GEM - depression in adults incorporating NICE guidance

"Mental health problems in primary care are common. The range of mental health problems encountered by a general practitioner is large, and includes for example: adjustment reactions (normal responses to external circumstances); short or longer term disability associated with symptoms of depression and anxiety (which can be defined psychiatrically with diagnoses such as depression, but can also be seen as socially constructed); and schizophrenia and bipolar disorder (with a clearer biological basis, more easily defined from symptoms, but also with significant social meaning and consequences). These can co-exist with each other, and also with problems related to consumption of alcohol or drugs, and with problems resulting from difficult traits and personality types.." (1).

Depression

NICE suggest that screening for depression should be undertaken in primary care and general hospital settings for depression in high-risk groups - for example, those with a past history of depression, significant physical illnesses causing disability, or other mental health problems, such as dementia....

• what period of time do the screening questions consider? GPN reference

There are various screening tools which exist to assess the severity of depression such as the Beck depression inventory

NICE use diagnostic criteria based on DSM IV diagnostic classification

• GPN reference

Considering management of mild depression in primary care:

• what period of "watchful waiting" might be indicated?
• should a patient be advised to exercise?
• is antidepressant medication the treatment of choice?
• GPN reference

Cognitive behaviour is a treatment modality that may be used in the primary care management of mild or moderate depression. What is cognitive behaviour therapy?

• GPN reference

How does the evidence base for antidepressant treatment for mild depression compare with the evidence base for treatment of moderate/severe depression?

• GPN reference

If a patient has moderate depression and is managed with antidepressant medication in primary care:

• what is the antidepressant depressant class of choice to be used in primary care?
• should venlafaxine be used in primary care?
• if a tricyclic antidepressant is used, which is the safest tricyclic in overdose?
• GPN reference

If a patient has a history of coronary heart disease, what is the selective serotonin reuptake inhibitor (SSRI) of choice?

• GPN reference

When starting and monitoring antidepressant treatment in primary care:

• what is the suggested period for intial review when starting treatment?
• what factors would mean an earlier review was necessary?
• if a patient is remission, for what minimum period of time should antidepressant medication be continued?
• GPN reference

If considering failure to respond/partial response to therapy?

• what period of time should be considered?
• is this period of time different in the elderly?
• GPN reference

When stopping antidepressant therapy:

• what period of time do NICE suggest that withdrawal of an antidepressant should occur over?
• when switching between antidepressants?
  • is cross-tapering
    • required when switching from dosulepin to citalopram?
    • fluoxetine to citalopram?
  • GPN reference

Antidepressants in pregnancy:

• what are the concerns regarding use of SSRIs in pregnancy?
• have tricyclic antidepressants of monamine oxidase inhibitors been widely used in pregnancy?
• GPN reference

Referral from primary care:

• in addition to diagnosis of severe depression, suggest some circumstances when a patient may be referred for specialist advice? GPN reference

Regarding SSRIs:

• what is the relationship between SSRIs and gastrointestinal bleeding? GPN reference
• do SSRIs affect driving ability? GPN reference
• how does the use of St John's wort affect the use of an SSRI? GPN reference
• what are the common discontinuation symptoms associated with abruptly stopping an SSRI? GPN reference

Reference:

1. Royal College of General Practitioners. Curriculum Statement 13 Care of People with Mental Health Problems.