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Protocol for the Management of
Depression in Primary Care
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Depression Templates (EMIS)
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Depression Patient Care Pathways
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Depression Pack
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Exercise Referral Scheme
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Computerised CBT
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Training and Support
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Audit
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Publications
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Presentations
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Posters
Depression was first classified as an 'illness' in western
medical diagnostic manuals in the 1930s and the social acceptance of depression
as an illness is very recent (www.studentdepression.org).
Depression is recognised as an illness that involves the body, mood and
thoughts; the predominant feelings are ones of sadness. Depression
affects the way a person eats and sleeps, the way one feels about oneself, and
the way one thinks about things. Depression describes an individual
episode of mood disorder; a depressive episode may be a single episode or it may
be part of a lifetime pattern
of mood disorder.
An internet search
(Google and MSN) identified the following definitions of
depression:
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A mental state characterized by a pessimistic sense of
inadequacy and a despondent lack of activity.
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Depression is an illness
characterised by a prolonged low mood which affects the ability to carry out
day to day activities.
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Depression is a mood
disorder with a number of physical manifestations in addition to its
psychological effects.
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Depression is a serious
and possibly life-threatening affliction.
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Depression is the second
most costly disease there is.
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Depression is a medical
illness caused by a chemical imbalance in the brain.
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Depression is defined as
the "loss of interest or pleasure in nearly all activities" and "sustained
fatigue without physical exertion".
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Depression usually isn't
caused by one event or thing; it's the result of one or more factors, and
its causes vary from person to person.
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Depression is more than
the blues or the blahs; it is more than the normal, everyday ups and downs.
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Depression is defined as
an illness when the feelings of depression persist and interfere with a
persons ability to function.
The official 2006 WHO definition of
depression states:
“Depression is a common mental disorder
that presents with depressed mood, loss of interest or pleasure,
feelings of guilt or low self-worth, disturbed sleep or appetite, low
energy, and poor concentration. These problems can become chronic or
recurrent and lead to substantial impairments in an individual's ability
to take care of his or her everyday responsibilities”.
Depression has no single cause
and varies from person to person. Depression as a disease is a multifactorial
syndrome with multiple processes which can manifest itself as a result of a
variety of circumstances and may be due to a multiplicity of factors.
The adoption and utilisation of a purely
biomedical perspective separates the biological from the other factors
and results in an artificial appraisal of depression. The
biopsychosocial model is useful to
understand the causation of depression where biological (genetic and
biochemical), sociological and psychological factors interact to produce
a picture of depression
The list below identifies some of the factors that
play a part in the onset of depression:
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Past experiences
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Personality
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Traumatic life event or series of
events
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Loss
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Lifestyle - poor diet, poor physical
fitness
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Disease and illness:
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Toxic-metabolic:
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Hyperthyroidism, hypothyroidism,
Cushing's syndrome, hypercalcaemia, hyponatraemia, diabetes mellitus.
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Neurological disorder:
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Stroke, subtotal haematoma,
multiple sclerosis, brain tumours (especially frontal), Parkinson's disease,
Huntington's disease, uncontrolled epilepsy, syphilis, dementias.
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Nutritional disorder:
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Other:
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Use of recreational drugs
e.g. sedative-hypnotics, cocaine.
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Alcohol.
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Prescribed medications
e.g. beta-blockers, alpha-methyldopa, levodopa, and oestrogens.
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Changes to the neurotransmitters in the
brain - although there is uncertainty as to whether this is a cause of
depression or a result of depression.
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Lack of identification of patients with depression; 80%
patients with depression present with non-specific physical symptoms and
avoid mentioning any symptoms concerned with emotions (University of York, 2002).
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Variability in the threshold at which GPs label patients
as needing treatment (Kendrick, 2000).
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The majority of depressed patients in general practice
receive less than the recommended doses and duration of antidepressant
treatment according to clinical practice guidelines (Kendrick, 2001).
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Patients are often reluctant to accept medication and
think that counselling should be offered (Priest, 1996).
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Stigma is a major factor in the failure of individuals
with depression to seek or maintain treatment (Corrigan, 2004).
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Patients often stop their medication as soon as they feel
better due to worries about addiction. Symptoms return in approximately 50%
patients who stop their prescription as soon as they feel better
(Montgomery, 1995).
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Inadequate follow-up of patients (Solberg, 1999).
