Tackling depression

We’ve all heard the statistic that one in five of us will have depression at some time in our lives, but few of us will have been moved to act upon it either for patients or ourselves. Depression has traditionally been considered to be the domain of psychiatrists and primary care doctors, which has led to patients’ management tending to become confined to these areas. But depression is seen in all specialties.

Left undiagnosed, depression can worsen the prognosis of almost all conditions. So to provide the best care for patients, it is essential for all junior doctors to be equipped with the skills to recognise, assess, and treat depression.

Depression is an internationally recognised disease. That it is for the fourth greatest contributor to the global burden of disease shows its cross cultural importance.^w1 The World Health Organization predicts that by 2020 depression will have risen to first place, representing 154 million people worldwide. The prevalence of depression in the community in the United Kingdom is 6.3%-17.1%.^w2 Because each episode may last several months, the burden that depression renders upon society is great. This corresponds to a yearly cost of £9bn (€12bn; $18bn)^w3 in lost earnings; 110 million missed working days; and a cost to the National Health Service of £369m, of which only 11% is spent on drugs.^w4 In the United States the yearly cost is $83bn. Depression is important on an individual level in terms of disability and misery, but it also has this wider economic impact on us all.

It is all too easy to compartmentalise medicine—newer modularised clinical courses tend to encourage this—each specialty forgotten as we file away the rotation’s notes. However, evidence shows that patients presenting in all specialties have depression, be it as the primary complaint or secondary diagnosis. Depression represents around 10% of all UK general practice consultations, but only one third of these patients have their depression diagnosed and treated.^w5 In medical wards, studies indicated that 30% of patients fit the criteria of the fourth edition of the Diagnostic and Statistical Manual of Mental Disorders for mild depression, and about half this proportion is seen among surgical inpatients.^{w6 w7} Many medical and surgical outpatients may present with physical symptoms—for example, abdominal pain or weight loss—but many of these may be the somatic symptoms of depression. We need to be on the lookout for symptoms of depression in all patients that we see.

Medical implications

Why does it matter that the old woman in hospital after a myocardial infarction is depressed? The reason is that depression is associated with many risks. The most serious is of suicide: an analysis of UK suicides showed that two thirds were directly attributable to depression.^w4 Most of these deaths were in elderly people, most of whom had considerable physical comorbidities. Of greater importance, especially in young people and people with milder depression, is the association with deliberate self harm, which has become more prevalent in recent years.

Most depressive illnesses will last about six months, but a proportion will become chronic, increasing the likelihood of the patient having a poor quality of life and being unable to work. Depression produces disability that is quantitatively comparable with that of other chronic conditions.^w8 About 80% of appropriately treated patients will fully recover, usually within a few weeks.^w9

Low mood heightens our sensitivity to physical distress and leaves us less able to cope with problems. Among patients at a cardiac unit those with a comorbid depressive illness were twice as likely to have a further cardiac event, and they scored significantly worse in assessments of long term quality of life.^{w10 w11} Similarly, surgical outpatients diagnosed with depressive illnesses tended to attend clinic more often and show the least response to treatment.^w12 To make life easier for yourself and your patient it is important to refresh your basic skills of diagnosing and treating depression.

Diagnosing depression

The most crucial skill to have is the ability to recognise depression, and this means knowing how to screen for it. Although depression may be obvious in an openly suicidal patient in the emergency room, it may be more subtle in presentation among the physically unwell. The diagnosis of depression is clinical, and requires two “typical” symptoms plus at least two other “core” symptoms (box 1). These should be present for a minimum of two weeks, cause considerable distress in social or occupational functioning and not be secondary to the effects of substance misuse, drugs, or bereavement.^w13 The number of symptoms roughly corresponds to the severity of the condition, so a depressive episode is described as being mild, moderate, or severe, plus biological or psychotic symptoms. The latter occur in the most severely depressed patients, who are referred to as having “psychotic depression.”^w13 It should also be noted that depression can present with any somatic symptom.

High risk groups should be routinely screened for depression, but it is also a worthwhile tool for general use (box 2). Effective screening involves asking just two questions, making it quick and simple.^w14 The specificity can be further increased by adding an optional third question,^w15 and one positive reply should lead to asking directly about other core symptoms to confirm and quantify the diagnosis.

(1) During the past month, have you often been bothered by feeling down, depressed, or hopeless?

(2) During the past month have you often been bothered by little interest or pleasure in doing things?

(3) Do you want help with these problems?

