Mental Health in Primary Care:

Management of Depression

Overview of MH in Primary CareRecognition and Management of Depression

Te Rau Hinengaro – the NZ Mental Health Survey

46.6% - Estimated lifetime risk for developing any mental health disorder

24.9% - Lifetime prevalence for the development of any anxiety disorder

20.2% - Lifetime prevalence for the development of any mood disorder

12.3% - Lifetime prevalence for the development of any substance-use disorder

20.7 % - Prevalence of mental disorder in past year

- Te Rau Hinengaro: The New Zealand Mental Health Survey (2006)

Te Rau Hinengaro – Mental Health of Maori

12 month ratesMaori – 29.5% Other - 19.3%

12 month mood disorder (depression, BPAD) ratesMaori – 11.6% Other – 7.5%

Corrected for age and socioeconomic factorsGap reduced but still increased rates

Higher rates of severe conditions among Maori Higher rates of suicidal thinking and behaviour Lower rates of access to health services

Te Rau Hinengaro – Mental Health of Pacific Peoples 12 month rates

Pacific – 24.4% Other - 19.3%NZ Born Pacific – 31.4% Migrated after age 18 – 15.0%!Higher rates in PI groups with longest history of

“colonisation”!

12 month mood disorder (depression, BPAD) ratesPacific – 8.3% Other – 7.5%

Corrected for age and socioeconomic factorsGap disappears, same overall rates BUT lower depression rates!!

Sl. higher rates of severe conditions among Pacific Higher rates of suicidal thinking and behaviour Much lower rates of access to health services

Mental Health Treatment – Unmet Need

Only 38.9% of all 12 month cases of mental disorders visited a health or non-health provider 28.3% to a GP 16.4% to a mental health specialist 4.8% to a social services professional 6.9% to a complementary or alternative medical

practitioner Of those who sought help, most visited a GP for

help with a mental disorder Rates of help-seeking/access to healthcare

lowest for PI, lower for Maori

- Te Rau Hinengaro: The New Zealand Mental Health Survey (2006)

How common are mental health problems –the scale of the problem…all classes and cultures

Our children

1 in 5 under the age of 15

Only 25% can access care

50% bullied, leading to: •Depression•Low self- esteem•Suicide

1: 10 have unrecognised dyslexia, dyspraxia

The workforce

1 in 5 adults at any time

1: 10 have depression

Suicide is the greatest cause of male deaths < 35 yrs

Work related stress affects 25-30%, ? > 1 million work days lost a year

Senior citizens

Dementia effects•5% over 65’s 10-20% over 80

1 in 6 over 65 suffer from depression

Major factors: •Social isolation •Physical ill- health

30% of >65s in med/surg beds have dementia

All communities

Many spoken languages in NZ; many cultural beliefs & mental health issues

Over-representation of Maori & Pacific people in MH acute inpatient & forensic care

Causes of MH Problems – not only a health issue

Life cycle time•Divorce•Retirement•Redundancy•Menopause

Life cycle time•Divorce•Retirement•Redundancy•Menopause

Isolated Women with small children

Isolated Women with small children

Victims of domestic violence

Victims of domestic violence

Employment stress•Bullying •Harassment

Employment stress•Bullying •Harassment Long term

physically ill

Long term physically ill

Elderly isolated men

Elderly isolated men

Socio-economicDisadvantage – poverty, housing, unemployment

Socio-economicDisadvantage – poverty, housing, unemployment

Alcohol & Drug misuse

Alcohol & Drug misuse

Treatment of Common MH Conditions in the Real World

Too often…Presenting physical symptoms are the main

focus of assessment and interventionWhen a MH condition is diagnosed people do not

access evidence-based interventions:An SSRI is started at 20 mg and continued unchanged

despite partial or non-responseThere is no practice-nurse phone support/follow-up

(despite compelling evidence of significant effectiveness)

Very limited access to effective talking therapies

…though the PHO primary care programmes have all slowly improved this situation.

