Managementul Depresiei in Medicina Primara

7/29/2019 Managementul Depresiei in Medicina Primara

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A Guide to Best Practice

Primary Care Services

or Depression


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DH INFORMATION READER BOX

Policy

HR/ Workforce

Management

PlanningClinical

Estates

Performance

IM & T

FinancePartnership Working

Document Purpose Best Practice Guidance

ROCR Ref: Gateway Ref: 6996

Title Primary Care Servise for Depression -

A Guide to Best Practice

Author Care Services Improvement Partnership (CSIP) / NPCRDC

Publication Date 01 September 2006

Target Audience GPs, PCT Mental Health Commissioners

Circulation List GPs, PCT Mental Health Commissioners

Description Changing the way care for depression is delivered is

complex. The precise issues will vary from place to place

reectinglocalcircumstances.Thechallengeremainsfor

primary care commissioners to engage GPs and their

practices in the development of mental health care. It is

hoped that this guidance document and the incentives in

the Quality and Outcomes Framework are mechanisms to

assist in achieving this goal.

Cross Ref N/A

Superseded Docs N/A

Action Required N/A

Timing N/A

Contact Details Emma Sarno

Care Services Improvement Partnership

North West Development Centre

Hyde Hospital, 2nd Floor, Hyde, Cheshire

SK14 5NY

0161 351 4920

www.csip.org.uk

For Recipients

AUTHORS

Janine Fletcher

Department o Nursing, University o Manchester

Peter Bower

NPCRDC, University o Manchester

Linda Gask

NPCRDC, University o Manchester

David Richards

Department o Health Sciences, University o York

Tim Saunders

NIMHE North West


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CONTENTS

EXECUTIVE SUMMARY Page 4

CHAPTER 1: Introduction Page 5CHAPTER 2: Depression In Primary Care Current Issues And The Latest Evidence Page 6

CHAPTER 3: Assessment O The Presence And Severity O Depression Page 9

CHAPTER 4: Clinical Pathways Page 11

CHAPTER 5: Monitoring And Follow Up Page 16

CHAPTER 6: Patient Preernce And Choice Page 21

CHAPTER 7: Roles For Proessionals Page 22

CHAPTER 8: Interace Issues Page 23

CHAPTER 9: Case Studies Page 24

CHAPTER 10: Audit And Monitoring Page 26

APPENDICES

Appendix 1: Screening For Depression In High Risk Groups Page 26

Appendix 2: Assessing The Severity O Depression (Icd-10 Primary Care Version) Page 27

Appendix 3: Other Scales For The Assessment O Severity And Outcome Page 28

Appendix 4: Asking About Risk Page 28

Appendix 5: Asking About Alcohol Problems The Cage Questionnaire Page 29

Appendix 6: Audit Questionnaire: Screening For Alcohol Misuse Page 30

Appendix 7: Relevant Patient Inormation Resources Page 32

Appendix 8: Treatments At Step 2 Page 32

Appendix 8: Websites With Inormation On The Collaborative Care Page 34

And Case Management Approach

Appendix 10: Phq-9 Monitoring Tool Pfer Page 34

Appendix 11: Recommended Categories For Response And Monitoring With The Phq-9 Page 36

REFERENCES Page 37USEFUL RESOURCES

Books and Reports Page 39

Organisations and Websites Page 41


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EXECUTIVE SUMMARY

Depression is highly prevalent in primary care, and

a major cause o disease burden. The prognosis o

many depressive disorders is poor, and rates o relapse

and recurrence are high.

Given the burden associated with depression, it is

crucial that the care provided in primary care is o the

highest quality. However, management o depression in

primary care is not always optimal.

There are a number o key issues that are increasingly

important to the delivery o primary care services or

managing depression.

Improving access to psychological therapies-

Research has indicated that psychological therapy

is both eective and popular with patients1,1,

but all services have problems with access. Lord

Layard has made a case or increased provision o

psychological therapies (especially CBT) rom an

economic perspective.

Improving access to psychological therapies

minimal interventions and sel help - Minimalinterventions are treatments that require less input

rom a proessional therapist compared to traditional

psychological therapy (also called sel help). These

interventions are usually based on books, computer

programmes or websites, and oten ocus on teaching

CBT techniques.

Stepped care - There are two key eatures o a

stepped care system: (a) the recommended treatment

should be the least intensive o those currentlyavailable, but still likely to provide signicant health

gain (b) the results o treatments are monitored

systematically, and changes are made (so-called

stepping up) i current treatments are not achieving

signicant health gain.

Depression as a chronic disease - Traditionally,

primary care services have been structured around

acute care. However, depression may be better viewed

as a chronic disease, characterised by high levels o

relapse and recurrence. This means that depression

may be best treated through the use o specic chronic

disease management models.

A population perspective on depression -

Population-based care is aimed at restructuring

service delivery to provide a strategy or care or all

patients within a dened population with a recurrent

or chronic illness.

Collaborative care and case management-

Research has indicated that an eective method

o improving depression outcomes is collaborative

care. This involves GPs and mental health specialists

working more closely to supervise the ongoing care o

depressed patients.


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CHAPTER 1: INTRODUCTION

Since the original version o this guidance document

was published in 00, a number o important

developments have taken place in the commissioning

and implementation o mental health services.

The new GP contract has had a signicant impact on

the way primary care services are delivered. The recent

additions to the Quality and Outcomes Framework

ocussing on depression include two new indicators

which encourage primary care to screen or depression

in high risk groups, namely diabetes and coronary

heart disease, and monitor the severity o depression in

patients with a new diagnosis.

Implementation o NICE guidelines and the incentives

in the Quality and Outcomes Framework is likely to lead

to signicant improvements in the management and

treatment o depression in primary care.

However, challenges lie ahead or both primary care

and mental health commissioners in overcoming

problems with current service delivery. These

challenges include improving access to a range

o psychological therapies in primary care and astrengthening o the primary-secondary care interace.

There are also opportunities around the redesign o

existing services such as community mental health

teams and counselling services, and the introduction o

new workers such as the graduate primary care mental

health workers and practitioners with a special interest.

This will require mental health commissioners to

develop improved access to a range o psychological

therapies in primary care, to mental health assessment

(where required), and a strengthening o the primary/

secondary care interace. There are also opportunities

around the redesign o existing services such as

community mental health teams and counselling

services, and the introduction o new workers such as

the graduate primary care mental health workers andpractitioners with a special interest.

There has been a call or a signicant increase in the

number o psychological therapists to deliver evidence

based interventions.1 Whilst this idea is supported

in principle, initial recommendations are likely to

take some time to be achieved. It is possible that a

signicant amount o primary care provision can be

supported by proessionals other than those with

specialist psychological therapy skills.

So ar the implementation o graduate primary care

mental health workers across the country has been

patchy and in some areas the opportunities have not

been realised. In areas where implementation has

been supported by local training programmes and

management structures, services are recognising the

benets o this new workorce. These new workers

are key to the delivery o the stepped care model and

proper career structures or this group o workers are a

matter o urgency.

Changing the way care or depression is delivered is

complex. The precise issues will vary rom place to

place refecting local circumstances. The challenge

remains or primary care commissioners to engage

GPs and their practices in the development o mental

health care. It is hoped that this best practice guidance

document and the incentives in the Quality and

Outcomes Framework are mechanisms to assist in

achieving this goal.


