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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)

or

  • 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, Mental Health Acute Response Service (MHARS (formerlyCrisis 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.
Presentation

  • 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

QUESTIONS TIPS FOR PRACTITIONER
  • 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.

Notification of Serious Untoward Incidents (SUIs)

Recent reviews of serious incidents have identified potential system and process changes which could improve the quality and responsiveness of care for people who require secondary care mental health services.

It would be helpful if GPs could please share any information in relation to substance misuse with GHC, particularly when a patient is injecting, as this aids clinical risk assessment and management. It is also really helpful if referrals into mental health services contain an appropriate risk assessment.

In all instances when a patient dies unexpectedly, especially if the cause of death is suspected suicide, GPs should inform GHC as soon as possible. This will allow GHC to quickly put in place support for those bereaved and minimise the risk of appointment letters etc. being sent to the deceased.

Contact: gordonbenson@nhs.net (Assistant Director of Governance & Compliance, GHC)

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