Effective recognition in primary care is the first stage in a structured approach to depression management, as Stephen Pilling (left) and Dr Paul Harvey explain


   

Depression is the most common mental disorder presenting in primary care and community settings. The estimated point prevalence for major depression among those aged 16 to 65 years in the UK is 21 per 1000.1 However, if the less specific and broader category of mixed depression and anxiety is included, the figure is much higher (see here).

However, the prevalence of depression varies considerably and is influenced by gender and a wide range of social, ethnic and economic factors. In practice, this means that between 5% and 10% of the adult population will suffer from depression and that at some point in their lives one in four women and one in 10 men in the UK are likely to suffer a period of depression serious enough to require treatment.2

Depression is a major cause of disability worldwide; in 1990 it was the fourth most common cause of loss of disability-adjusted life years and by 2020 it is expected to become the second most common cause.3

It is estimated that about 1.5 million disability-adjusted life years are lost each year in the developed world as a result of depression.4 The cost of lost productivity resulting from depression is therefore likely to far outweigh the health service costs associated with the illness; for example, the total cost of drug treatment for depression in the UK is estimated to be less than 20% of the total economic cost of depression.5

Developing the guideline

NICE commissioned the guideline entitled Depression: management of depression in primary and secondary care from the National Collaborating Centre for Mental Health, which was established by the Royal College of Psychiatrists and the British Psychological Society. A multi-disciplinary group including representatives from primary and secondary care and patient groups followed the standard NICE methodology for clinical practice guideline development and used the standard NICE grading system for evidence (see Figure 1 here).

The guideline identifies a number of key recommendations for implementation (Box 1, below). The guideline development group felt that these were most likely to reduce the variation in the availability of effective interventions for depression or to bring about a significant improvement in patient outcomes.

Box 1: Key recommendations for implementation

Screening in primary care and general hospital settings

Screening should be undertaken in primary care and general hospital settings for depression in high-risk groups – for example, those with a past history of depression, significant physical illnesses causing disability, or other mental health problems, such as dementia (C)

Watchful waiting

For patients with mild depression who do not want an intervention or who, in the opinion of the healthcare professional, may recover with no intervention, a further assessment should be arranged, normally within 2 weeks (watchful waiting) (C)

Antidepressants in mild depression

Antidepressants are not recommended for the initial treatment of mild depression, because the risk-benefit ratio is poor (C)

Guided self-help

For patients with mild depression, healthcare professionals should consider recommending a guided self-help programme based on cognitive behavioural therapy (CBT) (B)

Short-term psychological treatment

In both mild and moderate depression, psychological treatment specifically focused on depression (such as problem-solving therapy, brief CBT and counselling) of 6 to 8 sessions over 10 to 12 weeks should be considered (B)

Prescription of an SSRI

When an antidepressant is to be prescribed in routine care, it should be a selective serotonin reuptake inhibitor (SSRI), because SSRIs are as effective as tricyclic antidepressants and are less likely to be discontinued because of side-effects (A)

Tolerance and craving, discontinuation/withdrawal symptoms

All patients prescribed antidepressants should be informed that, although the drugs are not associated with tolerance and craving, discontinuation/withdrawal symptoms may occur on stopping, missing doses or, occasionally, on reducing the dose of the drug. These symptoms are usually mild and self-limiting but can occasionally be severe, particularly if the drug is stopped abruptly (C)

Initial presentation of severe depression

When patients present initially with severe depression, a combination of antidepressants and individual CBT should be considered as the combination is more cost effective than either treatment on its own (B)

Maintenance treatment with antidepressants

Patients who have had two or more depressive episodes in the recent past, and who have experienced significant functional impairment during the episodes, should be advised to continue antidepressants for 2 years (B)

Combined treatment for treatment-resistant depression

For patients whose depression is treatment resistant, the combination of antidepressant medication with CBT should be considered (B)

CBT for recurrent depression

CBT should be considered for patients with recurrent depression who have relapsed despite antidepressant treatment, or who express a preference for psychological interventions (C)

Recognition and treatment of depression

More than 80% of cases of recognised depression are treated in primary care, and most who receive active treatment are offered an antidepressant.6

However, only an estimated 60% of community cases of depression present in primary care;7 and of these, approximately 60% are unrecognised.

