Community / : Depression 1

DEPRESSION IDENTIFICATION

I. SCREENING (NICE CG90)

A. Alert to high-risk people
1. Past history of depression
2. Chronic physical health problem w associated functional impairment
3. Other mental health problems e.g. dementia
B. Two screening question test (Whooley & Simon, 2000) in these people
1. During last month, have you often been bothered by feeling down,
depressed or hopeless?
2. During last month, have you often been bothered by little interest or
pleasure in doing things?
a. If yes to either: follow-up.

II. DIAGNOSIS
A. DSM-IV criteria for major depression = henceforth, depression (at Its definition of severity makes it
less likely that a Dx of depression
least 5 out of 9 TOTAL Sx, all at least continuously > 2 weeks) will be based solely on Sx
1. Compulsory criteria (at least 1): counting.
a. Depressed mood
b. Anhedonia (loss of interest or pleasure)
ICD-10 was the Dx classification
2. Other criteria
system used in previous
a. Insomnia or hypoinsomnia guidelines. In practical terms,
b. Appetite or weight change clinicians are not expected to
c. Fatigue or loss of energy switch DSM-IV but should be
d. Increased/decreased psychomotor activity aware threshold for mild
depression is higher than ICD-10
e. Guilt or feelings of worthlessness (5Sx not 4!), and degree of
f. Diminished ability to think or concentrate, or indecisiveness functional impairment should be
g. Suicidal ideation routinely assessed before Dx.
B. Sub-threshold depression= <5: 2-4 Sx (may or may not need key Sx)
Using DSM-IV enables guidelines
C. Non-depressed: 0-1 Sx
to better target specific
interventions e.g. anti-
III. FURTHER ASSESSMENT depressants, for more severe
A. Confirmation requires more detailed clinical assessment; consider using depression.
validated measures: PHQ-9 (Patient Health Questionnaires), BDI (Beck
DSM-IV adopted for NICE
Depression Inventory). guideline & used in nearly all the
B. Comprehensive assessment should not rely solely on Sx count. Consider: evidence reviewed and it provides
1. Degree of impairment and/or disability definition for atypical Sx and
2. Duration of episode seasonal depression.
C. Always ask person directly about suicidal ideas and intents!!

IV. GRADING OF MAJOR DEPRESSION (DSM-IV CLASSIFICATION)

A. Severity graded by severity of Sx and functional impairment they cause,
once Dx criteria met.
1. Mild depression: must still have > 5/9 Sx but will have each
relatively mild, or functional impairment minor
a. It is not subthreshold depression! This is major depression.
2. Moderate depression: functional impairment in between
3. Severe depression: Most Sx & they markedly interfere w functioning.
Can occur w or w/o psychotic Sx.
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APPROACH TO NON-PHARMACOLOGICAL DEPRESSION

MANAGEMENT

I. STEPPED CARE MODEL (NICE)

A. Step 1 is diagnosis of suspected depression and all known depression
thereafter: assess, support, psychoeducate, active monitoring, and
referral for furthermore assessments and interventions.
B. Step 2-4 about management.

II. STEP 2
A. Persistent sub-threshold depressive Sx; OR mild to moderate depression
B. Preferred treatment options w/o chronic health problems:
1. Offer active monitoring discuss concerns, provide information
about depression, reassess within 2 w, contact the person if they
dont attend F/U appointment Evidence for low-intensity Tx:
a. Monitor those judged to recover w/o a formal intervention CCBT and self-help reduce Sx
depression vs. control (usual Tx,
b. Monitor those with sub-threshold depressive Sx who request an waitlist).
intervention
2. Low-intensity psychological and psychosocial interventions TREAD RCT of usual care vs.
a. Choice of intervention should be guided by patients increased exercise in 360 patients
w depression in 1o care = no
preference:
difference in mood. Caveats to
b. Individual self-help based on CBT principles methodology. Editorial: in those
c. Computerised CBT (CCBT) w significant depression,
d. Structured group physical activity programme recommending exercise can
e. Offer group CBT if they decline low-intensity Tx increase sense of failure if they
dont manage it BUT we should
f. Offer advice on sleep hygiene, if needed STILL encourage exercise in those
3. Do not routinely us antidepressants (because risk-benefit is poor); motivated and likely to achieve it.
consider if:
a. Past Hx of moderate-severe depression OR We dont know CCBT = face-to-
face CBT
b. Initially present w sub-threshold Sx that have been > 2y OR
c. They have sub-threshold Sx for < 2 y but they dont respond to
other interventions.

