Download Depression - Bradford VTS

Depression
Lawrence Pike
Depression
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Detection
Diagnosis
Treatment
Suicide
Referral
Recurrence
Depression - Detection
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50% missed, especially in patients with
chronic physical disease
Consulting styles makes a difference
Screening tools can help
Depression - Detection
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Consulting styles
– open questions
– more time
– more eye contact
– less interuptions
Depression - Detection
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Screening Tools:
– consider for those at high risk as improve
detection
– Hospital Anxiety and Depression Scale
• more sensitive than GPs (90% vs. 49%)
• less specific than GPs (86% vs. 96%)
– Two question test
• sensitivity 96% but specificity 57%
Depression - Detection
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Two Question Test:
– During the last month, have you often been
bothered by feeling down, depressed or
hopeless?
– During the last month, have you often been
bothered by little interest or pleasure in
doing things?
Depression - Diagnosis
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DSM-IV Criteria for Major Depression:
– Over the last 2 weeks five of the following
features should be present of which one or
more should be:
• 1/ depressed mood
• 2/ loss of interest or pleasure
– continued
Depression - Diagnosis
• 3/ significant weight loss or gain or a change in
appetite
• 4/ insomnia or hypersomnia
• 5/ psychomotor agitation or retardation
• 6/ fatigue or loss of energy
• 7/ feelings or worthlessness or excessive guilt
• 8/ diminshed ability to think or concentrate
• 9/ recurrent thoughts of death (not just fear of
dying) or suicidal ideas
Depression - Treatments
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General
Drug Treatment
Psychological Treatments
Other Treatments
Depression - Treatments
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General
– whichever treatment is agreed and offered,
patients have a better outcome if given
good clear information, especially a leaflet
Depression - Treatment - Drugs
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Antidepressants are all equally
efficacious
They have similar drop-out rates
Costs vary considerably
Trazodone and lofepramine are cost
effective and safe in overdose
Patients anxious addictive and need
information and reassurance
Depression - Treatment - Drugs
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When using tricyclics - use 100mg or
140mg for Lofepramine
Trial of 6 weeks
If fails use a different class of drug
Duration - 4-6 months after normal
St John’s Wort as effective as TCA
Stopping treatment- discontinuation
syndrome possible
Depression - Psychological
Treatments
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Problem solving - can be performed by
GP with some training but takes time
Cognitive Therapy
– of value in those who respond to concept,
prefer psychological treatment or have not
responded to drugs. “Beating the Blues”
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Counselling - not shown to be more
effective than GP although patients may
prefer
Depression - Other Treatments
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Written information
– can improve mild to moderate
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Exercise
Depression - Suicide
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Ask about known risk factors
– most important is how depressed the
patient is and whether they have made any
suicidal plans (as opposed to passive
thoughts)
Depression - Suicide Risk
Factors
Active Suicidal ideation
Recent self-harm
Definite plan
Hopelessness
Severe depressive symptoms
Psychotic symptoms (delusions,
hallucinations)
14
5
5
3
3
Depression - Suicide Risk
Factors
Background risk factors
!st degree family history of suicide
Bereavement
Male
Living alone
Physical Illness
Recent psychiatric hospital
discharge
4
3
?
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Depression - Referral
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Serious suicidal intention
Failure of treatment
– 2 courses of anti-depressant at full doses
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Difficulty with diagnosis
For specific treatments (CBT)
Severe psychomotor retardation
Depression - Referral
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Referral letters should contain:
– Considered diagnosis
– Why referral is being made
– Degree of urgency
– Treatment tried - including doses, duration
etc
Depression - Recurrence
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Recurrence Rate
– 50% after one episode, 70% after two,
90% after three.
– 15% in first year after 6 months treatment,
40% after less than 4 months treatment
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Relapses reduced by long term
antidepressants
Depression - Recurrence
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Cognitive behaviour therapy
– some evidence reduces relapses but no
satisfactory long term trials
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Discussion with patient
– Balance between long term medication and
risks of recurrence will need careful
consideration
Depression
www.psychiatry.ox.ac.uk/