Dr Ed Beveridge offers top tips for the assessment, management, and treatment of adults with depression in primary care
Read this article to learn more about:
- assessing and screening people with depression for underlying conditions
- pharmacological and nonpharmacological treatment options
- when to refer to secondary care or seek specialist advice.
Mental illness is common and has a significant impact not only on individuals and their families, but also on wider society.1 Depression is one of the most common mental disorders.2 General practitioners are familiar with its presentation as it is most often diagnosed and treated in primary care.3,4 The following tips, based on relevant guidance and clinical experience, focus on the primary care management of people with depression.
1 Recognise and identify depression
NICE Clinical Guideline (CG) 90 on Depression in adults: recognition and management recommends two initial questions to help identify people who may have depression:5
- during the last month, have you often been bothered by feeling down, depressed or hopeless?
- during the last month, have you often been bothered by having little interest or pleasure in doing things?
Be particularly alert to possible depression in people with a past history of depression or a chronic physical health problem with associated functional impairment.5,6
Symptoms should be present on most days for at least 2 weeks. The answer ‘yes’ to one or both questions should prompt a mental health assessment, which could involve a mental health professional if necessary.
2 Carry out a thorough assessment
Any assessment should take account of both the:5
- number and severity of symptoms, and
- degree of functional impairment.
Any past mental health history or family history of depression, and comorbid mental health or physical disorders, are important aspects of any diagnostic assessment.5 Classification systems such as ICD-107 and DSM-IV are agreed conventions to guide formal diagnosis, degree of severity, and treatment; NICE CG90 recommends the use of DSM-IV in preference to ICD-10.5 See Box 1 (below) for further detail on assessing depression using DSM-IV.5
Box 1: Assessing depression and its severity using DSM-IV criteria5
Assessment should include the number and severity of symptoms, duration of the current episode, and course of illness.
- persistent sadness or low mood; and/or
- marked loss of interests or pleasure.
At least one of these, most days, most of the time for at least 2 weeks.
If any of above present, ask about associated symptoms:
- disturbed sleep (decreased or increased compared to usual)
- decreased or increased appetite and/or weight
- fatigue or loss of energy
- agitation or slowing of movements
- poor concentration or indecisiveness
- feelings of worthlessness or excessive or inappropriate guilt
- suicidal thoughts or acts.
Then ask about duration and associated disability, past and family history of mood disorders, and availability of social support.
1 Factors that favour general advice and active monitoring:
- four or fewer of the above symptoms with little associated disability
- symptoms intermittent, or less than 2 weeks’ duration
- recent onset with identified stressor
- no past or family history of depression
- social support available
- lack of suicidal thoughts.
2 Factors that favour more active treatment in primary care:
- five or more symptoms with associated disability
- persistent or long-standing symptoms
- personal or family history of depression
- low social support
- occasional suicidal thoughts.
3 Factors that favour referral to mental health professionals:
- inadequate or incomplete response to two or more interventions
- recurrent episode within 1 year of last one
- history suggestive of bipolar disorder
- the person with depression or relatives request referral
- more persistent suicidal thoughts
4 Factors that favour urgent referral to specialist mental health services
- actively suicidal ideas or plans
- psychotic symptoms
- severe agitation accompanying severe symptoms
- severe self-neglect.
Adapted from: National Institute for Health and Care Excellence. Depression in adults: recognition and management. Clinical Guideline 90. NICE, 2009. Available from: www.nice.org.uk/cg90
NICE has not checked the use of its content in this article to confirm that it accurately reflects the NICE publication from which it is taken
Other standardised assessment self-report scales that may be used include the 9-item Patient Health Questionnaire [PHQ-9]8 and Hospital Anxiety and Depression Scale (HADS).9
3 Perform a baseline physical health assessment
Performing baseline physical investigations (e.g. a physical examination, recording weight, baseline blood tests) can uncover an occult cause for depressive symptoms. Remember that depressive symptoms and physical disorder often occur together.6,10 Possible physical disorders to look out for include hypothyroidism or hypercalcaemia, or evidence of comorbidity such as deranged liver function in people who regularly exceed recommended daily alcohol limits.
Baseline results can be useful for monitoring progress such as changes in weight in people who are not eating. Specific baseline investigations may be useful if a patient needs to be prescribed certain treatments, such as an atypical antipsychotic (test fasting blood glucose, glycosylated haemoglobin [HbA1c], blood lipid profile and prolactin levels11) or lithium (test renal and thyroid function, and calcium levels12). When a patient is referred to secondary care services, send the results of any baseline investigations to prevent them being repeated unnecessarily.
