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Public Health Wales
Antidepressant therapy in primary care
Antidepressant therapy in primary care
Quality improvement toolkit
Author:
Primary Care Quality and Information Service
Date: January 2013
Version: 1
Status: Final
Intended audience: Public (Internet) / NHS Wales (Intranet) / PHW
(Intranet)
Purpose and summary of document:
This document is for use by general practitioners treating and advising
patients with Depression. The purpose of this toolkit is to support
practices to review and reflect on the service they provide and the
information they record following patient consultations for Depression.
This audit may be of particular interest to clinicians who have seen the
recent WeMeReC Bulletin (Antidepressant therapy in primary care)
and the accompanying education module, and reinforces its main points
and supplements learning opportunities provided by the case studies.
This toolkit provides patient review criteria and guidance on how to
complete a straightforward audit. Also included is a review section
designed to prompt reflection and comment on the results of the audit
process. Completion of this audit would constitute a suitable piece of
Continuing Professional Development that could be included within the
appraisal process.
Publication / distribution:
 Publication in PHW document database (Primary Care Quality and
Information Service)
 Link from PHW e-bulletin
Author
Primary care quality and information
service
Version; 1
Date
Jan 2013
Status; Final
1
Intended audience: Public (Internet) /
PHW (Intranet / Internet) / PCQIS
Public Health Wales
Antidepressant therapy in primary care
Contents
Page Number
Background
4
Management Summary
4
Aim of Audit
7
Audit Objectives
7
Patients to be Included
7
Methodology
7
Audit Criteria
8
Case Review - Data Collection Sheet
9
Case Review – Data Collection Summary
10
References
11
Author
Primary care quality and information
service
Version; 1
Date
Jan 2013
Status; Final
2
Intended audience: Public (Internet) /
PHW (Intranet / Internet) / PCQIS
Public Health Wales
Antidepressant therapy in primary care
Background – NICE describe Depression as a broad and heterogeneous condition,
characterised by low mood and/or loss of pleasure in most activities. Severity is defined
by the number and severity of symptoms and degree of functional impairment 1
Management Summary
Antidepressant drugs – The 2009 NICE Guideline (NICE CG90) recommends that
antidepressants should not be used routinely to treat sub-threshold depressive
symptoms or mild depression (because the risk–benefit ratio is poor), but consider
them for patients with:
 a past history of moderate or severe depression or
 mild depression which complicates the care of the physical health problem or
 First presentation of sub-threshold depressive symptoms that have been present
for a long period (typically at least 2 years) or
 Sub-threshold depressive symptoms / mild depression that resist other interventions.
When prescribing for a patient with depression and chronic physical illness consider:
 the presence of additional physical health disorders
 the side effects, which may impact on the underlying physical disease (in particular,
SSRIs may result in / exacerbate hyponatraemia, especially in older people)
 The lack of evidence to support the use of specific antidepressants for patients
with particular chronic physical health problems
 interactions with other medications 1
Key Points
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Antidepressants should not be prescribed routinely for mild depression 1
A generic SSRI is usually first-line 2
SSRIs are safer than TCAs in overdose 1
Hyponatraemia should be considered in patients developing drowsiness,
confusion, or convulsions while taking an antidepressant 2 (see appendix A).
NSAID’s should not normally be offered to patients taking SSRI’s 4 (see appendix D).
Response at 4 to 6 weeks is a good predictor of overall response 5
When switching antidepressants, cross-tapering is preferred to abrupt cessation 5
Concomitant use of some antidepressants is contraindicated; a drug-free interval
would prevent interactions 5
The incidence of discontinuation reactions appears to increase with higher doses,
longer duration of therapy, and shorter half-life 2
In pregnancy caution should be exercised with all medication, but the SSRI’s
Sertraline and Citalopram are not known to be harmful 6 (although Citalopram should
be avoided in breast feeding) 3 Paroxetine and sertraline can be safely given to a
woman who is breastfeeding, provided the infant is healthy and his or her progress is
monitored; SSRI’s are better tolerated than TCAs and more likely to be prescribed at
recommended doses for an adequate period of time 1
If for a good clinical reason a tri-cyclic antidepressant (TCA) is used, imipramine and
nortriptyline are preferred for the treatment of depression in breastfeeding women 2
Author
Primary care quality and information
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Version; 1
Date
Jan 2013
Status; Final
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Intended audience: Public (Internet) /
PHW (Intranet / Internet) / PCQIS
Public Health Wales
Antidepressant therapy in primary care
Definitions of depression severity DSM-IV (see www.nice.org.uk/CG90niceguideline).
