Ben Green & Chris Dowrick
An extract from Psychiatry in General Practice
Depressive illness is one of the most frequent reasons for attending the General Practitioner. Depression is a major burden to its sufferers, their families and society, (Kind & Sorenson, 1993) The majority of depressed people who receive treatment are treated in primary care. However, some 50% of cases of depression are unrecognised, especially where the patient presents with physical problems. Although screening entire practice lists for depression is not feasible, pro-active case-finding has been advocated, using clinical skills, questionnaires such as the General Health Questionnaire (GHQ) and Hospital Anxiety and Depression scale (HAD), and computers (Wright, A F, 1994).
Everybody's mood varies according to events in the world around them. We are happy when we achieve something or saddened when we fail a test or lose something. When they are sad, some people say they are 'depressed', but the clinical depressions that are seen by doctors differ from the low mood brought on by everyday setbacks. Psychiatrists see a range of more severe mood disturbances and so find it easier to distinguish these from the normal variations of mood seen in the community. General practitioners need to be sensitive enough to distinguish emotional reactions to setbacks in life from anxiety syndromes, somatisation and clinical depressions. The theoretical model is that anxiety disorders, depressive episodes, somatisation and adjustment reactions are all different entities, but in practice it is not always that clear-cut. Major depression, as defined by psychiatrists, is unfortunately relatively common though.
Community studies have found prevalence rates of between five and 20%. About 10% of people aged over 65 have a major depressive episode at any time. The incidence of depression is higher in women and in urban rather than rural settings. Figure One shows how many cases of depression there are in a small General Practice of three thousand patients. You can also see how many of these illnesses are detected and how many are treated by general practitioners and psychiatrists.
What is depression?
Depression is a disorder of affect. Affective disorders are predominantly disturbances of mood that are severe in nature and persistent despite the influence of external events. Depression is characterised by severe and persistent low mood, which is often unresponsive to the efforts of friends and family to cheer the sufferer up. Patients who suffer with repeated episodes of depression have recurrent depressive disorder.
Depressive episodes can be classified into mild, moderate and severe types with or without psychotic symptoms. An episode must last more than two weeks.
A condition where the mood is persistently low, but does not quite fulfil all the criteria for a depressive episode is sometimes called dysthymia.
Clinical features of depression
Mild depressive episodes typically include features such as:
People with mild depressive episodes find it difficult to continue with their work and social lives, but usually continue to function, albeit less well than normal.
Moderate depressive episodes have a wider range of symptoms, which are present usually to a greater degree. Sufferers find it very difficult to function normally at work or home.
Severe depressive episodes typically may also include features such as:
People with severe depressive episodes find it impossible to continue with their work, domestic and social lives, and usually cease to function in these areas.
Depression is often accompanied by slowing of thought and biological features of depression completely unlike everyday sadness.
Crying is a frequent symptom, although some individuals are reluctant to admit this, and others feel so depressed it is as if they have 'gone beyond crying'.
Suicidal ideas occur in most depressed people, and asking about these is a crucial aspect of their assessment. Depressed patients often find it a relief to talk about these ideas with their doctor. Asking about suicidal ideas is a sequential process, beginning with questions about the severity of the low mood. The doctor can then ask if the patient has ever felt that life is not worth living. A 'yes' could be followed by enquiring whether the patient has ever felt like ending their own life. Finally the doctor needs to assess if the patient has any particular plans in mind.
Case History: Janet
Janet Gordon was aged 35 when she lost her job as a manageress of a department store. At first she looked on her period of unemployment as an opportunity to try out activities she had no time for before. She went hillwalking and painting every day. Two months later she had lost interest in these things and was despairing that she would never work again, although she had an exemplary work record. Her sleep at night was poor and she had started going to bed during the day. Janet cried almost daily and had lost interest in the food she cooked. All food tasted bland, she said to her mother (who was concerned when she saw how much weight Janet had lost). At her mother's suggestion Janet went to her family doctor where she complained about how tired she always felt. She asked for some sleeping tablets to help her sleep at night.
Case History: Alan
Alan Benson was brought to the accident and emergency department by his son. Alan had tried to hang himself from the banisters at the family home. Fortunately the clothes' line that he had chosen to hang himself with had broken under his weight. When he was seen by the psychiatrist Alan had a red weal mark around his throat from the noose. He was staring at a fixed point on the floor. Now and then he would groan deeply and whisper to himself. He kept repeating the words 'I'm for it..I'm for it now.' He would not make eye contact with the doctor and initially refused to answer questions.