4 Assess risk as thoroughly as you can
Risk assessment is complex. Suicidal thoughts are common in people with depression; however, suicidal plans or intent to act on these thoughts are less common, but of greater concern.13,14 People are generally appreciative of the opportunity to talk about these distressing experiences and an open, detailed discussion is often enough to reassure the GP that there is a low likelihood of a patient acting on their suicidal ideas. That said, past behaviour is a good predictor of future behaviour, so if people have self-harmed or made suicide attempts before, it is reasonable to regard their risk as higher and have a lower threshold for specialist referral.14,15 Don’t forget to explore other risks too, including self-neglect (especially reduced food and fluid intake) and impaired ability to look after children or dependent adults.
5 Screen for evidence of mania in the patient’s history
Some patients presenting with depressive episodes have bipolar affective disorder—rather than unipolar depression—and may develop mania when they are treated with antidepressants. This can be completely unpredictable (for example, when they have never had an episode of mania before) but if there is evidence of episodes of elation then consideration needs to be given to how best to treat the patient; options include lower doses of antidepressant, use of an atypical antipsychotic like quetiapine (which is licensed for both unipolar depression and mania),16 or using a mood stabiliser like lamotrigine.17 It may be appropriate to seek specialist advice in these cases and if a patient does develop signs of elation on an antidepressant, stop it immediately and seek specialist advice.
6 Signpost resources and encourage self help
Do not assume that people with depression understand what is happening to them. Sometimes psychoeducation, including information about the fact that they have a treatable disorder, is very powerful.18 There is a vast amount of information and support available, and much of it is available online (see Box 2, below). Some (but not all) patients will respond well to being signposted to these resources. Through these websites people can access information and sources of support, both online (such as chat rooms and forums) and in the form of local groups, often led or co-led by people with lived experience of mental illness. These resources will enable some people to recover and self-manage their mood, create helpful networks, and prevent relapse.
Box 2: Self-help resources for people with depression
A mental health charity, which provides advice and support to empower anyone experiencing a mental health problem.
- Helpline: 0300 123 3393
- Email: email@example.com
- Text: 86463
Royal College of Psychiatrists20
The College aims to improve the outcomes of people with mental illness and the mental health of individuals, their families, and communities. The Royal College of Psychiatrists’ Health Advice website page includes readable, user-friendly, and evidence-based information on various mental health problems, treatments, and other topics regularly updated by psychiatric experts.
Friends in Need21
Friends in Need is a community created and led by the UK charity Depression Alliance (which merged with Mind in 2016). Friends in Need provides a way for people affected by depression to meet online and in their local area.
SANE is a UK-wide charity working to improve quality of life for people affected by mental illness. SANE offers emotional support and information to anyone affected by mental health problems and provides a range of resources on different mental health conditions.
- Helpline: 0300 304 7000
7 Avoid prescribing antidepressants for mild depression
Prescribing antidepressants for people with mild (as opposed to moderate or severe) depression should be avoided because of a poor risk–benefit ratio.5,23 NICE CG90 also provides evidence-based treatment pathways for depression in a stepped-care model (see Table 1, below).5 Other forms of treatment like bibliotherapy (the use of books as therapy in the treatment of mental or psychological disorders) or guided self-help may be just as effective.4 It may be tempting to prescribe for mild depression where it is difficult to access psychological treatments, but is unlikely to help the patient recover in the long term.23
|Step 4||Severe and complex* depression; risk to life; severe self-neglect||Medication, high-intensity psychological interventions, electroconvulsive therapy, crisis service, combined treatments, multiprofessional and inpatient care|
|Step 3||Persistent subthreshold depressive symptoms or mild to moderate depression with inadequate response to initial interventions; moderate and severe depression||Medication, high-intensity psychological interventions, combined treatments, collaborative care† and referral for further assessment and interventions|
|Step 2||Persistent subthreshold depressive symptoms; mild to moderate depression||Low-intensity psychosocial interventions, psychological interventions, medication and referral for further assessment and interventions|
|Step 1||All known and suspected presentations of depression||Assessment, support, psychoeducation, active monitoring and referral for further assessment and interventions|
*Complex depression includes depression that shows an inadequate response to multiple treatments, is complicated by psychotic symptoms, and/or is associated with significant psychiatric comorbidity or psychosocial factors
†Only for depression where the person also has a chronic physical health problem and associated functional impairment (see Depression in adults with a chronic physical health problem: treatment and management [NICE Clinical Guideline 91]).
