Description
Depression is a common mental disorder that typically presents with 3 core symptoms, a number of associated symptoms and varying levels of impairment in social and occupational functioning.
ICD 10 Diagnostic Criteria:
Core Symptoms [two are needed]:
- Pervasive low mood that varies little from day to day
- Loss of interest and enjoyment
- Reduced energy and increased fatigability
Associated Symptoms:
- Reduced concentration and attention
- Reduced self esteem and confidence
- Ideas of guilt or unworthiness
- Bleak and pessimistic views of the future
- Ideas or acts of deliberate self harm or suicide
- Disturbed sleep
- Diminished appetite
Depressive episodes are subdivided into mild, moderate and severe categories, each requiring a different approach to treatment and care. Several scoring tools can help diagnostically and with assessment of severity. Please see Resources and Links tab for details.
Treatment
Lothian has developed a mixture of ‘stepped’ and ‘matched’ care approaches for helping those with depression. NICE definitions are:
- STEPPED CARE – the least intrusive, most effective and (usually) most available intervention is provided first; if a person does not benefit from the intervention initially offered, or declines an intervention with a good reason, they should be offered an appropriate intervention from the next step.
- MATCHED CARE – a comprehensive mental health assessment will determine which intervention a patient should receive. We should not force more ill patients to start at the bottom step, but intervene at the right level.
These models provide a range of evidence-based interventions that aim to match appropriate treatments to the severity of the patient’s depression. Treatment options for mild to moderate depression form part of the overall Lothian integrated care pathway for depression. For useful resources please see NICE Clinical Guideline 90 NICE Clinical Guideline 90 ‘Depression in Adults: recognition and management’ (Guideline 90) and SIGN Guideline 114 ‘Non-pharmaceutical management of depression in Adults
Who to refer:
| FOCUS of the Intervention | NATURE of the Intervention |
| STEP 1: Low mood, occasional / minimal symptoms of depression | Assessment, support, psycho-education, active monitoring [‘watchful waiting’] Please see RefHelp for a selection of approaches. These include counselling, stress control classes, book prescribing and reading, exercise for mental health, and psychological therapies including CBT and guided self help:Psychology Behavioural SERVICES Adult.aspx, Stress Emotional Crises.aspx There are local resources:Edinburgh – Mental Health InformationStation, ithriveedinburgh.org.ukWest Lothian – West Lothian MOOD Project supports people aged 55+ in West Lothian at risk of, or diagnosed with, depression or anxiety.Midlothian Mental Health Wellbeing Access Point – Midlothian Access Point |
| STEP 2: Persistent sub-threshold depressive symptoms; mild to moderate depression | Low-intensity psychosocial interventions, psychological interventions, medication and referral for further assessment and interventions:As Step 1 aboveReferral: Group CBT for Anxiety, DepressionGP Prescribing for depression (see below) |
| STEP 3: Persistent sub-threshold depressive symptoms or mild to moderate depression with inadequate response to initial interventions; moderate and severe depression | Medication, high-intensity psychological interventions, combined treatments, collaborative care and referral for further assessment and interventionsReferral for: Group CBT for PTSD/OCD, Individual CBT, Medication Review |
| STEP 4: Severe and complex depression **; risk to life; severe self-neglect. Medication | Medication, high-intensity psychological interventions, electroconvulsive therapy, crisis service, combined treatments, multi-professional and inpatient care |
** Complex depression includes depression that shows an inadequate response to multiple treatments, is complicated by psychotic symptoms, and/or is associated with significant psychiatric co-morbidity or psychosocial factors.
And a list of self-help approaches is available at:
https://apps.nhslothian.scot/refhelp/FurtherInfo/MentalHealthSelf-HelpWebsiteList/ (still to be updated)
Prescribing:
Please see the Lothian Joint Formulary for prescribing guidance in patients presenting with mild-moderate depression.
It is expected that the GP will have tried two antidepressants [from two different groups] and considered CBT before asking for medication advice.
GPs are free to discuss other treatment options [such as Lithium or MAOI] with patients if they feel competent, but such medications are usually started after secondary care review (and usually a full course of a talking treatment such as CBT).
Who not to refer:
Stable patients
- Medication advice for stable patients can be requested without need for full referral. This can be done through SCI Gateway by marking clearly on the referral ‘Advice Only’. This may include individuals receiving Lithium treatment, multiple psychotropic medications or MAOI treatment who are not in outpatient follow up. Specific concerns may relate to the ongoing requirement for treatment, the potential side-effects of longer-term treatment or patients’ request for discontinuation.
Patients requesting referral for diagnosis where the presentation does not fit with ICD-10 diagnostic criteria for depressive disorder and there is no suspicion of other underlying mental health problems requiring specialist diagnosis and input
- This would include patients with a clear diagnosis of Personality Disorder in whom previous diagnoses of depression (and associated treatments) have not been helpful and in whom the clinical presentation / situation has not changed.
How to refer:
Please refer via SCI Gateway to your local mental health team. Referrals to mental health services are usually step 2 and upwards.
If a person’s clinical needs mean that their referral, while not urgent, should be considered as a priority please make that clear in the referral form and explain the clinical reason for this.
For urgent referrals, refer via SCI Gateway. But there are also local arrangements for this – please see the section on mental health emergencies Mental Health Emergencies for details.
Factors suggesting urgency include: increasing risk, rapid deterioration or first-episode / relapse of psychosis.
Referrals for psychology, psychiatry, therapy all come through the same gateway – it is fine to ask for a specific intervention but the allocation meeting will direct the referral as they think most appropriate based on the referral and information already held on hospital systems.
- Please include an outline of patient’s current presentation and a brief summary of known past treatments is helpful.
- Please clearly state known risks including self-harm, vulnerability, or risk to any dependents/others.
- Please state clearly if the person is willing to consider group treatments, which usually have a shorter waiting list.
Scoring Tools
Mental Health – Depression PHQ9 Scoring Card.pdf Scoring PHQ-9 Example Completed.pdf
Mental Health – Depression GAD7 Scoring.pdf
Mental Health – Major Depression MDI Questionnaire.pdf Mental Health – Scoring of MDI Major Depression_Inventory.pdf
Self Help, Lifestyle and Community Engagement:
Mood Juice – online CBT-based resource https://www.moodjuice.scot.nhs.uk/
Living Life To The Full – online CBT-based resource https://llttf.com/
Mental Health Information Station – weekly drop in
The Mental Health Information Station runs every Thursday from 11am-3pm and is based at ‘A Sense of Some Place’ in the Walpole Hall [next to St Mary’s Cathedral], Palmerston Place, Edinburgh, EH12 5AW
https://services.nhslothian.scot/mentalhealthinformationstation/Pages/default.aspx
Edspace
Prescribing:
Lothian Joint Formulary: https://www.ljf.scot.nhs.uk/LothianJointFormularies/Adult/4.0/4.3/Pages/default.aspx
Management and monitoring of patients using Lithium: Lithium Treatment.pdf
NHS Scotland / CMO Lithium guideline – https://www.sehd.scot.nhs.uk/cmo/CMO(2019)04.pdf
[Psychiatrists asking GPs to start people on Lithium should send clear instructions]
Patients with renal impairment secondary to Lithium – Review Article
Lithium and chronic kidney disease; Mukesh Kripalani et al; BMJ 2009;339:b2452 (https://www.bmj.com/content/339/bmj.b2452)
NICE-discussing-firstline-treatments-for-less-severe-depression-pdf.pdf