His son said that the previous week his father had stopped going to work as a bailiff after he found out that his wife was having an affair. He had watched her obsessively for two days, not letting her out of his sight. Then a few days ago he had taken to his bed, and lain there for hours and hours not moving, not speaking, not eating and not drinking. He had talked about how everything was his fault and had at times been pleading with an unseen person to forgive him. He felt that he had committed some unpardonable crime and that he should now be punished.
Armed with this information the psychiatrist talked to Mr Benson again. This time Mr Benson replied, even if only briefly. He said that God was telling him that his wife had to find another man because her husband had been so evil. He confessed that he had once had an affair himself many years before, and that God had told him in the last week that He had punished Mr Benson with syphilis. His wife could be spared from the syphilis only if he killed himself. Once he was dead, he thought, his wife could begin a clean life with another man.
Many physical disorders can present with depressive illness. They include: hypothyroidism, hyperthyroidism, Addison's disease, Cushing's disease, electrolyte disturbances, alcoholism, drug abuse, carcinoma and dietary deficiencies (B12, B1, and folic acid). Various drugs can cause depression.
Psychological disorders that may mimic depression include adjustment reactions, anorexia nervosa, bulimia nervosa, anxiety disorders, substance abuse, obsessive-compulsive disorder, dysthymia, seasonal affective disorder, and abnormal bereavement reactions. Panic disorder commonly co-exists with or pre-dates depression, (Andrade et al, 1994).
Some physical presentations are associated with depressive illness, whether because they are somatisation of a psychological problem, or because chronic physical illness and chronic pain are associated with secondary depression.
Diagnosing and treating underlying physical causes must be attempted.
Risk factors for depression
In Young Adults:
In Older People:
The risk factors for older people identified above have some predictive value in identifying people at risk of depression three years later. Life satisfaction and bereavement help predict recurrences of depressive illness.
The higher prevalence of depression amongst women could be because women are more prone to depressive illness biologically or because of their social roles, or could be because male depression is underecognised, or incorrectly labelled. Suicide is more common among men than women.
It is worth remembering that of depressed patients who present to their GP only 50% are correctly diagnosed as suffering with depression. Most depressed people in the community do not receive treatment. Over 90% of depressed elderly people in the community suffer without treatment.
Armed with knowledge of its prevalence, causes and common features, one might assume that it is a simple task to diagnose depression in general practice settings. But often it isn't.
Certainly having a high index of suspicion and a professional
willingness to consider the possibility of depression are important factors in our ability
to diagnose depression. But our patients also have a significant part to play in enabling
- or preventing us - from arriving at a diagnosis of depression.
Depression itself often engenders feelings of hopelessness and despair. Patients may therefore feel that there is no point in talking to the doctor about it since there is nothing that they or anybody else can do about it. These negative perspectives can be compounded by GPs - often unwittingly - if we give the impression of rushing through our consultations and being unable or unwilling to sit and listen to our patients' concerns.
There is still a considerable stigma attached to mental illness. Many people have a great fear of the consequences of acknowledging their depression to a professional person: they may be 'carted off to a loony bin', or written off as 'mad'. If the word 'depression' appears in medical notes or on Med 3s they fear - often correctly - that this will be prejudicial to future employment or insurance prospects.
Fear of antidepressant medication is also a very important obstacle to disclosure of depression. A study undertaken by the Defeat Depression campaign showed that many people confuse antidepressants with benzodiazepines, and are genuinely worried about becoming dependent - 'getting hooked' on them, and about unpleasant effects of withdrawal. There is considerable public scepticism about the effectiveness of antidepressants. Most patients would prefer to be offered counselling rather than drugs, but doubt if they will be given such a choice by their GP.
Faced with this complex barrage of obstacles, it is perhaps suprising that we ever do manage to make a diagnosis of depression! So what can we do to increase our chances?
Time is a crucial factor. Howie et al (1991) found that longer consultations are more likely to allow for the expression of psychological problems. So are good communication skills (Miller and Goldberg 1991), particularly eye contact and the use of open ended questions.
