIs) such as fluoxetine; drugs chemically related to, but different from, theTCAs, such as trazodone; and a range of other chemically unrelated antidepressantsincluding mirtazapine (BNF, 4.3). Their effects and side effects vary considerably,although their mood-elevating effects are again thought to be mediated throughincreasing intra-synaptic levels of monoamines, some primarily affecting NA, some 5HTand others affecting both to varying degrees and in different ways.
Other drugs used either alone or in combination with antidepressants include lithiumsalts (BNF, 4.2.3), and the antipsychotics (BNF, 4.2), although the use of these drugs isusually reserved for people with severe, psychotic or chronic depressions, or asprophylactics. A full review of the evidence base for the use of the different types ofantidepressants is presented in Chapter 8. In addition, there is preliminary evidence that pharmocogenetic variations may affect theefficacy and tolerability of antidepressant drugs. It is likely that future research on thistopic will lead to the development of clinically meaningful pharmocogenetic markers,but at the moment the data is insufficient to make recommendations.
In 1917 Freud published Mourning and Melancholia, probably the first modernpsychological theory on the causes, meaning and psychological treatment of depression.
Since that time, numerous theories and methods for the psychological treatment ofpsychological disorders have been elaborated and championed, although psychologicaltreatments specifically for depression were developed only over the last 30 to 40 years,and research into their efficacy is more recent still (Roth & Fonagy, 1996). Many, but notall, such therapies are derived from Freudian psychoanalysis, but address the difficultiesof treating people with depression using a less rigid psychoanalytic approach (Fonagy,2003). In any event, the emergence of cognitive and behavioural approaches to thetreatment of mental health problems has led to a greater focus upon the evidence baseand the development of psychological treatments specifically adapted for people withdepression (for example, see Beck et al., 1979).
Psychological treatments for depression currently claiming efficacy in the treatment ofpeople with depressive illnesses and reviewed for this guideline in Chapter 6 include:cognitive behavioural therapy (CBT); behaviour therapy (BT); interpersonal psychotherapy(IPT); problem-solving therapy (PST); counselling; short-term psychodynamic psychotherapy;and couple-focused therapies. Psychological treatments have expanded rapidly in recentyears and generally have more widespread acceptance from patients (Priest et al., 1996). Inthe last 15 years in the UK there has been a very significant expansion of psychologicaltreatments in primary care for depression, in particular primary care counselling.
2.6.6 Service-level and other interventions Given the complexity of healthcare organisations, and the variation in the way care isdelivered (inpatient, outpatient, day hospital, community teams, etc.), choosing the rightservice configuration for the delivery of care to specific groups of people has gainedincreasing interest with regard to both policy (for example, see Department of Health,1999b), and research (e.g. evaluating day hospital treatment, Marshall et al., 2001).
Research using RCT designs has a number of difficulties; for example, using comparatorssuch as ‘standard care’ in the US make the results difficult to generalise or apply tocountries with very different types of ‘standard care’.
Service-level interventions considered for review in this guideline include: organisationaldevelopments, crisis teams, day hospital care, and non-statutory support and othersocial supports. Other types of interventions also reviewed for this guideline include:exercise, guided self-help, computerised cognitive behavioural therapy (CCBT) andscreening.
In Figure 1 a ‘stepped care’ model is developed, which draws attention to the differentneeds that depressed individuals have – depending on the characteristics of theirdepression and their personal and social circumstances – and the responses that arerequired from services. Stepped care provides a framework in which to organise theprovision of services supporting both patients and carers, and healthcare professionals inidentifying and accessing the most effective interventions.
Figure 1: The stepped care model.
What is the focus?
for care?
Step 5: Inpatient
Step 4: Mental health
Step 3: Primary care team,
Step 2: Primary care team,
Step 1: GP, practice nurse
Of those people whom primary healthcare professionals recognise as having depression,some prefer to avoid medical interventions, and others will improve in any case withoutthem. Thus, in depressions of only mild severity, many GPs prefer a ‘watchful waiting’approach, which can be accompanied by general advice on such matters as restoringnatural sleep rhythms and getting more structure into the day. However, other peopleprefer to accept, or indeed require, medical, psychological or social interventions, andthese patients are therefore offered more complex interventions. Various interventionsare effective, delivered by a range of workers in primary care.
Treatment of depression in primary care, however, often falls short of optimal guidelinerecommended practice (Donoghue & Tylee, 1996a) and outcomes are correspondinglybelow what is possible (Rost et al., 1995). As we have seen, only about one in five of thepatients at this level will need referral to a mental healthcare professional, the mainindications being failure of the depression to respond to treatment offered in primarycare, incomplete response or frequent recurrences of depression. Those patients who areactively suicidal or whose depression has psychotic features may also benefit fromspecialist referral.
Finally, there are a few patients who will need admission to an inpatient psychiatric bed.
Here they can receive round the clock nursing care and various special interventions.
