Depression

Recognition and Management

Dr Bruce Davies

www.bradfordvts.co.uk

What Is Depression?
A Continuum
Normal Mood Lowering
Abnormal Mood Lowering
Abnormal mood lowering and loss of function

What Is Depression?

Depressive disorder
Pervasive
Persistent
Wide range of symptoms

What Is Depression?

Range of symptoms

Negative views
Worthlessness
Incapacity
Guilt
Sleep disturbance
Diurnal mood variation
Loss of energy
Impaired concentration

What Is Depression?
Impaired work ability
Poor social functioning
Psychomotor retardation
Pessimism
Better off dead
Thoughts of suicide
Suicide / action
Fear / belief of bodily illness

Understandability

No longer important.
Do not alter treatment
thresholds.
Do not alter treatment.
Reactive /
endogenous = confine
to bin.

Vulnerabilities

Losses
Stressful life events
Lack of social
support
Physical illness
Familial factors
Genetic factors

What Is Depression? - Various Criteria.

Defeat Depression Campaign

Depressed mood or loss of pleasure for at
least 2 weeks. Plus 4 or more of:

Worthlessness or guilt
Impaired concentration
Loss of energy and fatigue
Thoughts of suicide
Loss or increase of appetite or weight
Insomnia or hypersomnia
Retardation or agitation

What Is Depression? - Various Criteria.

DSM IV
Duration > 2 weeks Depressed mood or Marked loss of interest or pleasure in
normal activities
Plus 4 of:

i.

Significant change in weight

ii.

Significant change in sleep pattern

iii.

Agitation or retardation

iv.

Fatigue or loss of energy

v.

Guilt / worthlessness

vi.

Cant concentrate or make decisions

vii.

Thoughts of death or suicide

What Is Depression? - Various Criteria.

ICD 10

Patient has low mood:

1)

How bad is it and how long has it been going on?

2)

Have you lost interest in things?

3)

Are you more tired than usual?

If the answer is yes to these, then:

ICD 10 (Continued)
4)

Have you lost confidence in yourself?

5)

Do you feel guilty about things?

6)

Concentration difficulties?

7)

Sleeping problems?

8)

Change in appetite or weight?

9)

Do you feel that life is not worth living any more?

ICD 10 (Continued)
Mild.
Two criteria from 1-3 and 2 others.
Moderate.
Two criteria from 1-3 and 3-4 others or a yes
to question 5.
Severe.
Most of the criteria in severe form especially
questions 5 & 9.

Variants

Depressive episodes that

do not meet the criteria for
major depression.
Lifelong mild fluctuating
depression (Dysthymia).
Mixed states of above two.
Manic depression
bipolar disorder.

Incidence Of Depression :
2000 Patients
100 - major
100 - minor
200 subclinical
Depression. In 50% of patients it
may not be acknowledged.

Numbers

10% of those diagnosed in primary care

are referred to psychiatrists.
1 in 1000 are admitted to hospital.
Lifetime incidence rates approach 33%.
5% of consulters have major depression.
5% have milder depression.
A further 10% have some depressive
features.

Numbers

At least one patient per surgery will have

depressive symptoms of some type.
Commoner in younger people including
children than thought in the past.
Men:women = 1:2.
Common in the physically ill.
50% recurrence rate.
12% become chronically depressed.

Why Missed?

50% are missed.

10% subsequently
recognised.
Of the 40% who remain
unrecognised:

Half remit spontaneously.

Half remain depressed 6
months later.

Missed: Patient Factors

Present somatic symptoms.

Physical problems.
Stigma.
Beliefs about GP role and time to listen.
Longstanding depression.
Less overt / typical.
Less insight.

Missed: Doctor Factors

More accurate doctors.

Make more eye contact.

Show less signs of hurry.
Are good listeners.
Ask questions with social and psychological content.

Less accurate doctors.

Ask many closed questions.

Ask questions derived from theory rather than what
the patient just said.

Assessment

Severity
Duration
Social network
Views of self, world
and future
Suicidal thoughts
Past history
Factors affecting
symptoms
Biological features

Assessment Skills

Directive not closed questions

Picking up on verbal clues
clarification
Picking up on non-verbal clues and
using them
Empathy
Summarising

Treatment Contract

Key skills

Re-frame symptoms as
depression
Link to life events
Negotiate antidepressants if necessary
Problem list and priorities
Set realistic time scale
Agree regular review

Explanations

Depressive illness is
clinically different
from the blues and
involves chemical
changes in the brain.
Depressive illness
has characteristic
symptoms and
explain them.

Explanations

Depression benefits
from both drug and
non-drug
approaches.

Pills for symptoms.

Talking for
problems.

Explanations

Anti-depressants are
not addictive or habit
forming.
Anti-depressants take
2-3 weeks to begin to
work and need to be
taken for 4-6 months
after the full benefit is
obtained to prevent
relapse.

Explanations

Side effects occur

and are expected
explain.
Drugs enable talking
therapy to work
better.
Regular review is
important and needs
to continue for at
least 6 months.

Explanations

Talking therapy can help solve

problems that are soluble, cope with
the insoluble and examine other
problems that seem unrealistic to the
patient or therapist.
Prevention of further trouble will be
considered when the treatment is
coming to an end.

References

Defeat Depression Campaign. The Royal

College of Psychiatrists. 1994.
Treating People with depression: a
practical guide for primary care. G
Wilkinson et al. Radcliffe 1998.
Recognition and management of
depression in general practice:
consensus statement. BMJ
1992;305:1198-202.