Post on 03-Apr-2018
7/29/2019 Managementul Depresiei in Medicina Primara
1/46
A Guide to Best Practice
Primary Care Services
or Depression
7/29/2019 Managementul Depresiei in Medicina Primara
2/46
DH INFORMATION READER BOX
Policy
HR/ Workforce
Management
PlanningClinical
Estates
Performance
IM & T
FinancePartnership Working
Document Purpose Best Practice Guidance
ROCR Ref: Gateway Ref: 6996
Title Primary Care Servise for Depression -
A Guide to Best Practice
Author Care Services Improvement Partnership (CSIP) / NPCRDC
Publication Date 01 September 2006
Target Audience GPs, PCT Mental Health Commissioners
Circulation List GPs, PCT Mental Health Commissioners
Description Changing the way care for depression is delivered is
complex. The precise issues will vary from place to place
reectinglocalcircumstances.Thechallengeremainsfor
primary care commissioners to engage GPs and their
practices in the development of mental health care. It is
hoped that this guidance document and the incentives in
the Quality and Outcomes Framework are mechanisms to
assist in achieving this goal.
Cross Ref N/A
Superseded Docs N/A
Action Required N/A
Timing N/A
Contact Details Emma Sarno
Care Services Improvement Partnership
North West Development Centre
Hyde Hospital, 2nd Floor, Hyde, Cheshire
SK14 5NY
0161 351 4920
www.csip.org.uk
For Recipients
AUTHORS
Janine Fletcher
Department o Nursing, University o Manchester
Peter Bower
NPCRDC, University o Manchester
Linda Gask
NPCRDC, University o Manchester
David Richards
Department o Health Sciences, University o York
Tim Saunders
NIMHE North West
7/29/2019 Managementul Depresiei in Medicina Primara
3/46
CONTENTS
EXECUTIVE SUMMARY Page 4
CHAPTER 1: Introduction Page 5CHAPTER 2: Depression In Primary Care Current Issues And The Latest Evidence Page 6
CHAPTER 3: Assessment O The Presence And Severity O Depression Page 9
CHAPTER 4: Clinical Pathways Page 11
CHAPTER 5: Monitoring And Follow Up Page 16
CHAPTER 6: Patient Preernce And Choice Page 21
CHAPTER 7: Roles For Proessionals Page 22
CHAPTER 8: Interace Issues Page 23
CHAPTER 9: Case Studies Page 24
CHAPTER 10: Audit And Monitoring Page 26
APPENDICES
Appendix 1: Screening For Depression In High Risk Groups Page 26
Appendix 2: Assessing The Severity O Depression (Icd-10 Primary Care Version) Page 27
Appendix 3: Other Scales For The Assessment O Severity And Outcome Page 28
Appendix 4: Asking About Risk Page 28
Appendix 5: Asking About Alcohol Problems The Cage Questionnaire Page 29
Appendix 6: Audit Questionnaire: Screening For Alcohol Misuse Page 30
Appendix 7: Relevant Patient Inormation Resources Page 32
Appendix 8: Treatments At Step 2 Page 32
Appendix 8: Websites With Inormation On The Collaborative Care Page 34
And Case Management Approach
Appendix 10: Phq-9 Monitoring Tool Pfer Page 34
Appendix 11: Recommended Categories For Response And Monitoring With The Phq-9 Page 36
REFERENCES Page 37USEFUL RESOURCES
Books and Reports Page 39
Organisations and Websites Page 41
Primary Care Services
or Depression
7/29/2019 Managementul Depresiei in Medicina Primara
4/46
EXECUTIVE SUMMARY
Depression is highly prevalent in primary care, and
a major cause o disease burden. The prognosis o
many depressive disorders is poor, and rates o relapse
and recurrence are high.
Given the burden associated with depression, it is
crucial that the care provided in primary care is o the
highest quality. However, management o depression in
primary care is not always optimal.
There are a number o key issues that are increasingly
important to the delivery o primary care services or
managing depression.
Improving access to psychological therapies-
Research has indicated that psychological therapy
is both eective and popular with patients1,1,
but all services have problems with access. Lord
Layard has made a case or increased provision o
psychological therapies (especially CBT) rom an
economic perspective.
