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Durham and Tees Valley VTS Sept 2017 Dr Rachel Lunney Dr Steven Rowan

Durham and Tees Valley VTS Sept 2017 Dr Rachel Lunney Dr Steven Rowan. Depression (In adults) NICE Clinical Guidelines 90 & 91 2009 & KTT8 2015. Learning outcomes By the end of this session GPRs will be able to:

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Durham and Tees Valley VTS Sept 2017 Dr Rachel Lunney Dr Steven Rowan

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  1. Durham and Tees Valley VTS Sept 2017 Dr Rachel Lunney Dr Steven Rowan Depression (In adults)NICE Clinical Guidelines 90 & 91 2009 & KTT8 2015

  2. Learning outcomes By the end of this session GPRs will be able to: Recall key elements of the NICE guideline on depression (CG90+91), regarding diagnosis, assessment and stepped care management Relate the NICE guideline to clinical cases of patients with depression Curriculum coverage (2012) 3.10 Care of People with Mental Health Problems

  3. Depression Why do I need to know this? Why the need for a NICE guideline? (NB Updated NICE guidance on Depression in children & young people not covered here: QS48 Sept 13 + update Aug 15)

  4. Depression – In context • Common: 2.6% Dep’n prevalence UK 16-74yr • 11.4% prevalence Anxiety & Depression F>M • Under-diagnosed, treatable • More common in chronic disease patients • Often over-treated with medication • Under-resourced for psychological therapies • Rewarding to treat • Close to your experience?

  5. 1) Key symptoms of depression? 2) How do you assess patients? 3) First line psychological treatment? 4) First choice drug? Your knowledge: starting point

  6. Lawrence’s story “It could happen to anyone” http://www.nhs.uk/video/Pages/Clinicaldepression.aspx

  7. Depression - Symptoms • Heterogeneous, but key = Low mood &/or loss of pleasure in activities (=screening questions) • Similar to “normal” experiences eg grief • Overlaps with anxiety symptoms, or mixed • Consider physical causes eg hypothyroidism • Assessment needs a specialist approach in Learning Disability and Dementia patients

  8. Psychological Low mood Reduced interest or pleasure in activities Feelings of excessive worthlessness or guilt Reduced concentration Recurrent thoughts of death or suicide (plans?) Biological/Physical Weight gain / loss or appetite loss Insomnia / hypersomnia Psychomotor agitation or retardation Tiredness or low energy Social Work, home, relationships, withdrawal…Impact Depression – Symptoms - BioPsySoc

  9. Making a diagnosis • Based on DSM-IV criteria for major depression • >/= 5 symptoms, for at least 2 weeks, present most of every day • Basis of PHQ9 score (useful?) • BUT don’t just “symptom count”! • Assess severity – Impact + high PHQ9 scores • Make a biopsychosocial assessment – inc social impact, PMH, FH.

  10. Depression – Assessing severity • Sub-threshold symptoms: Fewer than 5 symptoms. • Mild depression: Few (if any) symptoms over the 5 for diagnosis, + causing minor functional impairment. • Moderate depression: Symptoms or functional impairment between ‘mild’ and ‘severe’. • Severe depression: Most symptoms, + these markedly interfere with functioning. • Can occur with or without psychotic symptoms.

  11. PHQ9 Score Interpretation • No longer QOF but helps diagnosis & progress • Used in Psychological Therapies – Referral vs Discharge score • Interpretation of Total Score • Total Score Depression Severity (Impact) • 1-4 Minimal depression • 5-9 Mild depression • 10-14 Moderate depression • 15-19 Moderately severe depression • 20-27 Severe depression

  12. Previous QoF 2013/14 (Not NICE) QoF removed this 2014/15Biopsychosocial Assessment “Newly diagnosed depression >/= 18y should have a biopsychosocial assessment completed on the day of diagnosis.” Relevant now? Good holistic care Still valuable as a structure for considering impact, resources, challenges for patient?

  13. What was in the BPS Assessment? • Current symptoms, duration & severity • Past history and Family History of MH probs • Relationships (partner, children) & support • Living conditions • Employment & finances (Time off: pros/cons?) • Drug & alcohol use, present & past • Suicidal ideation • Treatment options, past Rx & responses

  14. Depression in Older People

  15. Depression in Older PeopleNot NICE: BMJ 2011: 343:d5219 • Dep’n >65y ass’d w physical illness & disability • Dep’n worsens outcomes in those conditions • Prevalence of dep’n 4.6-9.3% of all adults >75y • Higher - Parkinson’s, Dementia, CVA, DM, CVD • Social factors influence dep: eg bereavement • More functional impact than in younger pts • May present differently: somatisation, anxiety, cognitive impairment, psychomotor symptoms

