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Practice Nurse

Investigation and management of depressive illness

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Depression is a very common presenting problem to primary care. It also pervades much of the management of chronic disease. Treatment revolves around the integration of a number of approaches and not just pharmacological measures. This module is composed of 10 self assessment questions and tests your knowledge of common presentations of depression and related illness. On successful completion of the resource, you will obtain a certificate for 1 hour of continuous professional development appropriate for inclusion in your portfolio.

On completion of this resource, the user should

Have an improved understanding of the assessment of depression

Have an increased awareness of the treatments available for depressive illness

Have an improved understanding of the pharmacological approach to treating depressiveillness

Depression is a very common presenting problem to primary care. It also pervades much of the management of chronic disease. Treatment revolves around the integration of a number of approaches and not just pharmacological. This resource is composed of 10 self assessment questions and tests your knowledge of common presentations of depression and related illness. On successful completion of the resource, the user will obtain a certificate for 1 hour of continuous professional development appropriate or inclusion in your portfolio.

have an improved understanding of the assessment of depression

have an increased awareness of the treatments available for depressive illness

have an improved understanding of the pharmacological approach to treating depressive illness

Mental Health

A 55 year old male attends clinic. He has diabetes and has been complaining of low mood because of the diagnosis and difficulties with changes in his lifestyle. He currently takes atenolol,amlodipine and metformin. With which particular questionnaire would you assess this man's depression?

The Quality Outcomes Framework (QOF) encourages the screening of patients with chronic disease such as diabetes and coronary artery disease for diabetes. Useful questionnaires for depression include the Patient Health Questionnaire (PHQ)-9 as well as the Hospital Anxiety and

. PHQ-9 is a well validated and well used questionnaire in primary care.
The CAGE questionnaire is designed for assessment of alcohol abuse, GPAQ is for patient's views on the practice and Patient General Well Being Survey and Short Form-36 are assessments of general health.

Question 1

A 55 year old woman attends clinic feeling rather low and tearful. She has been feeling this way for a number of weeks as she has recently split from her husband and has some monetary problems.On further questioning, which of the following suggests that the patient can be managed with general advice and monitoring?

The fact that this woman has a short duration of symptoms would suggest that she can be monitored in practice with relevant support. The decision to provide general advice and monitoring or to prescribe or refer can also be informed by her score on the PHQ-9.
Risk factors for depression include:

Depression should be categorised as mild, moderate or severe depending on the severity and impact of symptoms of normal functioning and on the patients quality of life, this helps to determine what level of treatment, if any, should be commenced.

Question 2

The practice has been seeing a 30 year old woman who has been treated for depression. Four weeks ago she was commenced upon citalopram and has now come back to the clinic. Which of the following should be used to monitor her response to treatment?

In primary care, PHQ-9 is regarded as the most appropriate tool for monitoring response to treatment and also assessing severity of depression. It is not, however, a screening tool for depression. One's aim in the treatment of depression would be remission of symptoms as reflected by a PHQ-9 score of less than 5. A PHQ-9 score of 10 or above is highly sensitive for identifying major depression. There are two components of the PHQ-9, assessing symptoms in order to make a preliminary diagnosis of depression and obtaining some form of severity score in order to monitor the progress of a patient's treatment.

Question 3

A 42 year old man attends clinic complaining of feeling particularly down. He has had these problems for a few months since the collapse of his business and divorce from his wife. Which one of the following is a key diagnostic symptom in depression?

The three key symptoms of depression include:

Persistent sadness or low mood which is described in our case

With any of these features, one should ask about the following: poor appetite, disturbed sleep, poor concentration, guilt, agitation.

Question 4

A 45 year old female attends clinic feeling low and unhappy. During the consultation she is tearful and informs you that her problems are a result of her husband who she accuses of being lazy and wasteful with the couple's finances. She has been married 15 years and has no children. She feels that the relationship is dragging her down and she has had problems sleeping. Which of the following would be the best approach to treating this woman?

This woman's issues revolve principally around the marital relationship and it would be most appropriate, rather than treat with an anti-depressant, to suggest relationship counselling as the initial approach. The fact that there is a clearly identifiable cause for the patient's low mood actually improves the prognosis for this woman.
Depression is present when two or more core symptoms are present for at least part of the day, every day, for two weeks. These major symptoms are:

Anhedonia (Where a patient is not able to enjoy or take pleasure from usually enjoyable activities)

Question 5

A 35 year old woman attends clinic in a tearful state complaining of general low mood and problems sleeping. These problems have built up over a number of years and she is unhappy due to divorce as well as financial problems. She also explains that she has a strained relationship with her mother. She has tried support and counselling but her problems persist.Her PHQ-9 score suggests moderate depression and she merits treatment. What would be the most appropriate treatment to offer this patient?