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CHAPTER 2: DEPRESSION IN PRIMARYCARE CURRENT ISSUES AND THELATEST EVIDENCE

Depression is highly prevalent in primary care, and a

major cause o disease burden. The prognosis o many

depressive disorders is poor, and rates o relapse and

recurrence are high.

Given the burden associated with depression, it is crucial

that the care provided in primary care is o the highest

quality. However, management o depression in primary

care is not always optimal, with concerns about a ailure

to recognise depressive disorders, to provide medication

in line with current guidelines, and an inability to provide

access to psychological treatments. These problems

refect pressures on proessional time, training and

resources.-

The original eorts to overcome these problems through

initiatives such as the Deeat Depression campaign7 and

practice-based education8 had some success, but the

impact o these initiatives has been relatively modest.

In part, this refects the complexities associated with

the management o depression, and the many actors

that interact to reduce the quality o care in primary

care. There are no magic bullets, and improving the

quality o care or depression requires changes to

the way care is provided and additional resources to

develop the appropriate systems to enable primary care

proessionals to deliver high quality care.,9-11

Previous research on the management o depression in

primary care has tended to be critical in tone. However,

it is important to note that many GPs and primary care

teams have developed ways o managing depression

that are eective and valued by patients. The models

have been developed over time and are sensitive to

the particular nature o primary care and its role in

patients lives. However, the enthusiasm o primary care

proessionals or mental health work varies signicantly,

which means that good quality care is not always

available to all patients.

The models o care presented here are designed to build

on present good practice in primary care and refect the

current evidence base. The main innovations relate to

the standardised assessment o depression in primary

care, and the systematic organisation o care that

ollows rom that assessment.

Key issues rom the latest research

There are a number o key issues that are increasingly

important to the delivery o primary care services or

managing depression. Some relate to issues about

service structure, while others concern the particular

types o interventions that should be delivered.

Improving access to psychological

therapies the Layard approach

Research has indicated that psychological therapy

is both eective or depression1 and popular with

patients.1 However, almost all services have problems

with access, with long waiting lists resulting rom limited

numbers o trained therapists. This leads to rustration

or patients, primary care proessionals and therapists.

Lord Layard has made a case or increased provision

o psychological therapies (especially CBT) rom an

economic perspective.1 He argues that employment

and mental health may be linked as both cause and

consequence. Mental health problems account or

a signicant number o days lost rom work and a

signicant proportion o patients on incapacity benets.

I the accessibility and eectiveness o psychological

therapy can be translated into increased return to work,

then additional therapists can be employed on the basis

that the overall costs to society can be recouped.


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Improving access to psychological therapies

minimal interventions and sel help

Although increases in the number o therapists will go

some way towards bridging the gap between supply

and demand, it is unlikely to provide a complete

solution because o the high prevalence o depressive

problems in the community.

An alternative approach to getting more benet rom

current resources is to ocus on the delivery o minimal

interventions to a proportion o depressed patients.

The term minimal intervention reers to the act that

these treatments require less input rom a proessional

therapist compared to traditional psychological therapy.

Much o the ocus on minimal interventions concerns

sel help. Sel help interventions are usually based on

books, computer programmes or websites, and oten

ocus on teaching CBT techniques to patients to help

them manage their symptoms. There is encouraging

evidence that such approaches are eective in the

management o depressive disorders.1 Because

these treatments are generally not dependent on the

availability o a specialist psychological therapist, theyprovide one method o overcoming problems with

access.1

Although sel-help is oten based on health

technologies such as books, computer programmes

and websites, the National Institute o Clinical

Excellence (NICE) recommends the adoption o a

guided sel-help model with some limited therapist

contact. The guidance states:

For patients with mild depression, consider a

guided sel-help programme that consists o the

provision o appropriate written materials and limited

support over to 9 weeks, including ollow up, rom

a proessional who typically introduces the sel-help

programme and reviews progress and outcome.

Although NICE has highlighted this model, other

minimal interventions which may be o use are

computerised cognitive behaviour therapy,1

signposting 17 or group psychoeducation.18 All could

provide more ecient delivery o care, meaning more

patients can access eective treatment.

Stepped care

Stepped care links conventional psychological therapy

with minimal interventions in a system designed to

provide the greatest amount o benet rom current

resources. Stepped care is a model o healthcare

delivery with its origins in the US, which has been

applied to a range o disorders, particularly those o a

chronic nature.19-1

There are two key eatures o a stepped care system.

Firstly, the recommended treatment should be the

least intensive o those currently available, but still

likely to provide signicant health gain. In stepped

care, more intensive treatments are reserved or

patients who do not benet rom less intensive rst

line treatments.

Secondly, stepped care is sel-correcting, in that the

results o treatments and decisions about treatment

provision are monitored systematically, and changes

are made (so-called stepping up) i current

treatments are not achieving signicant health gain

or an individual patient.

This is similar to the way many clinicians implicitly

operate, but stepped care standardises systems

and procedures with an explicit aim o improving

eectiveness and eciency.


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Depression as a chronic disease

Traditionally, primary care services have been

structured around acute care. However, studies

o the natural history o depression have indicated

that depression may be better viewed as a chronic

disease, characterised by high levels o relapse and

recurrence. This means that depression may be best

treated through the use o specic chronic disease

management models, similar to the models adopted

in relation to other chronic diseases like asthma and

diabetes.

A population perspective on depression

Taking the chronic disease management perspective

on depression means that primary care organisations

will have to shit their perspective on depression rom

the care o the individual patient, to the care o the

entire population o depressed individuals. Population-

based care is aimed at restructuring service delivery

to provide a strategy or care or all patients within a

dened population with a recurrent or chronic illness.

Collaborative care and case management

Research has indicated that an eective method

o improving depression outcomes is collaborative

care. This involves GPs and mental health specialists

working more closely to supervise the ongoing

care o depressed patients. GPs are responsible or

recognition o the disorder, antidepressant prescription

and overall co-ordination o care, while the mental

health specialist (such as a psychiatrist) provides expert

consultation, support and advice. However, the most

signicant dierence associated with collaborativecare models is the introduction o a case manager.

The case manager takes responsibility or ollowing

up patients proactively, assessing patient adherence

to psychological and pharmacological treatments,

monitoring progress, taking action when treatment is

unsuccessul, and delivering psychological support

Case managers may be thought o as physician

extenders, who work under the supervision o the GP

to improve quality o care or patients with depression.

They do not work alone, but receive support rom a

specialist proessional, and share inormation with the

GP. A variety o proessionals may be able to take up

the case management role, including practice nurses,

mental health nurses, and the new graduate primary

care mental health workers.

Although the vast bulk o case managementinterventions have been tested in the United

States, two recent evaluations in England have also

demonstrated very positive results.

Summary

The previous section raised key issues in current

models o depression care. These themes have

inormed the model o care highlighted in this

commissioning guide, which can be discussed in

terms o three key aspects o care: assessment; clinicalpathways; and monitoring (Figure 1, overlea).


