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Francisco Machado 1998

Modern classification of depression.

Features of Major Depression Syndrome (MDS)

Presence of depressed mood or loss of interest or pleasure

plus 4 or more concomitant symptoms:

• worthlessness
• guilt
• poor concentration
• fatigue, reduced energy
• suicidal thoughts

• reduced or increased appetite
• excessive somnolence or more commonly insomnia
• retardation or agitation

For a minimum of 2 weeks with no other primary disorder.

Other forms of depressive disorder are recognised such as depressive episodes not fulfilling the criteria of MDS, bipolar depression and chronic fluctuating depression.

Epidemiology

• 5% of adults have major depression syndrome at any one time(1)
• can affect all ages from childhood onwards.

• more common in women, in the elderly, during the post natal period, and in areas of social deprivation.
• One third of the population will at sometime have a milder form of depression.
• 10% of all GP attenders have depression, 30% of all elderly GP attenders have depression

How does depression present in General practice.

McWhinney(2) describes some of the cues that should alert us that a patient might be depressed.

Cues suggesting depression

• Tiredness, lack of energy
• persistent ill defined symptoms for which no physical causes can be found e.g. dyspepsia, dizziness, bowel dysfunction, palpitations

• persistent unexplained pain e.g. headache, backache, abdominal pain
• increase in the number of visits to surgery for the patient or the patient's child
• difficulty sleeping
• anxiety symptoms

Once the suspicion of depression has been raised asking a patient a direct question about how they feel is the most sensitive way of making the diagnosis. Other questions about, sleep, concentration, anxiety , low esteem, are also relatively sensitive.

Recognition of depression in general practice.

About 50 % of patients with depression who see their GP are not recognized as being depressed. Factors that may help or hinder the detection of depression may be related to the patient, the doctor or the consultation process.

Patient factors

• Patients who present with physical complaints are less likely to have their depression recognised (3).
• Elderly patients often have coexisting physical problems, may be socially isolated and there is an increased chance of bereavement as their relatives and friends die. Many accept sadness as being a normal state of affairs, taking into consideration what "they have been through" (4) .
• People from different ethnic origins can present in different ways due to differing cultural beliefs.

Doctor factors

• General Practitioners who listen, maintain good eye contact, have an open style to their questions, enquire about feelings and ask direct questions about depression are more likely to recognise depression.
• Doctors differ in their ability to recognise depression and this in turn depends on their knowledge, skills and attitudes (5). Improving knowledge amongst GPs about depression and its treatment was one of the key aims of the "Defeat Depression Campaign".(6)

Consultation factors

• Longer consultations are more likely to identify psychological symptoms.
• Depression is recognised more often in women with major depression syndrome if the symptoms of depression are revealed early in the consultation than at the end (3) .

Improving the detection of depression

A concensus statement from the collaboration between the Royal Colleges of both General Practitioners and Psychiatrists(6) suggested that the following could help improve the detection of depression.

• Education of the public regarding depression as an illness so that patients could recognise symptoms and seek help. It was felt that alot had to be done to reduce the stigma attached to the illness. A study looking at women who had been diagnosed as having post natal depression (PND) found that whilst 90% felt there was something wrong, only 33% felt they had PND and over 80% had not reported their symptoms to a health professional.(7)
• Improvement of interviewing skills of members of the primary health care team. studies have shown that psychiatric skills can be improved in both GP trainees and established trainees by group teaching(8) . Educational packages aimed at improving the detection of psychological symptoms by the Primary Health Care Team (PHCT) have been shown to improve the detection of depression by GPs(9).
• Longer consultation times, continuity of care and the use of multiple brief consultations are all felt to improve recognition of depression.
• Screening questionnaires have been used in secondary care and for research for some time, but their use in GP is limited. The use of brief screening instruments for the detection of depression in the elderly had varying results in two practices(10) . In one it lead to an increased number of patients being identified in another there was no difference. The questionnaires may be seen as being too cumbersome for use in primary care, a Dutch study11 compared 4, 10, 15 & 30 item Geriatric depression Scales in patients over 65 for the detection of depression in general practice. They found that smaller item questionnaires had a lower positive and a higher negative predictive value but that these might be used to screen for patients who needed further detailed assessment. In my own practice we have used the Edinburgh Post Natal Depression Scales at the six week check to identify patients who require further assessment.

• A recent paper in the J Gen Intern Med suggests that by asking two questions:
  
  During the past month, have you been bothered by feeling down, depressed or hopeless?
  During the past month, have you often been able bothered by little interest or pleasure in doing things?
  
  A positive response to either was considered a positive test, which although not diagnostic should indicate that further questionaing is required

Management of depression in General Practice.

Once the diagnosis of depression is made a holistic approach to the patient is required paying attention to:

• the physical well-being of the patient
• the level of social support

• the personality of the patient
• the suicide risk
• the ability of the patient to understand and comply with treatment

It is estimated that only 10% of patients with depression are referred to a psychiatrist the rest are managed by the PHCT. The Defeat Depression Campaign made recommendations for the treatment of depression. These are outlined below

Role of Antidepressants

Antidepressants are most effective in the management of patients with major depressive disorder and those with moderate depression. It is now recognised that there are three phases to treatment,

• the acute phase lasting about 12 weeks,
• continuing phase lasting a further 3 to 6 months.
• In some patients with severe recurrent depression a prophylactic phase should be considered.

