In the second part of his review, Professor Safiullah Afghan looks at how to manage depression in a primary care setting
Professor Safiullah Afghan MBBS, MCPS, MSc, MRCPsych, MBA, Consultant Psychiatrist, Dorothy Pattison Hospital, Dudley and Walsall, Mental Health Partnership NHS Trust, Honorary Professor of Mental Health University of Wolverhampton
Management of clinical depression involves social, psychological and medical approaches and interventions. Depending on the severity of depression, these interventions are considered alone or in combination. The majority of patients with depression can be successfully treated by GPs. Primary care nurses, counsellors and psychologists can also manage some aspects of depression.Only about 10-15% of patients with more severe or complex presentations, including those experiencing resistance to treatment or diagnostic difficulties, will need to be referred to psychiatrists or secondary care mental health services.
Referral to a psychiatrist or specialist mental health service may be required if:
- The diagnosis is unclear and sits alongside an impairment in functioning
- The patient has not responded to routine treatment in primary care
- The patient has severe symptoms (severe depression with psychotic features)
- There is a moderate risk of self-harm or suicide
- There is a high risk of suicide, including persistent or frequent thoughts or plans, or if the patient has made a recent serious suicide attempt
- Patient refuses to eat and drink leading to dehydration and a threat to physical health and survival
- Patient requires electroconvulsive therapy.
The majority of people with mild depression do not require treatment with antidepressants. They mostly benefit from variety of non-pharmacological interventions that include behavioural activation, sleep scheduling, computer and online self help resources, including computerised CBT, problems solving etc.
Low-intensity psychological interventions NICE recommends low intensity psychological interventions for people with persistent sub-threshold depressive symptoms or mild depression. These include:
- Individual guided self-help. Based on the principles of CBT, this usually consists of 6–8 sessions (face-to-face and via telephone) over 9–12 weeks
- Computerised cognitive behavioural therapy (CCBT). This usually takes place over 9–12 weeks
- Structured group-based physical activity programme.
This usually consists of 2-3 sessions per week of moderate duration (45 minutes to 1 hour) over a 3-month period
- Group-based peer support. This usually consists of one session per week over 8–12 weeks. NICE also recommends high-intensity interventions as a viable treatment in moderate-to-severe depression (alone and in combination with antidepressants).
Regarding the management of mild depression or sub-threshold depressive symptoms, GPs should consider a period of active monitoring:
- Provide information about the nature and course of depression
- Arrange a follow-up within two weeks and contact the person if they fail to attend follow-up appointment
- If still unwell after two weeks, consider referral for a low-intensity psychological intervention.
Cognitive Behaviour Therapy
Cognitive behaviour therapy (CBT) tries to help people to look at their cognitive errors, assumptions and belief systems and attempts to alter the thoughts and beliefs that cause distress. CBT looks at the ‘here and now’ issues rather than things from the past. CBT helps people to learn new methods of coping, problem solving and dealing with others, through conflict resolution and techniques to improve communication, which they can use in future. It is a self-help therapy and the therapist works as a guide.
In a primary care-based randomised controlled trial carried out on depressed first generation British Pakistani women over a nine-month period, there is favourable evidence to support the view that social group interventions in combination with antidepressants are significantly more effective than antidepressants alone.
The patients, who had moderately severe clinical depression, displayed improvement in their depression, as well as social recovery at the end of the trial. The social intervention was culturally sensitive and consisted of a weekly session spread over a 10-week period. This small, group-based activity focused on shared skills, learning, leisure activities, confidence building and using educational methods to raise awareness about depression and antidepressant medication.1
Antidepressants are indicated in patients with moderate to severe forms of depressions. NICE recommends using SSRIs as first line medication.2 SNRIs (venlafaxine duloxetine) can be considered as second line alongside mirtazapine (NASSA). In many cases, GPs decide to start the medication at low doses to allow the patients time to adapt to the side effects. Most of the patients usually start to feel better after 4-6 weeks of treatment.
In some cases, GPs or psychiatrists may decide to change the type of antidepressant medication if no improvement is noted after 6-8 weeks of prescribing at a maximum dose, or if the patient has experienced intolerable side effects.
If the depressive symptoms are significantly improved after 12 weeks of treatment, patients are usually advised to continue the treatment for 6-9 months to prevent the depression from returning.
People who have previously experienced two or more major episodes of depression may require treatment to be continued for nearly two years or longer.
In the first episode of depression, NICE3 recommends:
- Generic SSRIs preferred – better tolerated, safer in overdose (citalopram, fluoxetine, paroxetine, or sertraline).
- For recurrent episode of depression, consider an antidepressant the person has responded well to in the past.
- In chronic physical health problem, sertraline (SSRI) is preferred due to lower risk of drug interactions.
Reducing inappropriate psychotropic prescribing
The wide variation in primary care prescribing patterns, especially antidepressants, has been recognised nationally. Some of these patterns are deemed inappropriate and could instead be considered for social prescribing.
A GP survey carried out in Scotland in 2014, “Know where to go”: A Scottish Association of Mental Health (SAMH) survey of GPs found the following important results.4
- 73% of GPs expressed need for more information about non-pharmaceutical treatment options for common mental health problems nn47% of GPs were not aware of, or not sure of, the local SIGN guidelines on non-pharmaceutical treatments for depression, and
- 87% of GPs said there was a need for information guides on local services for referral, including social prescribing opportunities.
Some GP practices in England prescribe exercise for mild forms of depression by directing the patient to NHS Choices or referring to accredited health trainers. Funding from personal budgets is utilised for this purpose. Similarly, sporting opportunities for patients with SMI are also considered by some primary care facilities. Time to change toolkit for sports and mental health projects is a good example to be considered for wider application in primary care.5
Prescribing in pregnancy and postnatal period
The principle of carrying out a risk benefit analysis is helpful and has been extensively covered by Jones et al (2014).6 The risks of not treating depression include harm to the mother through poor self care, inadequate obstetric care or selfharm.