Adapted from: National Institute for Health and Care Excellence. Depression in adults: recognition and management. Clinical Guideline 90. NICE, 2009. Available from: www.nice.org.uk/cg90 NICE has not checked the use of its content in this article to confirm that it accurately reflects the NICE publication from which it is taken
8 Consider psychological interventions for all patients with depression
There is a wealth of evidence to support the use of psychological interventions to treat depression, either alone or combined with medication. Much of the evidence for using psychological therapies to treat depression supports the use of cognitive behavioural therapy (CBT) but there is evidence for other therapies too, for example behavioural activation, and interpersonal therapy.23 Availability of the different psychological interventions varies throughout the UK and many of the services that are accessible to primary care are geared towards less complex cases. Complex cases (for example, where there is comorbid substance misuse or personality pathology) are more likely to be seen by more experienced psychologists and therapists, who may work in secondary care. Even people who seem too unwell to use psychological therapies at first can benefit from this type of treatment as their health improves, and it can become a key part of recovery and relapse prevention.
9 Be aware of a potential increased risk of suicide when initiating antidepressants
There is some evidence to suggest that in a very small number of cases (fewer than mainstream media coverage would have us believe24), suicide risk may increase after initiating an antidepressant.25 The reasons for this are unclear but the increased risk is possibly a result of people becoming more active and in a position to undertake acts they had previously been unable to, or due to unpleasant adverse effects such as agitation or insomnia. Warn patients and their families or carers about this increased risk and reassure them that it is rare, but be clear about what to do if they have concerns (including how to get help out of hours) and arrange a follow-up appointment, or telephone call, 1–2 weeks after initiating treatment. If you are particularly concerned about risk already and are not sure whether to treat or not, seek specialist advice.
10 Treat people at an adequate dose for adequate time before switching antidepressant
Advise patients that after starting an antidepressant it usually takes at least 2 weeks before they notice a subjective change in their mood, but that it can take 4 weeks or longer and changes in mood may occur quite gradually.23 If the patient’s response to the antidepressant is inadequate, check they are definitely taking it, encourage them to persevere for longer and, if they are tolerating it at the current dose, increase the dose. Practitioners should check the relevant summary of product characteristics and only prescribe within the dose range for each specific drug. Consider changing to a different antidepressant if the current treatment continues to be ineffective and the patient cannot tolerate a higher dose or higher doses do not work. All of the following provide useful information on switching antidepressants:
- NICE Depression in adults: recognition and management, CG905
- Switching antidepressants section of the NICE Clinical Knowledge Summary on Depression26
- The Maudsley Prescribing Guidelines in Psychiatry27
- Evidence-based guidelines for treating depressive disorders with antidepressants: a revision of the 2008 British Association for Psychopharmacology guidelines.23
11 Encourage people not to discontinue antidepressants too early
It is extremely common for people to want to stop antidepressants as soon as they can. This can be because:
- they feel better and do not see the need to continue
- they are experiencing unpleasant side-effects
- for some people, there is a perceived stigma or shame attached to taking medication for mental illness.
Often people are concerned about ‘addiction’ if they take antidepressants longer term and sometimes their concerns can be reinforced by discontinuation symptoms if they stop their medication suddenly.4 It is advisable to continue an antidepressant for at least 6 months after recovery, and for up to 24 months for recurrent episodes.5 Advise patients that the longer they take treatment, the lower their risk of relapse. Check that the patient is not experiencing side-effects they may not disclose immediately (such as sexual dysfunction28) and if they decide to stop their treatment, reduce the dose slowly and give them information about discontinuation symptoms to look out for.5
12 Refer for specialist advice if you need to
There will always be people who require more specialised treatment than primary care can provide. These include people:
- for whom the diagnosis is unclear
- who have an inadequate response to appropriate treatment (including pharmacological, psychological, or both)
- for whom there is significant concern about risk (especially acute risk).
The availability of specialist advice varies from place to place and it may be adequate to discuss a case with a psychiatrist, psychologist, or specialist nurse rather than requesting a face-to-face assessment. Specialists will generally expect that appropriate treatment (for example, as per NICE CG905) including different antidepressants has been offered before referral. As always, the more information you are able to offer about why you are referring the patient and what you have done so far, the better advice you will receive.
- Centre for Mental Health. The economic and social costs of mental health problems in 2009/10. London: Centre for Mental Health; 2010. Available at: www.ohrn.nhs.uk/resource/policy/EconomicandSocialcostofMI.pdf
- McManus S, Bebbington P, Jenkins R, Brugha T. Mental health and wellbeing in England: adult psychiatric morbidity survey 2014. Leeds: NHS Digital, 2016. Available at: content.digital.nhs.uk/catalogue/PUB21748/apms-2014-full-rpt.pdf
- Goldberg D, Huxley P. Mental illness in the community: the pathway to psychiatric care. London: Tavistock, 1980.