This is mainly because most of these patients consult for a somatic symptom and do not consider themselves mentally unwell, despite the presence of symptoms of depression. These patients also tend to have milder forms of depression.8

However, for those individuals who are identified as having depression, treatment often falls short of optimal recommended practice,9 and outcomes are correspondingly poor.10

Several methods have been developed to improve outcomes in depression, including facilitating antidepressant medication uptake and adherence,11 and providing, or facilitating referral to, psychological therapies.12 The emphasis in these approaches is to see depression as a potentially chronic condition requiring a disease management strategy similar to those of other chronic conditions, in particular a consistent care management approach.13

The stepped care approach

In developing a treatment approach for depression, the group encountered significant challenges in identifying the most effective treatments and organisational structures in which to deliver those treatments. Evidence from the USA on the development of stepped care programmes for the treatment of depression, which draw on chronic disease management models and the principles that the most cost-effective and least intrusive treatment should be offered first, suggested a framework to adopt for the guideline (Figure 1, below).13

Figure 1: The stepped care model
Reproduced from Depression: Management of depression in primary and secondary care by kind permission of NICE

The care and management of depression starts with effective recognition and diagnosis, as Figure 1 shows. Depression can be classified as mild, moderate or severe based on a symptom count drawn from WHO ICD-10 (Box 2, below), and this is crucial to an effective stepped care framework.

Box 2: Assessing the severity of depression
Key symptoms:
  • persistent sadness or low mood; and/or
  • loss of interests or pleasure
  • fatigue or low energy.
At least one of these, most days, most of the time for at least 2 weeks. If any of above are present, ask about associated symptoms:
  • disturbed sleep
  • poor concentration or indecisiveness
  • low self-confidence
  • poor or increased appetite
  • suicidal thoughts or acts
  • agitation or slowing of movements
  • guilt or self-blame
ICD-10 definitions

Mild depression: four symptoms
Moderate depression: five or six symptoms
Severe depression: seven or more symptoms, with or without psychotic features

The guideline also offers advice on other important factors that can influence the classification of depression and the choice of intervention to offer. The presence of personal support, lack of a family history of depression or of suicidal thoughts, coupled with limited disability and relatively recent onset of symptoms favour the use of limited interventions such as watchful waiting.

A greater number of symptoms, history of depression, limited social support, greater social disability and the presence of suicidal thoughts argue for more active interventions such as formal psychological therapies and antidepressant medication.

Poor response to two or more interventions, recent recurrence of depression and self-neglect argue for the involvement of mental health specialists. For those with active suicidal ideas or plans, psychotic symptoms and severe self-neglect, referral to a crisis team or psychiatrist should be considered.

Mild depression

Most patients presenting with depression in primary care will have mild depression, and the guideline recommends several approaches to treatment (Box 3, below). It is perhaps in this area that the guideline presents the most significant challenge to current practice in the management of depression in primary care.

Box 3: Key recommendations for mild depression
  • For patients with mild depression who do not want an intervention or who, in the opinion of the healthcare professional, may recover with no intervention, a further assessment should be arranged, normally within 2 weeks (‘watchful waiting’) (C)
  • For patients with mild depression, healthcare professionals should consider recommending a guided self-help programme based on cognitive behavioural therapy (CBT) (B)
  • In both mild and moderate depression, psychological treatment specifically focused on depression (such as problem-solving therapy, brief CBT and counselling) of 6 to 8 sessions over 10 to 12 weeks should be considered (B)
  • Antidepressants are not recommended for the initial treatment of mild depression, because the risk-benefit ratio is poor (C)

The guideline does not recommend antidepressant medication as the primary treatment for mild depression. In fact, antidepressant medication should normally only be offered to a limited number of individuals. These include patients with a previous history of depression, probably moderate or severe in nature, who responded well to a previous course of antidepressants, and whose symptoms, while still mild, present an opportunity to prevent a more severe depression developing.

Antidepressant medication may also be considered for individuals who have failed to respond to other interventions recommended by the guideline.

Another important consideration for the development group in moving away from recommending antidepressants as an initial treatment for mild depression was the emerging evidence on the risks associated with the use of antidepressant medication, in particular SSRIs. The recent Medicines and Healthcare products Regulatory Agency (MHRA) review of antidepressant drug treatments was based on concerns about withdrawal symptoms from SSRIs, the limited evidence of any associated benefits with increased doses of SSRIs and a potential increase in ideas of self-harm and suicide associated with the use of SSRIs in patients under 18 years old.14

The effective treatment of mild depression in primary care will require a significant restructuring of the current organisation and delivery of care. Implementing the guideline will demand greater availability of psychological therapies, but they are not the only alternatives to antidepressant drug therapy for the management of mild depression.

Guided self-help, which may in time see GPs writing prescriptions for self-help manuals from the local library, structured exercise programmes and computerised cognitive behavioural therapy are all cost-effective alternatives to both antidepressants and therapist-delivered psychological therapies for mild depression.

