What's New- June 2017?

This is a refresh and reformatting of the 2013 Depression pathway which utilised the National Map of Medicine pathway template. There are no major changes in practice/services; which include GP self-management, Primary Care level interventions, Improving Access to Psychological Therapy(IAPT)/Let's Talk and Specialist Mental Health services accessed via the 2gether Contact Centre. The 2gether Contact Centre can also now be used to access clinical advice at any stage by the patients GP.

N.B. NICE Guidance is due to be updated November 2017. This pathway will therefore be reviewed following this.

Depression Care Pathway Overview

Depression is characterised by:

  • depressed mood and/or loss of pleasure in most activities
  • a range of emotional, cognitive, physical, and behavioural symptoms

Depression is defined by the:

  • American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorder (DSM-5)


  • the tenth revision of the International Classification of Diseases (ICD-10)

Depression can range in severity from a mild disturbance to a severe illness with a risk of suicide

Severity is determined by:

  • number and severity of symptoms
  • degree of functional impairment

  • in the UK, depression is the third most common reason for consultation in general practice
  • mixed anxiety and depression is the most common mental disorder in a community setting
  • depression is the fourth leading cause of disability and disease worldwide
  • there is a higher incidence of depression in women than men
  • on average, the first episode of major depression occurs in the mid-20s

  • the average length of a depressive episode is 6-8 months
  • following their first episode of major depression, at least 50% of people will have at least one more episode
  • 50% of people diagnosed with depression still have a diagnosis of depression 1 year later
  • at least 10% of people have persistent or chronic depression
  • after a second episode, the risk of recurrence increases to 70%; after a third episode, the risk increases to 90%

Please click the relevant flowchart box to be taken directly to textual information:




Red Flags
Severe depression or urgent concern (if the person with depression):
  • is considered to be an immediate risk to themselves or others
  • is actively suicidal, has a current suicide plan, is at risk of self-harm
  • has psychotic symptoms, e.g. hallucinations, delusions
  • has severe agitation accompanying severe symptoms
  • presents with severe self-neglect
  • has deteriorating personal circumstances exacerbating their mental illness
If any urgent concern consider GP led pharmacological intervention, discussion and referral.  Referrer Information for Mental Health Services - Gloucestershire including the Contact Centre, Crisis Resolution and Home Treatment Teams can be found here.
2gether- A Guide to Suicide Risk Assessment and Management in Primary Care can be found here.


Practice Point

Please see the "Urgent Care: general" section on G-care for SWAST's guidance on Requesting Ambulance Transport (999 or Urgent).


  • co-morbid psychiatric diagnosis
  • a previous history of depression, mania or bipolar disorder, other mental health problems and/or suicide attempt
  • socio-economic factors, including:
    • poverty
    • homelessness
    • unemployment
  • chronic physical illness, especially those which are:
    • endocrinological
    • neurological
    • life-threatening
    • disabling
    • catastrophic
    • stigmatising
    • painful
    • deforming
  • chronic pain syndromes
  • family history of depression
  • catastrophic life event in the previous 6 months
  • chronic life difficulty in the absence of adequate social support
  • childhood abuse and/or neglect
  • Postnatal Depression - Please see Perinatal Mental Health Pathway

  • age
    • younger patients show more behavioural symptoms and irritability
    • older adults have:
      • more somatic symptoms
      • fewer complaints of low mood
      • more memory problems
  • stage of illness
  • severity of illness
  • co-morbidities

  • typical presentation:
    • persistent sense of sadness, anxiety or emptiness
    • lack of motivation and interest
    • feelings of hopelessness
    • feelings of worthlessness and/or guilt
    • marked physical slowness or agitation
    • complete lack of reactivity of mood to positive events
    • range of somatic symptoms, such as:
      • appetite and weight loss
      • reduced sleep (pattern of early waking and being unable to get back to sleep)
      • loss of energy or fatigue
    • depression being substantially worse in the morning (diurnal variation)
    • in severe depression, patients may develop psychotic symptoms, e.g. hallucinations and/or delusions
  • atypical presentation:
    • weight gain
    • reactive mood
    • increased appetite
    • excessive sleepiness

Physical symptoms of depression can include:

