Recent guidelines on the treatment of depression in primary care are comprehensive and serve as a useful aide-mémoire, reports Dr Rob Wicks
East Sussex Health Authority, in common with many others, seems to be producing new guidelines nearly every month. One of the more useful among them concerns the diagnosis and treatment of depression in primary care.
We all know that many of the patients we see each week are depressed. The problem is also supposed to be under-diagnosed. My first surgery after Christmas contained four new patients with depression – more than 25%!
Making a diagnosis for my patients wasn't a problem. They all offered classic symptoms of low mood, weepiness and sleep disturbance. Two of them have had psychological problems for the whole eight years I've worked here. One middle-aged man is well known to the local psychiatric services and another has a personality disorder.
The point I'm making is that these people have very sad lives, and although their symptoms have been helped by drugs, there are many other factors that I cannot change. Fortunately the majority of patients seen by GPs have simple reactive depression and do well.
|The East Sussex Health Authority guidelines on the diagnosis and treatment of depression in primary care|
These new guidelines (above) cover several areas and are divided into three broad categories. These are:
- When to consider depression
- How to confirm it
- What to do once depression is diagnosed
This last category covers:
- When to refer
- Whether to use psychological therapy
- The importance of an alcohol and/or drug history.
The various symptoms suggestive of depression are neatly summarised and the guidelines even indicate when patients are likely to respond to an antidepressant, namely if five or more of these cardinal symptoms have been present for two weeks. There is al.o a simplistic guide to suicide assessment.
The majority of this is all pretty basic stuff. As a seaside resort, however, we have a huge bedsit population, many of whom are mentally ill, and we have perhaps become blasé.
A recent local survey surprised us by revealing that our practice makes up 30% of the total mental health referrals locally.
The guidelines go on to indicate suggested antidepressant therapy, and cover suggested treatment lengths, when to change to a different class of drug, and what to do if response is inadequate, etc.
I wasn't surprised to find that tricyclic antidepressants were suggested as first-line therapy.
I always used to use them, and my starting dose was generally dothiepin 75mg. This is largely because my trainer had used it for years. I had never done a psychiatry job, and I was grateful for all the guidance he gave me.
However, many people complained of drowsiness and a dry mouth, and apart from the sedative benefits I wasn't bowled over by my results. People never seemed to come back for review as often as I would have expected.
When the SSRIs started to become popular, I began to use them. My personal view is that they seem to be the better class of drug, with less sedation, and they start to work much more quickly. I certainly find the anxiolytic properties of paroxetine useful, and the gastrointestinal side-effects often seem to be transient; many patients seem able to persevere with treatment.
The most interesting part of the guidelines for me concerns the length of treatment – six months is suggested, although obviously this is not prescriptive.
I am not sure that all my patients would follow my advice on this. Many of the people I see are very reluctant to start drug treatment for mental illness, and only accept that it is necessary after they start to feel better.
There still seems to be considerable stigma connected to a breakdown, which does not exist with hypertension or diabetes, although all three can be chronic conditions. However, giving a full explanation of the diagnosis and treatment, as outlined in the guidelines, should help with long-term compliance, if I remember to do it every time.
Psychological therapy as an adjunct is also mentioned, and I have no doubt that it has an important part to play. We are lucky in having a community psychiatric nurse attached to the surgery, who has a surgery one to two afternoons a week.
He will assess our urgent or worrying cases at the drop of a hat, and give them rapid access to secondary care, if he, or we, feel it is necessary. We even have a direct line telephone number to contact him.
I am sure not everybody has this luxury, and psychological therapy always used to involve a wait of several weeks before patients were seen before this new arrangement was set up.
Our management of depression and mental illness has certainly been improved by having a community psychiatric nurse on site, and the ongoing support that he can offer is usually beneficial to patients. His specialist knowledge is very useful and it is reassuring to have this readily available. I would highly recommend it.
The guidelines are a useful aide-mémoire and form a good framework on which to build treatment of depression. In particular the guidelines highlight the psychological support I have mentioned, and remind me that medication is not the full answer.