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Initial assessment

Severity o depression, risk and other important

actors are systematically assessed

Treatment decision making is based on the results o

that assessment and patient preerences

All patients are provided with high quality inormation

about depression, its treatment, and local services

Figure 1 Overview o the model

Clinical pathways

The clinical pathway consists o a number o steps.

Patients enter at dierent steps, depending on

severity and previous history

Many patients will enter the pathway at the rst or

second step, and will access higher steps in order, i

there is a lack o progress

Within steps, there are choices or patients about the

type o treatment that suits them best

Monitoring and ollow up

Each patient should have a planned schedule o

contacts to assess progress. The exact schedule

depends on severity and other actors

Scheduled contacts use objective outcome

measures as a marker o progress and an aid to

clinical decision making

Decisions may involve changes o treatments withinsteps, or moving patients up to new steps

CHAPTER 3: ASSESSMENT OF THEPRESENCE AND SEVERITY OF DEPRESSION

Screening

The psychological and social situation o some patients

makes them very vulnerable to depression. In these cases,

primary care proessionals may need to proactively screen

or symptoms o depression. NICE recommends primary

care routinely screens certain high risk groups:

Patients with signicant physical illness

Patients with other mental health problems, such as

dementia

Patients suering major lie events, such as childbirth,

long-term or recent unemployment and bereavement

Patients with a history o relationship diculties and

physical, sexual or emotional abuse

The new Quality and Outcomes Framework has now

incentivised screening in patients on the diabetes or

coronary heart disease register.

DEP1: The percentage o patients on the diabetes registerand /or the coronary heart disease register or whom

case nding or depression has been undertaken on

one occasion during the previous 1 months using two

standard screening questions.

Appendix 1 shows recommended questions or use in

screening or possible cases o depression.

Assessment

Depression is a sensitive and stigmatised subject and

there is no replacement or eective communication skills

to encourage the presentation o depression within the

consultation.


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However, idiosyncratic and unstructured approaches to

the assessment o depression may mean that patients are

oered the wrong treatment. I depression is suspected,

a more comprehensive assessment must be conducted.This may be most appropriately done by the GP, but

could be completed by a variety o appropriately trained

health proessionals. This assessment should involve

standardised measures o:

Severity o depression

Risk

Other relevant psychosocial actors

Ruling out o other causes (i.e. testing thyroid unction)

Severity

The new Quality and Outcomes Framework has now

incentivised the assessment o depression using a

validated assessment tool.

DEP: In those patients with a new diagnosis o

depression, recorded between the preceding 1 April to

1 March, the percentage o patients who have had an

assessment o severity at the outset o treatment using anassessment tool validated or use in primary care.

A number o dierent methods can be used to categorise

the severity o depression. Appendix details an

assessment o the severity o depression according to the

ICD-10 checklist. NICE recommends the categorisation o

patients by mild, moderate or severe levels o depression,

so as to guide clinical decision making. A categorisation tool

such as the ICD-10 can help. Other instruments may be o

use, and some alternatives are provided in Appendix .

Although the Quality and Outcomes Framework provides

incentives or assessment o severity at the outset o

treatment, it is recommended that measures be used to

assess the outcome o treatment and assist in decisions

about urther management. This will be discussed later in

the guide.

Such instruments are acceptable to patients i they are

sensitively introduced with a clear explanation o the

purpose o the task e.g. Would you mind taking a couple

o minutes to complete this orm - itll help us to decide

what is the best orm o help or how you are eeling (or to

show us how you have been progressing). Patients may

also nd the questionnaire useul or explaining to relatives

how they have been eeling.

Risk

Suicidal thoughts are very common in depression.

Patients with depression should always be asked directly

about suicidal thoughts and intent. Possible questions to

ask when assessing risk are included in Appendix .

There is a training package available or primary care and

mental health sta in the assessment and management

o suicide risk: Skills-based Training On Risk Management

(STORM). This package uses the train the trainers ormat

and can be commissioned by Trusts or dissemination to

all stawww.medicine.manchester.ac.uk/storm/

Other relevant actors

The assessment should also include questions relating to:

Previous mental health problems including treatment

and outcome

Family history o mental health problems

Associated disability

Availability o social support

Social problems (amily disputes, nancial,employment)

Alcohol (see Appendix and ) and drug use


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Patient education

The results o any assessment will need to be ed

back to patients sensitively. There is still a signicant

stigma associated with depression, and patients may

be initially unwilling to accept the diagnosis, and may

not want to start or to continue treatment. This means

there is a need or discussion with the patient about

diagnosis and treatment options, with a view to gaining

agreement about the treatment plan.

This will involve:

Feedback to the patient on the outcome o the

assessment

Providing patient inormation leafets about

depression, its treatment, useul management

strategies (such as liestyle changes diet,

exercise, sleep hygiene) and local services (see

Appendix 7 or relevant resources)

Discussing treatment options. The initial ocus

o these discussions will concern whether an

intervention is required or not. Patients who do

not require or do not want an intervention will be

invited back or a review with the GP in weeks.

Patients who do require an intervention will enter

the model at an appropriate step based on their

clinical need. This is explained in more detail in the

next section

CHAPTER 4: CLINICAL PATHWAYS

Key messages

The clinical pathway is represented by a number

o steps. Each step denes a certain type and

intensity o treatment. Patients may enter the

clinical pathway at dierent steps depending on

their initial presentation or previous history, and

may be stepped up at various points during the

course o their illness, depending on progress

Many patients will enter the pathway at the rst

or second step, and may access higher steps in

order, depending on clinical need

Within steps, there are some choices patients

can make about the type o treatment that suits

them best

As noted earlier, primary care organisations need to

develop ways o managing depression that provide the

greatest benet to their population.

Although the Layard initiative has the potential to

increase the number o psychological therapists, this

potential may not be realised or some time. Thereore,

it is likely that the introduction o sel help and other

minimal interventions within a stepped care system will

be a key driver o increases in the abilities o services to

meet demand.

The key idea underpinning stepped care is that patients

receive the least intensive intervention that is still

expected to provide signicant benet to their health.

Figure shows the basic stepped care model, and

shows how it diers rom traditional services.


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1

Figure has the more detailed stepped care model

based broadly on that proposed by NICE. There

are a number o important issues to note. First, the

main ocus or primary care is steps 1-, with step

requiring interace between primary care and specialist

services. Secondly, step 1 is or patients who do not

require or want a specic intervention. The other steps

are or increasing levels o symptoms, distress and

problem complexity. It may be appropriate or patients

to bypass previous steps i their symptoms are severe

enough, or i they had previously tried a step, but did

not benet. However, some patients may start at the

lower steps and access higher ones only i they do not

benet rom their initial treatment.

Although the model involves steps, it could be

argued that the main innovation is the introduction

o step . The greatest benet may be gained rom

stepped care i a signicant proportion o patientsare successully managed at step . Thereore, some

services may wish to use step as a deault or

mild to moderate depression in primary care, with

specic exceptions (e.g. severe depression, suicidal

ideation or other indicators o severe problems). Other

services may restrict step to patients with relatively

mild depression, and direct patients with moderate

disorders to step immediately.

The exact model adopted is likely to depend on the

available resources. Nevertheless, it should be noted

that one key advantage o stepped care is that patients

who do not benet rom less intensive interventions

at step are identied and encouraged to try other

treatments, because they are systematically assessed

ater their treatment.

