Progress in depression management: focusing on function

Continuing our series showcasing highlights from our Pulse365 Live and Virtual events, occupational health specialist Dr Tarun Gupta provides an update on progress in depression management in primary care including how to support patients to address functional problems to aid recovery

Depression affects a significant portion of the adult population (up to one in six adults in the UK at any given time),¹ presenting a complex challenge for primary care providers. It spans a continuum of severity, impacting personal and social functioning to varying degrees.

The updated NICE guidelines² introduce a nuanced approach to classification, distinguishing between ‘less severe’ and ‘more severe depression’ based on symptoms, duration, and impact. This better represents the available evidence than the traditional classification of depression and should make it easier for GPs to follow the recommendations in routine clinical practice.

Risk assessment – taking a holistic approach

Effective depression care requires comprehensive risk assessment, considering not just symptom severity, but also functional impairment and individual life circumstances.

With anxiety and depression often co-occurring, prioritising the treatment of depression is recommended. This approach recognises the importance of addressing the most debilitating condition first to facilitate overall recovery.

Supporting people to stay in work

Mental illness constitutes around 35% of all fit notes issued, with depression making up 40% of these, anxiety 15%, stress 25%, mixed anxiety and depression 13% and bereavement 5%.

Occupational health considerations, particularly through the use of fit notes, have evolved to emphasise keeping patients engaged in work where possible. This shift towards assessing what a patient can do, rather than what they can’t, helps maintain their connection to the workplace and has broader societal benefits.³

There is also greater awareness of how existing disability legislation can be applied to promote inclusion through reasonable adjustments, especially following changes in the workplace, such as ‘hybrid’ working introduced since the pandemic.

Brief occupational health enquiries in primary care can result in significant insight and consideration to use of the ‘may be fit’ for work section of the fit note, opening up potential discussions between employer and employee and moving away from an ‘all or nothing’ approach to work.

Consider asking the following focused questions as part of the GP consult, which typically takes a few minutes:

‘What do you do?’ Through this you can explore the individual’s job role, including shift pattern and any safety-critical aspects.
‘How does this condition impact your work?’ This invites the individual to briefly identify perceived challenges and describe functional restrictions.
‘What can we do to support your inclusion at work?’ This can lead to an open and joint discussion focused on pragmatic and reasonable workplace adjustments, and signposting to other resources such as occupational health. Suggest the patient discusses their concerns (especially around work-related stress) directly with their employer, with occupational health or union representative support as required. Reasonable adjustments in depression can include for example, reduced productivity targets following an exacerbation, or support to attend ongoing counselling or psychological therapy.

The GP can indicate any comments on the fit note in the relevant section for the employer.

Several GPs have reported work-related stress cases being successfully progressed by proactively encouraging direct discussion between the employer and employee, noting that medication and psychological therapies including through Employee Assistance Programmes (EAPs) via the employer, where available, are unlikely to be effective in isolation (see illustrative Case study below).

Case study

A 40-year-old manager requests a fit note for ‘stress’ and ‘low mood’, citing issues at home with an elderly parent and perceived workplace stressors, including workload.

The GP assessment, using a biopsychosocial approach and based on the ‘four Ps’, reveals:

Predisposing factors: notes reveal a family history of depression (father).
Precipitating factors: elderly parent has had a fall and needs care, disagreement with manager at work around how to manage workload and strain in employee-employer relationship.
Perpetuating factors: negative thought pattern around work, feeling helpless at home.
Protective factors: siblings live close by and can help too.

The GP determines a way forward is to offer brief psychological intervention in the primary care clinic setting, delivered by the mental health practitioner (MHP) or GP, to include discussion around how the psychosocial and perceived work-related stressors can be mitigated.

In this case, the patient is given advice on behavioural activation to increase activity: taking small steps, behaving ‘as if you feel better’. Activities to include physical activity and should be meaningful or have a sense of achievement, as well as being enjoyable or relaxing.

The GP issues a fit note for 4 weeks stating ‘may be fit for work’ with a comment to directly raise concerns around demands and workplace relationships with the employer. The patient is advised to book in with the social prescriber via reception at the GP surgery.

The patient returns in 4 weeks to say the fit note resulted in a meeting at work and constructive steps to address the raised workload concerns including being offered a permanent move to a different team. He has consulted the social prescriber, sought help from siblings and supported the elderly parent in their recovery satisfactorily – the patient thanked the GP for their support.

Digital health as a support pillar

Digital health technologies, including 24/7 support platforms such as Headspace and Calm Apps as well as the digital talking therapies, in particular online CBT, and remote monitoring via wearables and telehealth services are breaking down traditional barriers to care.

Remote monitoring enables early recognition of deterioration in psychological well-being and possible symptoms of depression, such as sleep disturbance and reduced activity levels, while telehealth can allow early intervention and support, including resources such as EAP via the employer, where available.

These tools offer both patients and providers innovative ways to address symptoms of depression, from both a preventive and reactive stance, including support with chronic management and reducing the risk of relapse.

Summary

Primary care’s role in managing depression is ever-evolving, with updated clinical guidelines, occupational health considerations and digital health innovations leading the way towards more effective and personalised care. Our focus as GPs remains on improving outcomes and quality of life for those affected by depression.

Dr Tarun Gupta is a GP and occupational health physician