  • pain
  • constant tiredness

  • anxiety:
    • when depression is accompanied by anxiety, the first priority should be to treat the depression
    • when the person has an anxiety disorder and co-morbid depression or depressive symptoms, consult the relevant guidelines:
      • consider treating the anxiety disorder first (if depression is relatively mild compared to anxiety) - effective treatment of the anxiety disorder will often improve the depression or depressive symptoms
  • insomnia
  • worries about social problems, e.g. financial difficulties
  • increased irritability and hostility
  • increased drug or alcohol use
  • in a new mother, constant worries about her infant or fear of harming the baby

  • anxiety
  • phobias
  • milder depressive symptoms
  • panic attacks
Differential Diagnosis

Before diagnosing depression, consider alternative explanations including:

  • centrally acting antihypertensives
  • lipid-soluble beta blockers
  • central nervous system depressants
  • opioid analgesics
  • isotretinoin
  • benzodiazepines
  • corticosteroids
  • H2-receptor antagonists
  • chemotherapy agents (vincristine, vinblastine, procarbazine, L-asparaginase)
  • levodopa
  • non-steroidal anti-inflammatory drugs (NSAIDs)
  • cholesterol lowering agents
  • beta blockers
  • oral contraceptives

  • endocrine disorders, such as:
    • hypothyroidism
    • Cushing’s disease
    • adrenal insufficiency
    • hyperparathyroidism
  • cancer, e.g. brain tumour
  • diabetes
  • cardiac disease
  • Parkinson’s disease
  • cerebrovascular disease, such as:
    • stroke
    • subarachnoid haemorrhage
  • autoimmune diseases
  • post-polio syndrome
  • human immunodeficiency virus (HIV)
Initial Primary Care Assessment

Immediate steps in primary care:

  • respectful probing and reflective listening:
    • help the patient feel understood and valued
    • promote optimism and motivation while assessment, diagnosis, and strategies are negotiated and actioned
    • this in itself is therapeutic

Take a full psychiatric history including:

  • history of self-harm
  • history of suicide attempt/s
  • past history of mania or hypomania or mixed episodes
  • response to any treatment for depression in the past

Enquire into past medical history:

  • medication history; the following medications may be associated with major depression:
    • corticosteroids
    • interferon
    • methyldopa
    • isotretinoin
    • varenicline
    • hormonal therapy

Physical examination must be performed at initial presentation to assess for any physical cause of depression and for co-morbid physical illness.

Screening Guide for Depression in Primary Care


During the last month have you been feeling down, depressed or hopeless?

During the last month have you often been bothered by having little interest or pleasure in doing things?

During the last month, have you often been bothered by:

  • Feelings of worthlessness?
  • Poor concentration?
  • Thoughts that life isn’t worth living?

Depression is often not directly presented. If it crosses your mind-ask the question.

Not getting any pleasure from activities that used to give pleasure is a key feature

Is the person vulnerable?

Have you had any previous episodes of depression?

Have you any family members that suffer from depression-now or in the past?

Are there aspects of your life that are particularly difficult at present?

How are your relationships and living circumstances?

Are you employed?

Do you have any financial concerns?

Having a previous episode, having a family member who has suffered from depression and/or struggling with a difficult relationship, life circumstances (incl. unemployment and/or financial strain) are all factors which render a person more vulnerable to low mood and depression.

Ask the person to rate their mood

Complete the PHQ9 or ask on a scale of -10 (very unpleasant) to +10 (very pleasant) how they would describe their mood on most days.


What is helping?

What have you been doing to cope and is it helping?

Ask about alcohol and or drug usage.

People will try and survive the suffering by doing things to help themselves. Sometimes, these activities are the very thing that is maintaining the depression (e.g. excessive alcohol consumption, avoiding others, stopping doing hobbies or stopping exercise etc.)

Further considerations:

Is the person chronically ill physically? Patients with a chronic physical illness are significantly more at risk of depression.