Stepped care is an innovative method o organising

services, and there are a number o complex issues

where guidance has yet to be provided. For example,

how much o the available resources should be placedat step ? How should decisions be made about which

step patients access initially? What sort o patients

might miss out lower steps?

The Service Delivery and Organisation (SDO) unding

body o the NHS has commissioned research on

these issues which will seek to provide more specic

guidance in the near uture.

Figure 2 The basic stepped care model

Primary Care Primary Care

Minimal

interventions

Specialist

Interventions

Specialist

Interventions

Traditional Models Stepped Care


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Treatments in the stepped care system

The main treatments which are recommended or

dierent categories o depression severity are detailed

briefy below (urther details o these treatments

are provided in Appendix 8). Some o these

recommendations are rom NICE guidance and other

reviews o evidence. It is not expected that all services

will necessarily have all the proposed treatments

available. Rather, this list should serve as a guide to

possible interventions.

Step 1

Watchul waiting. According to NICE, watchulwaiting can be used with (a) patients who do not

wish to have an intervention (b) patients who the

health proessional thinks will recover without an

intervention

Step 2

Guided sel-help. This involves a CBT-based sel-

help resource and limited support rom a health

care proessional

Computerised CBT, based on the recent

recommendations rom NICE

Group psycho-education. This involves a group

treatment, providing inormation about depression,

and strategies or managing it

Exercise on prescription. Being physically active

can assist in the recovery o depression. Exercise

on prescription schemes establish links withlocal leisure centres to allow patients to access

equipment and receive regular advice and

monitoring rom qualied proessionals

Signposting or reerral acilitation. This involves

assessing a patient and assisting them to

nd appropriate local or national voluntaryorganisations

Antidepressants are not generally recommended

or patients with mild depression because the

risk/benet ratio is poor. Medication is more

commonly used with patients at steps and

above. Exceptions may be made when patients

have ailed to benet rom other interventions at

lower steps, or where patients have a previous

history o moderate to severe depression

Step 3

Brie psychological therapy. There are a number o

relevant psychological therapies, including CBT and

counselling. The recommended treatment is -8

sessions over 10-1 weeks

Medication. According to the NICE guidelines, there is

more evidence or the eectiveness o antidepressant

medication in moderate to severe depressionthan in mild depression. In moderate depression,

antidepressant medication should be routinely oered

to all patients beore psychological interventions.

Careul monitoring o symptoms, side eects and

suicide risk (particularly in those aged under 0) should

be routinely undertaken, especially when initiating

antidepressant medication. Patient preerence and

past experience o treatment, and particular patient

characteristics should inorm the choice o drug. It

is also important to monitor patients or relapse anddiscontinuation/withdrawal symptoms when reducing

or stopping medication. Patients should be warned

about the risks o reducing or stopping medication


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Collaborative care and depression case

management. Although the prescription o

medication as recommended by NICE can be

conducted by the GP alone, it is likely that the

eectiveness and acceptability o the approach

will be enhanced through the addition o case

management through a collaborative care

approach. The key acets o such an approach are

as ollows:

Assigning a case manager to a patient, who

is supported by a specialist mental health

proessional, and collaborates with the GP in

the care o the patient

Provision o medication and/or brie

psychosocial interventions

Proactive management o the patient led by the

case manager, including regular ollow up (ace

to ace contact, or by phone), and monitoring o

progress

Feedback o inormation about treatment and

progress rom the case manager to the GP and

mental health specialist to assist in treatment

decision making in patients who ail to improve

Most o the published studies using depression

case management have involved medication,

and it is expected that a signicant proportion

o patients at this step will be on medication.

However, all patients will receive additional

psychosocial support rom the case manager, and

it is possible or the case management approach

to be used with psychosocial interventions alone,

i patients do not wish to use medication. For

example, a patient with a moderate depression

who does not wish to take medication may

receive case management, with psychosocial

support oered in the orm o acilitated sel-help

or signposting to other services, as appropriate

Appendix 9 details a number o websites with

relevant resources or use in the collaborative care

approach

Step 4

Psychological therapy. The treatment o choice is

CBT o longer duration (1-0 sessions over -9

months), although in some cases interpersonal

therapy may be used

Medication, collaborative care and depression

case management are again relevant with this

group o patients


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1

Chronic, atypical

reractory, recurrent

Severe depression

Moderate depression

Mild to moderate

depression

Sub-clinical and

patients who choose

not to have intervention

Step 1

Watchul waiting

Step 2

Guided sel-help, exercise on prescription,

psycho-education, signposting, or computerised CBT

Step 3

Medication, case management and collaborative

care, psychological therapy

Step 4

Medication, case management and

collaborative care, psychological therapy

Step 5

Specialist services

ASSESSMENT

Figure Overview o the stepped care system


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CHAPTER 5: MONITORINGAND FOLLOW UP

Key messages

All patients treated or depression should have a

planned schedule o contacts in order to assess

response to treatment and ongoing progress.

The exact schedule will depend on the severity o

depression and other relevant actors

Scheduled contacts should include the use o

objective outcome measures as a marker o

progress and an aid to clinical decision making

Decisions may involve change o treatment within

steps, or moving patients up to new steps i they

have ailed to progress

Phases in depression treatment

At a broad level, depression can be thought o as

having three phases:

Acute phase the aim o treatment is reducing

symptoms and achieving remission (approximately8-1 weeks i treatment is successul)

Continuation phase the aim is prevention o

the return o symptoms during the current period

(approximately months rom the end o the

acute phase)

Maintenance the aim is prevention o new

episodes o depression (approximately months

rom the end o the continuation phase)

The model recommends regular, proactive contact with

patients throughout these phases. The schedule will

depend on the severity o the problem, and the phase.

Figures - shows some suggested schedules ocontacts or patients at the dierent steps.

Monitoring response in acute

phase treatment

The goal o acute phase treatment is remission o

symptoms. The denition o remission will depend on

the assessment instruments used. A variety o tools

are available. In Appendix 10 there is a copy o a

questionnaire rom the United States called the PHQ-

9 which can be used reely. Appendix 11 includes

denitions o initial response to treatment and remission

which can be used in urther clinical decision making.

The Clinical Outcome in Routine Evaluation outcome

measure (CORE-OM) is oten used in primary care

in the UK, and may be another useul measure o

progress. Whatever instrument is used, it is important

that there are appropriate and agreed systems or

dening response to treatment and remission, similar to

those in Appendix 11.

Monitoring response may be undertaken by the

GP (e.g. during watchul waiting) or another health

proessional (e.g. practice nurse, graduate primary

care mental health worker, primary care mental health

proessional or a counsellor). In some cases, the

proessional providing the treatment may dier rom the

person monitoring progress. In all cases, inormation is

shared with the GP.


17/46

17

Decision making about acute

phase treatment

The result o the assessment o response to acute

phase treatment eeds into decision making about

urther care. As the goal is remission, patients who

improve, but do not remit, and those who do not

improve will need their treatment reviewing. Patients

who improve, but do not remit, may simply need

more time on the same treatment. However, patients

who ail to benet at all may be more likely to need an

alternative treatment within a step, or stepping up (see

Figures -).