III. STEP 3
A. Persistent sub-threshold depressive Sx; OR mild to moderate depression
with initial inadequate response; OR moderate to severe depression.
B. Preferred treatment for those w/o chronic physical health problems: Evidence high-intensity Tx (CBT,
1. Medications (usually SSRI) IPT)
CBT has some benefits over anti-
a. Anti-depressants for duration of illness & at least 6 months
depressants (e.g. depression score
2. High-intensity psychological interventions may be used for this at 12 m) and that adding CBT to
group (not moderate-severe depression, see below) anti-depressants beneficial.
a. CBT Benefit of adding anti-depressant
b. Interpersonal therapy (IPT) to CBT less clear.
Time-limited and structured. Limited evidence hasnt shown
Its central idea is that psychological Sx e.g. depressed mood IPT, behavioural activation, or
can be understood as a response to current difficulties in R/S couples thepary to be any better
and affect quality of those R/S. than CBT.
It focuses on conflict w another person, life changes that
affect how one feels about oneself & others, grief & loss,
difficulty in starting or keeping R/S going.
It may involve 8 to 16 sessions.
c. Behavioural activation
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Focuses on activity scheduling to encourage patients to

approach activities that they are avoiding and on analysing
SIGN guidance on non-drug
the cognitive processes (e.g. rumination) that serve as form management (2010)
of avoidance.
Pt then re-focused on their goals & valued directions of life. - Recommended self-help: guided
d. Behavioural couples therapy self-help based on CBT, CCBT.
3. Combined treatment (anti-depressants & psychological intervention - Recommended psychological Tx:
e.g. CBT) recommended for moderate/severe depression. behavioural activation, individual
C. Choice depends on patients preference, duration of episode, CBT, couple focused therapy, IPT,
trajectory of Sx, previous illness course, Tx response, likelihood of problem-solving therapy, ST
adherence to Tx, likely S/Es. psychodynamic therapy.

- To reduce relapse in those who

IV. STEP 4 have > 3 episodes of depression:
A. Severe and complex depression; risk to life; severe self-neglect mindfulness-based CBT in group
B. Medication, high-intensity psychological interventions, setting
(Evidence: increasing evidence
electroconvulsive therapy, crisis service, combined Tx (multi-
e.g. BMJ 2012 suggest MCBT
professional and inpatient care). reduces relapse rate in those w
recurrent major depression vs. w
V. OTHER NON-DRUG RECOMMENDED TREATMENTS usual care or placebo)
A. Counselling
-Others: exercise e.g. structured
B. Short-term psychodynamic psychotherapy exercise programmes may be
C. Group-based peer support programmes is a low-intensity option for considered.
those with chronic physical health problems - St Johns Wort = SIGN do not
recommend SJW (hypercium)
because of lack of standard doses
and common interactions w other
drugs esp. the Pill (COCP).
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APPROACH TO PHARMACOLOGICAL DEPRESSION MANAGEMENT

I. WHICH ANTIDEPRESSANT?
A. NICE guidelines
1. Equal efficacy. Choice depends on S/E, safety in OD, patient
preference, interaction potential, propensity to cause discontinuation
syndromes.
2. 1st-line = SSRI (generic) because equal efficacy to other anti-
depressants; have favourable risk-benefit ratio.
3. 2nd line = switch to another SSRI
4. 3rd line = alternative class e.g. venlafaxine, TCA, MAO-I
5. Vortioxetine (Brintellux) recommended as possible Tx for adults
having first or recurrent major depressive episode (if current episode
has not responded to 2 anti-depressants).
6. Escitalopram = no clinical important advantages.
7. No advantage for dual action antidepressants (e.g. duloxetine &
venlafaxine) over other drugs.
8. Increased risk of suicidal ideation in younger pt taking anti-
depressants.
B. Note that:
1. SSRIs associated w increased risk of bleeding (consider Rx gastro-
protective agent in older people who are taking NSAIDs)
2. Higher risk of drug interactions with fluoxetine, fluvoxamine, and
paroxetine.
3. Higher incidence of discontinuation Sx with paroxetine
4. Citalopram + escitalopram associated w prolonged QT interval.
C. Consider toxicity in OD for those at significant risk of suicide:
1. Venlafaxine associated w greater risk of death from OD
2. TCA (except lofepramine) associated w greatest risk in OD
D. Discuss drug choice w patient
E. Dosulepin should NOT be Rx.