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Lack of availability
of psychological therapies due to a lack appropriately trained therapists
(Depression Report, 2006).
|
Categories |
Costs
(£ billion) |
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Health and social care costs: |
12.5 |
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NHS
services |
6.5 |
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Informal care |
3.9 |
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Local authority social services |
1.4 |
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Other
public sector costs |
0.5 |
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Private expenditure |
0.2 |
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Human costs: |
41.8 |
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Households |
37 |
|
Institutional population |
1.3 |
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Premature mortality |
3.5 |
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Output losses: |
23.1 |
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Sickness |
3.9 |
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Non-employment |
9.4 |
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Unpaid
work |
8.0 |
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Premature mortality |
1.8 |
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Total cost
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77.4 |
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Depression reduces economic output through
time off-sick, non-employment and unemployment; there are currently more
people on incapacity benefits due to mental health problems than the total
number of unemployed people on Job Seeker’s Allowance (Depression Report,
2006).
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The
total loss of output due to depression and anxiety is approximately £12
billion per year, equivalent to 1% of the total national income (Depression
Report, 2006).
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Over 91 billion working days are lost due to mental health
problems every year; half of the days lost are due to anxiety and stress
conditions (MHF, 2003).
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71% people who have mental distress as their main
disability are out of work.
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Sickness due to mental distress has increased by 20% in
the past 20 years (MHF, 1995).
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Depression and anxiety attract only 2% of NHS spending on
mental health (Depression Report, 2006).
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Depression is associated with a 50% increase
in the medical costs of chronic medical illness, even after controlling for
severity of the physical illness (Katon, 2003).
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Between
1992 – 2003 there was an
180% increase in antidepressant prescriptions, and a 2083% increase in cost
in the UK (MHF, 2005).
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In 2005 the number of antidepressant
prescriptions in the UK totalled 29.4 million at a cost of £338.5 million,
half of these prescriptions issued and their costs were for an SSRI (DH,
2006)
Cost Matrix for Depression (SCMH,
2003, Chisholm, 2001)
| |
Care Costs |
Productivity Costs |
Other Costs |
Depressed
Individual |
Treatment - prescription fees;
therapy costs. |
Non-employment; unemployment;
time off-sick; work disability. |
Anguish; treatment; side
effects; suicide; premature mortality. |
| Family & Friends |
Informal care-giving. |
Time off work. |
Carer burden. |
| Employers |
Employer contributions to
treatment and care. |
Reduced productivity. |
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| Society |
NHS, Social Services & other
public sector costs. Taxation and insurance. |
Reduced productivity. |
Loss of lives; untreated
depression; unmet need. |
There are a wide
range of treatment options for
depression. However, in primary care, the main treatment for
depression has been antidepressant therapy. Evidence-based psychological
interventions are of limited availability due to long waiting lists because of a
lack of therapists or no therapists at all (Depression Report, 2006).
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Until the 1990s, the drugs of
choice were either the TCAs or the MAOIs; since then the SSRIs are the
antidepressants most frequently prescribed.
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TCA prescribing in the USA, between 1990 and
1995, declined by 17%, but this was matched by a 27% increase in SSRI
prescribing for the same period (Sclar, 2001).
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The SSRIs do have benefits, they are safer in
overdose and have an improved side effect profile over the older antidepressants
(NICE, 2004).
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The marketing of the SSRIs,
for
the first time, laid claim to a physical cause for a mental illness i.e. the
depletion of the neurotransmitter, serotonin, in the brains of people with
depression. This
identification of a biomedical model which
provided a physical cause for depression, helped to make the SSRIs a much more
socially acceptable antidepressant (Lacasse, 2005).
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There is an argument which states that the
biomedical concept of depression obscures the diversity of problems and
experiences of individuals and undervalues the social explanations and
interventions which cause depression (Moncrieff, 2006).
As a result of the research initiative which commenced with
the MSc Primary Care, Elmham and Swanton Morley Surgeries developed structured systematised care for patients
diagnosed with anxiety and/or depression.
Protocol for the Management of
Depression in Primary Care:
The availability and application of a practice protocol ensured a
consistent approach to the management of the care for depression across the
practice.
Depression Protocol
Depression Templates:
Two computer
templates were designed which all clinicians were encouraged to use:
1. 'Depression - Initial Diagnosis':
2. 'Depression Management':
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Used to record the Hospital and
Anxiety Depression Scale (HADS) score, plus any interventions
recommended by the clinician e.g. referral to exercise scheme, cCBT,
link worker.
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The use of the HADS score has enabled the practice to
try and distinguish between anxiety and depression as a diagnosis and, in
accordance with the NICE guidelines, depression is always treated as the
priority.
Depression Patient Care Pathways:
Elmham and Swanton Morley Surgeries worked closely with the mental health worker and local secondary
care professionals to develop patient care pathways for mild depression and
moderate depression:
Patient Care Pathway - MILD Depression
Patient Care Pathway - MODERATE Depression
Depression Pack:
Elmham and Swanton Morley
Surgeries developed a
‘Depression Pack’ which contains a variety of information for patients to dip in
and out of i.e. booklets on depression, anxiety, stress, leaflets on
counselling, relationships, exercise etc.