Anxiety, Depression and Substance

Use disorders in General Practice

(12 months):

Total Substance

11.3%

9.7%

6.7%

Total Depression

18.1%

2.5%

8.0% 2.0%

5.8%

Total Anxiety22.2%

1.0%

Patient Presentation to the GP

169 (43.9%) = physical acute illness. 70 (18.2%) = pain 55 (14.3%) = physical chronic condition. 22 (5.7%) = main reason

psychological

Barriers to Care – Patient Experience (Recent US/UK research)

5 commonest presentations to Primary Care where no obvious physical pathology: Headache, low back pain, lethargy, non-spec. GI

and CVS Sx Surveyed community prevalence of these

symptoms: On average significant Sx experienced every 3-4/7

What determined whether these symptoms were taken to the doctor/health centre?? Main factor distinguishing those who went to

Primary Care was the presence of stress/distress/mental health condition

Barriers to Care: Patient Perception - Disclosure

(MaGPIe data)

Not wanting to talk about emotional problems at all “They’re my private problems and I’m the only one

that can deal with it, I don’t see any relevant point in telling a doctor”

Problem not bad enough to talk about to anyone “Didn’t class them as medical, they weren’t the

reason I went to see doctor, they didn’t seem serious”

Barriers to Care: Patient Perception - Role of the GP

(MaGPIe data)

The GP is not the right person to talk to about mental health problems “Only there for the flu. If you’re having emotional

problems you don’t take that to the doctor” “He’s there for the physical side of health” “I went to a counsellor instead”

Worried about the GP's response “Thought he would presume I was a nutter and

prescribe pills, I didn’t think pills were the answer or he might refer me to a psychiatrist and I didn’t want to be stereotyped”

“Afraid of going back into hospital”

Co-Morbidity of Medical Illness and Depression

Illness % with DepressionCancer 40 – 50%Heart Disease 18 – 26%Diabetes 33%Multi-infarct Dementia 27 – 60%Multiple Sclerosis 30 – 60%Parkinson’s Disease 40%Stroke 30 – 50%

Mental/Physical Health Link – Example 1: Diabetes and Depression

Patients with diabetes have double the population incidence of depression – for reasons which are poorly understood

Depressed patients are three times more likely not to comply with medical treatment

Outcome of co-morbid diabetes/depression – poorer diet, more hyperglycaemia, greater disability, higher healthcare costs

BUT… treatment of depression/anxiety in diabetic patients results in dramatically improved mental and physical health outcomes, lower secondary care costs – the treatment pays for itself within 1 year

Mental/Physical Health Link – Example 2: Depression and Heart Disease

Depression predicts the incidence of heart disease

Depressed patients have greater than three times the risk of a cardiac event, in particular MI

Depressed patients have reduced post-MI survival, poorer adjustment, slower return to function, increased disability, increased medical costs

Treatment of co-morbid depression results in improved mental and physical health outcomes, and lower secondary care costs – the treatment pays for itself

Medically Unexplained Symptoms

20% of GP consultations

50% of outpatient consultations in specialist care

More dissatisfied with GP care

Improve with psychological therapy ++, medications +/-

Acute Care … money well spent ?

Medically unexplained symptomsCBT is effective in :

• Irritable bowel syndrome

• Chronic fatigue• Chronic Back pain• Somatisation disorders

CBT is most effective:

• Early in the disorder

Antidepressants are effective in:

• Irritable bowel syndrome (a bit)

• Chronic back pain (a bit) • Chronic fatigue (not)

CBT could be afforded in primary care by: • Reducing acute outpatient clinic referrals • Reducing one emergency admission a month would fund

0.75 of a psychologist• Provide 4-6 sessions for 150 people a year

Patient Presentation to the GP

169(43.9%) = physical acute illness

70 (18.2%) = pain 55 (14.3%) = physical chronic

condition 22 ( 5.7%) = main reason

psychological(38.2%)

cf (35.7%) = DSM Disorder past 12 mths

Primary MH Care: The Challenge

Most patients are experiencing physical symptoms and wanting help with these

Stigma, attitudes re GP role/interest, and beliefs re mental illness prevent ready discussion of MH issues even when the patient is aware of them