Periodic monitoring in the continuationand maintenance phases (Steps 3/4 only)

Patients with moderate and severe depression require

longer term monitoring. Some patients who achieve

remission may relapse, while others may have a

recurrent episode. Following remission and during the

continuation and maintenance phases, patients should

be proactively ollowed-up in order to monitor

their status.

Figures - summarise the structure o care at each o

the initial steps, and detail:

The initial treatment

The proposed schedule o contacts involved in the

initial treatment, plus appropriate proessionals to

deliver this treatment

The suggested point at which patient progress

during the acute phase is reviewed, together with

the appropriate proessional to conduct the review

The possible decisions to be made on the basis

o the progress review, and which proessionals

might be involved in the decision making

The proposed schedule o contacts involved in

the maintenance and continuation phases (where

appropriate)

The suggested point at which longer term

patient progress is reviewed, together with the

appropriate proessional to conduct the review

The exact nature o each step, the proessionals

involved and the treatments provided will depend

on local resources and current service structure.


or Depression


18/46

18

Initial treatment Sessions in

acute phase

Progress review Decision making

ollowing review

Treatment contacts

in maintenance and

continuation phase

Long term review

Watchul

waitingNone

2 weeks

GP

I improved

or remitted

no urther

intervention

I not

improved

step upFigure - Clinical pathway or step 1


acute phase


ollowing review

Treatment contacts

in maintenance and

continuation phase

Long term review

Guided

sel-help

CCBT

Exercise on

prescription

Signposting

2-3

sessions

(GW/PN)

Varies

depending

on program

Reerral to

appropriate

scheme

1-2

sessions(GW/PN)

8 weeks

GW/PN

I improved

more o initial

treatmentor another

treatment within

step, inorm GP

I remitted

inorm GP,

discharge

I not

improved

another

treatment within

step or step up,

inorm GP

Figure - Clinical pathway or step


19/46

19


acute phase


ollowing review

Treatment contacts

in maintenance and

continuation phase

Long term review

Brie therapy

Medication

with case

management

6-8 weekly

sessions

(Therapist)

6 ortnightly

monitoring

sessions

(GW/PN)

12 weeks

GW/PN

I improved

more o initial

treatment or

another treatment

within step, inorm

GP

I remitted

inorm GP,

I not improved

Discuss with GP

or therapist

another treatment

within step, OR

step up, inorm

GP

Figure - Clinical pathway or step Step 4

Every 2

months

or 12

months

GW/PN

6 and 12

months

GW/PN


or Depression


20/46

0


acute phase


ollowing review

Treatment contacts

in maintenance and

continuation phase

Long term review

Figure - Clinical pathway or step

Medication

and case

management

CBT/IPT

12 weekly

sessions

(Gateway,

PwSI, CPN)

16-20

weekly

sessions

(Therapist)

24 weeks

(Experienced

GW, Gateway,PwSI, CPN)

I improved

more o initial

treatment or

another treatment

within step, inorm

GP

I remitted

inorm GP,

I not improved

Discuss with GP

or therapist

another treatment

within step, OR

step up, inorm

GP

Every

month or

12 months

(Gateway,

PwSI, CPN)

6 and 12

months

(Gateway,

PwSI, CPN)


21/46

1

CHAPTER 6: PATIENTPREFERENCE AND CHOICE

One issue that is oten raised about standardised

systems o care is that they take little account o the

preerences, needs and wishes o individual patients.

Primary care has long prided itsel on being ocussed

on exactly these issues.

However, there is room or patient choice within the

proposed model.

Patients may make choices within steps. For example,

when patients enter step , they may choose rom a

number o equivalent interventions, such as guided

sel-help, exercise on prescription, and computerised

CBT, depending on what is available locally. Patients

entering case management can choose whether or not

to have a combination o medication and psychological

interventions, or medication alone.

Patients may also be able to choose between steps,

and choose to bypass lower level steps, i there is a

good reason that they are inappropriate.

However, it is important that patients decisions are

made on the basis o good inormation. Patients who

initiate treatment or depression should be oered

inormation on the services currently available, as

discussed in the section on patient assessment.

Patients treatment preerences should be part o

the initial assessment, and patients should also

be encouraged to discuss their evolving treatment

preerences with the case manager or primary care

proessional during treatment.


or Depression


22/46

CHAPTER 7: ROLES FORPROFESSIONALS

While the clinical pathways described above identiy

proessionals to undertake specic roles, this will

depend on local availability. No proessional should

take on any role or which they have not received

training or which they do not eel competent to

undertake.

The ollowing recommendations maybe useul:

GPs

Initial assessment

Patient education

Initial medication prescription

Practice nurse, graduate primary care

mental health worker

Screening

Patient education

Follow up and monitoring o progress

Guided sel-help

Signposting

Group psycho-education

Assisting with computerised cognitive

behaviour therapy

Case management in moderate depression

Primary care mental health

proessionals, counsellors

Brie CBT

Brie counselling

Gateway workers, practitioner with a special

interest, mental health nurses

Supervision or primary care proessionals

Training or primary care proessionals in the

recognition and management o depression

Strengthening links between primary and

secondary care interace

Case management in severe depression

Mental health specialist (psychiatrist,

psychological therapist, mental health nurse)

Diagnosis where dicult in primary care

Specialist medication advice

Specialist longer term psychological therapy

Consultation, support and supervision or primary

care proessionals and case manager


23/46

CHAPTER 8: INTERFACE ISSUES

As well as improving primary care mental health

services, eective management o depression in

primary care will require improvements at the primary-

secondary care interace. To achieve this, proessionals

working in both primary and secondary care will need

to work together and have agreed mechanisms or

communication.

Protocols between primary and specialist mental health

services can be written which enable patients who

have been successully treated by specialist services

to be urther treated and/or monitored in primary care.

An example might be a patient who makes an almostull recovery ollowing a short inpatient stay and may

only require brie intervention or case management by

a primary care proessional.

The new incentives to screen patients on the diabetes

and coronary heart disease registers means there is

potential or increased case-nding o people with

complex co-morbid problems at moderate severity and

above. Dealing with these sorts o problems requires

close working between primary care and mental

health teams. Research examining interventions to

improve outcomes or both diabetes and depression

have shown mixed results, and have shown it is

generally easier to impact on depression symptoms

than diabetes outcomes. The same is broadly true

or coronary heart disease - treating depression

improves the signs and symptoms o depression in

these patients, but there is less compelling evidence

at present that it improves the morbidity and mortality

associated with coronary heart disease.

As well as eective interace between primary and

secondary care, the employment agenda highlighted

by Lord Layard also suggests the need or more

eective working between health and employmentagencies, or example the services o Job Centre Plus

and condition management programmes run by the

Department o Work and Pensions (DWP).


or Depression


24/46

CHAPTER 9: CASE STUDIES

Case study 1 - Mild depression

Week 0 - Initial/screening appointment (GP)

Mr Clarkson presents to the GP with a recent history

o headaches and stiness in his joints which has

been aecting his sleep or the past weeks. Physical

examination does not indicate any physical cause. The

screening questions are positive, and assessment o

severity indicates that Mr Clarkson is suering rom mild

depression. Treatment options in steps 1 and are

discussed and Mr Clarkson says that he does not eel

he needs anything specic at this time. The GP gives thepatient some materials on depression and suggests Mr

Clarkson make another appointment in weeks time to

review the situation.