Improving access to psychological therapies
minimal interventions and sel help - Minimalinterventions are treatments that require less input
rom a proessional therapist compared to traditional
psychological therapy (also called sel help). These
interventions are usually based on books, computer
programmes or websites, and oten ocus on teaching
CBT techniques.
Stepped care - There are two key eatures o a
stepped care system: (a) the recommended treatment
should be the least intensive o those currentlyavailable, but still likely to provide signicant health
gain (b) the results o treatments are monitored
systematically, and changes are made (so-called
stepping up) i current treatments are not achieving
signicant health gain.
Depression as a chronic disease - Traditionally,
primary care services have been structured around
acute care. However, depression may be better viewed
as a chronic disease, characterised by high levels o
relapse and recurrence. This means that depression
may be best treated through the use o specic chronic
disease management models.
A population perspective on depression -
Population-based care is aimed at restructuring
service delivery to provide a strategy or care or all
patients within a dened population with a recurrent
or chronic illness.
Collaborative care and case management-
Research has indicated that an eective method
o improving depression outcomes is collaborative
care. This involves GPs and mental health specialists
working more closely to supervise the ongoing care o
depressed patients.
7/29/2019 Managementul Depresiei in Medicina Primara
5/46
CHAPTER 1: INTRODUCTION
Since the original version o this guidance document
was published in 00, a number o important
developments have taken place in the commissioning
and implementation o mental health services.
The new GP contract has had a signicant impact on
the way primary care services are delivered. The recent
additions to the Quality and Outcomes Framework
ocussing on depression include two new indicators
which encourage primary care to screen or depression
in high risk groups, namely diabetes and coronary
heart disease, and monitor the severity o depression in
patients with a new diagnosis.
Implementation o NICE guidelines and the incentives
in the Quality and Outcomes Framework is likely to lead
to signicant improvements in the management and
treatment o depression in primary care.
However, challenges lie ahead or both primary care
and mental health commissioners in overcoming
problems with current service delivery. These
challenges include improving access to a range
o psychological therapies in primary care and astrengthening o the primary-secondary care interace.
There are also opportunities around the redesign o
existing services such as community mental health
teams and counselling services, and the introduction o
new workers such as the graduate primary care mental
health workers and practitioners with a special interest.
This will require mental health commissioners to
develop improved access to a range o psychological
therapies in primary care, to mental health assessment
(where required), and a strengthening o the primary/
secondary care interace. There are also opportunities
around the redesign o existing services such as
community mental health teams and counselling
services, and the introduction o new workers such as
the graduate primary care mental health workers andpractitioners with a special interest.
There has been a call or a signicant increase in the
number o psychological therapists to deliver evidence
based interventions.1 Whilst this idea is supported
in principle, initial recommendations are likely to
take some time to be achieved. It is possible that a
signicant amount o primary care provision can be
supported by proessionals other than those with
specialist psychological therapy skills.
So ar the implementation o graduate primary care
mental health workers across the country has been
patchy and in some areas the opportunities have not
been realised. In areas where implementation has
been supported by local training programmes and
management structures, services are recognising the
benets o this new workorce. These new workers
are key to the delivery o the stepped care model and
proper career structures or this group o workers are a
matter o urgency.
Changing the way care or depression is delivered is
complex. The precise issues will vary rom place to
place refecting local circumstances. The challenge
remains or primary care commissioners to engage
GPs and their practices in the development o mental
health care. It is hoped that this best practice guidance
document and the incentives in the Quality and
Outcomes Framework are mechanisms to assist in
achieving this goal.
Primary Care Services
or Depression
7/29/2019 Managementul Depresiei in Medicina Primara
6/46
CHAPTER 2: DEPRESSION IN PRIMARYCARE CURRENT ISSUES AND THELATEST EVIDENCE
Depression is highly prevalent in primary care, and a
major cause o disease burden. The prognosis o many
depressive disorders is poor, and rates o relapse and
recurrence are high.