- National Collaborating Centre for Mental Health. Depression. The NICE guideline on the treatment and management of depression in adults (updated edition). National Clinical Practice Guideline 90. The British Psychological Society and The Royal College of Psychiatrists, 2010. Available at: www.nice.org.uk/guidance/cg90/evidence/full-guidance-243833293
- NICE. Depression in adults: recognition and management. Clinical Guideline 90. NICE, 2009 (updated 2016). Available at: www.nice.org.uk/cg90
- NICE. Depression in adults with a chronic physical health problem: recognition and management. Clinical Guideline 91. NICE, 2009. Available at: www.nice.org.uk/cg91
- World Health Organization. The ICD-10 classification of mental and behavioural disorders: clinical descriptions and diagnostic guidelines. Geneva; WHO, 1992. Available at: www.who.int/classifications/icd/en/bluebook.pdf
- Spitzer R, Kroenke K, Williams J. Validation and utility of a self-report version of the PRIME-MD. The PHQ primary care study. JAMA 1999; 282 (18): 1737–1744
- Zigmond A, Snaith R. The hospital anxiety and depression scale. Acta Psychiatrica Scandinavica 1983; 67 (6): 361–370
- Goodwin G. Depression and associated physical diseases and symptoms. Dialogues Clin Neurosci 2006; 8 (2): 259–265
- NICE. Psychosis and schizophrenia in adults: prevention and management. Clinical Guideline 178. NICE, 2014. www.nice.org.uk/cg178
- NICE. Bipolar disorder: assessment and management. Clinical Guideline 185. NICE, 2014. www.nice.org.uk/cg185
- Lönnqvist J. Psychiatric aspects of suicidal behavior: depression. In: Hawton K, van Heeringen K, editors. The international handbook of suicide and attempted suicide. New York: Wiley, 2000: 107–120.
- Centre for Suicide Research, Department of Psychiatry, University of Oxford. Clinical guideline: assessment of suicide risk in people with depression. Available at: cebmh.warne.ox.ac.uk/csr/clinicalguide/index.html
- Hawton K, Zahl D, Weatherall R. Suicide following deliberate self-harm: long-term follow-up of patients who presented to a general hospital. Br J Psychiatry 2003; 182: 537–542.
- British National Formulary. Quetiapine. Available at: beta-bnf.nice.org.uk/drug/quetiapine.html (accessed 7 April 2017)
- British National Formulary. Lamotrigine. beta-bnf.nice.org.uk/drug/lamotrigine.html (accessed 7 April 2017).
- Donker T, Griffiths K, Cuijpers P, Christensen H. Psychoeducation for depression, anxiety and psychological distress: a metaanalysis. BMC Medicine 2009; 7: 79 doi: 10.1186/1741-7015-7-79
- Mind website. Information and support. www.mind.org.uk/information-support/ (accessed 22 March 2017).
- Royal College of Psychiatrists. Mental health information for all. www.rcpsych.ac.uk/healthadvice.aspx (accessed 22 March 2017).
- Friends in Need website. www.friendsinneed.co.uk (accessed 22 March 2017).
- Sane website. Mental health conditions: depression. www.sane.org.uk/resources/mental_health_conditions/depression (accessed 22 March 2017).
- Cleare A, Pariante C, Young A. Evidencebased guidelines for treating depressive disorders with antidepressants: a revision of the 2008 British Association for Psychopharmacology guidelines. J Psychopharmacology 2015; 29 (5): 459–525.
- NHS choices website. Antidepressants linked to suicide and aggression in teens. Available at: www.nhs.uk/news/2016/01January/Pages/Antidepressants-linked-to-suicide-and-aggression-in-teens.aspx (accessed 7 April 2017).
- Pompili M, Serafini G, Innamorati M. Antidepressants and suicide risk: a comprehensive overview. Pharmaceuticals 2010; 3 (9): 2861–2883.
- NICE. Switching antidepressants. Depression. Clinical Knowledge Summaries. NICE, 2015. Available at: cks.nice.org.uk/depression#!prescribinginfosub:2
- Taylor D, Paton C, Kapur S. The Maudsley prescribing guidelines in psychiatry: 12th edition. Chichester: Wiley-Blackwell, 2015.
- Higgins A, Nash M, Lynch A. Antidepressantassociated sexual dysfunction: impact, effects, and treatment. Drug Health Patient Saf 2010; 2: 141–150 G