You are on page 1of 26

,

Outline
1. Depression

2. Post-natal depression
3. Post-traumatic stress disorder (PTSD) 4. Eating disorders

DEPRESSION

Slides based on a chapter entitled, Depression in Primary Health Care Clinics by Prof. Jane Gunn in collaboration with Prof. Christopher Dorwrick and Prof. Christos Lionis

Depressive disorders according to the two principal diagnostic classification


Table 1. Depressive disorders according to the two principal diagnostic classification

DSM-IV-TR American Psychiatric Association

ICD-10 World Health Organization (WHO)

296.xx Major Depressive Disorder 300.4 Dysthymic Disorder 311 Depressive Disorder NOS

F32 Depression F41.2 Chronic mixed anxiety and depression

Source: Gunn J, Dorwick C, Lionis C. Wonca Manual: primary care mental health clinics in print.

The spectrum of depression in primary care


Minor depression will report up to four

depressive symptoms including depressed mood or loss of interest or pleasure and these symptoms will have been present for at least two weeks.
Dysthymia is a chronically depressed mood

Minor depression is very common in the primary care setting.

that is present for at least two years, with the person reporting that they feel down, depressed or hopeless for most of the day on more days than not. People with Dysthymia will commonly report low interest in things and be filled with self-doubt and self-criticism.
Source: Gunn J, Dorwick C, Lionis C. Wonca Manual: primary care mental health clinics in print

People with Dysthymia are at an increased risk of developing an episode of Major Depressive Disorder.

GMS Contract and mental health


Mental health is also included in the new GP contract.

In order to achieve maximum quality and outcomes framework (QOF) points, practices must achieve the following standards.
mental health problems in place. 90% of patients with severe long-term mental health problems should have been reviewed in the previous 15 months. 90% of patients on lithium therapy should have had their lithium levels checked in the previous 6 months. 90% of patients receiving lithium should have a record of their serum creatinine and thyroid stimulating hormone (TSH) in the previous 15 months. 70% of patients on lithium should have lithium levels in the Source: Newson L,range Shah R, Patel A. Hot Topics for MRCGP and General Practitioners. therapeutic recorded within the previous 15 months.
4th edition. 2006.

There must be a register of people with severe long-term

Risk and protective factors for developing depression

Source: Gunn J, Dorwick C, Lionis C. Wonca Manual: primary care mental health clinics in print.

Depression and physical health conditions


Depression and physical illness commonly co-occur and depression is commoner in those with a chronic condition.
In an Australian survey:
6,738 primary care attendees the proportion likely to be depressed ranged from 16.44% for those

with no long-term physical conditions. through 23.44% for those with one long-term physical condition to 40.88% for those with five or more long term physical conditions. skin problems and back pain were as much associated with depression as diabetes and heart disease.

In a large Canadian population study having a long-term medical condition approximately doubled the risk of major depression; particularly for those reporting migraine headaches, sinusitis and back problems. There is also evidence to suggest that the mix of depression and long-term physical health problems carries with it a poor prognosis, diabetes and co-existing depression face substantially elevated mortality risks that are beyond what can be explained by cardiovascular deaths. Source: Gunn J, Dorwick C, Lionis C. Wonca Manual: primary care mental health clinics in print.

Summary of depressive symptoms in DSM-IV and ICD-10


Symptoms of depression 1 2 3 4 5 6 7 8 9 10 Depressed mood Markedly diminished interest or pleasure in activities Loss of energy or fatigue Loss of confidence or self-esteem Unreasonable self-reproach or guilt Recurrent thoughts of death/suicide, or any suicidal behaviour Diminished ability to think or concentrate, or indecisiveness Psychomotor agitation or retardation Insomnia or hypersomnia Change in appetite + + + + + + + + DSM-IV + + + + ICD-10 + + + + +

Source: Dowrick C. Beyond Depression: A new approach to understanding and management. 2nd ed. Oxford: Oxford University Press, 2009.

Assessing depression with two questions


During the past month have you often

bothered by feeling down, depressed or hopeless?


During the past month have you often been

bothered by little interest or pleasure in doing things?


Source: Dowrick C. Beyond Depression: A new approach to understanding and management. 2nd ed. Oxford: Oxford University Press, 2009.