Given the burden associated with depression, it is crucial
that the care provided in primary care is o the highest
quality. However, management o depression in primary
care is not always optimal, with concerns about a ailure
to recognise depressive disorders, to provide medication
in line with current guidelines, and an inability to provide
access to psychological treatments. These problems
refect pressures on proessional time, training and
resources.-
The original eorts to overcome these problems through
initiatives such as the Deeat Depression campaign7 and
practice-based education8 had some success, but the
impact o these initiatives has been relatively modest.
In part, this refects the complexities associated with
the management o depression, and the many actors
that interact to reduce the quality o care in primary
care. There are no magic bullets, and improving the
quality o care or depression requires changes to
the way care is provided and additional resources to
develop the appropriate systems to enable primary care
proessionals to deliver high quality care.,9-11
Previous research on the management o depression in
primary care has tended to be critical in tone. However,
it is important to note that many GPs and primary care
teams have developed ways o managing depression
that are eective and valued by patients. The models
have been developed over time and are sensitive to
the particular nature o primary care and its role in
patients lives. However, the enthusiasm o primary care
proessionals or mental health work varies signicantly,
which means that good quality care is not always
available to all patients.
The models o care presented here are designed to build
on present good practice in primary care and refect the
current evidence base. The main innovations relate to
the standardised assessment o depression in primary
care, and the systematic organisation o care that
ollows rom that assessment.
Key issues rom the latest research
There are a number o key issues that are increasingly
important to the delivery o primary care services or
managing depression. Some relate to issues about
service structure, while others concern the particular
types o interventions that should be delivered.
Improving access to psychological
therapies the Layard approach
Research has indicated that psychological therapy
is both eective or depression1 and popular with
patients.1 However, almost all services have problems
with access, with long waiting lists resulting rom limited
numbers o trained therapists. This leads to rustration
or patients, primary care proessionals and therapists.
Lord Layard has made a case or increased provision
o psychological therapies (especially CBT) rom an
economic perspective.1 He argues that employment
and mental health may be linked as both cause and
consequence. Mental health problems account or
a signicant number o days lost rom work and a
signicant proportion o patients on incapacity benets.
I the accessibility and eectiveness o psychological
therapy can be translated into increased return to work,
then additional therapists can be employed on the basis
that the overall costs to society can be recouped.
7/29/2019 Managementul Depresiei in Medicina Primara
7/46
7
Improving access to psychological therapies
minimal interventions and sel help
Although increases in the number o therapists will go
some way towards bridging the gap between supply
and demand, it is unlikely to provide a complete
solution because o the high prevalence o depressive
problems in the community.
An alternative approach to getting more benet rom
current resources is to ocus on the delivery o minimal
interventions to a proportion o depressed patients.
The term minimal intervention reers to the act that
these treatments require less input rom a proessional
therapist compared to traditional psychological therapy.
Much o the ocus on minimal interventions concerns
sel help. Sel help interventions are usually based on
books, computer programmes or websites, and oten
ocus on teaching CBT techniques to patients to help
them manage their symptoms. There is encouraging
evidence that such approaches are eective in the
management o depressive disorders.1 Because
these treatments are generally not dependent on the
availability o a specialist psychological therapist, theyprovide one method o overcoming problems with
access.1
Although sel-help is oten based on health
technologies such as books, computer programmes
and websites, the National Institute o Clinical
Excellence (NICE) recommends the adoption o a
guided sel-help model with some limited therapist
contact. The guidance states:
For patients with mild depression, consider a
guided sel-help programme that consists o the
provision o appropriate written materials and limited
support over to 9 weeks, including ollow up, rom
a proessional who typically introduces the sel-help
programme and reviews progress and outcome.
Although NICE has highlighted this model, other
minimal interventions which may be o use are
computerised cognitive behaviour therapy,1
signposting 17 or group psychoeducation.18 All could
provide more ecient delivery o care, meaning more
patients can access eective treatment.
Stepped care
Stepped care links conventional psychological therapy
with minimal interventions in a system designed to
provide the greatest amount o benet rom current
resources. Stepped care is a model o healthcare
delivery with its origins in the US, which has been
applied to a range o disorders, particularly those o a
chronic nature.19-1
There are two key eatures o a stepped care system.