You only have 15 min to address these issues, and agree a plan of action to address MH issues…

Frequency of Consultation and Identification of any Psychological

Issue

  

Variable Adjusted for age and sex

Number of prior consultations

RR 95%CI

Never before 1 -

Once or twice 1.8 1.3 – 2.6

Three or four times 2.3 1.6 – 3.2

Five or more times 2.9 2.1 – 4.1

Questions and Discussion

Major Depressive DisorderDiagnostic Criteria (DSM – IV)

1. Key Symptoms: Depressed MOOD

Diminished INTEREST

2. Other Symptoms: Appetite decrease (or increase) / weight loss (or gain) Marked sleep disturbance (increase or decrease) Psychomotor changes (agitation or retardation) Fatigue or loss of energy Feelings of worthlessness or guilt Diminished concentration or indecisiveness Recurrent thoughts of death or suicide

Either Key, and 4+ Other, for 2+weeks – MAJOR DEPRESSION

Depression “Subtypes”

Depression is a syndromal description, within which several discrete “subtypes” are identified. Those with important treatment implications are:

Melancholic – prominent early waking, diurnal variation, psychomotor agitation/retardation, guilty thinking Seems to respond better to Venlafaxine, TCA at antidepressant doses, need medication before any psychological intervention

Atypical – increased sleep, increased eating/weight, heightened interpersonal sensitivity, weighed down feeling/”leaden limbs” Poor response to most antidepressants; some response to Paroxetine, better response to Venlafaxine, Phenelzine (MAOI) – best outcome with CBT +/- antidepressants

Psychotic – onset of psychotic symptoms during a depressive episode, often mood congruent Poor response to antidepressants alone – need antipsychotic as well

Differential Diagnosis of Anxiety

vs Depression 1. Screen for Depression and Anxiety Disorders2. Given the common presence of symptoms of both,

what is the relative predominant cluster of symptoms?a. Depression – low mood, loss of interest/motivation,

anhedonia, early waking, low energy, hopelessness, etc. VERSUS

b. Anxiety – anxious mood, initial insomnia, “nervous energy”, etc.

3. What is the relative time course of symptoms of depression vs symptoms of anxiety?a. Are episodes of onset of depression, followed by onset

of anxiety symptoms, which resolve as depression recedes; OR

b. Has anxiety waxed and waned, with episodes of depression superimposed (most often with worsening of anxiety)

Differential Diagnosis of Unipolar vs Bipolar

Depression Bipolar – COMMON cause of poor treatment

response, risk of inducing mania 20% patients with depression have some form of

Bipolar Disorder – esp early onset, family history 2-Question screen for Bipolar:

Have you had periods where you can get by on less sleep than usual?

Have you had periods of doing things others may think inappropriate eg, spending too much money

Irritable mood common in both hypomania and depression

Outcome typically worse with antidepressants

Differential Diagnosis of Depression vs Alcohol

Abuse/Dependence Diagnosis of depression cannot be

accurately made in the face of significant alcohol abuse/dependence

Alcohol abuse/dependence can mimic major depression

In the presence of significant alcohol abuse/dependence need to first treat for this, then reassess re presence or not of persisting depressive symptoms

Suicide Risk Screening

It looks from what you’ve told me that you’ve been feeling

pretty bad lately -

Do you see any future for yourself?

Do you feel you would be better off dead?

When you’re at your worst have you thought about

ending your life?

Have you thought about how to do it?

Do you want to act on this plan?

Have you got access to (planned means)?

