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Recognition and Management

Dr Bruce Davies
What Is Depression?
A Continuum

Normal Mood Lowering

Abnormal Mood Lowering

Abnormal mood lowering and loss of function

What Is Depression?

 Depressive disorder
 Pervasive
 Persistent

 Wide range of symptoms

What Is Depression?
 Range of symptoms
 Negative views
 Worthlessness
 Incapacity
 Guilt
 Sleep disturbance
 Diurnal mood variation
 Loss of energy
 Impaired concentration
What Is Depression?
 Impaired work ability
 Poor social functioning

 Psychomotor retardation

 Pessimism

 Better off dead

 Thoughts of suicide

 Suicide / action

 Fear / belief of bodily illness

 No longer important.
 Do not alter
 Do not alter
 Reactive /
endogenous =
confine to bin.
 Losses
 Stressful life events
 Lack of social
 Physical illness
 Familial factors
 Genetic factors
What Is Depression? - Various Criteria.

Defeat Depression Campaign

 Depressed mood or loss of pleasure for
at least 2 weeks. Plus 4 or more of:
 Worthlessness or guilt
 Impaired concentration
 Loss of energy and fatigue
 Thoughts of suicide
 Loss or increase of appetite or weight
 Insomnia or hypersomnia
 Retardation or agitation
What Is Depression? - Various Criteria.
 Duration > 2 weeks Depressed mood or Marked loss of
interest or pleasure in normal activities
 Plus 4 of:
i. Significant change in weight
ii. Significant change in sleep pattern
iii. Agitation or retardation
iv. Fatigue or loss of energy
v. Guilt / worthlessness
vi. Can’t concentrate or make decisions
vii. Thoughts of death or suicide
What Is Depression? - Various Criteria.

ICD – 10
 Patient has low mood:
1)How bad is it and how long has it been going on?
2)Have you lost interest in things?
3)Are you more tired than usual?
If the answer is yes to these, then:
ICD – 10 (Continued)
4)Have you lost confidence in yourself?
5)Do you feel guilty about things?
6)Concentration difficulties?
7)Sleeping problems?
8)Change in appetite or weight?
9)Do you feel that life is not worth living any
ICD – 10 (Continued)
 Mild.
Two criteria from 1-3 and 2 others.
 Moderate.
Two criteria from 1-3 and 3-4 others or a yes
to question 5.
 Severe.
Most of the criteria in severe form especially
questions 5 & 9.
 Depressive episodes that
do not meet the criteria for
major depression.
 Lifelong mild fluctuating
depression (Dysthymia).
 Mixed states of above two.
 Manic depression –
bipolar disorder.
Incidence Of Depression :
2000 Patients

100 - major

100 - minor

200 – sub-

Depression. In 50% of patients it

may not be acknowledged.
 10% of those diagnosed in primary care
are referred to psychiatrists.
 1 in 1000 are admitted to hospital.
 Lifetime incidence rates approach 33%.
 5% of consulters have major
 5% have milder depression.
 A further 10% have some depressive
 At least one patient per surgery will
have depressive symptoms of some
 Commoner in younger people including
children than thought in the past.
 Men:women = 1:2.
 Common in the physically ill.
 50% recurrence rate.
 12% become chronically depressed.
Why Missed?
 50% are missed.
 10% subsequently
 Of the 40% who remain
 Half remit
 Half remain depressed 6
months later.
Missed: Patient Factors

 Present somatic symptoms.

 Physical problems.
 Stigma.
 Beliefs about GP role and time to listen.
 Longstanding depression.
 Less overt / typical.
 Less insight.
Missed: Doctor Factors
 More accurate doctors.
 Make more eye contact.
 Show less signs of hurry.
 Are good listeners.
 Ask questions with social and psychological
 Less accurate doctors.
 Ask many closed questions.
 Ask questions derived from theory rather than
what the patient just said.
 Severity
 Duration
 Social network
 Views of self, world
and future
 Suicidal thoughts
 Past history
 Factors affecting
 Biological features
Assessment Skills
 Directive not closed questions
 Picking up on verbal clues
 Picking up on non-verbal clues and
using them
 Empathy
 Summarising
Treatment Contract
 Key skills
 Re-frame symptoms as
 Link to life events
 Negotiate anti-
depressants if necessary
 Problem list and
 Set realistic time scale
 Agree regular review
 Depressive illness
is clinically different
from the blues and
involves chemical
changes in the
 Depressive illness
has characteristic
symptoms and
explain them.

 Depression benefits
from both drug and
 “Pills for symptoms.”
 “Talking for
 Anti-depressants
are not addictive or
habit forming.
 Anti-depressants
take 2-3 weeks to
begin to work and
need to be taken for
4-6 months after the
full benefit is
obtained to prevent
 Side effects occur
and are expected –
 Drugs enable talking
therapy to work
 Regular review is
important and needs
to continue for at
least 6 months.
 Talking therapy can help solve
problems that are soluble, cope with
the insoluble and examine other
problems that seem unrealistic to the
patient or therapist.
 Prevention of further trouble will be
considered when the treatment is
coming to an end.

 Defeat Depression Campaign. The

Royal College of Psychiatrists. 1994.
 Treating People with depression: a
practical guide for primary care. G
Wilkinson et al. Radcliffe 1998.
 Recognition and management of
depression in general practice:
consensus statement. BMJ