Relapses after the acute phase occurs in about 50% of patients if treatment is not continued, this drops to 20% if treatment is continued with adequate dosages of medication.

Choosing an antidepressant often involves choosing between a tricyclic antidepressant or a selective serotonin reuptake inhibitor type drug.

• A recent Drugs and therapeutic Bulletin(12) concluded that all antidepressants appear to be equally effective. The older TCA's are more likely to cause unwanted side effects, which often results in the prescription of a subtherapeutic dose. They are known to be dangerous in overdose. SSRI's also have side effects and are more costly.
• A recent attempt to decide between the two types of antidepressant using EBM and Health Economics in the general practice setting found that both types were efficacious, but their relative effectiveness and value for money could not be defined(13).
• Discussing the options with the patient may help decide which drug to use. If there are marked suicidal thoughts then TCAs are best avoided and an SSRI is prescribed but the patient still needs to monitored carefully.
• Care must be taken in transferring data from trials in secondary care into general practice where patients are often less depressed and the efficacy of drugs in this group is less known.
• Studies showing that GPs tend to prescribe lower doses of antidepressants compared with psychiatrists and poor compliance by patients may further undermine the drug treatment of depression in the GP setting. Poor compliance was demonstrated in one study where more than two thirds of the patients had stopped their medication within four weeks of their prescription(14). The most common reason was the incidence of side effects. It is important discuss possible side effects with the patient before starting treatment and to review the patient soon after they start their medication to reassess the situation and discuss problems the patient may be having with the treatment.

Patients must be reviewed during and after treatment has stopped as 30% of patients who have responded to treatment will relapse.

Non Drug Treatment

Of all the psychological treatments of depression, cognitive therapy has been shown to be effective in the general practice setting(15). There is also some evidence that relapse rates are lower in patients treated with cognitive therapy. However cognitive therapy is time consuming and requires further training. At present there are few patients who would have access to this form of treatment.

Not all PHCT have access to specialised mental health workers. Some studies have looked at whether psychological interventions by other members of the PHCT are effective. A study of women with post natal depression who were counseled by health visitors who had attended a six hour training course on counseling in PND, found higher rates of recovery in mothers who received counseling compared with those who did not.

There has been an increase in the number of counsellors in general practice but there efficacy in the management of depression has been questioned(15).

Often the practice is used as an information resource. Managing depression may require a number of approaches. In some patients providing information regarding local services including

• self help groups, e.g. MIND

• contact numbers for local social services and Citizens Advice Bereau
• Relate and other counselling services

will help the patient overcome their difficulties

When to refer?

Reasons for referral may be patient or doctor centered.

Patient centered reasons include:

• unclear diagnosis
• management problem due to concomitant illness

• high suicidal risk
• inadequate response to treatment
• consideration for prophylactic treatment

Doctor centered factors are often related to having access to resources available to the a psychiatrist which may not be routinely available to GPs, e.g. access to CPNs or day hospital. But on occasions the GP may not feel able to manage a patient on his/her own.

1. Herbst K, Paykel ES, eds. Depression. An integrative approach, Heinemann: Oxford 1989

2. McWhinney IR. A Textbook of Family Medicine, Oxford University Press 1989

3. Tylee A, Freeling P, Kerry S, Burns T. How does the content of consultations affect the recognition by general practitioners of major depression in women?. British Journal of General Practice 1995; 45: 575-578.

4. Tylee A, Katona C. Detecting and managing depression in older people. British Journal of General Practice 1996; 46: 207-208.

5. Tylee A, Priest R, Roberts A. Depression in General Practice, London: Martin Dunitz 1996.

6. Paykel ES, Priest RG. Recognition and management of depression in general practice: concensus statement. Br Med J 1992; 305: 198-202.

7. Whitton A, Warner R, Appleby L. The pathway to care in post-natal depression: women's attitudes to post-natal depression and its treatment. British Jornal of General Practice 1996; 46: 427-428.

8. Gask L, Goldberg D, Lesser AL et al. Improving the psychiatric skills of the general practice trainee: an evaluation of a group training course. Med Educ 1988; 22: 132-138.

9. Hannaford P, Thompson C, Simpson M. Evaluation of an educational programme to improve the recognition of psychological illness by general practitioners. British Jornal of General Practice 1996; 46: 333-337.

10. Iliffe S, Mitchley S, Gould M, Haines A. Evaluation of the use of brief screening instruments for dementia, depression and problem drinking among elderly people in general practice. British Jornal of General Practice 1994; 44: 503-507.

11. van Marwijk HWJ, Wallace P, de Bock G, Hermans J, Kaptein AA, Mulder JD. Evaluation of the feasibility, reliability and diagnostic value of shortened versions of the geriatric depression scale. British Jornal of General Practice 1995; 45: 195-199.

12. Three new antidepressants. DTB 1996; 34: 65-68

13. Kernick DP. Which antidepressant? A commentary from general practice on evidence-based medicine and health economics. British Jornal of General Practice 1997; 47: 95-98

14. Johnson DAW. Depression: treatment compliance in general practice. Acta Psychiatr Scand 1981; 63 (Suppl.): 447-453.

15. Moore RG. Improving the treatment of depression in primary care: problems and prospects. British Jornal of General Practice 1997; 47: 587-590.

Francisco Machado 1998

 

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