Do you feel others would be better off without you?* Escalating risk with each successive positive answer

Suicide Risk Factors(Presence indicates increased risk)

Severity of current depression and hopelessness Previous attempt(s) Alcohol/Drug abuse Social isolation Family History of suicide Medical co-morbidity Agitation Being an older male Recent significant loss(es)

Questions and Discussion

The Stress-Vulnerability Model

Multiple intersecting lines of research strongly suggest that a person’s mental health at any point is determined by the interaction of vulnerability factors, and current stress levels

Vulnerability (risk) factors – Biological – Genetic factors, brain insults/injury Psychological – adaptive/coping style

Stress – Ambient stress – work stress, financial pressure etc. “Life events” – bereavement, divorce, change, etc.

The Stress-Performance Relationship

STRESS

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“A little stress is a good thing, too much is not!”

Effects of Stress on the Body –The “Sabre-Tooth Tiger” Problem

Increase of fatty acids and cholesterol

Body Change

Tense muscles

Restricted flow of blood to skin

Increased perspiration

Blood clotting

Increased production of white blood cellsIncreased heart rate

Increased respiratory rate

Digestion depressed

Increase of acid in stomach

Decrease in saliva

Liver releases extra sugar

Pupils dilate

Action or Short-Term Effect

Quick Reaction

Blood diverted to other areas, minimises blood loss in injury

Cools body

Minimises blood loss in injuryFights infection

Increase flow of blood carrying oxygen and nutrients

Provides more oxygen; eliminate carbon dioxideBlood diverted to other areas where needed

Irritates stomach lining

Not needed for digestion

More energy available

More energy available

Increased visual perception

Potential Long-Term Effect

Headache; back, neck, shoulder and jaw pain;fatigue

Pallor, skin rashes; itching, dryness

Loss of fluids; body odour

Blood clots; stroke; heart attack

Immune system becomes unbalanced

High blood pressure irregular heart sounds; rapid heart rate; damage to heart muscle

Impaired breathing; hyperventilation

Nausea; indigestion; colitis, diarrhoea

Ulcers

Diabetes

Cholesterol build-up in arteries; stroke; heart attack

Impaired vision

Dry mouth; indigestion; loss of voice

Awareness and Recognition:Symptoms of Chronic Stress

Constant worry

Racing mind

Illogic

Can’t concentrate

Impatience

Depression

Loneliness

Churning stomach

Backache

Palpitations

Chest tightness

Poor sleeping habits

Rapid speech

Reckless driving

Excessive drinking

Easily distracted

Uncertainty

Forgetfulness

Poor memory

STRESS ANDYOUR MIND

STRESS ANDYOUR FEELINGS

STRESS ANDYOUR ACTIONS

STRESS ANDYOUR BODY

Irritability

Anxiety

Anger

Low self-esteem

Fatigue

Headaches

Diarrhoea

Poor eating habits

Drug use

Excessive smoking

The Link Between Stress and Mental Health/Illness

From time to time, everyone faces things in life that cause stress – we will all move up and down this continuum

Sometimes, people’s normal coping skills are not enough to deal with these stress events, leading to developing symptoms

In any one year, for 20% of the population, 35% of Primary Care attenders, life stressors will be causing a mental health or drug alcohol condition – or in our lifetimes this figure is 50%

Increasing intensity of stressors

Stress Chronic StressEmotional Disorders

(Depression, anxiety, alcohol and drug problems)

The Stress-Vulnerability Model: Vulnerability Threshold Research

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Time

Well

Unwell

Greater Resilience

Greater Vulnerability

VulnerabilityThreshold

The Stress-Vulnerability Model:Impact of Life Stress Research

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Stress:•Ambient life stress•“Life Events”

New Job

Marital Separation

Ambient Stress – e.g. work stress, marital problems, etc.

Job Loss

Life Events – one-off stressful events/changes

Time

Well

Unwell

The Stress-Vulnerability Model:Medication Effect Research

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Well

Unwell

Medication raises the vulnerability threshold for as long as it is taken

Time

The Stress-Vulnerability Model:CBT Effect Research

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Well

Unwell

CBT has a slower onset of action in raising the threshold, but the effect is sustained over time

Time

Questions and Discussion

Evidence-Based Treatments –Overview

General Messages:Expect full recovery, communicate this to

patient, treat vigorously, don’t accept non/poor-response

Non-specific therapeutic factors (rapport, strength of relationship, the person feeling validated and understood) make a significant contribution towards good outcome, and are the largest effect in psychotherapy outcome

Whatever interventions are made, persisting in treatment, and maintaining hope and an optimistic outlook, are the most critical factors

Evidence-Based Treatments –Overview

Supportive counseling and education re the condition – what GPs and PNs do every day!

