Assessing a patient with depression
Liam is 23 and lives in a bedsit having fallen out with his parents and his girlfriend. He abandoned his university course as a 'waste of time' and works shifts in a factory. He has come in for a signing off note following a fractured fifth metacarpal; he needs the money. He looks unkempt, and you reflect out loud that he looks fed up. He nods, then shrugs his shoulders. Dr Melanie Wynne-Jones discusses.
He nods, then shrugs his shoulders.
Dr Melanie Wynne-Jones discusses.
Is Liam depressed?
He may well be or he may simply be broke, lonely, or embarrassed/resentful at being asked personal questions. Other possibilities include:
·Other psychiatric illness
·Adverse life events
·Poor coping/social skills has he been fighting?
How common is depression?
Prevalence estimates vary, but for major depression among 16- to 65-year-olds in the UK the figures are 21/1,000 (males 17, females 25) and 98/1,000 for 'mixed depression and anxiety' (males 71, females 124)1. Depression is commoner (all figures are per 1,000) in:
·the elderly (over the age of 55 depression is commoner in men than women)
·people who are separated (56 female, 111 male), widowed males (70) and divorced females (46), with the lowest prevalence among the married
·Parents, particularly lone parents
·Social classes three and below
·The unemployed, especially women
·People finishing education earlier, especially men
·People in rented accomodation
·People who are homeless/living in hostels
·Neighbourhoods with social deprivation
·Women of Asian or Oriental ethnic origin
Around 90 per cent of mental health care is given in primary care; a quarter of GP consultations may include a mental health problem, but GPs may recognise less than half the cases of depression they see2. GPs with good communication skills and a willingness to talk about mental health problems are more likely to detect and address depression.
What symptoms should you ask about?
·Low/depressed mood sadness, feeling of emptiness or hopelessness, tearfulness, irritability
·Loss of interest or pleasure, enthusiasm or motivation
·Feeling/appearing agitated or restless
·Feeling slowed down, extremely tired, lacking in energy
·Sleep disturbance classically early morning or repeated wakening with rumination, but may be difficulty in going to sleep if also anxious
·Difficulty in thinking, concentrating, making decisions
·Physical symptoms which may be tempered by anxiety increased or reduced appetite and/or weight, constipation or diarrhoea
·Feelings of worthlessness, inadequacy, self-blame and guilt
·Thoughts of death or self-harm (see below).
For a diagnosis of depression, these should be persistent, ie present for most of the time over at least the past two weeks. ICD-10 (International Classification of Diseases)3 and the American DSM-IV4 set out precise criteria for diagnosing the presence and severity of depression. Ask also about:
·Alcohol and/or drug use (may be triggers or coping mechanisms)
·Symptoms that suggest psychosis (hallucinations, delusions, hypomania)
·Physical health (depression may be a symptom of, or have been triggered by, physical illness).
What other factors are operating?
Ask yourself (and your patient): 'Why now?' Relevant information may include:
·Risk factors for depression (see above)
·Recent loss bereavment, relationship/family breakdown, own or family member's redundancy or serious illness,
·Conflict with supportive partner/friend/colleague
·Stress work, money, young children
·Bullying or abuse at work, school or home; history of being abused, feelings possibly reactivated by current events
·Alcohol or substance abuse
·Trouble with the law (perhaps relating to one of the above); occasionally someone may simply want a 'note from the doctor' to get them out of trouble.
The person's ideas, concerns and expectations relating to depression are also important.
If they are frightened or ashamed of mental illness, have past experience of it personally, or
in the family, or have seen others struggle or recover, these will influence their behaviour in the consultation.
Is Liam at risk of suicide?
Many depressed people feel or say they would be better off dead, or that they feel worthless and a burden to others.
However, 5,000 people a year in the UK commit suicide, and the biggest group is young adult males; suicide is now the most common cause of death in men under 35. Other risk factors include living alone, physical illness, unemployment, alcohol or drug misuse, mental illness, feelings of hopelessness and recent self-harm. The NHS is committed to reducing suicides by 20 per cent by 2010.5
It is vital to make and record a suicide risk assessment for anyone who is depressed; most people respond honestly to sensitive questions and empathy. Talking about suicide is not a sign that they 'don't really mean it'.
A GP can expect a suicide every seven years,
and many suicides see their GPs in the preceding weeks.
Asking whether life no longer seems worth living, or whether they have felt they can't go on, can be followed by asking whether they have thought about harming themselves. Tentative/definite plans, putting their life in order, procuring the means, drafting suicide notes or arranging for loved ones to be absent are all danger signs requiring prompt referral to the local mental health team for assessment. Occasionally this may have to be done compulsorily under section 2 of the Mental Health Act.
This will already have been a time-consuming consultation, but if you and Liam agree he is suffering from depression, you will then need to explore options that could include:
·Simple support and watchful waiting
·'Talking' treatments counselling, cognitive behavioural therapy
·Referral to the mental health team or alcohol/drug services
·Practical help housing, benefits, employment advisers and so on.
References and resources
1 National Institute for Clinical Excellence draft guideline
management of depression in primary and secondary care, 2nd draft Dec 03 www.nice.org.uk
2 National service framework for mental health www.nelh.nhs.uk/nsf/mentalhealth/default.htm
3 The International Statistical Classification of Diseases and Related Health Problems (ICD-10; WHO 1992)
4 Criteria for Major Depressive Episode and Major Depressive Disorder DSM-IV Diagnostic and Statistical Manual of Mental Disorders (Fourth Edition 1994), The American Psychiatric Association www.psych.org/psych_pract/treatg/pg/Depression2e.cfm
5 National Suicide Prevention Strategy for England www.dh.gov.uk/assetRoot/04/01/95/48/04019548.pdf
Melanie Wynne-Jones is a GP in Marple, Cheshire