How

Recognition of depression is essential if it is to be treated, this sounds like common sense but how is it best to recognise depression and attempt to assess it's severity?

The following recommendations are for healthcare professionals working in primary care and general hospital settings (NICE,2009):

Depression Screening Tools

Screening questions should be asked when patients present with symptoms suggestive of depression, or are patients within a high-risk group i.e. a previous history of depression, existing chronic disease, physical illness causing disability, dementia, or other mental health problems.

Two Question Screen plus Help Question

The use of the 2 question screen plus the addition of the help question (Arroll, 2005) has a high sensitivity and specificity for diagnosing depression.

If the patient responds yes to either 1 or 2 and would like help then consider asking more detailed questions using the DSM-IV diagnostic criteria for depression.

Depression Screening Questions

Duration:

Mild Depression = Positive answer to two questions from 1-3, plus 2 others from questions 4-11.

Moderate Depression = Positive answer to two questions from 1-3, plus 3 or more from questions 4-11.

Severe Depression = Positive answer to most questions, especially Q.8 and Q.10, guilt and life not worth living.

Assessment of Suicide Risk

1 = Yes                         Treat depression, assess suicide risk at each visit, see again.
1 and 2 = Yes               Treat, Samaritans, ? refer
1, 2, 3 and 4 = Yes        Urgent referral to crisis team.

Depression Screening Questionnaires

Some of the screening tools which are available not only diagnose depression but also provide a score of severity. This is a useful addition to the depression toolbox as it facilitates a measure of not only initial severity but also of ongoing progress. Three validated depression severity scales which can be used within the primary care setting for patients under the age of 65 years are the Hospital Anxiety and Depression Scale, known as HADS (Zigmond & Snaith, 1983), the PHQ-9 questionnaire (Spitzer, 1999) and the Becks Depression Inventory (BDI) (Beck, 1961).

HADS:

PHQ-9:

Becks Depression Inventory-II (BDI):

Geriatric Depression Scale (GDS):

Edinburgh Postnatal Depression Scale (EPDS):

HOW to diagnose depression in primary care?

DSM-IV Criteria:

They are based on the criteria from Diagnostic and Statistical Manual of Mental Disorders (DSM-IV), eight symptoms and criteria are defined, together with some suggested questions for patients (Table 1). Depending on the answers to the questions and the duration of the symptoms depression can be major or minor, or can just indicate dysthymia (melancholy, Table 2).

Table 1: DSM-IV diagnostic criteria and suggested questions

Symptom	DSM-IV diagnostic criteria	Suggested questions
Depressed mood	Depressed mood most of the day, nearly every day	How has your mood been lately? How often does this happen? How long does it last?
Anhedonia	Markedly diminished interest or pleasure in almost all activities most of the day, nearly every day	Have you lost interest in your usual activities? Do you get less pleasure in things you used to enjoy?
Sleep disturbance	Insomnia or hypersomnia nearly every day	How have you been sleeping? How does that compare with your normal sleep?
Appetite or weight change	Substantial change in appetite nearly every day or unintentional weight loss or gain (≥5% of body weight in a month)	Has there been any change in your appetite or weight?
Decreased energy	Fatigue or loss of energy nearly every day	Have you noticed a decrease in your energy level?
Increased or decreased psychomotor activity	Psychomotor agitation or retardation nearly every day	Have you been feeling fidgety or had problems sitting still? Have you slowed down, like you were moving in slow motion or stuck in mud?
Decreased concentration	Diminished ability to think or concentrate, or indecisiveness, nearly every day	Have you been having trouble concentrating? Is it harder to make decisions than before?
Guilt or feelings of worthlessness	Feelings of worthlessness or excessive guilt nearly every day	Are you feeling guilty or blaming yourself for things? How would you describe yourself to someone who had never met you before?
Suicidal ideation	Recurrent thoughts of death or suicide	Have you felt that life is not worth living or that you'd be better off dead? Sometimes when a person feels down or depressed they might think about dying. Have you been having any thoughts like that?

Table 2: Diagnostic categories for depression and dysthymia (melancholy), and criteria for diagnosis

Diagnostic category	DSM-IV criteria	Duration
Major depression	≥5 depressive symptoms, including depressed mood or anhedonia, causing significant impairment in social, occupational, or other important areas of functioning	≥2 weeks
Minor depression	2 to 4 depressive symptoms, including depressed mood or anhedonia, causing significant impairment in social, occupational, or other important areas of functioning	≥2 weeks
Dysthymia	3 or 4 dysthymic symptoms, including depressed mood, causing significant impairment in social, occupational, or other important areas of functioning	≥2 years

HOW can patients help themselves?

There are several lifestyle activities which patients may engage with that will help to relieve some of the symptoms of depression and enable them to have an improved quality of life:

Take regular exercise.
Eat a healthy diet.
Have a life - work balance.
Ensure alcohol intake is within recommended limits.
Engage with social activities.
Resurrect, or develop, hobbies and / or interests.
Use MoodGYM - a freely available web-based programme which helps patients address negative thought patterns. MoodGYM is a self-help program to teach cognitive behaviour therapy skills to people vulnerable to depression and anxiety.

HOW do we manage the care of patients in primary care?

Exercise Referral Schemes:

Antidepressant Medication:

Concerns about antidepressant medication

Concerns about antidepressant medication dependence and addiction are widespread and growing (Haddad, 1999); discontinuation syndrome is the terminology used to describe the symptoms experienced by patients on stopping SSRI antidepressants. The pharmaceutical companies argue it is a unique syndrome but Medawar et al posit it is withdrawal, thereby inferring a dependence on the medication (Medawar, 2004). Whether the syndrome is withdrawal or discontinuation, the important aspect is what this means to the user, the person taking the SSRI.