Self-management focus – incl information/educn Lifestyle factors – Exercise, Sleep, Diet Activity Scheduling Brief problem solving Medications – around 50-60% response rate for any

1 medication (NB – placebo response rate 30%!) Phone follow-up/support – around 20% response

rate (as good as medication!) Cognitive Behaviour Therapy (also same response

rate as medication)

“The type of treatment matters less, than ensuring it is done properly, and followed up”

Ed Wagner

Effective Treatments for Depression

Mild Depression (PHQ-9 <15): Support/advice Exercise Activity Scheduling Problem Solving

Moderate/Severe Depression (PHQ-9 >15) The above plus… Antidepressant medication Cognitive Behavioural Therapy

Treatment of Depression –Medication vs CBT

The Effectiveness of Treatments:

Uncomplicated Depression – Acute Treatment RCT’s Meta-Analysis

a. CBT 58.9% vs 28.2%NNT – 3.27

b. SSRI vs placebo 51.3% vs 29.1%NNT – 4.50

c. TCA 54.5% vs 34%NNT – 4.86

Depression – Long-Term Treatment RCT’s Meta-Analysis

a. CBT vs Antidepressant 54.5% vs 35.5%NNT – 5.27

b. CBT vs Placebo 65.1% vs 37.0%NNT – 3.56

c. Problem solving vs TCA 59.1% vs 55.2%NNT – 25.85

(ie. More or less equal)

Source – RANZCP Guideline for Treatment of Major Depression (2002)

Getting maximum “bang for your buck” – practice nurse phone follow-up and support 2-4 x 5 min phone calls over the first 2-4 weeks

following diagnosis/initiating treatment – most often by practice nurse

Provide support, encouragement, enquire re medication adherence, address any questions, reinforce key messages (incl time taken to respond to antidepressants)

Treatment effect is as strong as that of SSRI – is an extremely cost-effective intervention

Self-Management

Key to improved outcomes in depression as in all chronic conditions

Use of information resources, care plans – negotiate agreed plan, follow-up re progress with this

Start small/achievable and build from there

Expect it will require fine tuning over time

Six Principles of Self-Management

1. Activities that protect & promote health (Live a healthier lifestyle)

2. Monitor signs/symptoms of illness and take appropriate action to respond

3. Know and understand your health condition

4. Be actively involved in decision making

5. Manage the social / emotional and physical impact

6. Follow a care plan that is agreed with your health professionals

(Battersby, 2005)

Key Components of SMS

1. Build patient’s self-efficacy (confidence)

2. Improve health literacy

3. Use behaviour change techniques

4. Share decision making 5. Collaborative, planned

care with regular F/up

Share responsibility and decision making so patients feel in control and realise how important their actions are

Exercise in Depression

Evidence that in elderly (over 60) exercise programme has same efficacy as antidepressants

Must be vigorous exercise (for age/fitness)

Some evidence that balance of aerobic and resistance exercise ideal

Integrate into Activity Scehduling

Activity Scheduling

Use of structured activity scheduling tool Key aspect of “Behavioural Management”

See handout Reverses cycle of low mood/despondency –

reduced activity – more time to dwell on negative thoughts – lower mood

Important to include rating of sense of pleasure and mastery from activity

Activity Scheduling Tool

DIARY OF DAILY ACTIVITIES Please list all activities undertaken during the day. Rate each activity (using the scale below) for Sense of Pleasure (P) and Sense of Achievement (A). SUNDAY P A MONDAY P A TUESDAY P A WEDNESDAY P A 8.00am 9.00am 10.00am 11.00am 12.00pm 1.00pm 2.00pm 3.00pm 4.00pm 5.00pm 6.00pm 7.00pm 8.00pm 9.00pm 10.00pm RATING SCALE FOR SENSE OF PLEASURE (P) AND SENSE OF ACHIEVEMENT (A). 0 1 2 3 4 5 6

