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Management of depression in practice and how to decide when referral is appropriate

Most of the depressed patients seen in general practice will not need referral, but you need to be confident you can treat them properly, writes Dr Lorna Gold

epression, overt or somatised, is a common reason for general practice consultations, and ability to manage mild to moderate depression is as fundamental for a GP as ability to manage hypertension or urinary tract infections.

Most registrars, even those who have done psychiatry as part of their training, find the idea of managing depression in the community quite daunting at first. Psychiatrists see only the most severe end of the spectrum of depressive illness.

Most of the depressed patients you see in general practice will not need referral. It is worthwhile, early in your training, to ensure your knowledge is adequate and to get rid of any prejudices that might make it difficult for you to treat these patients properly.

Depression is as disabling as physical disease and should carry no more stigma for the sufferer than, say, bowel cancer or pneumonia.

Managing depression need not worry you if you are armed with sufficient knowledge and an appropriate attitude, but every GP, however experienced, sometimes needs help from within the practice, from the community mental health team or from hospital-based psychiatry services.

When to seek help from your trainer or other members of the primary health care team

lFor advice about which drugs to prescribe. There are dozens of psychoactive drugs in the BNF and you cannot expect to become familiar with all of them. Use the practice formulary, if there is one, as the basis for a tutorial.

lFor advice about resources which may range from a rapid response home treatment team to confidential safe houses for battered women.

lFor access to practice-based clinics run, for example, by an attached community psychiatric nurse or counsellor.

lFor debriefing. Do not underestimate the need for this. Treating depression can be emotionally exhausting even for an experienced GP. Depressed patients are not simply unhappy. Their illness can make them insecure, self-centred, help-rejecting, aggressive and sometimes manipulative. Some will resent the label of depression and repeatedly question your diagnosis. It is easy for a young doctor to become irritated with what he sees as the patient's difficult personality, to lose confidence when his efforts do not seem to be effective or appreciated, or even to start to imagine that the patient's depression is his fault.

lFor support if the patient or relatives express doubts about your ability, as a GP in training, to provide adequate care.

Few patients are comfortable with the idea of psychiatric referral, and it is important to explain that you are seeking a specialist opinion because there is a medical need, not as a punitive measure or because the patient is 'mad'. Community mental health teams, where available, are less intimidating than hospital psychiatry services, and in some areas there are home treatment teams which provide 24-hour care to patients who might otherwise be admitted under the mental health Act. We use the following practice-based guidelines.

When to refer urgently to secondary care

lSuicide attempt or expressed suicidal intent. A study in the BMJ showed that health workers' assessment of suicidal intent is unreliable. It is inadvisable ever to treat a patient's claim to be suicidal with scepticism, even if they have a history of making threats which they do not follow through.

lSevere retarded depression or self-neglect. It is rare to see such severe depression now, but the mute, immobile, incontinent patient needs to be in hospital.

lPostnatal depression. The baby is at risk as well as the mother. If the symptoms are mild and insight is preserved, antidepressant medication or cognitive-behavioural counselling and support by the health visitor may be sufficient.

lDepression with psychotic features such as hallucinations and morbid delusional ideas.

When to refer routinely to secondary care

lThe elderly patient with apparent depression. If a patient over 65 develops a first episode of depression, think of organic pathology. Carry out a full physical examination, check for thyroid disease and diabetes (which I have seen present as agitated depression several times) and organise a chest X-ray. If these are normal, it is worth referral to exclude such conditions as cerebral tumours and normal pressure hydrocephalus.

lThe patient who needs psychotherapy, such as child sexual abuse survivors. Few GPs have the time or expertise to attempt formal psychotherapy, and it is unwise to dabble in psychotherapeutic techniques.

lWhen you think the patient may have a personality disorder. I do not like to attach this label without specialist advice.

lDepression in association with other physical illnesses such as epilepsy, where antidepressant treatment could cause fits to get worse, or where drug or alcohol misuse is a complicating factor.

lFailure to respond to conventional treatment regimes. Most GPs are familiar with the use of anxiolytics and low-dose neuroleptic drugs in combination with antidepressants, and many initiate lithium, but if you are considering

using a drug outwith its licensed indications it is worth seeking a psychiatric opinion first.

Managing depression need

not worry you if you are armed with sufficient knowledge and

an appropriate attitude~

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