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Exercise Referral Scheme
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Antidepressant Medication
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Concerns about antidepressant medication
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Patient experience of antidepressant
medication
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HOW common is depression?
(MHF, 2003)
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Depression is very
common.
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Between 5 and 10 per
cent of the population are suffering from the
illness to some extent at any one time.
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Over a lifetime you
have a 20 per cent, or one in five, chance of having
an episode of depression.
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Women are twice as
likely to get depression as men.
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15% of people aged 65 years and
over have depression.
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?
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It is estimated that approximately 50% people with depression in the community
do not present to their GP.
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At least two-thirds of depressed people
who see their GP present with physical or somatic symptoms rather than
psychological symptoms, making recognition harder.
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Many patients with
established physical diseases become depressed during the course of their
illness; recognition of depression for this population is important and can
lead to improved outcomes.
The following recommendations are for healthcare
professionals working in primary care and general hospital settings (NICE,2004):
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Screening should be undertaken in
primary care and general hospital settings for depression in high-risk
groups:
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Past history of depression.
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Significant physical
illnesses causing disability.
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Other mental health problems e.g. dementia.
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Healthcare professionals should bear in mind the potential physical causes of
depression and the possibility that depression may be caused by medication.
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Healthcare professionals should
consider screening if appropriate.
Depression:
management of depression in primary and secondary care - NICE guidance
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.
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During the past month have you often been bothered
by feeling down, depressed or hopeless?
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During the past month have you often been bothered by little interest or
pleasure in doing things?
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Is this something you would like help with?
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
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Has it been interfering with your life for the past 2
weeks?
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Have you lost interest in things?
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Do you feel tired or lacking in energy?
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Have
you lost confidence in yourself?
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Do you find it difficult
to concentrate?
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Do you find you are not
sleeping well?
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Have you lost your
appetite/weight?
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Do you feel guilty about
things?
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Do you feel you are
being punished?
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Do you feel that life is
not worth living anymore?
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Have you ever thought
about ending it all?
Duration:
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How long have you felt
like this?
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Does this last for most
of the day?
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Do you feel like this
most days?
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
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Do you feel life is not
worth living anymore? |
1 |
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Have you felt like acting on this? |
2 |
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Have you made any plans? |
3 |
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Have you tried before? |
4 |
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, the
PHQ-9
questionnaire and the Becks Depression Inventory 2nd Edition (BMA, 2006);
patients over the age of 65 years can use the
Geriatric Depression Scale.
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Validated for use in primary and community care settings
(Snaith,
2003; Olsson, 2005).
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It is self-administered and takes up to 5 minutes to
complete.
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The Anxiety and Depression scales both comprise 7
questions rated from a score 0 to 3, depending on the severity of the
problem described in each question.
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The 2 sub-scales can also be aggregated to form an
overall anxiety and depression score.
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The anxiety and depression scores are categorised as
normal (0-7), mild (8-10), moderate (11-14), and severe (15-21).
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The HADS allows you to establish the severity of both
anxiety and depression simultaneously, anxiety and depression are
independent measures.
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The HADS depression subscale has a 90% sensitivity and
86% specificity for depression compared to the gold standard of a structured
diagnostic interview.
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http://www.patient.co.uk/showdoc/40002439 link to
information about HADS.
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HADS scoring sheet
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A 9 question self-report measure of severity that takes
approximately 3 minutes to complete.
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It uses
DSM-IV criteria and scores are categorised as
minimal (1-4), mild (5-9), moderate (10-14), moderately severe (15-19) and
severe depression (20-27).
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It was developed and validated in the US and can be
downloaded free of charge from:
www.depression-primarycare.org, or click on this link
PHQ-9.
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A 21 item self-report instrument that uses the
DSM-IV
criteria.
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It takes approximately 5 minutes to fill in.
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A total score of 0-13 is considered minimal range, 14-19
is mild, 20-28 is moderate, and 29-63 is severe.
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Suitable as a screening test for depressive symptoms in
the elderly.
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Ideal for evaluating the clinical severity of depression,
and therefore for monitoring treatment.
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It is easy to administer, needs no prior psychiatric
knowledge and has been well validated in many environments.
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Depression is increasingly common in the age group 65 years and
over, and even more so in the 85+ age group.
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Therefore for this group of patients the Geriatric
Depression Scale is available.
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http://www.patient.co.uk/showdoc/40002438 link to
on-line GDS.
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
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Suggested questions |
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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? |
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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? |
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Sleep disturbance |
Insomnia or hypersomnia nearly every day |
How have you been sleeping? How does that compare with your
normal sleep? |
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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? |
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Decreased energy |
Fatigue or loss of energy nearly every day |
Have you noticed a decrease in your energy level? |
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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? |
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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? |
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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? |
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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? |
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Table 2: Diagnostic categories for
depression and dysthymia (melancholy), and criteria
for diagnosis
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Diagnostic category |
DSM-IV criteria |
Duration |
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Major depression |
≥5 depressive symptoms, including depressed mood or anhedonia,
causing significant impairment in social, occupational, or other
important areas of functioning |
≥2 weeks |
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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 |
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Dysthymia |
3 or 4 dysthymic symptoms, including depressed mood, causing
significant impairment in social, occupational, or other important
areas of functioning |
≥2 years |
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.
Exercise Referral Schemes:
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There are 1,300 exercise referral schemes across the UK.
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An exercise referral scheme is a supervised exercise programme which research
indicates is as effective as antidepressant medication in treating mild or
moderate depression.
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A study undertaken by the Mental Health
Foundation (MHF, 2005) indicated that only 42% of GPs across the UK have access
(or know they have access) to an exercise referral scheme.