NONE MILD MODERATE GREAT

Brief Problem Solving

Proven effective in mild-mod depression Focus is in mobilising the patient’s coping

and problem-solving capacity, to overcome the issues that are causing stress/inducing depression

Uses structured approach, increases sense of mastery and reverses “helplessness – hopelessness”

NDI Phase 2 – “The Journal” an online self-management tool Advertising campaign starts June 2010 Can be self-directed access OR via GP Uses K-10 to monitor progress People set goals re activity, exercise, diet Get txt/email encouragement from “JK” Includes a section on Problem Solving Will be a great aide to managing

depression in primary care!

Cognitive Behaviour Therapy (CBT)

Structured, time-limited, ‘here and now’ Specific skills for now and future Five components to problem (“Five-Part

Model”) Cognitive model Evidence Balanced thinking

CBT - 5-Part Model

Thoughts orCognitions

Physiology,Sensations

Behaviours,Actions

Feelings,Emotions

Environment (Past & Present), Situation

CBT - 5-Part Model (contd)

SITUATIONAUTOMATIC

THTS ANDIMAGES

REACTION

EMOTIONAL

BEHAVIOUR

PHYSIOLOGYLENS OR FILTER THROUGH WHICH WE PRECEIVE ORINTERPRET SITUATIONS

COGNITIVE COMPONENT

Classes of “Warpy Thoughts” – Automatic, absolute, unbalanced

Mind reading (“He thinks I’m a loser”) Fortune telling (“I won’t get the job even if I apply”) Catastrophising (“This plane is going to crash”) Unrealistic expectations of self (“Shoulds… musts…”) Personalising(“Everything is my fault”) Perfectionism (“no matter what I do it’s never good

enough”) Overgeneralising (“I always muck everything up”) Black-White thinking (“I didn’t win, I’m useless”) Looking on the dark side (“The world is a bad place”)

Pharmacotherapy of Typical Depression

First line Rx in most instances is SSRI Severe/Agitated Depression – Dual action Ads

(Venlafaxine, Mirtazapine, TCA) more effective Non- or partial-treatment response – strong

evidence for both Nortriptyline and new dual action ADs (Venlafaxine, Mirtazapine – NB: Voc. Reg. GP can apply for SA) Nortriptyline in therapeutic doses – usually 75-100 mg Venlafaxine dose v. variable 75 mg to 450 mg

NB – monitor for incr BP at higher doses Mirtazapine dose 30-45 mg nocte

Treatment with SSRI

Initiate at 20 mg mane (if sedative effect change to nocte)

Significant anxiety - ??initiate with low-dose BZP or Quetiapine

Significant S/E – change to alternate SSRI No or minimal response 2-3 weeks, increase

to 40 mg Persisting poor response 4-6 weeks, change

to alternate SSRI progress as above

Pharmacotherapy of Other Depression Subtypes

Melancholic Depression – TCA/Dual action ADs more effective

Atypical Depression – Only Phenelzine has strong evidence of effectiveness; some evidence Paroxetine and Venlafaxine

Psychotic Depression – MUST treat with antipsychotic (eg, low dose Risperidone) plus antidepressant

Antidepressant Prescribing Issues in Particular Populations:

Intention to Treat Meta-analyses of Antidepressant trialsChildren/Adolescents – Fluoxetine only AD

with any evidence of effectiveness; significant concern re harms with ADs esp. other SSRI

Over 60 – trend-level data to suggest elderly do better with dual action ADs – VF and TCA (BUT TCA S/E issues)

Males – trend-level data to suggest men do better on TCA

Antidepressant Prescribing

Issues in Pregnancy/Lactation:

