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In the first of a new series on subjects that might crop up in the MRCGP exam Dr Victoria Jennings takes a look at depression

In the first of a new series on subjects that might crop up in the MRCGP exam Dr Victoria Jennings takes a look at depression

In the past year there has been new NICE guidance on depression and also several papers on SSRIs and St John's wort, making this an important topic for the exam.

NICE recommends screening high-risk patients by asking them:

  • During the last month, have you often been bothered by feeling down, depressed or hopeless?
  • During the last month, have you often been bothered by having little interest or pleasure in doing things?

Further evaluation is in accordance with the ICD-10 criteria (WHO, 1992).Over the last two weeks, most days, most of the time, have you felt at least one of:

  • persistent sadness or low mood
  • anhedonia
  • fatigue

accompanied by some of the following:

  • low self-confidence·
  • change in weight/appetite
  • change in sleep·
  • psychomotor agitation or retardation
  • feelings of worthlessness/guilt/self-blame
  • poor concentration
  • suicidal thoughts/acts

Mild depression has four symptoms or less. Moderate has five or six. Severe has seven or more.


  • Consider watchful waiting for two weeks
  • Encourage them to exercise.
  • Try computerised cognitive behaviour therapy ( CBT) ­ and other CBT or psychological interventions such as counselling or problem-solving therapy
  • Antidepressants are not recommended initially as risk-benefit ratio is poor, but consider if symptoms persist despite the above, or in patients with a history of depression.


Refer urgently if suicidal, psychotic, severe agitation or neglect.

All patients should be offered anti-depressants. Use SSRIs first-line ­ start with fluoxetine or citalopram as there are fewer discontinuation reactions. Sertraline has the best evidence base in patients with heart disease. Address fears of addiction, warn about possible side-effects, withdrawal symptoms and delayed-onset of action. Monitor those at increased risk of agitation and all those under 30 one week after starting treatment. Review all others regularly. If there is no response after one month (six weeks in the elderly), consider changing drug. If the response is partial, reassess at six weeks.

Second-line drugs include another SSRI, mirtazipine, tricyclics (see full guideline). Note that venlafaxine should now only be initiated by psychiatrists or GPSIs.

  • Also use psychological treatments as above.

There has been a lot in the media about increased suicide risk with SSRIs, especially in children. CSM guidance (December 2004) says:

  • there is no evidence of additional benefit from increasing the dose above the recommended daily dose· monitor frequently for signs of restlessness/agitation· taper the dose to minimise withdrawal reactions

BMJ February 2005 published three papers on SSRIsI. These concluded:

  • SSRIs are effective in moderate and severe depression, there is no clear suicide relation
  • SSRIs and tricyclics may induce or worsen suicidal ideation, possibly because they cause agitation in the early phases of treatment

Careful monitoring is needed.· In children/adolescents the balance between benefits and harm seems to be negative. Antidepressants should not be prescribed in this group.

SSRIs can increase the risk of GI bleeding. Use with caution in the at-risk, especially if on aspirin/NSAIDs. Consider gastroprotection, although further studies are needed.

There is evidence of benefit in mild/moderate depression but be aware of uncertainty about doses and drug interactions. A recent randomised controlled trial compared St John's wort with paroxetine in patients with acute major depression. St John's Wort was as effective and better tolerated.

Victoria Jennings has recently passed summative assessment and the MRCGP and is now a salaried GP in Soham, Cambridgeshire

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