Stepped Care Approach to depression according to the NICE Guidelines


Step 1: Support and education Engaging with the person, acknowledging their suffering and offering to help them find a way out of their depression or distress can be a very therapeutic process Step 2: Low intensity psychosocial and psychological interventions or medication e.g. Cognitive Behaviour Therapy

Step 3: Medication, high intensity psychological treatments, combined treatments, collaborative care, referral.

Step 4: Medication, high intensity psychological interventions, electroconvulsive therapy (ECT), crisis intervention, combined treatments, multiprofessional and inpatient care.

Source: Gunn J, Dorwick C, Lionis C. Wonca Manual: primary care mental health clinics in print.

Behaviour Therapy

Source: France R, Robson M. Behaviour therapy in primary care: a practical guide: Croom

Behavioural Activation
Behavioural activation comprises of the following basic techniques to increase positive behaviours:
Increasing Positive Behaviour

Reinforcing Choosing the next appropriate step

Modeling and Shaping Prompting or cueing

Reinforcement

Source: France R, Robson M. Behaviour therapy in primary care: a practical guide: Croom Helm,

Suicide Risk

Source: Gunn J, Dorwick C, Lionis C. Wonca Manual: primary care mental health clinics in print.

POST-NATAL DEPRESSION

Key Symptoms
Low mood (tends to be worse first thing in the

Source: Newson L, Shah R, Patel A. Hot Topics for MRCGP and General Practitioners. 4th edition. 2006.

morning, but not always) Not really enjoying anything. Lack of interest in yourself and your baby Lack of motivation to do anything Often feeling tearful Feeling irritable a lot of the time Feelings of guilt, rejection, or inadequacy Poor concentration (like forgetting or losing things) or being unable to make a decision about things Feeling unable to cope with anything

Key Recommendations
The Edinburgh Post-natal Depression Scale

a validated detection tool Psychological treatments


Cognitive-behavioural therapy (CBT). Interpersonal therapy Other types of therapy including problem-solving

therapy and psychodynamic psychotherapy may also be used to treat postnatal depression.

Source: Newson L, Shah R, Patel A. Hot Topics for MRCGP and General Practitioners. 4th edition. 2006.

POST TRAUMATIC STRESS DISORDER

Key Symptoms
Re-experiencing (flashbacks, nightmares)

Avoidance
Hyperarousal Emotional numbing with a sense of detachment Depression Drug or alcohol misuse Anger Somatisation

Source: NICE Guidelines Post Traumatic Stress Disorder, March 2005.

Key Recommendations
Debriefing should not be offered routinely to people who

have experienced a traumatic event. Watchful waiting in mild cases of PTSD. Patients with severe symptoms or with severe PTSD in the first month after the traumatic event should be offered trauma-focused CBT. All people with PTSD should be offered a course of trauma-focused psychological treatment. Treatment may be effective even when problems present many years after the traumatic event. Drug treatments should not be used as a first-line treatment in preference to trauma-focused CBT, but may be an option for adults who decline psychological treatment; in particular mirtazapine and paroxetine. Consider screening people at high risk of developing PTSD one month after the traumatic event.

Source: NICE Guidelines Post Traumatic Stress Disorder, March 2005.

EATING DISORDERS

Key Symptoms and Findings


Young women with low BMI

Non-overweight patients consulting with


excessive weight concerns Women with menstrual disturbances or amenorrhoea Patients with GI symptoms Those with physical signs of starvation or repeated vomiting Children with poor growth Screening Questions:
Do you think you have an eating problem?

Source: Newson Shah R, Patelexcessively A. Hot Topics for MRCGP General Practitioners. 4th Do L, you worry about and your weight?

Key Recommendations
A comprehensive assessment should take place,

including physical, social and psychological needs. GPs should take responsibility for the initial assessment and coordination of care when a patient presents. Get help early; patients with eating disorders should be assessed and treated as soon as possible. Where laxative abuse is present, patients should be advised to gradually reduce laxative use and be informed that laxative use does not significantly reduce calorie absorption. The right to confidentiality of children and adolescents with eating disorders should be Source: Newson L, Shah R, Patel A. Hot Topics for MRCGP and General Practitioners. respected.

Useful websites
Department of Health www.doh.gov.uk
National Institute for Health and Clinical

Evidence http://www.nice.org.uk