Firstly, the recommended treatment should be the
least intensive o those currently available, but still
likely to provide signicant health gain. In stepped
care, more intensive treatments are reserved or
patients who do not benet rom less intensive rst
line treatments.
Secondly, stepped care is sel-correcting, in that the
results o treatments and decisions about treatment
provision are monitored systematically, and changes
are made (so-called stepping up) i current
treatments are not achieving signicant health gain
or an individual patient.
This is similar to the way many clinicians implicitly
operate, but stepped care standardises systems
and procedures with an explicit aim o improving
eectiveness and eciency.
Primary Care Services
or Depression
7/29/2019 Managementul Depresiei in Medicina Primara
8/46
8
Depression as a chronic disease
Traditionally, primary care services have been
structured around acute care. However, studies
o the natural history o depression have indicated
that depression may be better viewed as a chronic
disease, characterised by high levels o relapse and
recurrence. This means that depression may be best
treated through the use o specic chronic disease
management models, similar to the models adopted
in relation to other chronic diseases like asthma and
diabetes.
A population perspective on depression
Taking the chronic disease management perspective
on depression means that primary care organisations
will have to shit their perspective on depression rom
the care o the individual patient, to the care o the
entire population o depressed individuals. Population-
based care is aimed at restructuring service delivery
to provide a strategy or care or all patients within a
dened population with a recurrent or chronic illness.
Collaborative care and case management
Research has indicated that an eective method
o improving depression outcomes is collaborative
care. This involves GPs and mental health specialists
working more closely to supervise the ongoing
care o depressed patients. GPs are responsible or
recognition o the disorder, antidepressant prescription
and overall co-ordination o care, while the mental
health specialist (such as a psychiatrist) provides expert
consultation, support and advice. However, the most
signicant dierence associated with collaborativecare models is the introduction o a case manager.
The case manager takes responsibility or ollowing
up patients proactively, assessing patient adherence
to psychological and pharmacological treatments,
monitoring progress, taking action when treatment is
unsuccessul, and delivering psychological support
Case managers may be thought o as physician
extenders, who work under the supervision o the GP
to improve quality o care or patients with depression.
They do not work alone, but receive support rom a
specialist proessional, and share inormation with the
GP. A variety o proessionals may be able to take up
the case management role, including practice nurses,
mental health nurses, and the new graduate primary
care mental health workers.
Although the vast bulk o case managementinterventions have been tested in the United
States, two recent evaluations in England have also
demonstrated very positive results.
Summary
The previous section raised key issues in current
models o depression care. These themes have
inormed the model o care highlighted in this
commissioning guide, which can be discussed in
terms o three key aspects o care: assessment; clinicalpathways; and monitoring (Figure 1, overlea).
7/29/2019 Managementul Depresiei in Medicina Primara
9/46
9
Initial assessment
Severity o depression, risk and other important
actors are systematically assessed
Treatment decision making is based on the results o
that assessment and patient preerences
All patients are provided with high quality inormation
about depression, its treatment, and local services
Figure 1 Overview o the model
Clinical pathways
The clinical pathway consists o a number o steps.
Patients enter at dierent steps, depending on
severity and previous history
Many patients will enter the pathway at the rst or
second step, and will access higher steps in order, i
there is a lack o progress
Within steps, there are choices or patients about the
type o treatment that suits them best
Monitoring and ollow up
Each patient should have a planned schedule o
contacts to assess progress. The exact schedule
depends on severity and other actors
Scheduled contacts use objective outcome
measures as a marker o progress and an aid to
clinical decision making
Decisions may involve changes o treatments withinsteps, or moving patients up to new steps
CHAPTER 3: ASSESSMENT OF THEPRESENCE AND SEVERITY OF DEPRESSION
Screening
The psychological and social situation o some patients
makes them very vulnerable to depression. In these cases,
primary care proessionals may need to proactively screen
or symptoms o depression. NICE recommends primary
care routinely screens certain high risk groups:
Patients with signicant physical illness
Patients with other mental health problems, such as
dementia
Patients suering major lie events, such as childbirth,
long-term or recent unemployment and bereavement
Patients with a history o relationship diculties and
physical, sexual or emotional abuse
The new Quality and Outcomes Framework has now
incentivised screening in patients on the diabetes or
coronary heart disease register.