The 1999 Drugs and Therapeutics review (Drugs and Therapeutics Bulletin, 1999) considered the withdrawal of antidepressants purely from the perspective of recovery from the depressive illness identified by a normal mood and functioning equal to that before the illness. Their advice to doctors on withdrawing antidepressant medication considers problems of relapse or recurrence of depression on discontinuation but no reference is made to actual or potential psychological concerns patients may harbour about stopping antidepressants.

Patient experience of antidepressant medication

A number of qualitative studies have been undertaken which aimed to widen understanding of the patient experience of depression and antidepressant medication:

HOW does antidepressant medication work? (www.medinfo.co.uk)

The brain is made up of millions of interconnected brain cells (neurons). Messages travel along these cells rather like electricity down a wire, but when the message reaches the end of the neuron, it has to jump the gap (synapse) to the next cell or group of cells. This is achieved by the neuron releasing tiny amounts of a chemical (neurotransmitter) into the gap between the nerve cells. The receiving neuron has many places on its surface which act rather like locks, for which the appropriate neurotransmitter is the key. These are called receptors. When enough of the neurotransmitter has locked on to these receptors, a nerve impulse is started in the new nerve, and thus the message gets from one nerve to the next. In order to allow the nerve to recover and receive the next message, and in order to replenish stocks of the neurotransmitter in the original neuron, ready to send the next message, the body has a clever way of removing the neurotransmitter from the receptors, and allowing it to be taken back into the originating nerve (re-uptake). In depression certain neurotransmitters are relatively lacking. One of those is serotonin, also known as 5-hydroxytryptamine or 5-HT. The SSRIs (Selective Serotonin Re-uptake Inhibitors) slow down the process of returning the serotonin to the end of the neuron it comes from. This leads to the chemical remaining in the vicinity of the receptors for longer, making it more likely that enough will build up to set off the impulse in the next neuron. Thus, the SSRIs work by allowing the body to make the best use of the reduced amounts of serotonin that it has at the time. In due course, the levels of natural serotonin will rise again, and the SSRI can be reduced and withdrawn.

HOW does CBT work?

There are now two forms of cognitive behavioural therapy (CBT) available:

Face to face counselling with a CBT Therapist - CBT is undertaken by a qualified CBT therapist who listens, talks and helps the patient correct negative thought processes and thereby improves the patients relationship with others. CBT has been shown to be as effective as antidepressant medication in treating depression.
Computerised CBT e.g. Beating the Blues (Ultrasis) - software programme which enables the patients to look at their negative thought processes and learn alternative thought processes. cCBT is recommended for people with mild depression in preference to the immediate commencement of antidepressant medication or immediate referral to face-to-face CBT. A course of cCBT consists of 8 one hour sessions taken either weekly or fortnightly. Patients with moderate depression may benefit from cCBT after antidepressant medication has been commenced.

Over half the people with mild or moderate depression respond well to psychological counselling.

CCBT - NICE Guidance

HOW effective are SSRIs?

An analysis of SSRI trial data published by Kirsch et al in 2002 (Kirsch, 2002) revealed that the antidepressants:

Often failed to outperform placebo and when they do the difference is small.
The placebo response was greatest in patients with less severe depression i.e. the group of patients most likely to be treated in primary care.
People do improve with an SSRI antidepressant but this effect is reproduced by placebo in mild to moderate depression, the effect may therefore be due to non-pharmacological elements i.e. talking, trust in the GP, relief at the provision of care and a plan of action, or the instillation of hope (MHF, 2005).

Kirsch et al (Kirsch 2008) have undertaken a further meta-analysis of data submitted to the Food and Drug Administration (FDA) in order to identify whether there is a link between initial depression severity and antidepressant benefit. The researchers obtained data on all the clinical trials submitted to the FDA for the licensing of four SSRIs - fluoxetine, venlafaxine, nefazodone, and paroxetine, and found:
- The overall effect of these new generation of antidepressants was below the recommended criteria for clinical significance.
- There was virtually no difference in the improvement scores for drug and placebo in patients with moderate depression.
- There was only a small and clinically insignificant difference among patients with very severe depression.
- The difference in improvement between the antidepressant and placebo did reach clinical significance, however, in the most severely depressed patients.
- Additional analyses indicated that the apparent clinical effectiveness of the antidepressants among these most severely depressed patients reflected a decreased responsiveness to placebo rather than an increased responsiveness to antidepressants.

Kirsch et al therefore conclude that there is little reason to prescribe new-generation antidepressant medications to any but the most severely depressed patients unless alternative treatments have been ineffective. They also identify that the finding that extremely depressed patients are less responsive to placebo than less severely depressed patients but have similar responses to antidepressants is a potentially important insight into how patients with depression respond to antidepressants and placebos that should be investigated further.

Prozac Revelation

Depression Screening Tools

Two Question Screen plus Help Question

Depression Screening Questions

Duration:

Assessment of Suicide Risk

Depression Screening Questionnaires

HADS:

DSM-IV Criteria:

Table 1: DSM-IV diagnostic criteria and suggested questions

Symptom

DSM-IV diagnostic criteria

Suggested questions

Table 2: Diagnostic categories for depression and dysthymia (melancholy), and criteria for diagnosis

Diagnostic category

DSM-IV criteria

Duration

Exercise Referral Schemes:

Antidepressant Medication:

Concerns about antidepressant medication

Patient experience of antidepressant medication

HOW does antidepressant medication work? (www.medinfo.co.uk)