Depression is a common condition. Five to 10 per cent of people seen in primary care suffer from major depression and as many as two to three times more people may experience depressive symptoms but do not meet diagnostic criteria for major depressive disorder.
Depression is characterised by persistent low mood, loss of interest, reduced energy and impaired daily functioning.
Recognition of depression in primary care is crucial. However, making the diagnosis may not be straightforward.
About half of depressed people in the community do not present to their GP, and at least two thirds of those who do see a GP present with physical or somatic rather than psychological symptoms.
Patient preferences for psychological treatments for depression have become amplified by an increasingly negative media portrayal of antidepressant medication to the public as dangerous and addictive.
GPs may be perceived as inappropriately over-prescribing antidepressants.
NICE recently issued guidelines which offer a structured approach to depression management. Both pharmacological and psychological approaches play an important role (see box right).
CBT is the psychological treatment of choice in depression, being as effective as antidepressant medication in major depression. CBT combined with antidepressant medication is more effective than either alone and reduces the risk of long-term relapse.
CBT is a problem-focused approach, which breaks down problems into five areas using a cognitive behavioural model (see below). These areas are interrelated: the way people think alters the way they feel and behave.
Depressed people display characteristically negative ways of thinking about themselves (self-criticism), the world and the future (hopelessness).
Thinking negatively makes people feel more depressed in a vicious cycle of negative thoughts and depressed mood.
Changes in feelings and emotions, such as persistent low mood, loss of enjoyment or pleasure in usual activities, anxiety and panic, anger, guilt and shame are present. These are accompanied by common physical symptoms such as tiredness and lethargy, changes in sleep, appetite and weight, reduced libido, agitation and increased pain.
Depressed people tend to reduce activities that are enjoyable or which provide a sense of achievement in life. Becoming withdrawn and isolated heightens feelings of depression in a vicious cycle.
It is important to consider the life events, social or environmental difficulties, both past and present, which contribute to depression.
Management using CBT
CBT teaches patients long-term skills in changing the dysfunctional beliefs and behaviour patterns that interact as 'vicious cycles' to cause and maintain depression.
This includes learning to 're-frame' negative thoughts and/or beliefs, behavioural activation - increasing activities, perhaps by increasing exercise or social activities. This increases energy and improves mood in a positive cycle, changing negative underlying beliefs and low self- esteem. The impact of antidepressant medication can be also be conceptualised within the CBM: 'physical' alterations in brain biochemistry trigger positive changes in thoughts, feelings and behaviour
There is little doubt about the effectiveness of CBT in the management of depression. However, at present, many regions have little or no access to CBT services. So what is a practical approach to depression in primary care?
Mild to moderate cases
There is little evidence supporting antidepressant medication for mild depression.
Consider interventions such as guided self-help, exercise, computerised CBT or psychological treatments such as CBT or problem-solving therapy.
Some patients may improve while being monitored without additional help (watchful waiting). GPs themselves can also learn simple, effective CBT approaches to use in routine 10-minute appointments.
Moderate to severe cases
NICE recommends offering antidepressant medication to all patients with moderate to severe depression before psychological interventions.
SSRIs are the treatment of choice, with fewer side effects than tricyclics.
Fluoxetine or citalopram are reasonable initial choices, producing fewer discontinuation reactions. Recent evidence shows escitalopram may be better tolerated than citalopram.
Psychological interventions (particularly CBT) and social support should also be offered where available.
In the White Paper, Our health, our care, our say published last month, the DoH revealed that it had asked NICE to review computer-based CBT systems in a bid to make such therapies more widely available.
- Dr David is a GP and cognitive behavioural practitioner in north London.
QUESTIONS TO ASK
During the last month, have you often been bothered by:
- Feeling down, depressed or hopeless?
- Having little interest or pleasure in doing things?
- Katon W, Schulberg H. Epidemiology of depression in primary care. Gen Hosp Psychiatry 1992; 14: 237-47
- NICE. Depression: management of depression in primary and secondary care. Clinical guideline 23. London: NICE, 2004
- Churchill R, Khaira M, Gretton V,et al. Treating depression in general practice: factors affecting patients' treatment preferences. Br J Gen Pract 2000; 460: 905-6
- Williams CJ and Garland A. A cognitive-behavioural assessment model for use in everyday clinical practice. Advan Psychiatr Treatment 2002; 8: 172
- Moore N, Verdoux H, Fantino B. Prospective, multicentre, randomised, double-blind study of the efficacy of escitalopram versus citalopram in outpatient treatment of major depressive disorder. Int Clin Psychopharmacol 2005; 20: 131-7 .
- Rush AJ, Bose A. Escitalopram in clinical practice: results of an open-label trial in a naturalistic setting. Depression and Anxiety 2005; 21:26 -32 - Gorman JM, Korotzer A, Su G Efficacy comparison of escitalopram and citalopram in the treatment of major depressive disorder: pooled analysis of placebo-controlled trials. CNS Spectrums. 2002; 7 (Suppl 1): 40-44
NICE GUIDELINES FOR DEPRESSION
STEP 1: Recognition/diagnosis
Who is responsible?: GP, practice nurse
What is the focus?: Recognition of depression
What do they do?: Assessment
STEP 2: Treatment of mild depression (primary care)
Who is responsible?: Primary health care team (PHCT), primary care
mental health worker
What is the focus?: Mild depression self help, computerised.
What do they do?: Watchful waiting, guided CBT, exercise, brief
Step 3: Treatment of moderate to severe depression
Who is responsible?: PHCT including mental health worker (primary care)
What is the focus?: Moderate to severe depression
What do they do?: Medication, psychological interventions, social
STEP 4: Treatment by mental health specialists
Who is responsible?: Mental health specialists including crisis teams
What is the focus?: Treatment of resistant, recurrent, atypical or
psychotic depression and those at significant risk
What do they do?: Medication, complex psychological interventions,
STEP 5: Inpatient treatment
Who is responsible?: Inpatient care, crisis teams
What is the focus?: Risk to life, severe self-neglect
What do they do?: Medication, combined treatments, ECT