Need to balance (uncertain) risks of “safe” medications, with known risks to mother AND child of untreated depression:Nortriptyline, Fluoxetine considered “safe”

during pregancy, MAY cause withdrawal syndrome in neonate

Paroxetine contraindicated 1st TrimesterNortriptyline, Paroxetine only ADs with very low

levels in breast milk of treated mothersNB – BZP relative contraindication (esp 1st

Trimester)

Managing Side Effects

The art of prescribing – matching medication effect profile to symptoms (e.g., sedating vs activating)

Managing sleep disturbance – short term hypnosedative eg Zopiclone, OR If also anxiety/agitation – low-dose Quetiapine

SSRI-related sleep disturbance – Short half-life SSRI OR change to alternate

agent

Sexual dysfunction – a tough one!

Monitoring and Follow-up Need to closely monitor patients

receiving antidepressants for worsening and suicidality especially at beginning of treatment and with changes in dosage

Also need to instruct patients and families to be alert for worsening or suicidal thoughts and to immediately report such symptoms

Use practice recall systems

Promoting Adherence

Shared decision making Inquire into prior use of antidepressants Explain that it may take 2 to 4 weeks for

therapeutic response, longer for full effect Discuss most common side effects Advise patients to continue medication

even if they feel better Explain risk of stopping too soonPhone follow-up/support – doubles

adherence!!! Is good practice nurse role.

Follow Up

Close follow up by telephone and or visits until stable (phone support betw visits impt)

Depression scale (eg,PHQ-9) to assess progress

Titrate dose for total remission Maintain effective dose for 6 to 12 months

(continuation phase) Monitor for early signs of recurrence Consider maintenance therapy if there have

been more than 2 episodes

Antidepressant Continuance Relapse of depression is COMMON:

After one episode 50%, after 2 episodes 75%, after 3 episodes 90%

Risk reduced if patient accesses CBT

Usual advice re duration of antidepressant treatment (from research re more severe depression):First episode – 6-12 mthsSecond episode – 12-24 mthsThird + episode – 24 mths plus ??long-term Rx

Poorly Treatment Responsive Depression

Defined as non- or partial-response to an adequate dose of medication, for an adequate duration, with good adherence

Effectively means 20-40 mg SSRI for 4-6 weeks (NB if no response at 20 mg after 2-3 weeks, trial increase to 40 mg)

Should be seen as a trigger for further assessment re cause of poor responseNeeds assertive response – greater duration of

depression, poorer chances of recovery

Poorly Treatment Responsive Depression

Review diagnosis/presentation – ?adherence (common…) – ?why - address?psychosocial issues/trigger – need CBT?bipolar depression – need mood stabiliser?atypical depression – need effective ADs/CBT?comorbid A+D – need A+D Intervention?other comorbidity - anxiety disorder, ADHD,

etc

Intervention for these as appropriate

Poorly Treatment Responsive Depression –

STAR*D Trial If above factors excluded, evidence-

based treatment options for treatment non-responsive depression are:Substitute option 1 – Alternate SSRI*Substitute option 2 - Venlafaxine or TCAAugment option – Lithium, T3Addition option – CBT

Continued non-response OR unsure - Indication for Psychiatric Consultation

*Note that non-response to 1 SSRI is NOT highly predictive of non-response to a second, so first-line strategy should be trial of a second SSRI.

When to Consult/Refer to DHB MHS

Any case with serious suicide risk Any case with psychotic symptoms or

possible evolving psychosis Complex presentations with serious

impairment in function Includes cases with significant comorbidities

Cases which fail to respond to treatmentEarly referral important – duration of illness

inversely related to odds of full recovery

Other Resources for your Patients

The PHO may have Community Health Coordinator roles to assist with cultural & social issues, linking to community resources, sorting benefits/housing etc

Most PHOs now have access to funded CBT/counselling

Think of the Primary Mental Health NGO’s – Lifeline, James Family, Relationship Services, Presbyterian Support etc.