  16. Depression in Older PeopleNot NICE: BMJ 2011: 343:d5219 • Management should be adapted to older pt’s • PHQ9 the only validated GP tool for older pt’s • Exclude physical conditions: routine bloods • Highest completed suicide risk by age: ask pt • Psychosocial interventions are key e.g. groups, meaningful activities, structured exercise • Drugs: SSRIs first line, & safest

  17. Depression So how should we manage it? NICE advice: Stepped Care Psychological therapies Medications

  18. NICE 90 +91 - Key messages • Patient-centred, culturally appropriate • Severity inc impact are key to assessment: BPS • Intervention should reflect severity (stepped care model) and patient preference • Offer Psychological therapies for mild • Add medication for moderate and severe: effective • Consider chronic health problems – Psych’l therapies first. Offer med’n if dep’n affecting their condition • Treat for at least 6/12 from resolution • Consider relapse prevention

  19. NICE 90 +91 – Stepped care • Consider depression esp in chronic conditions • Low intensity psychosocial intervention for mild-moderate or “sub-threshold” symptoms • Meds only help mild depression if past mod-severe episode, no response to psy’social interv’n , or 2 years sub-threshold symptoms • Moderate to severe – Medseffective* + high-intensity psychological support (eg CBT) • *Meta-analysis of 234 studies: Ann Int Med 2011; 155: 772

  20. Identify depression - esp in chronic conditions. Consider using Whooley screening questions: “During the last month, have you often been bothered by: Feeling down, depressed or hopeless? Having little interest or pleasure in doing things?” • Then make a comprehensive assessment inc: • Symptoms - Duration • Degree of functional impairment PHQ9 may help • Exclude other explanations / causes

  21. Explore history & severity : • Past Hx of depression & chronic conditions • Hx of mood elevation (Bipolar under-diagnosed)* • Response to previous treatments • Interpersonal relationships – Support? Impact? • Living conditions & social isolation * - Not in NICE 90. Hot Topics 2011. Bipolar is covered in VTS separately.

  22. Ask directly about suicidal ideation and intent. If at risk: • Adequate social support & aware of sources of help? eg Samaritans 08457 90 90 90 • Arrange help appropriate to level of risk • Immediate risk: urgent referral to specialist services • Risk of suicide: increased support & referral to MHT • Advise to seek help if the situation deteriorates • Psychoeducation – inc self help booklets, wesbites eg MoodGym, Mood Juice, NHS Choices Moodzone • Monitoring – watchful waiting, consider review

  23. Psychological treatment: • Sleep hygiene • Active monitoring and review (by 2 wks) • Low-Intensity Psychosocial & Psychological Interventions • Individual guided self-help based on CBT principles • Computerised CBT • Structured group physical activity programme (Ch’c C) • Group-based CBT • Other local services you are aware of?

  24. Drug treatment: • Do not use antidepressants for persistent sub-threshold depressive symptoms or mild depression • Unless: • Hx of moderate or severe depression • Sub-threshold symptoms present for >/= 2yrs • Sub-threshold depressive symptoms /mild depression persisting after other interventions • Mild depression complicating a chronic condition • - Meds are safe, SSRIs improve QoL, inc post-MI.

  25. Step 2 summary • Low intensity psychological interventions inc self help • Watchful waiting & review • No medication unless sig’t history or 2yr low Step 3: Mild-moderate Depression What do we offer when more is needed?

  26. Choice of intervention should be influenced by: • Duration of episode & trajectory of symptoms • Hx depression & response to treatment • Likely concordance & potential adverse effects • Patient preference • Patients with moderate or severe depression: • Combine antidepressants with high-intensity psychological intervention

  27. Psychological Intervention: High-Intensity • Individual or group-based CBT (inc Ch’c Cond’n) • Interpersonal psychotherapy (IPT) • Behavioural activation • Behavioural couples therapy • Counselling (can family help/join in?) • Short-term psychodynamic psychotherapy

  28. Psychological InterventionWhat’s available?How to “sell it” to patients? http://www.nhs.uk/video/Pages/Talkingtherapies.aspx

  29. Antidepressants

  30. Antidepressant drug choice. Consider: • Side effects & interactions Citalopram & Sertraline safest; caution w NSAIDS or Aspirin Citalopram contraind’d w meds prolonging QT interval eg Amiodarone TCAs contraind’d with Warfarin – use Mirtazapine

  31. Antidepressant drug choice. Consider: • Patient’s perception / experience • Toxicity in overdose (eg TCAs, Venlafaxine) • Discuss choice of antidepressant & give information: • Gradual development of full effect (from 2 weeks) • Concordance, inc 6/12 (or longer) after remission • Discontinuation symptoms

  32. Review and ongoing care: • No risk suicide: 2wks then every 2-4wks for 3mths, then at longer intervals • Risk of suicide / <30yrs: 1wk then frequently until lower risk Absent / minimal response at 3-4 wks: • Concordance? • Consider increasing dose &/or support • Consider switching antidepressant (if SEs or patient prefers.) See Switching Chart on VTS site