Mental Health Foundation - 'Up and Running'
(NICE, 2004)
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Within primary care, depression is
most commonly treated with
drugs (Barbui, 2004).
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Concordance with antidepressant medication
is poor, leading to relapse and recurrence of symptoms (Keller, 2002;
Manning,
2003; Masand, 2003).
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The most favoured antidepressant medications are the selective serotonin reuptake inhibitors (SSRIs)
and to a lesser extent the tricyclic antidepressants (TCAs).
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Randomised controlled trial (RCT) evidence
(Kirsch, 2002) indicates that for many patients there is little clinically
important difference between antidepressants and placebo, and that placebo
response is greatest in mild depression.
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More evidence exists for
the effectiveness of antidepressant medication in moderate to severe depression
than in milder depression. Antidepressants are as effective as psychological
interventions, widely available and cost less.
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Careful monitoring of symptoms,
side effects and suicide risk (particularly in those aged under 30) should be
routinely undertaken, especially when initiating antidepressant medication.
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Patient preference and past experience of treatment, and particular patient
characteristics should inform the choice of drug.
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It is important to
monitor patients for relapse and discontinuation/withdrawal symptoms when
reducing or stopping medication.
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Patients should be warned about the risks of
reducing or stopping medication.
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Antidepressants are not recommended for the initial treatment of mild
depression, because the risk–benefit ratio is poor.
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Antidepressants should be considered for patients with mild
depression that is persisting after other interventions, and those whose
depression is associated with psychosocial and medical problems.
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Antidepressants should be considered when patients with a past
history of moderate or severe depression present with mild depression.
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.
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Between
30% and 60% of patients do not take their medication as prescribed (Demyttenaere,
2000).
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Patients are reluctant and/or refuse to take
antidepressant medication because of concerns about dependence and addiction (Haddad, 1999).
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Patients discontinue antidepressant
medication due to adverse drug effects or inefficacy (Bandolier, 2004).
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27% of dysthymic patients experienced discontinuation symptoms on
stopping their SSRI (Bogetto, 2002).
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.
Social Audit - Medicines out of
control?
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 (Lewis, 1995; Grime, 2003; Garfield, 2003; Brown, 2001).
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The qualitative study
by Garfield et al considered the patient perspective at the commencement of
antidepressant treatment; it aimed to identify factors important to patients
when beginning antidepressants (Garfield, 2003). Garfield et al
described an uncertainty amongst a majority of the respondents in their
study as to the exact role of antidepressant medication in the recovery
process, with the respondents attributing circumstance change to the
recovery process. It may be that those patients who have the greatest
fear of stopping their medication attribute their recovery more greatly to
the antidepressants than to circumstance change. Patients who had been
on antidepressants for more than three months were excluded from this study,
consequently the experience of stopping medication was not addressed by any
of the respondents.
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A recent small
qualitative study interviewed nine patients to understand the user
perspective of depression (Louch et al, 2006) and found that patients with mild to
moderate depression not only want the same dimensions of quality care that
all other patients want i.e. structured care, information about depression,
information about the side effects of antidepressant medication, but that
patients experience feelings of fear and anxiety when the time comes to stop
antidepressant medication. Several of the respondents identified a paradox
between being on medication and coming off medication, they described a desire
not to continue antidepressant medication lifelong but counteracted this with
descriptions of their fear of returning to a previous mental state.
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The
qualitative study by Grime and Pollock (Grime, 2003) aimed to understand
patients’ views and experiences of taking antidepressant medication and
similarly reported that some patients are afraid to stop antidepressant
medication because of a fear of the return of the symptoms of depression.
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.
There are now two forms of cognitive behavioural
therapy (CBT) available:
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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.
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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
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An analysis of SSRI trial data published by Kirsch et al
in 2002 (Kirsch, 2002)
revealed that the antidepressants:
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Often failed to outperform placebo and
when they do the difference is small.
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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.
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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).
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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:
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The overall effect of these new
generation of antidepressants was below the recommended
criteria for clinical significance.
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There was virtually no difference in the
improvement scores for drug and placebo in patients with
moderate depression.
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There was only a small and clinically
insignificant difference among patients with very severe
depression.
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The difference in improvement between the
antidepressant and placebo did reach clinical significance,
however, in the most severely depressed patients.
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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.
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Nurse-led chronic disease management is
part of the everyday workload for many nurses working in general practice.
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Nurse-led clinics in general practice are an
effective management tool for chronic disease (Campbell, 1998; Plummer,
2000).
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A study by Von Korff (Von Korff, 2001) asks whether depression
should in fact be included with the other chronic conditions such as
diabetes, asthma and hypertension, and therefore managed systematically in
primary care.
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Providing structured systematised care for
patients with depression will help alleviate some of the current problems in the
management of depression in primary care.
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Nurses are ideally placed to
undertake structured systematised care, they have both the skills and the
knowledge applicable to chronic disease management.
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However, managing
depression as a chronic disease is not universally recognised, and nurse-led
care for depression is not common within primary care.
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Appropriate training will enable
general practice nurses to undertake a proactive role in identifying depression,
supporting recovery from illness and preventing relapse (Gillam, 2000).
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The involvement of service users is
an important part of the NHS strategy to improve service quality in the
NHS.
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By understanding the patient experience of both depression as an
illness and of stopping antidepressant medication the quality of care should
be improved.
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Any improvement in the quality of a service
needs to start from the perspective of the user as the views of service
users on quality differ from the views of healthcare professionals, managers
and policy makers.
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Involving service users helps to avoid
inappropriate services being developed and should result in innovative and
imaginative ways to deal with depression in primary care.
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