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At the heart of general practice since 1960

COPD questions to send cases soaring five-fold

It is now nine months since the NICE guidance was issued, but many areas are still waiting for extra resources to fulfil its aims of increased management within primary care ­ Dr Pavan Kumar Mallikarjun and Professor Femi Oyebode advise

Behind the headlines

 · In December 2004, when the guidelines were published, experts warned GPs would need more education, training and greater support from specialist services to meet the NICE recommendations.

 · A mental health policy paper for the Number 10 strategy unit published the same month called for an extra 10,000 CBT therapists over the next 10 years.

 · Researchers at the University of Bristol concluded the Government had missed an opportunity to develop psychological services because it had spent the money on antidepressants. The BMJ study concluded that 1.5 million people could have received CBT over a decade had a more 'appropriate balance' been struck between therapy and drugs.

 · A University of Southampton study published in April concluded that GPs need better systems to help spot depression. The study found only a third of patients who rated themselves as depressed were diagnosed by their GP.

 · The Centre for Mental Health last week said the consensus was that waiting time for counselling and CBT had not changed since the NICE guidelines were published.

The NICE guidelines

·The National Institute for Clinical Excellence issued guidelines for the management of depression and anxiety in December 2004 to improve the standards of care for patients, and to diminish the variation in the provision and quality of care within the NHS.

·The NICE guidelines recommend a stepped-care approach moving from recognition and management in primary care to involvement of specialist mental health services including inpatient care.

·Both guidelines expect that the majority of patients with depression and anxiety disorders will be managed in primary

care, with referral to secondary care for patients who fail at least two interventions in primary care or have severe forms of the illnesses.

1. Severity of depression

Core symptoms:

(At least one of these must be present on most days, most of the time for two weeks):

·Low mood ·Loss of interests or pleasure ·Excessive fatigue / low energy

Associated symptoms:

·Disturbed sleep ·Decreased/increased appetite

·Poor concentration or indecisiveness ·Low self-confidence

·Agitation or retardation of movements ·Suicidal thoughts or acts

·Excessive guilt or self-blame

·Mild depression: four symptoms

·Moderate depression: five or six symptoms

·Severe depression: seven or more symptoms, with or without psychotic symptoms

2. Referral to

secondary care

Urgent:

·Active suicidal ideas or plans

·Psychotic symptoms

·Severe self-neglect

·Severe depression with severe agitation

Other:

·Poor or incomplete response to two interventions

·Recurrent episode within one year of last one

·Patients or relatives request

·Self-neglect

Useful websites

Royal college of psychiatrists: www.rcpsych.ac.uk

Relate: www.relate.org.uk

Fellowship of Depressives Anonymous: www.depressionanon.co.uk

Patient information leaflets: www.patient.co.uk

GP notebook: www.gpnotebook.co.uk

Factsheets and leaflets

Depression: www.rcpsych.ac.uk/info/help/dep/index.asp

Antidepressants: www.rcpsych.ac.uk/info/factsheets/pfacanti.pdf

Anxiety: www.patient.co.uk/showdoc/27000124/

Anxiety self-help guide: www.patient.co.uk/showdoc/23069094/

Switching antidepressants: www.gpnotebook.co.uk/cache/1651179592.htm

Pavan Kumar Mallikarjun is senior house officer, Queen Elizabeth psychiatric hospital, Birmingham

Femi Oyebode is head of department of psychiatry, University of Birmingham, Queen Elizabeth psychiatric hospital, Birmingham

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