This patient has a reasonably long history of depressive symptoms and has tried supportive approaches.Therefore, as indicated in the question, therapeutic approaches are suggested. The most appropriate first line agent in this woman with moderate depression would be a SSRI (selective serotonin re-uptake inhibitor) like escitalopram.
Before commencing a patient on an SSRI they should be informed of:

The importance of taking the drug as prescribed, even after their mood is good again

The gradual development of the anti depressant effect

The danger of stopping the antidepressant suddenly

Other available SSRIs are citalopram, fluoxetine, fluvoxamine, paroxetine and sertraline.

Question 6

A 55 year old female attend clinic after being started on fluoxetine for depression approximately4 weeks ago. She has not felt that much better since starting the fluoxetine at a dose of 10mg daily.What should be done next for this patient?

It is important to monitor the response to the introduction of pharmacological treatment for depression. This can be facilitated through the PHQ-9 questionaire and through interaction with the patient.

If after the first three weeks of treatment the patient hasn't made a good clinical response then it should be first checked that the patient is taking the drug as prescribed. If so, and there is no adequate response and no significant side effects, then the dose should be up-titrated. Consider switching treatment if the response is still not adequate, if there are significant side effects or if the patient has good reasons why they would prefer to change drug.

NICE guidelines on management of depression

Question 7

A 32 year old woman attends clinic one week after the delivery of her first child. Although all the family are happy, she feels rather down and has been frequently tearful, emotional and has had disturbed sleep. She has a lot of support from family and her relationship with her husband is fine.She doesn't know why she feels like this which makes her more upset. What is the likely diagnosis?

This woman has typical features of baby blues, a mild depressive and typically self limiting illness which occurs within a few days of delivery. This patient should be counselled and supported with advice on the fact that such feelings are often common and typically resolve. She should be asked to return if the symptoms deteriorate or her feelings do not resolve.
The baby blues is very common with around 70% of mothers experiencing low mood at some point soon after birth and some experiencing the blues during pregnancy. The baby blues usually only last up to 10 days after birth whilst post natal depression can go on for 6 months.

Question 8

A 55 year old male attends clinic three months after he was admitted and treated in hospital for amyocardial infarction. He made a good recovery from this and was discharged on atenolol, aspirin,ramipril and simvastatin. However, he informs you that he has been a changed man since the heart attack. He has been rather snappy at home with his family, fears about his mortality and has generally been feeling low. He enquires if there is anything that he could take to improve his mood.Which would you advise?

Depressive symptoms post-MI are very common with patients three times more likely to experience depression after a heart attack than the general population. This is not surprising as major life stressors are known triggers for depressive episodes.
Studies indicate that treatment with an SSRIis effective in improving these symptoms which might otherwise interfere with convalescence and rehabilitation. Tricyclic antidepressants such as amitriptyline are relatively contra-indicated post MI due to potentially increased risk of arrhythmias. Similarly with regard to the Selective Noradrenergic Uptake Inhibitor, venlafaxine, concerns have been raised relating to cardiovascular risk although meta-anlyses have not demonstrated any increased risk. However, the MHRA have advised not using venlafaxine in patients with increased cardiovascular risk.

Antidepressant use in patients with acute coronary syndrome

Question 9

A 45 year old woman attends clinic as she has had problems after starting fluoxetineapproximately 4 weeks ago when she was diagnosed with depression. Although she began to feel better, over the last 2 weeks she has felt more agitated, has noticed that her sleep is worse and that she now feels tense and has occasional palpitations. She is currently taking 20mg of fluoxetine.What is the most appropriate approach for this patient?

This patient has now developed symptoms of agitation, poor sleep and irritation suggesting aserotonin syndrome, a side effect of the fluoxetine. The most appropriate approach is to stop the medication. An alternative antidepressant may be tried if her depressive symptoms persist.
Serotonin syndrome is a potentially life threatening adverse drug reaction, caused by excessive stimulation of the central nervous system and peripheral serotonin receptors. It can occur with normal therapeutic drug use, intentional overdoses of antidepressants and with drug interactions. Features include confusion, delirium, shivering, sweating, changes inblood pressure and myoclonus (brief, involuntary twitching of a muscle or muscle group). The first line of treatment is always firstly to stop the offending drug, some patients may need further support depending on the severity of the syndrome.

Investigation and management of depressive illness

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