We need to help some patients to reattribute physical symptoms to psychological causes. If a patient is feeling tired all the time, has no energy or interest in life and is sleeping very badly, these chances of their being depressed are very high. Often a direct question - 'do you think you may be depressed?' - is all that is needed to move the consultation onto a psychological agenda. Sometimes it is better to take a more circuitous route. The word 'stress' is a very useful bridge, since it intrinsically has both physical and mental components: 'Are under any extra or unusual stress at the moment?', or 'Do you think these symptoms might be due to stress?' are effective open ended questions. For those few patients who appear reluctant to consider any diagnosis of depression it may initially be most profitable to concentrate on its more physical manifestations - sleep and appetite disturbance, or energy loss - without forcing the issue of their underlying causation.
And we must also accept patients' genuine anxieties about the stigma attached to depression, and acknowledge their concerns about the harmful effects of drug therapies. Good basic consultation skills include enquiry into patients' expectations and fears about the nature and consequences of their problems. This will take us a long way towards understanding not only whether our patients are depressed, but the context and meaning that their depression has for them. Many people experience enormous relief when their problems are explored in this way. To a large extent, therefore, effective diagnosis is also the most crucial aspect of effective treatment.
There are two important dimensions to be considered in deciding how best to manage depression in general practice.
The first concerns the severity of the depression. Mild depression may often be managed effectively through sympathetic exploration of the factors precipitating it - whether physical illness, a recent personal crisis in work or relationships - and encouragement of the patient's own coping mechanisms and supportive informal social networks.
Moderate and severe depression have been shown to respond to antidepressant drug therapy. As we have seen it is essential to discuss patients' anxieties and expectations of drug treatment before starting it. Also, drugs should be viewed as complementary rather than alternative to talking about depression.
Problem-solving is a useful and simple skill to develop. The first stage is the creation of a problem list. This is something usually best done by the patient between sessions, althouhg they may need some help initially. The patient writes down a list of problems which he is experiencing at present, either in terms of how he feels - miserable, tired, bored etc - or in terms of things he is unable to do - go to work, enjoy sex, avoid rows. He can then rank these problems in order of importance, and set goals for overcoming them. These goals should be staged and not too ambitious. For instance, if feeling bored is a central concern, it might be useful to discuss which aspects of life give the most pleasure and interest - watching TV soaps, walking the dog, having a bath, and agreeing that the patient will spend a set amount of time each day doing just that.
Problem-solving works well in conjunction with drug therapy, and directly addresses the sense of hopelesness that is central to depression. It enables both doctor and patient to achieve a sense of purpose and direction, and provides a practical means of monitoring and demonstrating progress.
The second dimension to the management of depression in general practice concerns the views and experience of the doctor and the patient.
GPs vary considerably in their skills, experience and confidence in dealing with depression. Some of us will prefer to refer early to other professional colleagues, whether counsellors, psychologists or psychiatrists, while others are more comfortable about managing even acute and severe problems.
Patients, as we have seen, may also have strong views about the causes, effects and treatment of depression. If we are to manage it effectively we must take these into account. When people feel they are being listened to, and have genuine choices about what happens to them - whether they receive counselling or drug therapy or both, whether they are referred for psychiatric opinion or not - they are more likely to be committed to the management plan that emerges. Many patients, even when expressing suicidal thoughts, may prefer to be managed at home by their GP than be admitted to a psychiatric ward: the problem then becomes one for us, in assessing the degree of risk and responsibility that we feel able to sustain.
It is worth remembering that, as hopelessness and worthlessness are central aspects of the experience of depression, involving our patients in genuine decision-making about the management of their illness is intrinsically therapeutic.
Studies of treatments versus placebo have endorsed the value of physical therapies such as ECT in severe depression and antidepressants in mild, moderate and severe depression. Most depressive illnesses respond to such treatments. Tricyclic antidepressants need to be taken regularly in adequate doses for an adequate length of time. Inadequate doses of tricyclic antidepressant are linked to suicidal behaviour in some studies. Newer antidepressants (SSRIs and RIMAs) offer lower cardiotoxicity and relative safety in overdose.
Some psychological treatments have proven efficacy, notably cognitive-behavioural therapy and interpersonal psychotherapy for mild and moderate depression. Their drawbacks are that they take longer to have an effect and are not well-standardised.