Personal experience has shown that in the general hospital setting, patients with severe depression are often misdiagnosed—an example is the elderly patient admitted with no speech or movement assumed to have been failing to cope and subsequently left untreated in a side room. Severe depression often results in slowed movements, poverty of speech, hallucinations or delusions, and apathy. If these signs are recognised the patient should be urgently referred to the liaison psychiatry team.

Managing the patient

Once you have identified a patient with depression, you should act upon the diagnosis. This means doing a risk assessment (box 3) and formulating a management plan. You should always ask directly about suicidal ideation and any previous suicide attempts. Most people who complete suicides have a past history of deliberate self harm, and two thirds have seen a doctor within four weeks of their death. Asking about these thoughts does not increase the risk of suicide.^w8 Do not assume that because a patient is in hospital he or she is safe—take the same precautions for inpatients and outpatients.

The first stage in treatment is to decide who should undertake the management of the patient. For most cases of mild depression, it is safe for a junior doctor to treat the patient in the inpatient setting, with referral to the general practitioner after discharge, but some patients should be referred to a psychiatrist (box 4). In the UK, management of depression follows a stepped approach as recommended in the guidelines of the National Institute for Health and Clinical Excellence.^w16 Mild and moderate depressive episodes are treated in the community by general practitioners; more severe or complex cases are looked after by specialists.

Mild cases

For patients with mild depression (and this will be most in other clinical settings) antidepressants are not recommended as there is little proved benefit. A first approach is watchful waiting. Some patients will recover without treatment having discussed the diagnosis, so review them in two weeks, or speak to their general practitioner to arrange this. Next comes advice on sleep and anxiety management, a structured exercise programme (three 45 minute sessions of activity a week), and guided self help materials. Guided self help consists of giving the patient information about depression and strategies for recovery and then regularly assessing progress. A good starting point is the Royal College of Psychiatrists’ website (www.rcpsych.ac.uk) or voluntary organisations, such as MIND or the Samaritans.^{w17 w18} NICE also advocates the use of computerised cognitive behaviour therapy programmes where available.

Antidepressants

Antidepressant drugs are the mainstay of treatment for patients with moderate or severe depression. The preferred choice is a selective serotonin reuptake inhibitor (for example, fluoxetine, citalopram, sertraline) because they are as effective as tricyclic antidepressants and better tolerated by patients. Discuss the reasons behind starting drugs, and inform patients that serotonin reuptake inhibitors are not addictive, of the risks of sudden withdrawal, and that they may experience side effects that can precede the beneficial effects (for example, gastrointestinal upset, headaches, agitation, and insomnia). Second line treatments include mirtazapine, venlafaxine, or tricyclic antidepressants.

Until recently it was thought that it took several weeks for antidepressants to take effect; it now seems that most patients benefit within a few days.^w19 All patients should be regularly reviewed, initially 2-4 weeks after starting treatment.^w16 Three to four fifths of patients recover from their depression within weeks of starting an antidepressant.^w20 It is worth noting that no one class of antidepressant has been proved to be more effective than another, but newer drugs tend to have fewer side effects.^{w19 w21}

Further options

The best psychological treatment for depression is cognitive behaviour therapy, and all patients with moderate to severe depression who have not adequately responded to other treatments should be referred for a brief course (16-20 sessions) with a psychologist.

Patients with severe depression should be referred to a psychiatrist—either the liaison psychiatry team or a community psychiatrist. A combination of antidepressants and cognitive behaviour therapy is the most likely form of management, but patients who pose high risk may be treated by the crisis resolution team, as a day patient, or admitted for inpatient care. The biopsychosocial model of care is now widely appreciated to be more efficacious than a single approach,^w22 so a comprehensive package of care overseen by a dedicated care coordinator should be the ultimate aim.^w21 Contrary to popular belief, electroconvulsive treatment is now the last treatment of choice, being reserved for patients whose depression leads them to stop eating and drinking, to be at high risk of suicide, or to be in a depressive stupor. It is an extremely effective treatment, but causes long term memory loss in some people.^w19

All junior doctors everywhere will come across patients who have depression. Given that screening takes only seconds and that effective treatment may benefit the patient’s psychological and physical health, there is no excuse for not being proactive. Try to keep the differential of depression at the front of your mind and you could help reduce the burden it currently represents.

Competing interests: None declared.

Provenance and peer review: Not commissioned; externally peer reviewed

In the BMJ: see the recent Clinical Review “Management of depression in adults” (BMJ 2008;336:435-9; doi: 10.1136/bmj.39478.609097.BE).

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