For patients with mild depression who do not want an intervention or who,in the opinion of the healthcare professional, may recover with nointervention, a further assessment should be arranged, normally within twoweeks (‘watchful waiting’). (C) Healthcare professionals should make contact with patients with depressionwho do not attend follow-up appointments. (C) Patients with mild depression may benefit from advice on sleep hygiene andanxiety management. (C) For any guideline on the treatment of depression to be credible it has to be informed atevery stage of its development by the perspective of patients. Intensive patient input hasled to the development of the tiered and multifaceted management cascade described inthis guideline (‘stepped care’). Patients are keen to be given much more explanation andinformation about depression and to be offered a range of possible treatment choices.
The patient view is that healthcare professionals have previously been over-reliant on theprescribing of antidepressant medications often without adequate psychological support(Smith, 1995; Singh, 1995). A patient narrative is described overleaf. The following is a personal account of an experience of long-term depression.
‘Happily, my experience of taking antidepressants was not too unpleasant. I hadbeen suffering from recurrent periodic bouts of depression for quite a long timewithout realising it. Various medications were prescribed for short-term use, whichalleviated the condition for a while, although I was, and still am, averse tobecoming dependent on them. Sometimes the side effects were extremelyunpleasant – at times I felt almost suicidal and felt that the treatment was actuallymaking me worse. I started to doubt my doctor’s competence, feeling that hedidn’t understand or care. ‘The really effective treatment only began when I consulted a GP who knew myand my family history, not just my medical history. He took time to explain whatwas happening, described the possible side effects, the interaction with alcoholand other medications, but, most importantly, assured me that depression did notnecessarily have to be a “life sentence”. ‘After a short period on antidepressants we explored alternative therapies andidentified practical steps that I could take in order to develop a coping strategywithout recourse to antidepressants. This was done in a spirit of equal partnershipbetween the GP and myself, with me being able to make informed choices. ‘By far the worst thing about my depression was not knowing what washappening to me, the feeling that life had nothing to offer me, the lack of interestand loss of motivation, in short, the feeling of helplessness and hopelessness. ‘I still suffer bouts of depression, but now understand what is happening, andknow how to cope and seek help, as I know I can, and will, come out of it. ‘The provision of alternative therapies is paramount, instead of the reliance onmedication as an ongoing first line defence. It is of extreme importance thatpatients feel that they will get well, and feel that they can contribute to theeconomy instead of feeling that they are a burden on it. ‘In summary, the main priorities should be the provision of understanding, time,choice and above all, hope. These are not as cost prohibitive as some of thealternatives.’ Patients have, through their involvement in the preparation of this guideline, madetangible changes to the suggested management of depression, particularly in primarycare settings. They have endorsed the use of the term ‘patient’, where appropriate, torefer to people with depression.
2.8 Patient preference, information, consent and There is now a wide range of different possible treatments, each with their owncombination of general and specific effects, side effects and mechanisms of action, andvariation in the NHS sites at which healthcare may be provided for people who aredepressed and their carers. With this in mind, the provision of comprehensive information,using clear and understandable language, is increasingly necessary. Written material in thelanguage of the patient, and access to interpreters for those whose first language is otherthan English, is essential in order for people to be able to express their preferences. This isespecially the case when a range of broadly equivalent treatments is available for peoplewith mild to moderate depression. Patients and carers need a good understanding of thetreatment options and the risks involved before treatment is initiated.
The principle of informed consent should be followed even when a person has severedepression, or when a person is being treated under the Mental Health Act. When aperson with recurrent depressive illness is sometimes unable to give consent,consideration should be given to the development and recording of advance directives.
In addition, given the emotional, social and economic cost that depression usuallyentails, patients and their families may need help in contacting support groups and self-help groups. This is also important to promote understanding and collaborationbetween patients, their carers and healthcare professionals at all levels of primary andsecondary care.
A number of different treatment approaches may be equally effective forpatients who are depressed, especially for those with mild and moderatedepression who are not considered to be at substantial risk of self-harm.
Patient preference and the experience and outcome of previous treatment(s)should be considered when deciding on treatment. (GPP) Common concerns about taking medication should be addressed. Forexample, patients should be advised that craving and tolerance do not occur,and that taking medication should not be seen as a sign of weakness. (GPP) Patients and, where appropriate, families and carers should be provided withinformation on the nature, course and treatment of depression including theuse and likely side-effect profile of medication. (GPP) When talking to patients and carers, healthcare professionals should useeveryday, jargon-free language. If technical terms are used they should beexplained to the patient. (GPP) Where possible, all services should provide written material in the languageof the patient, and independent interpreters should be sought for peoplewhose preferred language is not English. (GPP) Where available, consideration should be given to providing psychotherapiesand information about medications in the patient’s own language if this isnot English. (GPP) Healthcare professionals should make all efforts necessary to ensure that apatient can give meaningful and properly informed consent before treatmentis initiated. This is especially important when a patient has a more severedepression or is subject to the Mental Health Act. (GPP) Although there are limitations with advance directives about the choice oftreatment for people who are depressed, it is recommended that they aredeveloped and documented in care plans, especially for people who haverecurrent severe or psychotic depression, and for those who have beentreated under the Mental Health Act. (GPP) Patients, families and carers should be informed of self-help groups andsupport groups and be encouraged to participate in such programmes whereappropriate. (GPP)



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