The harm to the foetus or neonate commonly includes neglect and rarely infanticide. Patients who are already receiving antidepressants and are at high risk of relapse should be best maintained on antidepressants during and after pregnancy.
Those who develop a moderate or severe depressive illness during pregnancy should be treated with antidepressant drugs. The accumulating evidence suggests that there is most experience with amitriptyline, imipramine (anticholinergic side effects and withdrawal symptoms may occur)7 and SSRI (fluoxetine), which carries increased chance of earlier delivery and reduced birth weight.
The neonate may experience discontinuation symptoms such as agitation and irritability, or even convulsions (with SSRIs). The risk is assumed to be particularly high with short half-life drugs such as paroxetine and venlafaxine.
Management in adolescents
The majority of adolescents with depression and emotional difficulties who attend the GP present with physical health complaints, while a smaller proportion present with mood symptoms. NICE guidelines recommend the need for primary care professionals to be familiar with screening for mood disorders, to recognise depression and to provide support.8 For young people with depression, NICE recommends watchful waiting initially, and if the mild depression persists, then supportive psychotherapy, group CBT or guided self help as a form of treatment.9
In children below the age of 17, only one antidepressant (SSRI), namely fluoxetine, is recommended for use in cases of severe depression, usually under the care of a specialist. Caution is advised in prescribing other antidepressants, especially paroxetine, due to recognised risks of increasing suicidal ideation and behaviour, and imipramine, due to cardiovascular risks.10
Management in older adults
Antidepressants appear to have similar effectiveness in elderly and younger patients. The goal of treatment should be remission of symptoms. Initial dosing with antidepressants should be half of the usual adult starting dose and be titrated regularly until the patient responds, until the maximum dose is reached, or until side effects limit further increases. Common side effects of medications include falls, nausea, dizziness, headaches and, less commonly, hyponatremia and QT interval changes. Older patients should be treated for at least a year from when clinical improvement is noted, and those with recurrent depression or severe symptoms should continue treatment indefinitely.
Factors that can influence antidepressant prescribing can include previous response, concurrent conditions (e.g. benign prostatic hypertrophy in men, bipolar disorder, psychotic depression), other medications and risk of overdose.
Many older patients with depression have substantial comorbidities such as heart failure, diabetes and cancer; chronic disease is a risk factor for development of depression.11 Although the presence of medical illness can make the diagnosis of depression more difficult, there is no clear evidence that comorbid conditions substantially decrease the effectiveness of antidepressants.12
Models of care
There is strong emerging evidence that burden of depressive disorders is predicted to rise over the coming decades, and its prevalence particularly increases in aging populations and those with associated long-term conditions.
There is emerging consensus and recognition that collaborative care models across primary and secondary care offer opportunities for effective and good quality care for patients.
A systematic review and meta regression by Coventry et al (2014) included 74 randomised control trials and over 21,000 participants suffering from depressive disorder and mixed anxiety and depression.
The results predicted improvement in depression through the use of collaborative care, including psychological interventions and antidepressants.13
Similarly, a randomised control trial by Richards et al (2013) looked at the effectiveness of collaborative care versus usual care in primary care settings in the UK for management of patients with moderate to severe depression and demonstrated significantly improved outcomes for collaborative care at four months, which was maintained at 12 months. It also demonstrated benefits to secondary outcomes including medication use, mental health quality of life, and patient satisfaction.14
Although, there has been substantial improvement in the public awareness, recognition, diagnosis and treatment of depressive disorders in primary care settings, there exists a noticeable gap in the provision of effective pharmacological and psychological treatments for depressive disorders, especially in individuals with chronic physical illnesses and long-term conditions.
However, there is every reason to be optimistic for improved outcomes for treatments of depressive disorders due to improvements in training in primary care, development and application of evidence-based guidelines and a move towards greater integration and collaboration between primary care, acute hospital care and secondary care mental health services.15
1 Gater R, Waheed W et al (2010) The British Journal of Psychiatry,197 (3) 227-233
2 National Institute of Health and Clinical Excellence (2015) – First-choice antidepressant use in adults with depression or generalised anxiety disorder https://www.nice.org.uk/advice/ktt8/chapter/evidence-context
3 National Institute for Health and Clinical Excellence (2009) Depression in adults. The treatment and management of depression in adults, NICE clinical guideline 90
4 “Know where to go” (2014) A SAMH survey of GPs in Scotland (www.samh.org.uk/media/424477/final_kwtg_gp_report.pdf)
6 Jones SC & McDonald L (2014) British Journal of Family Medicine, 25
7 Davis RL et al (2007) Pharmacoepidemiology Drug Safety;16:1086–1094
8 National Institute of Health and Clinical Excellence (2005) - Depression in children and young people. Clinical Guideline 28. London: NICE
9 Gledhill J and Hodes M (2015) Progress in Neurology and Psychiatry, Vol 19, issue 2.
10 Noury JL, Nardo JM et al (2015) BMJ; 351: h4320
11 Frank C (2014) Canadian Family Physician; 60(2): 121–126
12 Rayner L, Price A, Evans A, Valsraj K, Higginson IJ, Hotopf M (2010). Cochrane Database Systematic Review; 3
13 Coventry PA, Hudson JL, Kontopantelis E, Archer J, Richards DA, Gilbody S, et al. (2014) PLoS ONE 9(9)
14 Richards DA, Hill JJ, Gask L et al (2013) BMJ 2013;
15 Five Year Forward View (2014) NHS England publication