Moderate depression

Perhaps only 20% of individuals who present with depression in primary care will meet the criteria for moderate depression. However, these individuals are at greater risk of long-term problems, and the recommended approaches to management differ from those for mild depression. The risk-benefit ratio,which militated against the routine use of antidepressants in mild depression shifts, and antidepressant medication, specifically the SSRIs, become the initial choice for the treatment of moderate depression (Box 4, below).

Box 4: Key recommendations for moderate and severe depression
  • In moderate depression, antidepressant medication should be routinely offered to all patients before psychological interventions (B)
  • When considering individual psychological treatments for moderate, severe and treatment-resistant depression, the treatment of choice is CBT. IPT should be considered if the patient expresses a preference for it or if, in the view of the healthcare professional, the patient may benefit from it (B)
  • When patients present initially with severe depression, a combination of antidepressants and individual CBT should be considered as the combination is more cost effective than either treatment on its own (B)

Psychological therapies, in particular cognitive behavioural therapy (CBT) or interpersonal therapy (IPT) are important but should normally be offered only if a patient has not responded to medication or has a poor history of response to medication, or has declined the offer of medication.

Following the MHRA review, the guideline provides very careful advice on initiating antidepressant medication, monitoring risk, particularly in individuals who are suicidal, and on the avoidance of, and where necessary the management of, withdrawal symptoms (Box 5, below).

Box 5: Initiating and monitoring SSRIs and other antidepressants
  • When an antidepressant is to be prescribed in routine care, it should be a selective serotonin reuptake inhibitor (SSRI), because SSRIs are as effective as tricyclic antidepressants and are less likely to be discontinued because of side-effects (A)
  • Venlafaxine treatment should only be initiated by specialist mental health medical practitioners including general practitioners with a special interest in mental health (C)
  • Common concerns about taking medication should be addressed. For example, 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)
  • All patients who are prescribed antidepressants should be informed, at the time that treatment is initiated, of potential side-effects and of the risk of discontinuation/withdrawal symptoms (C)
  • Patients started on antidepressants who are considered to present an increased suicide risk or are younger than 30 years (because of the potential increased risk of suicidal thoughts associated with the early stages of antidepressant treatment for this group) should normally be seen after 1 week and frequently thereafter as appropriate until the risk is no longer considered significant (C)
  • Particularly in the initial stages of SSRI treatment, healthcare professionals should actively seek out signs of akathisia, suicidal ideation, and increased anxiety and agitation. They should also advise patients of the risk of these symptoms in the early stages of treatment and advise them to seek help promptly if these are at all distressing (C)
  • Patients started on antidepressants who are not considered to be at increased risk of suicide should normally be seen after 2 weeks. Thereafter they should be seen on an appropriate and regular basis, for example, at intervals of 2-4 weeks in the first 3 months and at longer intervals thereafter, if response is good (C)
  • Antidepressants should be continued for at least 6 months after remission of an episode of depression, because this greatly reduces the risk of relapse (A)
  • When a patient has taken antidepressants for 6 months after remission, healthcare professionals should review with the patient the need for continued antidepressant treatment. This review should include consideration of the number of previous episodes, presence of residual symptoms, and concurrent psychosocial difficulties (C)

Severe depression

Severe depression often has a poor outcome, and it is therefore important that the patient receives effective treatment as soon as it is recognised. In contrast to its recommendations for moderate depression, the NICE guideline recommends offering a combination of pharmacological and psychological treatment initially.

This recommendation follows a cost-effectiveness analysis, which demonstrated that although combined treatments are more expensive than either intervention alone, the combination is more cost effective, being associated with lower long-term relapse rates and better outcomes at the end of treatment (see Box 6, below).

Box 6: Chronic and treatment-resistant depression
  • Patients with chronic depression should be offered a combination of CBT and antidepressant medication (A)
  • Patients who have had two or more depressive episodes in the recent past, and who have experienced significant functional impairment during the episodes, should be advised to continue antidepressants for 2 years (B)
  • Where a patient with depression has a previous history of relapse and poor or limited response to other interventions, consideration should be given to CBT (B)
  • A trial of lithium augmentation should be considered for patients whose depression has failed to respond to several antidepressants and who are prepared to tolerate the burdens associated with its use (B)

The psychological treatment recommended for severe depression often involves 16 to 20 sessions, considerably more than for the psychological treatments usually delivered in primary care, where the number is often nearer to six or eight.

Again, this represents a significant challenge to primary care, not only in terms of the resources required to provide these interventions, but also in terms of staff skills and knowledge.

However, the total number of individuals who require combination treatments represents less than 10% of patients identified with depression in primary care; and those requiring combined treatments in primary care are relatively few. This is in part because many patients with severe depression who do not respond to treatment will be referred to secondary care mental health services.