 Sub-threshold depressive symptoms (appendix A): Fewer than 5 symptoms (as below).
 Mild depression: Few or no symptoms in excess of the 5 required to base a diagnosis,
and symptoms result in only minor functional impairment.
 Moderate depression: Symptoms / functional impairment between ‘mild’ and ‘severe’.
 Severe depression: Most symptoms. Markedly interfere with functioning. Can occur with
or without psychotic symptoms 1
DSM-IV major/minor depressive disorder:
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Depressed mood by self-report or observation by others
Loss of interest or pleasure in activities
Fatigue/loss of energy
Worthlessness/excessive or inappropriate guilt
Recurrent thoughts of death, suicidal thoughts, or actual suicide attempts
Diminished ability to think/concentrate or indecisiveness
Psychomotor agitation or retardation
Insomnia / hypersomnia
Significant appetite and / or weight loss
ASSESSMENT - Stepped care treatment of depression 2 Assessment of depression is based
on the DSM-IV criteria and should include the number and severity of symptoms, duration of
current episode, and illness trajectory (See appendix B) 1
Step / focus of care
Responsible for care
Interventions
1
All known and
suspected presentations
of depression
GP, practice nurse
Assessment, support, psychoeducation, active monitoring and
referral for further assessment
and interventions
2
Mild to moderate
depression; persistent
sub-threshold depressive
symptoms
Primary care team,
primary care mental
health worker
Low-intensity psychosocial
interventions, psychological
interventions, medication and
referral for further assessment
and interventions
3
Moderate / severe
depression; mild to
moderate depression
With poor response to
initial interventions;
persistent sub-threshold
depressive symptoms
Primary care team,
primary care mental
health worker
Medication, high-intensity
psychological interventions,
combined treatments, and
referral for further assessment
and interventions
Severe and complex
depression
Mental health
specialists including
crisis teams
Risk to life; severe
self-neglect
Inpatient care,
crisis teams
4
Medication, high-intensity
psychological interventions,
electroconvulsive therapy, crisis
service, combined treatments,
multi-professional / in-patient care.
Adapted version; Original idea from NICE guideline and World Federation of Societies of Biological
Psychiatry (WFSBP) guidelines
Author
Primary care quality and information
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Version; 1
Date
Jan 2013
Status; Final
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Intended audience: Public (Internet) /
PHW (Intranet / Internet) / PCQIS
Public Health Wales
Antidepressant therapy in primary care
TREATMENT may be psychological (e.g. active monitoring; cognitive behavioural
therapy) or pharmacological (e.g. antidepressants). For more information refer to
WeMeReC Bulletin, Managing Depression in Primary Care, September 2010
Antidepressants may be considered for people with;
 History of moderate or severe depression
 Sub-threshold depressive symptoms (present for at least two years)
 Mild depression resistant to other interventions
 Mild depression complicating the care of a chronic physical health problem
People suffering depression typically prefer psychological and psychosocial
treatments to medication 1 (See appendix C)
These include;
 Cognitive behavioural therapy (CBT)
 Behavioural activation
 Inter-personal therapy (IPT)
MONITORING (WeMeReC)
 Patients to be reviewed within 2 weeks of starting treatment and regularly
thereafter, typically at 2 to 4 week intervals

Patients <30 years; or at increased risk of suicide to be seen more frequently.
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Treatment to continue for at least 4 weeks at a therapeutic dose (6 weeks in
elderly patients) to determine efficacy; if effective, to be continued as below.
Continuation and maintenance therapy
Patients benefiting from treatment should continue for at least 6 months after remission
of symptoms as evidence indicates that this will greatly reduce the risk of relapse.
If the risk of relapse is significant or if the consequences of relapse are likely to be
severe, treatment should be continued for at least 2 years, at an effective
maintenance dose.
Psychological interventions, such as individual CBT or mindfulness-based cognitive
therapy, can also be beneficial in some people to prevent relapse.
Stopping antidepressants
To avoid or reduce discontinuation symptoms the dose of antidepressant should be
reduced gradually, usually over a period of at least 4 weeks (unnecessary with fluoxetine
– unless previously at higher doses)
Reduce the dose over longer periods for drugs with a shorter half-life (e.g. paroxetine
and venlafaxine). Advise the patient to see their practitioner if they experience
significant discontinuation symptoms.