Week 2 - Review appointment (GP)

Two weeks later, the assessment indicates no symptoms,

and it is agreed that no urther action is required.

Case study 2 - Mild depression


Mrs Jones is a year-old teacher who presents to

her GP complaining o poor sleep and appetite and

tearulness or the past our or ve weeks. A physical

examination indicates no abnormalities. The GP asks

the patient the two screening questions and ollowing

a positive response asks specic questions about

symptoms, impact and risk and completes the ICD-10.

The patient is asked to complete the screening tool (PHQ-

9). Both scores are indicative o mild depression and this

is discussed with the patient. The patient agrees she

has been eeling a little ed-up and drinking slightly more

alcohol than normal but isnt at risk and has no previous

history. The patient shows some interest in psychological

therapy, and the GP gives the patient an inormation

leafet on available therapies, and suggests the patient

might wish to use some sel help materials in the rst

instance. An appointment is made to see the graduateworker to discuss some guided sel-help in more detail.

Week 2 - Guided sel-help session 1 (graduate primary

care mental health worker)

The graduate primary care mental health worker briefy

discusses the nature o the patients problems and

possible materials that may be o use. They decide on

a depression sel-help book, and the graduate primary

care mental health worker suggests scheduling pleasant

activities more regularly, and shows the patient how themanual can help with this. They make an appointment

or weeks. This inormation is ed back to the GP by

addition in the medical records.

Week 4 - Guided sel-help session (graduate primary


The patient and worker discuss the patients use o

the manual and any diculties that have arisen. Other

activities are also discussed. The patient continues to be

concerned about her alcohol consumption so the worker

gives her contact details or the local voluntary alcohol

support service. This inormation is added to the medical

records.

Week 6 - Guided sel-help session (graduate primary


The patient and worker continue to discuss the patients

use o the manual. The patient did contact the voluntary

alcohol service and has signed up or a support group.

Week 8 Monitoring session (graduate primary caremental health worker)

The worker gets the patient to complete the PHQ-9.

Scoring the questionnaire indicates that the patients


25/46

problems have remitted. The patient is happy to continue

using the manual and attending the voluntary support

group. The results o the assessment are ed back to the

GP and entered onto the medical record. The patient isremoved rom the workers caseload.

Case study 3 - Moderate to

severe depression


Mr Allen attends surgery complaining o not eeling right

since being made redundant months ago. Unable to

establish any specic physical complaints the GP asks

Mr Allen what he is doing with his time and discovers that

the patient is spending most o his time in the house just

watching TV. He has stopped going to his darts matches

as it all seems like too much eort. Completion and

scoring o the ICD-10 and PHQ-9 indicates a moderate

level o depression. The patient also discloses that he

had a similar depression when his wie let him years

ago. He has never posed a risk to himsel or others but

on this occasion has thought his amily would be better

o without him. The GP probes into this urther and

using the recommended risk questions asks i the patient

has made any plans to act on his thoughts. Having

established that Mr Allen has no plans to harm himsel

because he would leave too much debt or his daughter,

the GP discusses the treatment options with the patient.

The GP and the patient agree to try medication. The GP

prescribes an anti-depressant which has minimal risk in

overdose and explains side-eects, the time required or

medication to work and any possibility o increasing the

dose in the uture to therapeutic levels. The GP explains

to the patient that he will be assigned a practice nurse

to manage his case and support and assist him over the

next ew months, who will contact him by telephone in

the next week to discuss the medication. The patient is

given a patient inormation leafet on depression and an

appointment to be seen in the clinic at the practice held

by the local Citizens Advice Bureau regarding his debt

problems.

Week 1 Initial ollow up (Practice nurse)

One week later the practice nurse contacts Mr Allen to

discuss his medication, answer any queries he has, and to

give support. The nurse establishes that he orgot about

his CAB appointment and reschedules him another one

and agrees to remind him by telephone the aternoon

beore the appointment.

Weeks 3, 5, 7, 9 Follow up (Practice nurse)

The practice nurse continues to contact Mr Allen to

discuss his medication, answer any queries he has, and to

give support. Mr Allen did attend his appointment and is

being supported by the CAB worker to deal with his debts.

Week 12 Progress review session (Practice nurse)

The PN sees Mr Allen to conduct a review o his progress

with the PHQ-9. Scoring the questionnaire indicates that

Mr Allen has had a partial response to the medication.

Further discussion indicates some problems with

loneliness Mr Allen is assisted to increase his social

support through activity scheduling/behavioural activation

and using local support groups. Mr Allen is happy with this

and does not wish to change his medication at present.

This inormation is discussed with the GP and added to

the medical records.

Months 2, 4, 8, 10 post acute phase (Practice Nurse)

The PN conducts telephone ollow-up, checks progress is

maintained and discusses medication.

Months 6 and 12 (Practice Nurse)

The patient is invited or an appointment with the Practice

Nurse to review progress and the PHQ9 is completed.


or Depression


26/46

CHAPTER 10: AUDIT AND MONITORING

Patients on a practice list with depression will need

to be identiable through the clinical record keeping

system (oten reerred to as registers). For audit

purposes it would also be benecial to classiy the

depression (i.e. mild, severe, atypical etc).

It is recommended that this identication record

should be separate rom any Severe Mental Illness

(SMI) registers.

It is recommended that audit involves checking the

ollowing are being undertaken:

Primary care has protocols in place or the

screening o high-risk groups and that these

protocols are adhered to

Screening tools are used to aid diagnosis

Standard questionnaires are used to monitor

progress

Patients are oered the appropriate number o

monitoring and review appointments

Medication is prescribed appropriately andmonitored regularly:

Not used or mild depression

Inormation is given to the patient

Prescribed in accordance with NICE guidelines

Maintenance prescribing is monitored regularly

Appropriate psychological therapies are available

and oered to the patient

Patient satisaction is monitored (using a standardpatient satisaction questionnaire)

APPENDICES

Appendix 1: Screening or Depression in

High Risk GroupsDuring the last month, have you oten been bothered

by eeling down, depressed or hopeless?

and

During the last month, have you oten been bothered

by having little interest or pleasure in doing things?

I the patients response to BOTH questions is no, the

screen is negative.

I the patient responds yes to EITHER question, use arecommended screening tool (Appendix and ).


27/46

7

Appendix 2: Assessing the severity o

depression (ICD-10 Primary Care Version)

KEY SYMPTOMS

Have any o the ollowing occurred most o the time or two weeks or more:

A. Persistent sadness or low mood.......................................

B. Loss o interest or pleasure.......................................

C. Fatigue or low energy.....................................

ASSOCIATED SYMPTOMS1. Sleep disturbance.. ....................................

Diculty alling asleep

Early morning wakening

. Appetite disturbance......................................

Appetite loss

Appetite increase

. Poor concentration or indecisiveness.......................................

. Agitation or slowing o movement ....................................

. Decreased libido......................................

. Low sel condence....................................

7. Suicidal thoughts or acts....................................

8. Guilt or sel-blame...................................

I YES to any o the above, continue below

Conclusion:

Positive to A,B or C and:

o the associated symptoms above = MILD- o the associated symptoms = MODERATE

7 or more o the associated symptoms = SEVERE


or Depression


28/46

8

Appendix 3: Other scales or the

assessment o severity and outcome

Patient Health Questionnaire (PHQ-9). Developed

specically or primary care and used widely in the US.

