Download depression - Swindon General Practice Education

DEPRESSION
NICE
OCTOBER 2009
Severities of depression
1.Subthreshold depressive symptoms<5 symptoms
2.Mild depressionfew symptoms in excess of the 5,and
minor functional impairment
3. Moderate depression
symptoms or functional impairment
between ‘mild’ and ‘severe’
4.Severe depression
most symptoms and markedly
interfere with functioning.
+/- psychotic symptoms
STEPPED-CARE MODEL
STEP 1
• RECOGNITION
-feeling down, depressed or hopeless?
-having little interest or pleasure?
STEP 1
• Assessment and initial management
-h/o depression
-h/o mood elevation
-response to previous treatments
-social situation
-suicidal ideation and intent
• Risk assessment and monitoring
-immediate risk
refer urgently
-at risk
provide increased support-freq contact
ref to mental health services
• Advise person and family/carer
-potential for increased
agitation/anxiety/suicidal ideation early in
treatment
-vigilant for mood
changes,negativity,hopelessness
STEP 2
• GENERAL MEASURES
-sleep hygiene
-Active monitoring
mild depression who do not want an
intervention
subthreshold symptoms who request an
intervention
who may recover with no formal
intervention
Active monitoring
discuss concerns/presenting problem
further assessment -2/52
provide information
make contact if DNA
STEP 2
• Drug treatment
not routinely used,but consider if
-past h/o moderate/severe depression OR
-initial presentation of subthreshold
symptoms for at least 2 yrs OR
-subthreshold or mild depression persisting
after other interventions
• Depression with chronic physical health
problem
-as before
-mild depression that complicates the care
of the physical health problem
• Do no prescribe or advise use of St John’s
wort
STEP 2
• Psychosocial and psychological
interventions
STEP 3
• Choosing treatments
-duration of the episode
-previouse illness course and response to
treatment
-Person’s preference
-likelihood of adherence and potential SE
• Persistent subthreshold/mild-moderate
1.Antidepressants
OR
2.High intensity psychological intervention
-CBT
-IPT
-Behavioural activation
-Behavioural couples therapy
• Moderate to severe depression
combine antidepressants with high intensity
psychological treatment [CBT or IPT]
STEP 3
• Choosing an antidepressant
-anticipated adverse events
-potential interactions
Efficacy and tolerability of any previous
antidepressants
-normally choose an SSRI in generic form
-toxicity in OD for people at significant risk of
suicide
• Starting antidepressant treatment
-explore any concerns
-gradual effect
-take as prescribed
-need to continue beyond remission
-SEs and drug interactions
-risk and nature of discontinuation symptoms
-addiction does not occur
-see them after 2/52
-ever 2-4 weeks in the first 3/12,and then
longer intervals if response is good
-if risk of suicide or <30yrs see them after
1/52 and then frequently until risk is no
longer clinically important
• If person experiences SEs early in treatment
consider,
-monitoring closely if SEs are mild and acceptable
OR
-stopping/changing if person prefers
OR
-short term concomitant treatment with
benzodiazepine if anxiety/agitation/insomnia are
problomatic
• If no improvement after 2-4 weeks-check
that the drug is taken as prescribed
• If response absent or minimal after 3-4
weeks with therapeutic dose
-increase dose
-switch
• Combining psychological and drug
treatment
-if not responded to either consider
combining antidepressants with CBT
• Referral
-if depression has not responded to various
augmentation and combination treatments
consider referral
• Stopping or reducing antidepressants
-discontinuation symptoms
usually self limiting over about 1/52
see GP if significant
monitor and reassure if mild
consider reintroducing original at the dose that
was effective if symptoms severe
-gradually reduce the dose over 4 weeks
STEP 4
• Consider reintroducing treatments that have
been inadequately delivered
• Assess a person referred to specialist mental
health services
• Develop a multi disciplinary care plan with the
person
-identifies roles of all professionals involved
-crisis plan
-shared with person/GP/other relevant people