  33. Review and ongoing care: • Inadequate response at 3-4 wks : Up dose or swap drug (KTT8 2015; past advice was do so at 4-6 wks: NICE CG90/91) • 1 week gap • Some response at 3-4wk? Continue 2-4wk more before switching drug/amending dose • Follow guidance on withdrawal • Continue meds for 6 months after resolution High risk of relapse (or past severe or recurrent): • Treat for 2 years • Add post-resolution CBT or Mindfulness Therapy

  34. Mindfulness

  35. Mindfulness Evidence shows that Mindfulness-Based Cognitive Therapy can, on average, reduce the risk of relapse for people who experience recurrent depression by 43%. Research also suggests that it’s particularly effective for vulnerable groups who are more likely to relapse (J Williams et al, “Mindfulness-Based Cognitive Therapy for Preventing Relapse in Recurrent Depression: A Randomized Dismantling Trial”, 2013.). As a psycho-social approach to staying well, it’s a cost-effective and accessible treatment for individuals and providers (M Williams and W Kuyken, “Mindfulness-based cognitive therapy: a promising new approach to preventing depressive relapse”, 2012). http://www.mentalhealth.org.uk/help-information/mental-health-a-z/M/mindfulness/

  36. Mindfulness • NICE: >/= 3 episodes, chronic, relapsing dep – 50% reduction in relapse rate • Klyken 2015: RCT Mindfulness (MBCT) vs maintenance antidepressants in chronic dep’n – 55% reduction in antidepressant use • MYRIAD study – Adolescents, 7 yr study of primay prevention in shcools. MBCT helps children more adversely affected in childhood

  37. Completing antidepressant drugs: • Patients may be unconfident to try • Agree a time; share the plan • Reassure pts about transient withdrawal effects • Reduce over 4 weeks usually • Slower withdrawal with Paroxetine and Venlafaxine • Warn about relapse – plan ahead, to reduce the risk

  38. Not NICE: Do drugs really work?BMJ 2012; 344:e1014/Ann Int Med 2011; 155: 772 • BMJ editorial of meta-analysis of 234 studies inc unpublished evidence & head-to-head drug trials • Antidepressants work in major depression • 2/3 of patients respond to treatment by 12 weeks • This counters claims of low effect sizes in past studies • No clinically important differences between drugs in efficacy, maintenance or relapse prevention • Some differences in speed of onset & side effects: e.g. Mirtazapine has highest risk of weight gain

  39. Step 3 summary • High intensity psychological interventions • Medication tailored to other conditions, preference, side effects • Maintenance phase then slow reduction • Relapse prevention Step 4: When step 3 treatment is not enough, depression is severe or patient at risk

  40. When step 1-3 interventions do not help? • Do not start combined antidepressants in primary care • Refer to specialist mental health services for oversight • High-intensity psychological interventions • Increased intensity & duration of the interventions • Develop a multidisciplinary care plan with the patient : • Include a crisis plan • Identify crisis triggers & strategies to manage these • Shared with the patient & others eg Ch’c Cond’n Team

  41. When step 1-3 interventions do not help? • Use crisis resolution & home treatment teams for crises • Consider advance decisions & advance statements if appropriate • Consider inpatient treatment if significant risk of suicide, self-harm or neglect • Consider ECT for severe, life-threatening depression, when a rapid response is required, or other treatments have failed

  42. NICE Clinical Guidelines 90 & 91Depression Summary: • Identify depression esp in longterm conditions • Diagnose it carefully - >/= 5 symptoms • Assess severity, impact + suicide risk: BPS assessment • Treat in a stepped care approach –Psychological intervention first, + med’s later usually • Tailor the approach in chronic conditions • Review and end treatment carefully • You can make a difference!

  43. AKT Question • Which one of the following is the most appropriate first line management for mild depression? • A) Citalopram • B) Self-guided Cognitive Behavioural Therapy • C) Psychoeducation • D) Mindfulness • E) Interpersonal psychotherapy

  44. AKT Question: Answers • Which one of the following is the most appropriate first line management for mild depression? (Mild = Step 2) • A) Citalopram (No: step 3) • B) Self-guided Cognitive Behavioural Therapy (Y: It’s a low intensity psychological Rx. Step 2) • C) Psychoeducation (No: For all. Step 1) • D) Mindfulness (No: For relapse prevention) • E) Interpersonal psychotherapy (No: step 3. It’s an high intensity psychological Rx)

  45. NICE Clinical Guidelines 90 & 91Depression Small groups: Relate the guidance to patient cases – Diagnosis, severity, treatment Consider and discuss your learning needs

  46. Case discussion Share your patient scenario. Relate NICE to: • Your clinical assessment of the patient (inc history, examination) • How you made a diagnosis • How/whether you assessed severity • Your approach to management (consider psychological therapies, medications, options) • Follow up • Anything you would do differently re NICE guidance?  • What further questions, learning needs or challenges does this patient highlight for you? 

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