  • consider the role of the physical health problem
  • check optimal treatment for the physical health problem to being provided and adhered to
  • seek specialist advice if necessary

Investigations to rule out an organic cause are guided by clinical presentation - basic investigations that are indicated include:

  • biochemistry :
    • blood glucose
    • urea and electrolytes
    • creatinine
    • liver function tests (LFTs)
    • thyroid function tests (TFTs)
    • erythrocyte sedimentation rate (ESR) or C-reactive protein (CRP)
    • calcium levels
  • haematology:
    • full blood count (FBC)
    • urinary or blood drug screening
  • if indicated clinically or by history, consider HIV and syphilis serology

Consider seeking specialist advice on whether investigations such as brain imaging are indicated, if the patient presents with:

  • unexplained headache
  • personality changes
  • possible signs of space-occupying lesion
  • possible convulsions
  • altered state of alertness


Reliance on laboratory tests should be greater if:

  • medical review detects symptoms that are rarely encountered in mood or anxiety disorders
  • patient is older
  • the first major depressive episode occurs after age 40 years


The severity of depression can be defined as follows:

  • subthreshold depression:
    • significant depressive symptoms below the threshold for DSM-5/ICD-10 depression
  • mild depression:
    • symptoms barely meet the minimum criteria; and
    • there is mild functional impairment
  • moderate depression:
    • more than the minimum number of symptoms are present; and
    • there is moderate functional impairment
  • severe depression:
    • most symptoms are present; and
    • there is a marked or greater functional impairment
GP Led Self-Management

Consider referral to or signpost patient to Gloucestershire’s Community Drug & Alcohol Recovery Service

  • Substance misuse is in itself not an exclusion to other work, but it will likely impair it, so this may be first step

Practice Point

The Contact Centre may be contacted for advice at any stage:

Tel: 08000 151 499

Email: 2gnft.FPCC-Admin@nhs.net

Fax: 01452 894418

Address: Tri Service Centre, Warerwells Police HQ, Waterwells Drive, Gloucester, GL2 2BP
Primary Care Management / Prescribing Guidance

  • shared decision making should take place throughout diagnosis and treatment
  • information on depression, its treatment, and self-help options should be provided to patients and their families and carers
  • if appropriate, the impact of the presenting problem on the care of children and young people should also be assessed and if necessary, local safeguarding procedures followed

When a person presents with symptoms of anxiety and depression, assess the nature and extent of symptoms:

  • if predominantly depression with features of anxiety, treat the depressive disorder first (see 'Depression' pathway)
  • if predominantly anxiety disorder and co-morbid depression or depressive symptoms, treat the anxiety disorder first
  • if both anxiety and depressive symptoms with no formal diagnosis, that are associated with functional impairment, discuss with the person the symptoms to treat first and the choice of intervention

Provide advice/refer/signpost patients to any of the following self-management services if not previously considered;

Consider referral to or signpost patient to substance misuse services (Substance misuse is in itself not an exclusion to other work, but it will likely impair it, so this may be first step)

Follow up

A telephone call is often sufficient to check in on how the person is coping OR consider giving the patient a bio-psychosocial assessment form and ask them to make a follow up appointment. Re-assess at this stage in order to decide whether further action or more watchful waiting is required.

Please follow this link to the Joint Formulary information on antidepressant drugs.

Consider referral to Mental Health Intermediate Care Team (ICT) for further advice / assessment / support and local services

Please use the MH ICT referral form to access these services.

Contact details and referral advice for 2gether's Contact Centre, Crisis Resolution and Home Treatment Teams and other mental health services that accept direct referral are available here.

Improving Access to Psychological Therapy (IAPT) / Let's Talk – 2gether

Let's Talk is an NHS service provided by 2gether NHS Foundation Trust. Accredited therapists offer evidence based psychological treatment, support and resources to assist in the management of anxiety disorders and depression. The service will offer treatments to people aged 18+ who are a resident in Gloucestershire and who are struggling with a common mental health problem.

Available for patients with:

  • mild to moderate severity depression with minimal risk

The team provide evidence based psychological treatment (mainly CBT) through group and individual work for depression. 

  • guided self-help based on CBT, mainly delivered over the telephone using a variety of resources.
  • enrolment on a Let's Talk psychoeducational course based on CBT.

  • individual or group work
  • high intensity individual cognitive behavioural therapy (CBT) for depression

Self-referral is encouraged by calling: 0800 073 2200 (Open Mon-Fri 9am-5pm)

You can refer a patient to the Let's Talk therapy team by completing the confidential online Health Professionals' referral form, or by sending a written referral form.

Please use the MH ICT referral form to access these services.

Paper referrals should be sent to Mental Health Intermediate Care Team, Ambrose House, Meteor Court, Barnett Way, Barnwood, Gloucester, GL4 3GG or sent via email.

Tel: 0800 073 2200

Email: 2gnft.talk2gether@nhs.net

Once a GP referral has been received, Let's Talk will contact the patient to arrange a telephone assessment, care if needed, and will write to GP to inform them of the outcome.

