prescribing in the real world
the real world
The Pulse campaign has highlighted how the current NICE guidance on depression is unrealistic for many GPs because of the lack of therapies available. We asked two GP mental health experts Dr Ian Walton and Professor Christopher Dowrick for their advice on good prescribing until therapy access improves
Q1 When would you prescribe antidepressants even if this went against NICE guidance? When would it be completely inappropriate?
IWIt is not appropriate to prescribe to children. It has become apparent that the brain is still developing and antidepressants can interfere with this. All efforts should therefore be made to treat the child with talking therapies.
With regard to adults, in my experience some patients still choose the option of anti-depressants (see case study 1), even when told they may not be the recommended treatment of choice. Antidepressants can be very successful at lifting mild to moderate depression and some of their apparent
effectiveness may be due to a powerful
placebo effect illustrated by several studies.
cDI think patient choice is a key factor in helping GPs decide on management options, given the current degree of uncertainty about the efficacy of antidepressants for
diagnoses of mild and moderate depression, and given the evidence of broad equivalence between antidepressant medication and
several focused psychological therapies for severe depression.
So, if patients who fulfil criteria for mild or moderate depression have a view
that antidepressants are likely to be helpful (eg because they have found them so in
the past) I would be willing to offer them a prescription.
Q2 What services could you recommend to GPs that might act as substitutes to mainstream psychological therapies?
IWRelate can be useful for couples. A major cause of depression is debt, so referral to
Citizens Advice (we have it in-house) can be effective. Surprisingly few patients ask for referral to private counsellors.
cDEvery local community is likely to have a wide variety of services outside formal health care which distressed patients may find useful. It is good practice for primary care teams to build up a list or folder of self-help and voluntary organisations, faith communities, exercise-based programmes in local health centres tai-chi, yoga, meditation, etc. Give patients maximum choice.
Among the increasing number of
websites offering self-help psychological therapies, I particularly recommend http://moodgym.anu.edu.au/ access is free.
Q3 What should a GP do for a patient with mild depression
who faces a four-month wait for assessment and CBT, but is
clearly very distressed during
IWDepressed patients are permanently highly aroused emotionally, often with high anxiety, and so they need to learn to calm down and get some fun back into their lives by doing things that used to give them satisfaction and enjoyment.
This, I explain, may take great effort on their part at first, but I then negotiate a
simple goal that would fit these criteria
(it might be something like going to
their friend's for a chat and a cup of tea and hopefully a bit of a laugh once a week) and see them a week or two later and hopefully expand on any goals that have been achieved.
Helping the patient make the first step will often give them the push they need.
I would normally see patients every one or two months as appropriate until they get their therapy and each time we'd review the decision.
cDIn my experience, most patients have many other options for finding solutions to their problems than those available (or not as the case may be!) within the NHS. This is what I focus on with distressed/depressed patients.
I tend to see them fortnightly until we are both clear on an agreed action plan, then monthly until problems have resolved. I think a decision to prescribe antidepressants or to refer to CBT, etc, is often incidental, rather than central to this (see case study 2).
Instead of seeing our distressed patients as passive victims of disease or social circumstance, whom it is our job to manage or cure, we would do better to see them as active agents, experts in leading their lives.
Case study 1
When an antidepressant might be appropriate for mild depression
Liz was a 29-year-old married mother of two. Her father had died suddenly from an MI at 48 just over a year before and she had never fully got over it.
She knew she was shouting at the children too much and though life was always a bit of a financial struggle, there were no major debts. Her husband was supportive and she felt guilty about what a poor mother she was being. She was not suicidal and was managing to function in daily life, but nowhere near the level she was previously.
I started by explaining to her how after terrible events, such as the death of her father, the brain can go into a defensive mode and could then start imagining lots of bad things that could happen to her and her family (negative introspection). We all have bad things happen to us in life, yet they nearly all just come out of the blue.
Because Liz spent a lot of her time imagining all these negative things, she would constantly feel low and anxious and this would affect her sleep, in particular by making her dream more.
I asked her when she last had some fun and she couldn't remember. When I asked how many times her children laughed a day (a three-year-old laughs about 300 times a day) and if they were depressed, she seemed to take the point.
I then suggested she took her kids out and joined in their fun a couple of times in the next week, negotiating a goal. She felt she could do that. I then suggested she be referred to a counsellor to learn relaxation and to come to terms with the sudden death of her father but she was averse to this.
I said that if she could, have a brisk walk or similar exercise three times a week to raise her serotonin levels. She didn't see how she could achieve this and asked about antidepressants.
I went through their potential dangers and benefits, explaining how they can take a couple of weeks to start working, but then she'd start noticing better sleep and eating patterns and she'd start having good days again. These good days would then become more frequent. She should then continue on the medication for six months after recovery to prevent relapse.
At this point it was obvious that she wanted medication, as she couldn't see another route out of her depression. I was happy to prescribe.
Two weeks later she had taken the children on a day out which she had enjoyed. We set another goal of having coffee at her sister's twice a week and she never looked back. Two months later she decided to stop her antidepressants, despite my explaining that she was twice as likely to relapse.
She said she felt fine and would know if she was slipping and could restart the tablets then.
Case study 2
Empowering the patient as an alternative to medication
George was distraught when his mother died. He had had a major row with her several years before, and they had lost contact, so he only heard about her death by coming across an advertisement in the
He ruminated endlessly about how he had missed the funeral, and how his relatives should have let him know what was happening, to give him a chance to make his peace with her.
He gave up his job as handyman in a local residential home, and tried various antidepressants for a long time, with little apparent effect.
I used to dread him coming to see me. He was miserable and angry, furious with the world and how it had let him down. He would sit and tell me how awful his life was, how everything had been ruined. If only he had known about his mother in time!
I felt as hopeless and frustrated as he did.
One day he started talking about a lilac tree that was growing out of control in his back garden, blocking the light into his kitchen. We agreed it might be a good thing to take an axe to it, not just to get more light in to the kitchen, but also as a way of letting out some of his aggression.
'I really attacked that tree,' he said next time I saw him, a huge smile on his face. 'Boy, did it feel good.'
It proved a real turning point. He no longer felt so angry, or so useless, and had started doing some work on the inside of his house, repainting his hall and then his bedroom.
A few months later he was going out several days a week,
helping his son redecorate his home.
Then he moved on to help his daughter, who had just bought her first house and needed a lot of practical support in setting it up. He made a wooden bench for her garden.
His wife was delighted. She tells me: 'I feel like I've got him
Christopher Dowrick is a GP in Aintree and professor of primary medical care and head of school of population, community and behavioural sciences at the University of Liverpool
he is a member of the Department of Health's mental health taskforce
Ian Walton is a GP in Sandwell and chair of the charity Primary Care Mental Health and Education (Primhe)