Items relate closely to the criteria or depression in the

DSM-IV. Copyright Pzer Inc. Details are provided in

Appendix 9 and 10. Can be downloaded ree rom:

www.depression-primarycare.org/clinicians/toolkits/

materials/orms/phq9/questionnaire/

General Health Questionnaire (GHQ) (1 items). Easy

to complete and well validated. Available in several

languages. Available rom NFER-Nelson Publishing Co

Ltd Tel: 08 0197).

Hospital Anxiety and Depression Scale (HADS) (1

items). Used requently in primary care, especially

useul with patients who also have physical illness.

Available rom NFER-Nelson Publishing Co Ltd Tel:

08 0197.

Beck Depression Inventory (BDIII) (1 items) Copyright

belongs to the Psychological Corporation and can be

purchased at www.pnotebook.com

Geriatric Depression Scale (GDS) is used or screening

with the elderly. Not subject to copyright. Can be

downloaded rom www.miahonline.org

Edinburgh Postnatal Depression Scale (EPDS) is

commonly used by health visitors to screen or

postnatal depression. Not subject to copyright and can

be downloaded rom www.priory.com/psych.htm

See also Cox, J. and Holden, J. (199) Perinatal

Psychiatry: use and misuse o the Edinburgh Postnatal

Depression Scale. London: Gaskell.

The CORE-OM is a patient completed outcome

measure and part o the CORE System. It is a -item

questionnaire designed to measure clients global

distress, including subjective well-being, commonly

experienced problems, unctioning, and risk. Although

protected by copyright, no charge is made or the

CORE-OM and practitioners who are interested inusing it can photocopy materials i their content is not

changed in any way. Further inormation on training,

support systems and sotware are available at

www.coreims.co.uk/index.php

These questionnaires can be used to assess severity

and monitor progress.

Most scales can be completed by patients whilst in

the waiting area. Patients who have diculty reading

or are non-English speakers may require additionalhelp. Minimal sta input is required or the scoring o

responses.

Appendix 4: Asking About Risk

Intention - thoughts

Do things ever eel that bad that you think about

harming or killing yoursel?

Do you ever eel that lie is not worth living?

Plans

Have you made plans to end you lie?

Do you know how you would kill yoursel?

Actions

Have you made any actual preparations to kill yoursel?

Have you ever attempted suicide in the past?

Prevention

How likely is it that you will act on such thoughts

and plans?

What is stopping you killing or harming yoursel

at the moment?


29/46

9

Risk Factors or Suicide:

Recent marital confict

Currently untreated severe mental illness

Alcohol abuse

Previous suicide attempts

It is also important to ask about risk to others,

especially where patients are not known to the primary

care practice. An example question might be Have you

ever been in trouble with the police?

Categorising risk

Appendix 5: Asking About Alcohol

Problems the CAGE Questionnaire

Have you ever elt you ought to Cut down

on your drinking?

Have peopleAnnoyed you by criticising your drinking?

Have you ever elt bad or Guilty about your drinking?

Have you ever had a drink rst thing in the morning

to steady your nerves or get rid o a hangover (Eye-

opener)?

Two or more Yes responses yield a positive screen

test or alcohol.

Risk Description Action

Low risk No current

thoughts, or

inrequent

thoughts

Continue ollow-up

visits and monitor.

Normalise thoughts

and dierentiate

between thoughts

and actions.

Intermediate

risk

Frequent

currentthoughts but no

plans or intent

Assess risk careully

at each visit. Liasewith specialist

mental health

service. Ensure

patient knows how

to access services.

High risk Current

thoughts with

plans and

preparations

Reer to specialist

mental health

service and engage

in collaborative

approach to

treatment and

monitoring.


or Depression


30/46

0

Appendix 6: AUDIT Questionnaire: Screen

For Alcohol Misuse27

Please circle the answer that is correct or you

1. How oten do you have a drink containing alcohol?

Never

Monthly or less

times a month

times a week

or more times a week

. How many standard drinks containing alcohol do

you have on a typical day when drinking?

1 or

or

or

7 to 9

10 or more

. How oten do you have six or more drinkson one occasion?

Never

Less than monthly

Monthly

Weekly

Daily or almost daily

. During the past year, how oten have you ound

that you were not able to stop drinking once you

had started?

Never

Less than monthly

Monthly

Weekly


. During the past year, how oten have you ailed to

do what was normally expected o you because

o drinking? Never

Less than monthly

Monthly

Weekly


. During the past year, how oten have you needed

a drink in the morning to get yoursel going ater a

heavy drinking session?

Never

Less than monthly

Monthly

Weekly



31/46

1

7. During the past year, how oten have you had a

eeling o guilt or remorse ater drinking?

Never

Less than monthly

Monthly

Weekly


8. During the past year, have you been unable

to remember what happened the night beore

because you had been drinking?

Never

Less than monthly

Monthly

Weekly


9. Have you or someone else been injured as a

result o your drinking?

No

Yes, but not in the past year

Yes, during the past year

10.Has a relative or riend, doctor or other health

worker been concerned about your drinking or

suggested you cut down?

No

Yes, but not in the past year

Yes, during the past year

Scoring the audit

Scores or each question range rom 0 to , with the

rst response or each question (e.g. never) scoring 0,

the second (e.g. less than monthly) scoring 1, the third

(e.g. monthly) scoring , the ourth (e.g. weekly) scoring

, and the last response (e.g. daily or almost daily)

scoring . For questions 9 and 10, which only have

three responses, the scoring is 0, and .

A score o 8 or more is associated with harmul or

hazardous drinking. A score o 1 or more in women,

and 1 or more in men, is likely to indicate

alcohol dependence.


or Depression


32/46

APPENDIX 7: RELEVANT PATIENTINFORMATION RESOURCES

Many GPs have the variety o leafets available at

www.patient.co.ukon their computers or printing or

individual patient use.

Below are some o the other web-sites and

organisations rom where patient inormation leafets

can be accessed or purchased.

MIND produces a variety o leafets, some o which are

available in languages other than English. They can be

printed by individuals or ordered on-line or a cost to

organisations www.mind.org.uk

The Royal College o Psychiatrists produce leafets on

depression, anti-depressants and psychotherapy in a

variety o languages which can be printed rom

www.rcpsych.ac.uk

The British Association o Behavioural and Cognitive

Psychotherapies (BABCP) have leafets on depression,

sel-help which are printable or available to order at a

cost www.babcp.com

Depression Alliance have a number o on-line patient

inormation leafets on depression and available

treatments www.depressionalliance.org/

The Mental Health Foundation have leafets available to

order at cost and can be printed rom the web-site by

individual patients www.mentalhealth.org.uk

The Department o Health has produced a ree leafet

with inormation on dierent psychological therapies

www.doh.gov.ukand search or talking therapies.

APPENDIX 8: TREATMENTS AT STEP 2

Guided sel-help

Sel-help involves providing patients with both

inormation about a condition and skills and techniques

to overcome symptoms and assist with problems. These

skills and techniques are oten based on cognitive-

behaviour therapy (CBT). Guided sel-help is appropriate

or mild depression.

