Depression for general practice nurses

Depression for general practice nurses

Definition

Depression is characterised by persistent low mood and/or loss of pleasure in most activities and a range of associated emotional, cognitive, physical, and behavioural symptoms. It is defined by the presence of symptoms for at least 2 weeks of sufficient severity to cause clinically significant distress or impairment in social, occupational, or other areas of functioning.¹

Depressive disorders are very common and are among the leading causes of disability worldwide. In people aged 18-44 years, depression is the leading cause of disability and premature death. Prevalence varies with age and sex, peaking in older adults with more than 7% of women and more than 5% of men affected by depression.^2,3

Causes and complications

The cause of depression is unknown, but is likely to result from a complex interaction of biological, psychological, and social factors. Factors that may increase the risk of depression include people suffering from chronic physical illnesses such as diabetes mellitus, chronic obstructive pulmonary disease, cardiovascular disease, stroke, and especially people with chronic pain syndromes. Psychosocial issues, adverse childhood experiences, and loss are also associated with depression for example divorce, unemployment, poverty, homelessness, and bereavement . Genetic and family factors can be a risk factor for depression and in particular the presence of family history of depressive illness.^3,4

Depression can lead to a range of adverse consequences including an overall reduced quality of life for the person and their families. An impaired ability to normal function for people with depression can result in limited ability to carry on at work, which then may cause a downward spiral impact on mood and feelings of guilt further exacerbating mental health. This can also fuel potential neglect of dependants, family problems, relationship break-ups and creates an increased risk of alcohol and substance abuse.^3,4

Suicide is the main cause of the increased mortality of depression and is commonest in those with comorbid physical and mental illness. Two-thirds of people who attempt suicide have suffered depression. There is a four-times higher risk of suicide in depressed people compared with the general population and the risk of suicide is nearly 20-times higher in the most severely ill.^5,6

Prognosis

With treatment, episodes of depression usually last about 3–6 months. More than 50% of people experiencing a major depressive episode recover within 6 months, and nearly 75% within a year. Up to 27% of people do not recover and go on to develop a chronic depressive illness. The likelihood of recurrence is high, and this risk increases with every episode of depression.^8,9

The outcome is less favourable in older people, where the possibility exists that a serious depressive illness creates a permanent change in personality, mood, and outlook. The prognosis is also worse for people who have severe symptoms, co-existent anxiety or personality disorders, and those people who have psychotic features at presentation.^10,11

Diagnosis

Depression is diagnosed using the Diagnostic and Statistical Manual of Mental Disorders, fifth edition (DSM-5) criteria.¹

Practice nurses should be alert to possible depression, particularly in people with a past history of depression or a chronic physical health problem with associated functional impairment.

When thinking about depression in these people or other you should consider asking the person about the two 'core' symptoms of depression as part of the consultation. These questions are

1. During the last month have you often been bothered by feeling down, depressed, or hopeless?

2. Do you have little interest or pleasure in doing things?

If the person replies that at least one of the two 'core' symptoms have been present most days, most of the time, for at least 2 weeks, you could then go on to ask about any associated symptoms of depression which include disturbed sleep (particularly early morning wakening), decreased or increased appetite and/or weight, fatigue/loss of energy, poor concentration or indecisiveness, feelings of worthlessness, hopelessness, or excessive or inappropriate guilt.^1,2

It is also important to ask about suicidal thoughts or acts. Previously healthcare professionals were reluctant to ask questions about suicidal ideation as they did not know quite to broach this topic worrying that it would somehow encourage the person to think about suicide. There is no evidence that this is the case, and in fact studies have shown that healthcare professionals who take the time to explore the persons thoughts, active plans and their protective thinking around suicide have prevented suicides.

A possible question to start this conversation is ‘I can see that you are feeling quite low at the moment, have you thought how you might get out of this situation?’ This frames the idea that their mood might influence their decision-making and their plans for the future.

The severity of depression is determined by both the number and severity of symptoms, and the degree of functional impairment.¹²

Depression questionnaires can be helpful in detecting depression and in assessing severity, but should not be used alone to determine the presence of depression that needs treatment. The three recommended questionnaires, which are validated for use in primary care, are PHQ-9 (Patient Health Questionnaire 9), HADS (Hospital Anxiety and Depression Scale), and BDI-II (Beck Depression Inventory-II).

Investigations are not routinely indicated for people with depression, but may be necessary to exclude other causes for symptoms or conditions known to be associated with depression, such as hypercalcaemia and hypothyroidism.

