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Ten tips on treating depression

GP Dr John Hague offers pointers on screening, antidepressant use, CBT, exercise and useful resources.

GP Dr John Hague offers pointers on screening, antidepressant use, CBT, exercise and useful resources.

1. Screening is worth doing. The QOF has introduced the concept of screening for depression in high risk groups to everyday practice, using the "2 questions":

• During the last month, have you often been bothered by feeling down, depressed or hopeless?

and

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

So why bother? Well, if you screen your diabetic patients, and treat the depressed third that you will find, then you can increase the number of diabetics with good control by over 40% , and cut misery and poor health, while also helping your income. You can save lives too, as a third of those who have an MI have depression in the year after, and the risk of death is three times higher than in post-MI patients who are not depressed.

2. Ratings scales are invaluable- both to confirm a diagnosis and to monitor progress. In our practice we've been using scales for several years. Every consultation room has multiple copies of the PHQ-9, with its sister scale GAD-7, that measures anxiety, along with laminated sheets to help us decipher the score. We feel that the questionnaires help us recognise patients that we would previously have missed, and it definitely helps patients to understand why we are making the diagnosis. The scales are also very useful to monitor patients and that helps with the DEP 2 and DEP3 QOF targets, if used at the appropriate time. You can use them to show patients that they are beginning to respond, and to help you spot non-response.

3. Make sure patients get written information about both depression and drugs. We all know that patients retain only a tiny fraction of what we say and this can hamper effective care. I use the excellent handouts available from www.patient.co.uk - available via the Mentor Library if you have EMIS. There are also good handouts available from the Royal College of Psychiatrists and the WHO Guide to Mental and Neurological Health in Primary Care Patients really value the information, they help to reinforce what you have said, and can also be useful for them to show to relatives and friends. Increasingly good quality information is also available on the NHS Choices.

4. Don't dismiss watchful waiting as a stratgey. I have to confess to have neglected this for a few years, until reminded of it by the NICE depression guideline. If you have a patient with mild depression it is well worthwhile just making a follow up appointment in a couple of weeks, in addition to giving them some simple literature, and well-being advice. You will be surprised at how many have begun to improve in this time

5. Use bibliotherapy or free-to-access CCBT sites. If you are fortunate enough to have a ‘books on prescription' scheme in your area, then you could use this, otherwise look at the booklist I use. I've had several patients who have been so impressed with a book that they have passed them onto friends. Most of the books are based on cognitive behavioural principles, and can help patients to unlearn patterns of negative or unhelpful thinking. If you're fortunate enough that your PCT has purchased one of the NICE recommended computerised CBT packages, then you could use that. But if your patient has access to the internet, then they can also benefit from one of the several free to access ‘computer CBT' websites that are available: Living Life to the Fullor Mood Gym.

6. Remember that exercise advice doesn't have to be formalised. You could use an ‘exercise on referral' scheme, but people greatly benefit from just going for regular walks, jogging, or going to a leisure centre. Playing in team games also helps build social networks.

7. Don't forget local education facilities as a resource. Many county councils will run courses that can be of direct benefit to people with depression. In one memorable surgery I had two patients come to discuss how much better they felt, and both had benefited much more from the ‘self esteem' course run by the council, than anything else.

8. Get to know a few drugs well and use them in a logical fashion. There's no need to be too complicated about this. You only really need to be familiar with a couple of SSRIs as first line drugs, which you can use in moderate and severe depression - starting at half the usual dose for the first few days to reduce initiation side effects. If the first one doesn't work you could prescribe the other SSRI as a second line drug, or become familiar with a couple of other non-SSRI treatments.

9. Make sure patients know how long they need to take drugs for, and how to stop them. People need to take antidepressants for at least 6 months after full recovery, and stop them over a month to minimise discontinuation symptoms. This ‘maintenance period' should be longer if it is a second or subsequent episode of depression.

10. Consider a referral for talking treatment. More and more areas have an Improving Access to Psychological Therapies (IAPT) service. Patients with moderate or severe depression should be offered the choice of referral to IAPT, for consideration of CBT. For moderate depression it's a straight choice and down to patient preference. For severe depression a combination of CBT and medication is likely to be more beneficial. The (telephone or internet) guided self-help offered by psychological well-being practitioners as the first step in IAPT can be incredibly effective, irrespective of the severity of the depression. Patients who do not respond will be stepped up to face-to-face CBT, being offered up to 20 sessions.

Dr John Hague is a GP in Ipswich, and NHS East of England GP clinical lead for the IAPT programme.

Competing interests: none declared

Make sure copies of PHQ-9 are easily accessible PHQ-9

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