There is some evidence rom the UK that pure sel-

help through written materials improves outcomes or

patients in primary care,1,8 and that guided sel-help

can be conducted by non-mental health specialists suchas practice nurses.9,0

A comprehensive sel-help booklet or depression can

be ordered rom the Oxord Cognitive Therapy Centre at

www.octc.co.uk/html/sel-help.html

Overcoming Depression is written by Chris Williams,

and two o the chapters on Problem Solving and Being

Assertive are available ree o charge at

www.calipso.co.uk

Newcastle, North Tyneside and Northumberland MentalHealth Trust sel-help booklets are available ree to

download at www.nnt.nhs.uk/mh/

Computerised CBT

Computerised packages may be designed to unction

with very little guidance, although monitoring o outcome

is still recommended. There is evidence rom the UK that

computerised CBT (with brie guidance) is clinically and

cost-eective in primary care.1

The National Institute o Clinical Excellence has reviewed

the evidence or computerised packages and provided

guidance. www.nice.org.uk/page.aspx?o=ta097


33/46

Reerral acilitation (signposting)

Reerral acilitation involves assessing a patient and

helping them nd appropriate local or national voluntary

organisations. On occasion, statutory organisations

may be suggested or new support groups established.

Reerral acilitation is based on the availability o local

groups, up to date inormation on their scope, and

agreement rom these groups concerning reerral. It is

recommended that a proessional such as a graduate

worker visits groups in order to gather inormation on a

pro-orma concerning each group, which allows easy

and rapid sharing o inormation about

available resources.

Reerral acilitation is appropriate or mental health

problems o mild to moderate severity, and may be

relevant or patients with depressive symptoms who

are acing particular psychosocial diculties or which

there are relevant groups available.

There is one study in the UK that suggests that reerral

acilitation improves patient outcome.17 There is one

ongoing UK trial that is examining the eects o reerral

acilitation specically by graduate primary care mental

health workers.

Group psycho-education

Group psycho-education or depression is group

treatment which involves providing inormation about

depression, issues that aect mood, how to identiy

and change thoughts, activities and interactions that

aect mood, relaxation training, and goal planning.

Groups o -10 people are ormed on a locality basis

and each group meets or 8, hour sessions.

Because o the educational nature o the intervention,

it can be used in a variety o settings, including

those outside health such as adult education. The

intervention can be used in a preventive capacity (i.e.in patients at risk o developing depression) or with

patients with specic depressive problems.

Group psychoeducation is appropriate or mild

depression. There is evidence rom UK primary care

that group psychoeducation is eective.18

Exercise on Prescription

Exercise on Prescription (EoP) can be used as a non-

drug treatment in the treatment o depression and aims

to help people increase their physical activity.

Being physically active can assist in the recovery

o depression and can also prevent against re-

occurrence. However, seven in ten adults are not

active enough to get the health benets. The EoP

Government schemes aim to tackle health inequalities

by improving access to sport and exercise.

Many o the schemes already in operation have

established links with local leisure centres and patients

can access the equipment and receive regular advice

and monitoring rom qualied registered tness

proessionals. National standards or EoP have

been published by the Department o Health which

encourage the development o new and eective high

quality projects nationwide.

There is some evidence that exercise is eective in

improving depression. Guidance is available at

www.dh.gov.uk/PolicyAndGuidance/HealthAndSocialCareTopics/HealthyLiving/s/en


or Depression


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APPENDIX 9: WEBSITES WITHINFORMATION ON THECOLLABORATIVE CARE AND CASE

MANAGEMENT APPROACH

Helping the Chronically Ill through Quality Improvement

and Research (a national program o the Robert Wood

Johnson Foundation)

www.improvingchroniccare.org

The MacArthur Initiative on Depression in Primary Care

www.depression-primarycare.org

The Health Disparities Collaborative

www.healthdisparities.net

APPENDIX 10: PHQ-9MONITORING TOOL(COPYRIGHT PFIzER)

The Patient Health Questionnaire (PHQ-9) is a brie

9-item patient sel-report questionnaire specically

developed or use in primary care and used extensively

in the United States. The PHQ-9 has acceptable

reliability, validity, sensitivity and specicity as an

assessment tool or the diagnosis o depression in

primary care. The questionnaire can also be used to

monitor progress with possible scores ranging rom

0 to 7 with higher scores indicative o

increasing severity.

www.depression-primarycare.org


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1. Over the last 2 weeks, how oten have you been bothered by any o the ollowing problems?

Read each item careully, and circle your response.

a. Little interest or pleasure in doing things

Not at all Several days More than hal the days Nearly every day

b. Feeling down, depressed, or hopeless


c. Trouble alling asleep, staying asleep, or sleeping too much


d. Feeling tired or having little energyNot at all Several days More than hal the days Nearly every day

e. Poor appetite or overeating


. Feeling bad about yoursel, eeling that you are a ailure, or eeling that you have

let yoursel or your amily down


g. Trouble concentrating on things such as reading the newspaper or watching television


h. Moving or speaking so slowly that other people could have noticed.

Or being so fdgety or restless that you have been moving around a lot more than usual


i. Thinking that you would be better o dead or that you want to hurt yoursel in some way


2. I you checked o any problem on this questionnaire so ar, how difcult have these problems made

it or you to do your work, take care o things at home, or get along with other people?

Not Dicult at All Somewhat Dicult Very Dicult Extremely Dicult

Scoring the PHQ-9 when used to measure severity involves counting one point or each o the 9 items in

question 1 ticked several days, two points or each ticked hal the days and three points or those ticked

nearly every day. Sum the total or a severity score.

Patient Name Date


or Depression


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APPENDIX 11: RECOMMENDED

CATEGORIES FOR RESPONSE AND

MONITORING WITH THE PHQ-9

Defnition o improvement

Improved A reduction o or more points

on the baseline score

Not improved Drop o 1 point or no change or

increase

Defnition o remission

A PHQ-9 score o less than is the eventual goal o

acute phase treatment. When this goal is achieved,

patients enter the continuation phase o treatment.

Changes o treatments within steps and stepping up

are considered or patients who do not meet this goal.

SCORE SEVERITY CLINICAL PATHWAY

0 Severe depression Step or


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7

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9

USEFUL RESOURCES

Books & Reports

Department o Health (1999) National service

ramework or Mental Health: Modern Standards and

service models. London, Department o Health.

Department o Health (1999). Saving Lives: Our

Healthier Nation. London, HMSO.

www.dh.gov.uk/assetRoot/0/0/9/9/0099pd

National service ramework or mental health: modern

standards and service models.

www.dh.gov.uk/assetRoot/0/07/7/09/007709.pd

Executive Summary: Saving lives: Our Healthier Nation

is an action plan to tackle poor health.

Department o Health (000) The NHS Plan ~ A plan

or investment, A plan or reorm. London, Department

o Health.

www.dh.gov.uk/assetRoot/0/0/7/8/0078.pd

Department o Health (001). The Mental Health Policy

Implementation Guide. London, Department o Health.

www.dh.gov.uk/assetRoot/0/0/89/0/00890.pd.

This policy guidance supports the delivery o adult

mental health policy locally.Department

Documents

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