Feedback from both patients and clinicians regarding the use of the Depression
Pack was very positive.
Depression Pack
Exercise Referral Scheme:
Elmham and Swanton Morley Surgeries have access to an exercise referral scheme in Norfolk PCT,
this is a popular and useful resource for patients, particularly those patients
who have been diagnosed with mild depression.
Mental
Health Foundation - 'Up and Running'
Computerised CBT:
Elmham and Swanton Morley Surgeries purchased an annual licence for the
computerised CBT programme, 'Beating the Blues', in December 2005. Due to
the success of this programme, it is now in its third year of operation.
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Beating the Blues is
recommended by NICE as the preferred cCBT programme for anxiety and depression
(NICE, 2006).
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Beating the Blues is available to all patients in the practice and
consists of eight one hour sessions taken either weekly or fortnightly.
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Feedback to date has been extremely positive from the majority of patients.
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The
use of cCBT has freed up the time of the mental health link worker, thus
enabling the link worker to be able to provide more one to one support for those patients who require this form of
therapy.
Beating the Blues
CCBT - NICE Guidance
CCBT - NICE - Public
Information
Training and Support:
The mental health link worker has provided
both the GPs and the Nurse Department staff with training and support around the
topics of depression and anxiety.
Audit:
Elmham and Swanton Morley Surgeries has audited its activity and effectiveness in the management of
the care of depression and application of these additional tools.
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Quarterly audit throughout 2006 demonstrated a
reduction in prescribing of either
TCAs or SSRI antidepressants.
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There was a steady increase in
the number of depression packs given out to patients.
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The
percentage of patients who have a HADS score entered for anxiety and depression
is increasing.
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Some research has been undertaken to
understand the patient’s experience and perspective about taking antidepressant
medication, however there is no evidence in the literature which looks at the
patient experience and patient needs when stopping antidepressant medication.
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Between 30% and 60% of patients do not take their
antidepressant medication as prescribed, this means that between 40% and 70% of
patients do take their medication as prescribed.
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Much of the literature is focussed
on improving concordance with medication in order to reduce relapse rates.
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It is important to ensure patients
with depression do not continue taking antidepressant medication for a
length of time which exceeds their recovery from depression.
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All medications have a risk/benefit
profile and are appropriate to treat and maintain an illness until recovery,
however exceeding this may alter the risk/benefit profile adversely.
My MSc Primary Care dissertation was a
small qualitative study which aimed to understand the user perspective and
identify possible changes in order to improve our depression care service in the
practice. In-depth interviews were used to explore the experiences,
expectations and needs of nine patients with mild to moderate depression.
The results from this study indicate that patients with depression expect
a depression service which has the dimensions of quality applicable to any
quality healthcare service i.e. access, structured follow-up, patient-centred
care, shared decision making, information, continuity of care. However, there
was one unexpected finding from this study; I found that some patients have
considerable anxiety about stopping antidepressant medication when they are
‘better’.
My PhD is a study based in a single UK
general practice; it uses a qualitative framework to explore the nature of the
concerns patients experience when they stop their antidepressant medication. A
mixed method approach has been adopted, utilising questionnaires and in-depth
interviews to ask the research question:
"What is the nature of the concerns
patients experience when they stop their antidepressant medication", and, "Are these
concerns dependent upon a personal construction of the meaning of recovery from
a depressive illness?”
The study
sample consists of patients with depression who have been prescribed either a
tricyclic antidepressant or an SSRI antidepressant and whose care is managed
solely in
primary care.
Research Flow Chart
The primary aims of this study are to:
The secondary
aims of this study are to:
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Identify patients’ explanatory models for their illness.
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Understand how and what patients define as recovery from
depression.
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Identify whether concerns about stopping antidepressant
medication really are a problem.
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Explore patient concerns and fears about stopping
antidepressant medication.
The objectives of this research study are
to improve patient care by:
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Informing healthcare professionals so they become aware
of patient fears about stopping antidepressant medication in order to avoid
long-term use of expensive medications in patients who may no longer
need them.
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Providing knowledge of patient fears in order to
facilitate the development of an appropriate counselling strategy(s) for use
by healthcare professionals in primary care.
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Understanding what model of recovery the patient has, if
indeed they actually have a model of recovery, and how this model
contributes to decisions about continuing or discontinuing medication.
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Potentially reducing relapse rates because of the
improved overall management of depression.
MSc Primary Care:
Publications:
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PhD Primary Care:
Publications:
Presentations:
Posters:
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