Post-viral depression is also a well-recognised phenomenon especially in some individuals with long COVID syndrome. Other diagnoses to consider when making an assessment of a person with possible depression include grief reactions, bipolar disorders, dementia, and obstructive sleep apnoea syndrome.^3,13

Management

Most importantly, if the person discloses an active plan for suicide, has persistent thoughts of suicide then, expresses a sense of hopelessness or has a chaotic or impulsive tendencies or substance misuse issues you should consider contacting the Crisis Resolution and Home Treatment (CRHT) team for an urgent assessment as voluntary admission or compulsory admission may be required.¹⁴ The CRHT team assesses the person's needs, manages the risks of being at home, assists with self-help strategies, visits frequently, offers psychological and practical help, and administers medication.

If this is not required then you may consider discussing the persons care with colleagues and instead review the person frequently in primary care. It is important that practice nurses manage any safeguarding concerns for children or vulnerable adults in their care and follow local safeguarding procedures. You should match the choice of treatment to meet the needs and preferences of the person. Use the least intrusive and most resource efficient treatment appropriate for their clinical needs, or one that has worked for them in the past. You should also provide written information to review.⁴

Compulsory admission

If the person needs to be admitted to hospital, every attempt should be made to persuade them to go voluntarily. If admission is necessary but the person declines, compulsory admission may be arranged under sections 2, 3, or 4 of the Mental Health Act. The Mental Health Act allows compulsory admission of people who have a mental disorder of a nature or degree that warrants assessment or treatment in hospital, and need to be admitted in the interests of their own health or safety, or for the protection of other people.¹⁵

Other options for management

Clearly if there is an opportunity to optimise and manage any comorbid condition associated with depression then this should be undertaken. This could include tackling underlying alcohol or substance abuse. If there is co-morbid anxiety, the first priority is to treat the depression.

For people where a physical illness has caused functional impairment or chronic pain leading to depression, this may require a multifaceted approach including pain specialists, cognitive behavioural therapy, physiotherapy and specialisms appropriate to the disease area.

If the person has psychotic symptoms or an eating disorder you should seek immediate expert advice from a psychiatrist.⁴

For people with mild depression who do not want an intervention you should consider a period of active monitoring, discuss the presenting problems and any concerns they may have and provide information about the nature and course of depression. You should also arrange a timely follow up, normally within 2 weeks. For people with mild-to-moderate depression consider offering a low-intensity psychosocial intervention accessed by referral or self-referral to IAPT (Improving Access to Psychological Therapies).

For people with moderate or severe depression offer an antidepressant and a high-intensity psychological intervention. Psychological interventions are accessed by referral or self-referral to IAPT. The type of intervention offered will depend on the severity of depression, the response to any previous treatment, the likelihood of adherence to treatment and potential adverse effects, and the person's preferences and priorities.⁴

Medication

It is important to recognise that antidepressant medication should not be offered as first-line treatment for less severe depression, unless that is the person's preference, and that people have a right to decline treatment.

Antidepressants should be considered for people with a previous history of moderate or severe depression, depressive symptoms that have persisted for years, mild depression that persists after other psychological interventions or mild depression that is complicating the care of a chronic physical health problem.

For a first episode of depression, a generic selective serotonin reuptake inhibitor such as citalopram, fluoxetine, paroxetine, or sertraline should be offered. For a recurrent episode, an antidepressant that has previously elicited a good response should be offered. You should also provide information about not suddenly stopping medication, the risk of withdrawal and how to minimise these effects by tapering when it is appropriate to stop anti-depressant medication.⁴

Psychosocial and psychological interventions or 'talking cures'

Low-intensity psychosocial interventions are suitable for people with persistent depressive symptoms or mild depression, and include individual guided self-help, based on the principles of cognitive behavioural therapy (CBT) which includes written material or other media relevant to reading age, and usually consists of 6–8 sessions over 9–12 weeks.⁴

More recently the advent of computerised cognitive behavioural therapy (CCBT) can be provided via a stand-alone computer-based or web-based programme and usually takes place over 9–12 weeks. This has been shown to be as effective as face-to-face therapy for most individuals with milder depression.

High-intensity psychological interventions are generally reserved for people with moderate-to-severe depression, and includes CBT usually given over 16–20 sessions over 3–4 months. For people with severe depression, two sessions per week might be provided for the first 2–3 weeks of treatment.

Counselling and short-term psychodynamic therapy can be considered for people who decline antidepressants and high-intensity psychological interventions. Counselling is usually provided in 6–10 sessions over a period of 8–12 weeks. Short-term psychodynamic therapy usually consists of 16–20 sessions over 4–6 months.⁴

Follow-up

Regular follow-up of people is critically important. Practice nurses can have a pivotal role in ongoing management of these individuals. Follow-up is especially important where there is a risk of suicide, where there is evidence of a chaotic lifestyle and/or substance misuse, where there may be issues of safeguarding.⁴

The review period should be determined by the risk of suicide and the need to assess the tolerability and effectiveness of any treatments started or changed.