For any ongoing need the MH ICT / IAPT Team will refer on to Specialist Care Contact Centre



Mental Health Intermediate Care (Nursing) Team (MH ICT) / Mental Health Triage Nurse - 2gether

Available for patients with:

  • broader mental health assessment required
  • mental health medication reviews
  • queries about risk or deterioration
  • resistance to initial treatment

Routine response to referral is 28 days

Paper referrals should be sent to Mental Health Intermediate Care Team, Ambrose House, Meteor Court, Barnett Way, Barnwood, Gloucester, GL4 3GG or sent via email.

Tel: 0800 073 2200

Email: 2gnft.MHICTadminhub@nhs.net

Please use the MH ICT referral form to access these services.


North Locality (Chelt/Tewk/N.Cots) 01242 634241
West Locality (Gloucester/Forest) 01452 894220
South Locality (Stroud/Cirencester) 01453 563054


Specialist Care Contact Centre – 2gether

The 2gether Contact Centre is staffed by call handlers and senior mental health practitioners. They offer referral advice, screen referrals and arrange assessment appointments. They accept referrals from GPs and health professionals in consultations with GPs. They do not accept self-referrals.

Available for patients with moderate or severe depression associated with:

  • complexity of presentation (e.g. Due to complex co-morbidities, polypharmacy or aspects of social situation)
  • concerns about risk to self or other
  • demonstrated resistance to primary care management

The specialist care contact centre will triage referrals depending on need to offer:

  • routine assessment with Recovery - within 28 days
  • urgent assessment with Recovery - within 72 hours
  • crisis assessment/Intervention (if urgent concerns) by Home Treatment Team - same day

  • the initial assessment might offer advice on management or the offer of an on-going intervention according to a care plan agreed with the service user and drawn up by their care co-ordinator and a secondary care medic.
  • the multidisciplinary team includes a Consultant Psychiatrist and their medical team, Community Mental Health Nurses, Occupational Therapists, Social Workers, Psychologists and Support Workers.
  • interventions will be individualised, but may include both individual and group work provided in clinical or community settings.

  • lack adequate support outside of a hospital setting
  • have complicated psychiatric or general medical conditions
  • carry significant risk to themselves or others but cannot be managed safely outside a hospital setting

Tel: 0800 015 1499

Email: 2gnft.FPCC-Admin@nhs.net

Opening hours: 9am-5pm, Mon-Fri (except Bank Holidays).

For out of hours emergency referrals please ring the Crisis Teams on 0800 169 0389.


  • a summary of the patient's mental health difficulties
  • risks associated with their condition, including current/past risk, risk to others and risk of neglect
  • previous contact with mental health services
  • any history of substance abuse
  • current contact details
  • expectations of referrer and referee
  • ability to attend appointments
  • any language difficulties

For more information please follow the resource link below.

Practice Point

Expert opinion suggests that the PHQ-9 may in fact overestimate the severity of depression and should instead be used to contribute to the overall assessment of a patient and monitor their progress.


Patient Resources

Please see the Community Resources and Patient & Carer Information & Leaflets sections.

Resources for Professionals

National Standards

Please see the National and NICE Guidance section.

There are no significant variations from the national standards in this pathway.


Pathway Leads




Peter Carter

Commissioning Manager

Gloucestershire Clinical Commissioning Group

Jon Haynes

Clinical Director

2gether NHS Foundation Trust

Dr Binuja Justin

Specialty Trainee

2gether NHS Foundation Trust

Alex Burrage

IAPT Clinical Lead

Let’s Talk - MH ICT, 2gether NHS Foundation Trust

Caroline Andrews

Lead Nurse Adult

2gether NHS Foundation Trust

Latha Guruvaiah

Consultant Psychiatrist

2gether NHS Foundation Trust

Reason for Pathway Selection

This is a refresh and reformatting of the 2013 Depression pathway which utilised the national Map of Medicine pathway template. There are no major changes in practice/services; which include GP self-management, Primary Care level interventions, Improving Access to Psychological Therapy (IAPT)/Let's Talk and Specialist Mental Health services accessed via the 2gether Contact Centre. The 2gether Contact Centre can also now be used to access clinical advice at any stage by the patient GP.

Completion Date

June 2017

Review Date

May 2018