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Depression- Adults

Step-1 Recognition , assessment and initial management of depression in adults.Asking questions 
and initial 
management.Be alert to possible depression particularly
 in people with

○ past h/o depression
○ chronic physical health problem
with associated functional impairment

. feeling down depressed or hopeless ? having little interest or pleasure in doing things.Review persons mental state and associated functional , interpersonal and social difficulties Consider using a validated measure of symptoms , functions and / or disability For people with language or communication difficulties , consider using the Distress Thermometer and / or asking a family member or carer about symptoms
 
Investigate further if distress is identified.

Subthreshold depressive 
symptoms describe a situation
 when an individual has some of the 9 defining symptoms of depression but they are insufficient in number or 
severity to meet full criteria to diagnose 
depression
 
( National Collaborating Centre for 
Mental Health 2009a )

If depression suspected- conduct a comprehensive assessment that does not rely simply on a symptom count- take into account-degree of associated functional impairment and / or disability duration of the episode.h/o depression and co-morbid conditions past h/o mood elevation response to previous Rx quality of interpersonal relationships living conditions and social isolation.

Learning disability or acquired cognitive impairment.consider d’g/w specialist where possible provide same interventions as for others – adjust method of delivery or duration if needed

ALWAYS ASK A PERSON WITH DEPRESSION DIRECTLY ABOUT SUICIDAL IDEATION AND INTENT . IF RISK OF SELF HARM OR SUICIDE

People with a chronic physical health problems.Ask three further questions 

During the last month , have you often
 been bothered by
feelings of worthlessness poor concentration thoughts of death.Consider the role of the physical health problem and any prescribed medication in depression
 Check that the optimal treatment for the physical health problem is being provided- seek specialist adv if needed

Risk assessment and monitoring-Assess and refer urgently if the person
 presents considerable immediate risk to themselves or others.potential for ↑↑ ed agitation , anxiety and suicidal ideation early in treatment – actively seek out these symptoms and review Rx if they develop marked and / or prolonged agitation
 need to be vigilant for mood changes , negativity , hopelessness and suicidal ideation particularly when starting /changing Rx or when pt experiences ↑↑ stress

Persistent subthreshold depressive symptoms or 
mild to moderate depression

Sleep hygiene Regular physical exercise Active monitoring 
○ discuss problems and any concerns 
○ assessment within 2 wks 
○ provide info about depression
○ make contact if pt DNAs appointments
Individual guided self-help based on CBT principle

can be computer based – CCBT
 Structured group physical activity Programme
 Group based CBT Modified for abilities – liaise with team treating the physical health problem Delivered in groups by a competent practitioner -2-3 sessions over 10-14 wks A group based peer self help Programme Individual guided self- help based on CBT principle

Do not use ADs routinely for persistent SDS or mild depression – but consider if

○ past h/o moderate or severe depression OR
○ symptoms of SDS’s present for atleast 2 yrs OR
○ symptoms persist after other interventions.mild depression that complicates the care pf the physical health problem OR
 a past h/o moderate or severe depression OR
 symptoms of SDS’s present for atleast 2 yrs OR
 SDS’s or mild depression persisting after other interventions.Persistent subthreshold depressive symptoms or mild to moderate depression with inadequate response to initial interventions and moderate and severe depression- see Step 3

duration / trajectory of symptoms previous illness course and response to Rx adherence / potential SEs persons preference course and Rx of any chronic physical health problem.Offer an antidepressant- normally an SSRI OR
 High intensity psychological intervention as
○ CBT
○ IPT ( interpersonal therapy )
○ Behavioral activation 
○ Behavioral couples therapy.

Provide an anti depressant – normally an SSRI OR one of the following high intensity psychological interventions

○ group-based CBT
○ individual CBT OR
○ behavioral couples therapy
 If initial presentation is of moderate depression- offer group based CBT , individual CBT or behavioral couples therapy

Combine antidepressants with a high intensity psychological intervention
 ( CBT or IPT )For people with severe depression consider offering both individual CBT and an antidepressant

References
 Depression in adults : recognition and management Clinical guideline CG 90 October 2009 Last updated April 2018 NICE Pathways https://pathways.nice.org.uk/pathways/depression Depression in adults with a chronic physical health problem : recognition and management Clinical guideline CG 90 October 2009

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