If a person's depression has had no or a limited response to treatment with psychological therapy alone, and no obvious cause can be found and resolved, discuss further treatment options. These include switching to an alternative psychological treatment, adding an SSRI to the psychological therapy, or switching to an SSRI alone.⁴

In general, for people not considered to be at an increased risk of suicide arrange reviews every 2–4 weeks for the first 3 months then longer intervals if the response to treatment is good. You should support and encourage people who have benefitted from taking an antidepressant to continue it for at least 6 months after remission as this greatly reduces the risk of relapse.⁴

You should emphasise the fact that antidepressants are not associated with addiction.

Some people with depression should take medication for longer 6 months, particularly if they have had previous episodes, persisting residual symptoms or ongoing physical health problems and psychosocial difficulties. For people at significant risk of relapse or those with a history of recurrent depression, discuss treatments to reduce the risk of recurrence including: for these people who are at the highest risk for relapse they should continue treatment for at least 2 years, maintained at the effective treatment dose.⁴ NICE is currently developing a quality standard, which sets out priority areas for quality improvement for the care of adults with depression, including the need for support for patients who wish to reduce their use of antidepressants, or stop drug therapy.¹⁶

Conclusion

Practice nurses are ideally placed to recognise possible signs of depression in patients they see for management of their long-term conditions, especially when low mood starts to interfere with self-care.

Assessing suicide risk and escalating this to other colleagues when appropriate, especially to the Crisis Team, is a crucial skill to develop. Ongoing management of this risk and assessing progress of either medication and/or taking cures are key elements of the care of people with depression.

Honing these skills can be a rewarding part of the toolkit that practice nurses use in helping people with mental health problems recover from depression to fulfil their life potential.

References

1. American Psychiatric Association. Diagnostic and statistical manual of mental disorders: DSM-5 TR. 5th edn, text revision. https://www.psychiatry.org/psychiatrists/practice/dsm

2. WHO. Depression and other common mental disorders: 2017 https://www.who.int/publications/i/item/depression-global-health-estimates

3. Depression in adults. BMJ Best Practice; 2022. https://bestpractice.bmj.com/topics/en-gb/55

4. NICE NG222. Depression in adults: treatment and management; 2022. https://www.nice.org.uk/guidance/ng222

5. Bostwick JM, Pankratz VS. Affective disorders and suicide risk: a re-examination. American Journal of Psychiatry 2000;157(12):1925-1932.

6. Cassano P, Fava M. Depression and public health: an overview. Journal of Psychosomatic Research 2002;53(4), 849-857.

7. Kessler RC, Berglund P, Demler O, et al. The epidemiology of major depressive disorder: results from the National Comorbidity Survey Replication (NCS-R). Journal of the American Medical Association 2003;289(23), 3095-3105.

8. American Psychological Association. Clinical practice guideline for the treatment of depression across three age cohorts: 2019. https://www.apa.org/depression-guideline

9. British Columbia Medical Association. Major depressive disorder in adults: diagnosis & management; 2013 https://www2.gov.bc.ca/gov/content/health/practitioner-professional-resources/bc-guidelines/depression-in-adults

10. Cleare A, Pariante CM, Young AH, et al. Evidence-based guidelines for treating depressive disorders with antidepressants: a revision of the 2008 British Association for Psychopharmacology guidelines. Journal of Psychopharmacology 2015;29(5), 459-525.

11. Malhi, G.S. and Mann, J. (2018) Depression. Lancet. https://www.ncbi.nlm.nih.gov/pubmed/30396512

12. WHO. ICD-11 (International classification of diseases for mortality and morbidity statistics, 11th Revision); 2022. https://icd.who.int/en

13. Malhi GS, Bassett D, Boyce P, et al. Royal Australian and New Zealand College of Psychiatrists clinical practice guidelines for mood disorders. Australian and New Zealand Journal of Psychiatry 2015;49(12): 1-185

14. HM Government. Preventing suicide in England: Fourth progress report of the cross-government outcomes strategy to save lives; 2019. https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/772184/national-suicide-prevention-strategy-4th-progress-report.pdf

15. Department of Health. Reference guide for the Mental Health Act 1993; 2015. https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/417412/Reference_Guide.pdf

16. NICE. Adults with depression who want to quit antidepressants should given support on how to do it safely after time. Press release 17 January 2023. https://www.nice.org.uk/news/nice-draft-quality-standard-depression-adults-update-2023