The guideline also gives recommendations on care and treatment in specialist services, including pharmacological augmentation strategies, specialist crisis teams and electroconvulsive therapy.

Treatment-resistant and chronic depression

As many as 30% of depressed patients develop depression that is chronic in nature and often responds only partially to treatment. These are the individuals whose lives are most often blighted by depression and who place a considerable demand on the healthcare system. The guideline provides specific recommendations for their management.

In primary care settings, often in conjunction with advice from a secondary care specialist, the guideline makes recommendations that include the use of antidepressant medication other than SSRIs, combination therapies and the augmentation of antidepressants with lithium (Box 6, above).

Implementing the guideline

The guideline has identified a number of effective treatments which, if they are to be delivered effectively, require several key challenges to be addressed in primary care over the coming years, including:

  • A shift away from the use of antidepressants for the treatment of mild depression
  • The development of a stepped care approach to the management of depression
  • The development of alternative interventions, including guided self-help, structured exercise and computer-delivered psychological treatments for mild depression
  • An increase in provision of psychological interventions for mild, moderate and severe depression
  • Improved staff skills in, and knowledge of, the treatment of depression.

In addition to recommendations on treatment, the guideline makes a number of recommendations for further research, on the nosology of depression, the underlying biology and, importantly, the social and personality factors that interact with treatment response.

Conclusion

Depression is a treatable disease but, unfortunately, it is not always treated appropriately.This guideline should help clinicians in primary and secondary care to change that situation.

Successful implementation depends on better recognition of depression, the increased availability of a range of nonpharmacological interventions including self-help, exercise and computerised treatments as well as psychological therapies. For the full benefits of this enhanced range of options to be really cost effective the systems for the delivery of care in depression will need to be restructured.

The guideline is available in several formats: the NICE guideline, a quick reference guide, a version for patients and carers and the full guideline, published by the National Collaborating Centre for Mental Health. In addition, NICE provides a guide to the potential cost impact of the guideline and simple costing tools for use by commissioners and managers; separate costing tools are provided for both England and Wales. All are available online from www.nice.org.uk.

References

  1. Meltzer H, Gill B, Petticrew M et al. The prevalence of psychiatric morbidity among adults living in private households. OPCS Surveys of Psychiatric Morbidity, Report 1. London: HMSO, 1995.
  2. National Depression Campaign. National Depression Campaign Survey. London: National Depression Campaign, 1999.
  3. Murray CJ, Lopez AD, Jamison DT. The global burden of disease in 1990: summary results, sensitivity analysis and future directions. Bull World Health Organ 1994; 72(3): 495-509.
  4. World Bank. World Development Report: Investing in Health. Geneva:World Bank, 1993.
  5. World Health Organization.World Health Report 2001: Mental Health: new understanding, new hope. Geneva:WHO, 2001.
  6. Eccles M, Freemantle N, Mason J. North of England evidence-based guideline development project: summary version of guidelines for the choice of antidepressants for depression in primary care. North of England Anti-depressant Guideline Development Group.Fam Pract 1999; 16(2): 103-11.
  7. Meltzer H, Bebbington P, Brugha T et al. The reluctance to seek treatment for neurotic disorders. J Mental Health 2000; 9(3): 319-27.
  8. Thompson C, Ostler K, Peveler RC et al. Dimensional perspective on the recognition of depressive symptoms in primary care: The Hampshire Depression Project 3.Br J Psychiatry 2001; 179: 317-23.
  9. Donoghue JM, Tylee A. The treatment of depression: prescribing patterns of antidepressants in primary care in the UK. Br J Psychiatry 1996; 168(2): 164-8.
  10. Rost K, Nutting P, Smith J et al. Improving depression outcomes in community primary care practice. J Gen Intern Med 2001; 16: 143-9.
  11. Simon GE, VonKorff M, Rutter C, Wagner E. Randomised trial of monitoring, feedback, and management of care by telephone to improve treatment of depression in primary care. Br Med J 2000; 320: 550-4.
  12. Wells KB, Sherbourne C, Schoenbaum M et al. Impact of disseminating quality improvement programs for depression in managed primary care: a randomized controlled trial. JAMA 2000; 283(2): 212-20.
  13. Von Korff M,Goldberg D.Improving outcomes in depression – the whole process of care needs to be enhanced. Br Med J 2001; 323: 948-9. (Editorial.)
  14. Medicines and Healthcare products Regulatory Agency. Report of the CSM Expert Working Group on the Safety of Selective Serotonin Reuptake Inhibitors. London: Department of Health, 2004.

Guidelines in Practice, February 2005, Volume 8(2)
© 2005 MGP Ltd
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