People with depression who benefit from treatment with antidepressants are advised to
continue with treatment for at least 6 months after remission, extending to at least 2
years for people at higher risk of harm if they relapse. (NICE Quality Standards 2011)
Author
Primary care quality and information
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Version; 1
Date
Jan 2013
Status; Final
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Intended audience: Public (Internet) /
PHW (Intranet / Internet) / PCQIS
Public Health Wales
Antidepressant therapy in primary care
Aim of Case Review
 To improve the care of patients who take anti-depressant medication for
depression.
Review Objectives
 To establish that the severity of depression is recorded in all reviewed cases
 To confirm that the treatment provided is, in all cases reviewed consistent with the
available guidance and is appropriate to the severity of the patient’s condition
Patients to be included in the Case Review;
Patients who take Anti-depressant medication for Depression (READ Code E2B1.) in
the last 6 months, or in the last 12 months, whichever the practice decides.
Patients to be excluded
Those patients not managed entirely by the practice throughout the review period
Methodology
 Identify a suitable review period (patients reviewed in the 12 months from ...)
 Use retrospective data gathered prior to the audit start date
 Compile a list of patients from the practice records of those taking anti-depressant
Medication; exclude;
1) Those taking antidepressants for conditions other than depression, such as neuralgia
2) Those patients not managed entirely within the practice
 Select a suitable number (suggest 10) of patients, manually review the case notes
and record the findings against the stated criteria using the collection sheet
provided (See appendix F)
 Collate, using the data summary sheet (page 9) and analyse results of the data
collection
 Reflect on the results of the audit and agree those recommendations that you
consider appropriate, which may include recalling patients who do not meet the
criteria (See appendix G)
 Decide on a date to re-audit. PCQIS suggests that the audit is repeated 6-12
months from the date that the current audit is completed
IMPORTANT
The results and subsequent recommendations should be viewed as a development
opportunity, and it is for the practice to decide how best to utilise the findings.
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Intended audience: Public (Internet) /
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Antidepressant therapy in primary care
Criteria - By reviewing selected medical records, reflect on the patient’s history with
regard to their depression treatment, and answer the following;
1. Assessment
1a. Is there a record of an assessment of mood at, or just prior to the date of diagnosis?
1b. If yes, was a rating scale used to assess mood?
1c. If yes to 1a, was an appropriate READ Code ascribed at that time (see Appendix)?
1d. Were alternative or adjunctive treatments (e.g. psychological or talking therapies)
considered at diagnosis?
1e
if yes to 1d would the patient have been able to access such services within a
reasonable period of time?
1f.
If yes to 1b did using a rating scale help to reach a diagnosis or manage the patient?
2. Initial Review
2a. Was the drug, chosen on initiation the most appropriate at the time?
2b. Was the patient invited for review within 1 month of initiation?
2c. If yes to 2b, did the patient attend?
2d. If yes to 2c, is there a recorded review of tolerability / therapeutic effect of the
medication?
3. Ongoing review
3a. Was the patient invited for a further review within 2 months of initiation?
3b. If yes to 3a, did the patient attend?
3c. If yes to 3b; is it recorded that the patient’s depression symptoms were reviewed at
this time?
3d. If yes to 3c, Was any rating scale used in the assessment of progress?
3e. If, at review, the patients symptoms had not improved; was the medication dose
increased or the agent changed?
3f.
If no to 3e is it clear from the record why not?
3g. If the patient is on an Anti-Depressant, or another therapy for depression, for more than
6 months, is there a record of having received planned follow-up at least every 6 months?
4. Ongoing Medication
4a. Is the patient’s current medication the most appropriate?
4b. Was the patient ever prescribed more than one anti-depressant drug simultaneously?
4c. If yes, is it clear from the record why a further anti-depressant drug was prescribed?
5. Discontinuation of Medication
5a. Have any of the patients medications been discontinued within the last 6 weeks?
5b. If yes did this decision correlate with established guidance regarding the duration of
treatment and discontinuation (pp6)?
5c. If no to 5b, was there a documented reason for the alternate management?
Author
Primary care quality and information
service
Version; 1
Date
Jan 2013
Status; Final
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Intended audience: Public (Internet) /
PHW (Intranet / Internet) / PCQIS
Public Health Wales
Antidepressant therapy in primary care
Case Review – Data Collection Table
Please indicate Yes / No as appropriate
Patient
Criteria
1a
1b
1c
1d
1e
1f
2a
2b
2c
2d
3a
3b
3c
3d
3e
3f
3g
4a
1
2
3
4
5
6
7
8
9
10
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Intended audience: Public (Internet) /
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4b
4c
5a
5b
5c
Public Health Wales
Case Review – Data Collection Summary.