DEP1: The percentage o patients on the diabetes registerand /or the coronary heart disease register or whom
case nding or depression has been undertaken on
one occasion during the previous 1 months using two
standard screening questions.
Appendix 1 shows recommended questions or use in
screening or possible cases o depression.
Assessment
Depression is a sensitive and stigmatised subject and
there is no replacement or eective communication skills
to encourage the presentation o depression within the
consultation.
Primary Care Services
or Depression
7/29/2019 Managementul Depresiei in Medicina Primara
10/46
10
However, idiosyncratic and unstructured approaches to
the assessment o depression may mean that patients are
oered the wrong treatment. I depression is suspected,
a more comprehensive assessment must be conducted.This may be most appropriately done by the GP, but
could be completed by a variety o appropriately trained
health proessionals. This assessment should involve
standardised measures o:
Severity o depression
Risk
Other relevant psychosocial actors
Ruling out o other causes (i.e. testing thyroid unction)
Severity
The new Quality and Outcomes Framework has now
incentivised the assessment o depression using a
validated assessment tool.
DEP: In those patients with a new diagnosis o
depression, recorded between the preceding 1 April to
1 March, the percentage o patients who have had an
assessment o severity at the outset o treatment using anassessment tool validated or use in primary care.
A number o dierent methods can be used to categorise
the severity o depression. Appendix details an
assessment o the severity o depression according to the
ICD-10 checklist. NICE recommends the categorisation o
patients by mild, moderate or severe levels o depression,
so as to guide clinical decision making. A categorisation tool
such as the ICD-10 can help. Other instruments may be o
use, and some alternatives are provided in Appendix .
Although the Quality and Outcomes Framework provides
incentives or assessment o severity at the outset o
treatment, it is recommended that measures be used to
assess the outcome o treatment and assist in decisions
about urther management. This will be discussed later in
the guide.
Such instruments are acceptable to patients i they are
sensitively introduced with a clear explanation o the
purpose o the task e.g. Would you mind taking a couple
o minutes to complete this orm - itll help us to decide
what is the best orm o help or how you are eeling (or to
show us how you have been progressing). Patients may
also nd the questionnaire useul or explaining to relatives
how they have been eeling.
Risk
Suicidal thoughts are very common in depression.
Patients with depression should always be asked directly
about suicidal thoughts and intent. Possible questions to
ask when assessing risk are included in Appendix .
There is a training package available or primary care and
mental health sta in the assessment and management
o suicide risk: Skills-based Training On Risk Management
(STORM). This package uses the train the trainers ormat
and can be commissioned by Trusts or dissemination to
all stawww.medicine.manchester.ac.uk/storm/
Other relevant actors
The assessment should also include questions relating to:
Previous mental health problems including treatment
and outcome
Family history o mental health problems
Associated disability
Availability o social support
Social problems (amily disputes, nancial,employment)
Alcohol (see Appendix and ) and drug use
7/29/2019 Managementul Depresiei in Medicina Primara
11/46
11
Patient education
The results o any assessment will need to be ed
back to patients sensitively. There is still a signicant
stigma associated with depression, and patients may
be initially unwilling to accept the diagnosis, and may
not want to start or to continue treatment. This means
there is a need or discussion with the patient about
diagnosis and treatment options, with a view to gaining
agreement about the treatment plan.
This will involve:
Feedback to the patient on the outcome o the
assessment
Providing patient inormation leafets about
depression, its treatment, useul management
strategies (such as liestyle changes diet,
exercise, sleep hygiene) and local services (see
Appendix 7 or relevant resources)
Discussing treatment options. The initial ocus
o these discussions will concern whether an
intervention is required or not. Patients who do
not require or do not want an intervention will be
invited back or a review with the GP in weeks.