II. STARTING AND STOPPING ANTI-DEPRESSANTS

A. Start low and go slow
B. Review after 2 weeks. Then 2-4 weekly for the first 3 months (or more
frequently if e.g. high-risk suicide)
C. Continue once remission achieved (at least 6 months)
D. Reduce slowly (e..g over 4 weeks, but depends on individual and drug
half-life)
E. If significant S/E early in Tx:
1. Continue w close monitoring if acceptable to patients
2. Stop/change anti-depressant
3. Offer short-term (2 wks) benzodiazepine to help
F. Expect initial improvement after 2-4 wks. If no response after 3-4 wks,
review Dx, increase support, and consider:
1. Increase dose
2. Switch to alternative
G. If inadequate response, after 6-8 wks consider switching to
alternative.
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III. SIDE EFFECTS

N D Headache
Anxiety Insomnia/drowsiness Weight loss/gain
Sexual difficult Care in people w risk Bleeding
(aorgasmia) of falls
Citalopram: prolonged QT & arrhythmias. Avoid in those w long QT +
w other drugs that prolong QT. Annual ECG. Do not give more than
40 mg BD. Sertraline is DOC post-MI.
Drug interactions!

IV. ANTI-DEPRESSANTS AND PREGNANCY

A. NICE CKS 2015
B. Evidence on safety limited and inconsistent get specialist help (UK
teratology information service, specialist perinatal mental health team,
2o care psychiatrist)
C. All women of CBA should be made aware of potential S/Es of drugs Rx, if
they were to get pregnant.
D. Decisions made on individual basis taking into account risk/benefits
1. Risks associated w pregnancy
2. Risks of stopping antidepressants abruptly (discontinuation Sx)
3. Risks to mum and baby of NOT taking medication (severe depression
in pregnancy OB complications, suicide attempts, low birth weight,
still birth, NICU admissions)
4. Risk of antidepressants in pregnancy
E. Risks of SSRI
1. Evidence is patchy.
2. 1st trimester congenital malformations
3. > 20 weeks persistent pulmonary HTN of newborn; neonatal
withdrawal Sx
4. Although there are risks, SSRIs still an option
F. Options available
1. No intervention (watchful waiting)
2. Psychological intervention
3. Medications = TCA/SSRI (or combined w psych therapy)
G. There is no best medication: no anti-depressants are licensed
specifically for use in pregnancy or breastfeeding
H. AVOID MAO-Is and SJW

V. ANTI-DEPRESSANTS AND BREASTFEEDING

A. All TCAs, except doxepin, can be safely given to women who is
breastfeeding (imipramine and nortriptyline preferred)
B. SSRIs of choice for breastfeeding are paroxetine and sertraline
1. Citalopram and fluoxetine not recommended, can be considered if
women has been successfully treated w them during pregnancy.
C. MAO-I, venlafaxine, duloxetine, mirtazapine, reboxetine, SJW are not
recommended 1st-line in breastfeeding women.
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VI. CO-MORBIDITIES
A. Drug and EtOH misuse = depression, self-arm, and suicide more
common in this group (both CAUSE and CONSEQUENCE).
B. Post-natal depression
1. Risk factors
a. Previous mental health (including depression during pregnancy)
b. Lack of support
c. Experience of abuse
d. Low self-esteem
e. Poverty and poor living conditions
f. Major life events EPDS: (1) laugh and see funny
side; (2) enjoy things; (3) blamed
2. Baby blues are common but usually resolve 10-14 days after birth myself unnecessarily; (4) anxious
3. At each post-natal contact, women should be asked about their or worried for no good reason; (5)
emotional well-being, what family + social support they have, and scared or panicky for no good
their usual coping strategies for dealing w day-to-day matters. reason; (6) things getting on top
of me; (7) difficulty sleeping; (8)
4. Edinburgh postnatal depression scale 10 questions
sad; (9) crying; (10) thoughts of
5. Timely intervention psychological therapy, anti-depressants, or self-harm.
both.
6. MEN can experience this too!

VII. DIFFERENTIALS Hughes et al. (2016)

A. Depression or unrecognised bipolar disorder unrecognised bipolar disorder
B. Features of anxiety among UK primary care patients
C. Eating disorders screening questions (SCOFF) prescribed anti-depressants.
Aged 16-40 years Rx anti-
1. Have you ever felt so uncomfortably full that you have had to make depressants in 1o care for
yourself Sick? depression or anxiety but
2. Do you ever worry you have lost Control over how much you eat? unrecognised that they have
3. Have you recently lost or gained more than One stone in 3-m period? bipolar (up to 10% = substantial)
4. Do you believe yourself to be Fat when others say you are too thin?
5. Would you say Food dominates your life?
a. Score 1 point for every yes answer
b. Scores of > 2 indicate possible eating disorder.