Antidepressant therapy in primary care
Start date of the review _________
End date of the review ________
Criteria
Description – Review 1, Assessment
1
Patients taking Anti-Depressant Medication for Depression during the chosen time period; Number in Sample
1a
Of Is there a record of an assessment of mood at, or just prior to the date of diagnosis?
1b
If yes, was a rating scale used to assess mood?
1c
If yes to 1a, was an appropriate READ Code ascribed at that time (see Appendix)?
1d
Were alternative or adjunctive treatments (e.g. psychological or talking therapies) considered at diagnosis?
1e
if yes to 1d would the patient have been able to access such services within a reasonable period of time?
1f
If yes to 1b did using a rating scale help to reach a diagnosis or manage the patient?
Number
%
Number
%
Comments from Review 1;
Description – Review 2, Initial Review
Criteria
2a
Was the drug, chosen on initiation the most appropriate at the time?
2b
Was the patient invited for review within 1 month of initiation?
2c
If yes to 2b, did the patient attend?
2d
If yes to 2c, is there a recorded review of tolerability / therapeutic effect of the medication?
Comments from Review 2;
Author
Primary care quality and information
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Version; 1
Date
Jan 2013
Status; Final
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Intended audience: Public (Internet) /
PHW (Intranet / Internet) / PCQIS
Public Health Wales
Criteria
Antidepressant therapy in primary care
Description – Review 3, Ongoing Review
Number
3a
Was the patient invited for a further review within 2 months of initiation?
3b
If yes to 3a, did the patient attend?
3c
If yes to 3b; is it recorded that the patient’s depression symptoms were reviewed at this time?
3d
If yes to 3c, Was any rating scale used in the assessment of progress?
3e
If, at review, the patient’s symptoms had not improved; was the medication dose increased or the agent
changed?
3f
If no to 3e is it clear from the record why not?
3g
If the patient is on an Anti-Depressant, or another therapy for depression, for more than
record of having received planned follow-up at least every 6 months
6 months, is there a
Comments from Review 3;
Author
Primary care quality and information
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Version; 1
Date
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Status; Final
10
Intended audience: Public (Internet) /
PHW (Intranet / Internet) / PCQIS
%
Public Health Wales
Antidepressant therapy in primary care
Description – Review 4, Ongoing Medication
Criteria
4a
Is the patient’s current medication the most appropriate?
4b
Was the patient ever prescribed more than one anti-depressant drug simultaneously?
4c
If yes, is it clear from the record why a further anti-depressant drug was prescribed?
Number
%
Number
%
Comments from Review 4;
Description – Review 5, Discontinuation of Medication
Criteria
5a
Have any of the patients medications been discontinued within the last 6 weeks?
5b
If yes did this decision correlate with established guidance regarding the duration of treatment and
discontinuation (pp6)?
5c
If no to 5b, was there a documented reason for the alternate management?
Comments from Review 5;
Author
Primary care quality and information
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Version; 1
Date
Jan 2013
Status; Final
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Intended audience: Public (Internet) /
PHW (Intranet / Internet) / PCQIS
Public Health Wales
Antidepressant therapy in primary care
References
1
National Institute for Health and Clinical Excellence (NICE) Clinical Guideline (CG) 90;
Depression; The treatment and management of depression in adults (Oct 2009).
2
Welsh Medicines Resource Centre (WeMeReC); Antidepressant therapy in primary care
(December 2010)
3
Clinical Knowledge Summaries (2011); Depression, antenatal and post natal
management; which antidepressant should I prescribe for a woman who is
breastfeeding?
4
National Institute for Health and Clinical Excellence. Depression in adults with a
chronic physical health problem: treatment and management. NICE Clinical
Guideline 91, October 2009
5
Taylor D et al. The Maudsley Prescribing Guidelines;10th Edition. London:
Information Healthcare, 2009
6
BNF, 2012; http://www.medicinescomplete.com/mc/bnf/current/PHP2413selective-serotonin-re-uptake-inhibitors.htm
Author
Primary care quality and information
service
Version; 1
Date
Jan 2013
Status; Final
12
Intended audience: Public (Internet) /
PHW (Intranet / Internet) / PCQIS