Patients who do require an intervention will enter
the model at an appropriate step based on their
clinical need. This is explained in more detail in the
next section
CHAPTER 4: CLINICAL PATHWAYS
Key messages
The clinical pathway is represented by a number
o steps. Each step denes a certain type and
intensity o treatment. Patients may enter the
clinical pathway at dierent steps depending on
their initial presentation or previous history, and
may be stepped up at various points during the
course o their illness, depending on progress
Many patients will enter the pathway at the rst
or second step, and may access higher steps in
order, depending on clinical need
Within steps, there are some choices patients
can make about the type o treatment that suits
them best
As noted earlier, primary care organisations need to
develop ways o managing depression that provide the
greatest benet to their population.
Although the Layard initiative has the potential to
increase the number o psychological therapists, this
potential may not be realised or some time. Thereore,
it is likely that the introduction o sel help and other
minimal interventions within a stepped care system will
be a key driver o increases in the abilities o services to
meet demand.
The key idea underpinning stepped care is that patients
receive the least intensive intervention that is still
expected to provide signicant benet to their health.
Figure shows the basic stepped care model, and
shows how it diers rom traditional services.
Primary Care Services
or Depression
7/29/2019 Managementul Depresiei in Medicina Primara
12/46
1
Figure has the more detailed stepped care model
based broadly on that proposed by NICE. There
are a number o important issues to note. First, the
main ocus or primary care is steps 1-, with step
requiring interace between primary care and specialist
services. Secondly, step 1 is or patients who do not
require or want a specic intervention. The other steps
are or increasing levels o symptoms, distress and
problem complexity. It may be appropriate or patients
to bypass previous steps i their symptoms are severe
enough, or i they had previously tried a step, but did
not benet. However, some patients may start at the
lower steps and access higher ones only i they do not
benet rom their initial treatment.
Although the model involves steps, it could be
argued that the main innovation is the introduction
o step . The greatest benet may be gained rom
stepped care i a signicant proportion o patientsare successully managed at step . Thereore, some
services may wish to use step as a deault or
mild to moderate depression in primary care, with
specic exceptions (e.g. severe depression, suicidal
ideation or other indicators o severe problems). Other
services may restrict step to patients with relatively
mild depression, and direct patients with moderate
disorders to step immediately.
The exact model adopted is likely to depend on the
available resources. Nevertheless, it should be noted
that one key advantage o stepped care is that patients
who do not benet rom less intensive interventions
at step are identied and encouraged to try other
treatments, because they are systematically assessed
ater their treatment.
Stepped care is an innovative method o organising
services, and there are a number o complex issues
where guidance has yet to be provided. For example,
how much o the available resources should be placedat step ? How should decisions be made about which
step patients access initially? What sort o patients
might miss out lower steps?
The Service Delivery and Organisation (SDO) unding
body o the NHS has commissioned research on
these issues which will seek to provide more specic
guidance in the near uture.
Figure 2 The basic stepped care model
Primary Care Primary Care
Minimal
interventions
Specialist
Interventions
Specialist
Interventions
Traditional Models Stepped Care
7/29/2019 Managementul Depresiei in Medicina Primara
13/46
1
Treatments in the stepped care system
The main treatments which are recommended or
dierent categories o depression severity are detailed
briefy below (urther details o these treatments
are provided in Appendix 8). Some o these
recommendations are rom NICE guidance and other
reviews o evidence. It is not expected that all services
will necessarily have all the proposed treatments
available. Rather, this list should serve as a guide to
possible interventions.
Step 1
Watchul waiting. According to NICE, watchulwaiting can be used with (a) patients who do not
wish to have an intervention (b) patients who the
health proessional thinks will recover without an
intervention
Step 2
Guided sel-help. This involves a CBT-based sel-
help resource and limited support rom a health
care proessional
Computerised CBT, based on the recent
recommendations rom NICE
Group psycho-education. This involves a group
treatment, providing inormation about depression,
and strategies or managing it
Exercise on prescription. Being physically active
can assist in the recovery o depression. Exercise
on prescription schemes establish links withlocal leisure centres to allow patients to access
equipment and receive regular advice and
monitoring rom qualied proessionals
Signposting or reerral acilitation. This involves
assessing a patient and assisting them to
nd appropriate local or national voluntaryorganisations
Antidepressants are not generally recommended
or patients with mild depression because the
risk/benet ratio is poor. Medication is more
commonly used with patients at steps and
above. Exceptions may be made when patients
have ailed to benet rom other interventions at
lower steps, or where patients have a previous
history o moderate to severe depression
Step 3
Brie psychological therapy. There are a number o
relevant psychological therapies, including CBT and
counselling. The recommended treatment is -8
sessions over 10-1 weeks
Medication. According to the NICE guidelines, there is
more evidence or the eectiveness o antidepressant
medication in moderate to severe depressionthan in mild depression. In moderate depression,
antidepressant medication should be routinely oered
to all patients beore psychological interventions.