What kind of cases to refer on
Cases of mild to moderate depression requiring additional counselling or psychotherapy. There is evidence that cognitive behavioural therapy and interpersonal psychotherapy may help maintain health when combined with antidepressant medication, but there is as yet little evidence to suggest that counselling alone is a suitable treatment for major depression. Where there is evidence of continued relationship or family difficulties psychotherapy may be particularly useful.
Cases of moderate to severe depression may need vigorous treatment by a community psychiatric team and close follow-up to help prevent relapse and improve prognosis.
Severely depressed patients with or without psychotic symptoms require inpatient admission and may respond best to electro-convulsive treatment.
Who to refer people to
Counsellors, psychotherapists, community psychiatric nurses, occupational therapists, social workers and psychologists, unless also medically qualified, are not trained to diagnose depression, recognise its aetiology, or formulate long-term management plans. If referring on to one of these agencies as the sole provider of psychological care, the onus is on the general practitioner to diagnose the depression correctly, to be certain about its aetiology and to have a clear long-term management protocol in mind. The General practitioner must therefore be sure to have excluded physical illness as a cause of the depression before referring on to non- medically trained carers.
Consultant psychiatrists can diagnose the illness correctly and coordinate a treatment package that may involve any of the above agencies, with admission, if necessary, to day hospital or inpatient facilities.
Prognosis Psychiatrists writing around the turn of the century could describe episodes of depressive illness in asylum patients that had lasted ten years or more. Records from the nineteenth century Ticehurst House asylum describe long depressive episodes, and one patient in particular with nihilistic delusions about his bowels who had to be exclusively tube-fed for many years. Despite the good intentions of therapists and doctors these depressions were devastatingly difficult to treat with the psychological management of the time. It was the arrival of physical treatments that changed the prognosis of depression. ECT arrived in the nineteen thirties to be followed by MAOIs and tricyclic antidepressants in the fifties and sixties. Lithium and carbamazepine have offered prophylaxis against repeat episodes. The newer SSRI drugs have offered still more acceptable treatments for depression.
The long-term prognosis for depression is still guarded though. Up to 15% of patients who have had depression will go on to kill themselves. Recurrent episodes of depression are the norm rather than the exception. Long-term studies of lithium prophylaxis suggest that lithium may reduce the number of episodes and prevent suicide. Studies of long-term use of antidepressants suggest beneficial effects. Long-term efficacy of psychotherapy and counselling has not been proven.
References and further reading
Andrade, L, Eaton WW, Chilcoat, H. (1994) Lifetime comorbidity of panic attacks and major depression in a population-based study. British Journal of Psychiatry, 165, 363-369.
Defeat Depression Campaign (1992) Attitudes towards depression. London, Defeat Depression Campaign.
Donaldson, L J. (1994) Sick doctors. BMJ,309, 557-558.
Dowrick C: Better detection of depression in primary care- what is the health gain? MD thesis, University of Liverpool [in progress].
Freeling P et al (1985) Unrecognised depression in general practice. BMJ, 290, 1880-3
Green, B H (1995) Mental Health Screening (in press)
Green, B H, Copeland, J R M, Dewey, M E et al. (1992) Risk factors for Depression in Old Age. Acta Psychiatrica Scandinavica, 86 (3), 213-7.
Green, B H, Dewey, M E, Copeland, J R M, et al. (1994) Risk factors for recovery and recurrence of depression in the elderly. International Journal of Geriatric Psychiatry, (in press)
Howie J et al. (1991) Long to short consultation ratio - a proxy measure of quality of care in general practice. Br J Gen Pract, 41, 48-54.
Kind, P, Sorenson, J. (1993) The cost of depression. Int. Clin. Psychopharmacol. 7, 191- 195.
Miller T and Goldberg D. (1991) Link between the ability to detect and manage emotional disorders. Br J Gen Pract, 41, 357-359.
Piccinelli, M & Wilkinson, G. (1994) Outcome of depression in psychiatric settings. B J Psych, 164, 297-304.
Roy, A. (1985) Early parental separation and adult depression. Archives of General Psychiatry, 37, 987-991.
Tylee At et al. (1993) Why do general practitioners recognize major depression in one woman patient yet miss it in another? Brit J Gen Pract, 43, 327-330
Weissman MM, Klerman, G L. (1977) Sex differences in the epidemiology of depression. Archives of General Psychiatry, 34, 98-111.
Wright, A F. (1994) Should general practitioners be testing for depression? British Journal of General Practice, 44, 132-135.
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