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Managing depression in GMS2
Professor Andre Tylee
Section of Primary Care Mental Health
Institute of Psychiatry
Kings College
London
Be circumspect!!1. Japanese drink little red wine, eat very little fat and suffer fewer
heart attacks than Americans, Australians, British, or Canadians.
2. Mexicans eat a lot of fat and suffer fewer heart attacks than Americans, Australians, British, Canadians.
4. Italians drink lots of red wine and suffer fewer heart attacks than Americans, Australians, British, Canadians.
5. Germans drink lots of beer and eat lots of sausages/fats and suffer fewer heart attacks than Americans, Australians, British, Canadians.
6. Ukrainians drink lots of vodka, eat lots of cabbage rolls and suffer fewer heart attacks than Americans, Australians, British, Canadians.
CONCLUSION
• Eat and drink what you like. Speaking English is apparently what kills you.
QoF changes in GMS2
4 Areas of interest
• Mental health – Psychosis/bipolar/other psychosis register and care plan, follow up.
• Dementia – Register and care plan
• Learning disabilities – register only
• Depression - use of tools and screening
Depression-QoF
• Screening two groups with >30% risk of depression (diabetics and CHD patients)
• Baseline assessment of severity using one of 3 self rating tools
• In the future (GMS3 etc) – likely to be more case management and more interventions for mild depression
Why Depression?
• Mixed anxiety and depression is prevalent in at least 10% of adult attenders (NICE)
• 12% of total global health burden and second only to cardiovascular disease by 2020
• Increasingly seen as chronic and relapsing• 109.7 million lost working days in 2000 and
2615 deaths due to depression in England• Cost in England ?£9b (£370m direct treatment
costs).
Stepped Care Modelhttp://www.nice.org.uk/pdf/CG023NICEguideline.pdf
Depression (ICD)
• Low mood, interest, energy;sleep, appetite/wt, guilt, concentration, self-harm, self
esteem, psychomotor agitation or retardation
• Four groupsMild (4), Moderate (5-6), Severe (7-10)
• At least 2 weeks with loss of function• Other symptoms;
angry/irritable/constipation/increased alcohol, cigarettes,drugs/physical aches and pains etc
• FH/PH, sociocultural problems, relationship problems, diet, risk, pleasurable activities, negative thinking etc). Physical conditions.
Step 1- recognition
• Present in up to a third post MI (Davies et al BMJ 2004)
• Increased mortality if depression/CHD coexist (Barth J et al Psychosomatic Medicine 2004)
• 24% lifetime prevalence in diabetes (Goldney et al Diabetes Care 2004)
• Depression clinically relevant in nearly 1/3 of diabetics (Anderson et al Diabetes Care 2001)
• Depression treatment may improve glycaemic control (Lustman,1997,1998,2000)
Screening• 2 questions: mood and interest in high risk
groups (Whooley et al J of General Int Med 1997))
– During the last month, have you often been bothered by feeling down, depressed/ hopeless?
– During the last month, have you often been bothered by having little interest or pleasure in doing things?
• Yes to either is positive. No to both makes depression highly unlikely.
• A third question about wanting help increases the specificity (Arroll et al BMJ 2005).
