SIGN 114:SIGN 114:Non-pharmaceutical Management of Non-pharmaceutical Management of

Depression in AdultsDepression in Adults

Michelle AllanMichelle Allan1616thth February 2010 February 2010

Background…Background… 20% Scottish population experience depression @ some 20% Scottish population experience depression @ some

pointpoint

500,000 GP consultations in Scotland 2006/7 (depression & 500,000 GP consultations in Scotland 2006/7 (depression & affective disorders)affective disorders)

>1/2 with depression don’t seek formal Rx>1/2 with depression don’t seek formal Rx

Prescribed antidepressants = most common interventionPrescribed antidepressants = most common intervention– 3.65million items costing £43.7m 2006/73.65million items costing £43.7m 2006/7

8.8% population 8.8% population ≥≥15yrs use antidepressants daily15yrs use antidepressants daily

2/3 attempt self-chosen therapies2/3 attempt self-chosen therapies– e.g. St Johns wort, exercise, counsellinge.g. St Johns wort, exercise, counselling

Multi-factorial illness…Multi-factorial illness… BiologicalBiological

– Sleep disruption, appetite changesSleep disruption, appetite changes PsychologicalPsychological

– Impaired concentration/memoryImpaired concentration/memory– Increased negative thinkingIncreased negative thinking

SocialSocial– Loss of self confidenceLoss of self confidence– Withdrawal from social contactWithdrawal from social contact

Recovery In One Domain May Recovery In One Domain May Be Reflected In Concurrent Be Reflected In Concurrent Improvement In The OthersImprovement In The Others

Thus interventions covering Thus interventions covering biological & psychosocial modes biological & psychosocial modes should be consideredshould be considered

Psychological TherapiesPsychological Therapies Delivered by those trained to approved levels Delivered by those trained to approved levels

of competencyof competency Behavioural activation, Interpersonal therapy Behavioural activation, Interpersonal therapy

& Individual CBT recommended as Rx options & Individual CBT recommended as Rx options [A][A]– Couple focused approach should be considered Couple focused approach should be considered

Problem solving therapy & short term Problem solving therapy & short term psychodynamic therapy may be considered [B]psychodynamic therapy may be considered [B]

Consider mindfulness based cognitive therapy Consider mindfulness based cognitive therapy in group setting to reduce relapse in those in group setting to reduce relapse in those with with ≥3 episodes of depression≥3 episodes of depression

ExerciseExercise Structured exercise is a treatment optionStructured exercise is a treatment option

– Local gym, pool, voluntary walking groupsLocal gym, pool, voluntary walking groups Make patients aware of factors which Make patients aware of factors which

improve & help maintain motivationimprove & help maintain motivation– Set realistic goals: allows individual to monitor Set realistic goals: allows individual to monitor

progressprogress– Exercising with othersExercising with others– Exercise class or buddy system: increase Exercise class or buddy system: increase

enjoymentenjoyment No difference in effectiveness in comparison No difference in effectiveness in comparison

with antidepressant medications & CBTwith antidepressant medications & CBT

Self Help & Lifestyle Self Help & Lifestyle ModificationModification

General advice on healthy lifestyle. General advice on healthy lifestyle. Address:Address:– alcohol & drug usealcohol & drug use– diet & eating behavioursdiet & eating behaviours– maintenance of social networks & maintenance of social networks &

personally meaningful activitiespersonally meaningful activities– sleep problemssleep problems

Self Help & Lifestyle Self Help & Lifestyle ModificationModification

Referral to self-help groupsReferral to self-help groups Guided self-help based on CBT or Guided self-help based on CBT or

behavioural principles is behavioural principles is recommendedrecommended– Computerised CBT recommended within Computerised CBT recommended within

this contextthis contexte.g.e.g. http://bluepages.anu.edu.auhttp://bluepages.anu.edu.au

http://moodgym.anu.edu.auhttp://moodgym.anu.edu.au

St John’s Wort / Hypericum St John’s Wort / Hypericum extractextract

Cumulative evidence suggests Hypericum Cumulative evidence suggests Hypericum extract has a modest effect over placebo in extract has a modest effect over placebo in Rx mild/moderate depressionRx mild/moderate depression– GPs should not advise use of hypericum due to GPs should not advise use of hypericum due to

lack of standardisation of dose & risk of lack of standardisation of dose & risk of interactions with several common meds inc. OCPinteractions with several common meds inc. OCP

– GPs should facilitate full consideration of potential GPs should facilitate full consideration of potential drug interactions in patients using hypericumdrug interactions in patients using hypericum

– OD: confusion, autonomic instability, renal & OD: confusion, autonomic instability, renal & muscle damagemuscle damage

Insufficient evidence for…Insufficient evidence for… InositolInositol Polyunsaturated fatty Polyunsaturated fatty

acidsacids S-adenosyl L-S-adenosyl L-

methioninemethionine ChromiumChromium GinsengGinseng Ginkgo bilobaGinkgo biloba GlutamineGlutamine SeleniumSelenium FolateFolate

AcupunctureAcupuncture Animal assisted therapyAnimal assisted therapy HomeopathyHomeopathy Light therapyLight therapy Massage therapyMassage therapy YogaYoga ReikiReiki T’ai chiT’ai chi AromatherapyAromatherapy ReflexologyReflexology Emotional freedom Emotional freedom

techniquetechnique Thought field therapyThought field therapy

‘‘Checklist’ for providing Checklist’ for providing informationinformation

PresentationPresentation– Common, treatable, screening toolsCommon, treatable, screening tools

ManagementManagement– Information on treatments:+/-, risk of Information on treatments:+/-, risk of

not responding, timescalenot responding, timescale– Waiting timesWaiting times– Other sources of support incl. library for Other sources of support incl. library for

booksbooks– Healthy lifestyle behavioursHealthy lifestyle behaviours

http://go2.wordpress.com/?id=725X1342&site=londonstimestees.wordpress.com&url=http%3A%2F%2Flondonstimestees.files.wordpress.com%2F2007%2F07%2Fa-printfection-great-depression.jpg

InformationInformation Patient/carer info leafletPatient/carer info leaflet

– http://www.sign.ac.uk/pdf/pat114.pdfhttp://www.sign.ac.uk/pdf/pat114.pdf www.livinglifetothefull.comwww.livinglifetothefull.com www.moodjuice.scot.nhs.ukwww.moodjuice.scot.nhs.uk Breathing spaceBreathing space SamaritansSamaritans SAMHSAMH SANElineSANEline