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Depression in Adults

 

Referral information

For information on referral criteria, information required and referral process click on hyperlinks below:


Crisis mental health services (24/7 Health Professionals Line)

Single Point of Access (SPoA)

Specialist mental health advice – routine or urgent

Psychological therapy

Social prescribing

 


Background

Depression is a common condition, but it is often over-diagnosed. It is essential to appreciate that not every patient who presents with distress or low mood will be experiencing depression.

It is a treatable condition, with effective evidence-based treatments, including medication, psychological therapy and social interventions.

 

Red flags

  • Risk to self, including:
  • imminent or high-risk of suicide
  • severe self-neglect, including poor oral intake
  • Risk to others
  • Psychosis



Assessment

Ask about:

  • core symptoms– feelings of persistent low mood, anergy (fatigue / loss of motivation) and anhedonia. Need to be present for at least 2 weeks to diagnose depression.
  • additional symptoms– feelings of hopelessness, guilt, anxiety, restlessness, agitation, poor concentration, memory problems, disrupted sleep, appetite change, sexual dysfunction, reduced self-confidence.
  • functional impact of symptoms to help inform severity of depression.
  • episodes of elevated mood and/or psychotic symptoms.
  • substance misuse and coping strategies.

Assess risk by asking if they “have ever thought that life is not worth living” or that they “would be better off dead”. Ascertain if they have made any plans and whether there are any protective factors stopping them going through with it. Be mindful of the potential risk to others, especially dependent children.  

 

On examination:

  • Look for signs of self-neglect, poor eye contract, reducedemotion (flattened or blunted affect), slow speech, psychomotor retardation or agitation.

 

Consider alternative causes:

  • Recent significant life event causing acute stress or grief reaction
  • Do they laugh or smile? (unlikely if truly depressed)
  • Physical causes e.g. hypothyroidism, anaemia, diabetes, Parkinson’s Disease etc.

Medication-induced e.g. steroids, oral contraceptives, Champix, isotretinoin, certain beta-blockers



Assess severity to guide management. Consider using PHQ 9 . As a rough rule of thumb:

  • Less severe depression (subthreshold and mild): “stopped seeing friends".
  • More severe depression (moderate and severe): “stopped going to work or getting out of bed”.

 

Investigations

Consider blood tests if appropriate, including:

  • Full blood count
  • Renal function
  • Thyroid function tests
  • Liver function tests
  • Ferritin
  • B12 and folate

 

Primary care management


General principles

Take a stepped care approach.

Avoid rushing to make a diagnosis.

Provide patient information

Inspire hope and emphasise the effectiveness of treatments.

Address any underlying issues/factors and manage any co-morbidities:

  • where anxiety co-exists, the priority should be to treat the depression.
  • where dementia co-exists, consider psychological therapies. Avoid using antidepressants routinely.

Encourage self-care, including:

  • be physically active
  • good sleep hygiene
  • regular, healthy eating
  • connect with others
  • keep a daily routine
  • reduce alcohol and steer clear of recreational drugs
  • practising mindfulness / relaxation
  • set goals
  • one fun activity a day

Signpost to self help wellbeing resources.

Consider implications on fitness to drive

Closely safety-net and provide OOH contact numbers, including:

  • Mental health connect (24/7 phoneline for CIOS): 0800 038 5300
  • Samaritans (24/7 free phoneline):116 123

 

Less severe depression

1. Consider watchful waiting for 2-4 weeks.

2. Consider offering psychological therapy.

3. Do not routinely offer antidepressant medication – there is no evidence of benefit compared to placebo. Consider offering if:

  • PMHx more severe depression.
  • Subthreshold depression for at least 2 years.
  • No response to psychological therapy or self-help wellbeing resources.
  • Mild depression complicating long-term physical conditions.

4. Organise follow-up in general practice – if no improvement at 8-12 weeks re-consider the diagnosis and manage as per more severe depression.



More severe depression

1. Offer both psychological therapy and antidepressant medication – a patient may need to be effectively established on medication before gaining benefit, or engaging with, psychological interventions.  

2. Organise follow-up using clinical acumen to decide on review interval. A reasonable approach is to follow-up:

  • patients at increased risk of suicide, especially those under 30yrs on SSRI or SNRI, within 1 week and frequently thereafter until risk subsides.
  • all others, at 6 weeks as antidepressants may take until then to have an effect. Decide ongoing frequency of review based on patient preference, co-morbidities and response to treatments.
  • Ensure DNAs are actively followed up.

 

Resources

HCPs:

Patients:

 

Review date

30th November 2023

Next review date

30th November 2024

Clinical editor

Dr Laura Vines

Contributors

Dr Jeremy Sandbrook, consultant psychiatrist

Version

1.0