Recommended self rating scales
– The Patient Health Questionnaire (PHQ-9)– The Beck Depression Inventory Second edition
(BDI-II)– The Hospital Anxiety and Depression Scale
(HADS)
PHQ-9 (Kroenke et al J Gen Int Med 2001)
• 9 question self report measure • Takes 3 minutes to complete• DSM-IV criteria• “Minimal/mild/moderate/mod severe/severe” • Widely used in US and free of charge from;
http://www.depressionprimarycare.org/clinicians/toolkits/materials/forms/phq9/questionnaire/
PHQ-9• Interest/Mood/Tired/Appetite/Esteem/
Concentration/Agitation or retardation/Suicidal – Not at all/several days/>50% days/nearly every day
• Difficulty with work/home/other people etc – Not difficult/somewhat/very/extremely
• Interest/mood at least 50% of days• Difficulty at least “somewhat”• 5-9 minimal/10-14 mild/15-19 moderate to
severe /20+ severe
HADS (Snaith and Zigmond NFER Nelson 1994)
• Valid in primary care• Self rated (2-5mins)• Anxiety and depression scales of 7 questions each (0-
3). Many prefer as does anxiety too.• >11 probable depression or probable anxiety• Normal/mild/moderate/severe for anxiety and
depression• Free on EMIS Web Mentor. Paper costs 10-60p/copy
BUT NEGOTIATE and order from;
– http://www.nfer-nelson.co.uk
BDI-II (Arnau et al Health Psychol 2001)
• 21 item self report (longer - 5 mins)• DSM IV • Minimal/mild/moderate/severe• BDI 12 = HDRS 10, • BDI 16 = HDRS 13, BDI 20 = HDRS 17
– (Grundy et al 1996)
• Order from;
– http://harcourtassessment.com
Stepped Care Model
Step 2- principles• Choose the least intensive intervention available
and likely to help. Monitor progress to step up (or jump) interventions as needed.
• Entry may be at any level and interventions on lower steps may also help.
• Develop a team approach depending on availability. Agree a small number of codes e.g. mild/mod/severe). There is a national email group currently sharing best practice through PRIMHE.
Mild depression
• Antidepressants– Not recommended for initial treatment– Consider if symptoms persist after other
interventions [C] or if past history of moderate to severe depression [C]
– THREAD Study funded by Dept of Health should help improve evidence base and we do the baseline severity for you.
Mild depression
• Exercise advice– Structured/supervised aerobic exercise; 3 sessions per
week for 45-60 minutes for 10-12 weeks [C] especially in elderly
– Any is better than none
• Offer guided self-help– Recommend CBT-based guided self help [B]
– Provide written material, introduce this and review progress over 6-8 weeks [B]
Step2- Materials
• Give out depression information leaflets
– (www.mentalneurologicalprimarycare.org)
• Useful books (Bibliotherapy)– E.g.Overcoming Depression. Chris Williams.
2002
– Self help booklets
• (www.northumberland-haz.org.uk/salhhelp)
Mild depression
• Offer psychological interventions as available– Good therapeutic alliance important [C]– Problem-solving or brief CBT or brief
counselling (6-8 sessions for 10-12 weeks) [B]– Computerised CBT for mild/moderate
depression [B]• E.g Beating the Blues (www.Ultrasis.com)
OTC medication
• St John’s Wort– Cannot prescribe, is efficacious and fewer side
effects for mild/moderate depression– Varying formulations/strengths– Interacts with drugs (e.g.contraceptive pill)– Risk if taken with antidepressants, or similar
OTC medication like 5HTP, TMG or SaMe
Mild depression
Watchful waitingIf patient doesn’t want an intervention and doctor thinks they will get better then arrange reassessment within 2/52 [C]
Make contact with those who don’t re-attend [C]
Sleep and anxiety management Advice about sleep hygiene and anxiety management
[C]
Stepped Care Model
Step 3 - Psychological treatments
Usually 16-20 sessions (depends on availability)• CBT (or IPT) often with antidepressant
[B]• CBT alone;
– Drug refusers/SE’s [both B]– Drug non responders [C]
• Couples therapy (C)
Anti-depressants for moderate –severe depression
Recommended [A] and SSRI first-line(A)– Address concerns [GPP]
• side effects/discontinuation [C]– Review regularly [GPP] and if no response to
initial SSRI at 6-8 wks – check concordance [GPP], increase dose
[C] or switch class [C]– Continue 6 months+ post remission [A]
Moderate to severe depression
• Chronic depression (12%)– Drug + CBT [A]– Consider befriending (weekly for 2-6/12) [C]– Consider work [C]
• Collaborative enhanced care – Telephone support [B]– USA Multifaceted care programmes [C]