Careul monitoring o symptoms, side eects and
suicide risk (particularly in those aged under 0) should
be routinely undertaken, especially when initiating
antidepressant medication. Patient preerence and
past experience o treatment, and particular patient
characteristics should inorm the choice o drug. It
is also important to monitor patients or relapse anddiscontinuation/withdrawal symptoms when reducing
or stopping medication. Patients should be warned
about the risks o reducing or stopping medication
Primary Care Services
or Depression
7/29/2019 Managementul Depresiei in Medicina Primara
14/46
1
Collaborative care and depression case
management. Although the prescription o
medication as recommended by NICE can be
conducted by the GP alone, it is likely that the
eectiveness and acceptability o the approach
will be enhanced through the addition o case
management through a collaborative care
approach. The key acets o such an approach are
as ollows:
Assigning a case manager to a patient, who
is supported by a specialist mental health
proessional, and collaborates with the GP in
the care o the patient
Provision o medication and/or brie
psychosocial interventions
Proactive management o the patient led by the
case manager, including regular ollow up (ace
to ace contact, or by phone), and monitoring o
progress
Feedback o inormation about treatment and
progress rom the case manager to the GP and
mental health specialist to assist in treatment
decision making in patients who ail to improve
Most o the published studies using depression
case management have involved medication,
and it is expected that a signicant proportion
o patients at this step will be on medication.
However, all patients will receive additional
psychosocial support rom the case manager, and
it is possible or the case management approach
to be used with psychosocial interventions alone,
i patients do not wish to use medication. For
example, a patient with a moderate depression
who does not wish to take medication may
receive case management, with psychosocial
support oered in the orm o acilitated sel-help
or signposting to other services, as appropriate
Appendix 9 details a number o websites with
relevant resources or use in the collaborative care
approach
Step 4
Psychological therapy. The treatment o choice is
CBT o longer duration (1-0 sessions over -9
months), although in some cases interpersonal
therapy may be used
Medication, collaborative care and depression
case management are again relevant with this
group o patients
7/29/2019 Managementul Depresiei in Medicina Primara
15/46
1
Chronic, atypical
reractory, recurrent
Severe depression
Moderate depression
Mild to moderate
depression
Sub-clinical and
patients who choose
not to have intervention
Step 1
Watchul waiting
Step 2
Guided sel-help, exercise on prescription,
psycho-education, signposting, or computerised CBT
Step 3
Medication, case management and collaborative
care, psychological therapy
Step 4
Medication, case management and
collaborative care, psychological therapy
Step 5
Specialist services
ASSESSMENT
Figure Overview o the stepped care system
Primary Care Services
or Depression
7/29/2019 Managementul Depresiei in Medicina Primara
16/46
1
CHAPTER 5: MONITORINGAND FOLLOW UP
Key messages
All patients treated or depression should have a
planned schedule o contacts in order to assess
response to treatment and ongoing progress.
The exact schedule will depend on the severity o
depression and other relevant actors
Scheduled contacts should include the use o
objective outcome measures as a marker o
progress and an aid to clinical decision making
Decisions may involve change o treatment within
steps, or moving patients up to new steps i they
have ailed to progress
Phases in depression treatment
At a broad level, depression can be thought o as
having three phases:
Acute phase the aim o treatment is reducing
symptoms and achieving remission (approximately8-1 weeks i treatment is successul)
Continuation phase the aim is prevention o
the return o symptoms during the current period
(approximately months rom the end o the
acute phase)
Maintenance the aim is prevention o new
episodes o depression (approximately months
rom the end o the continuation phase)
The model recommends regular, proactive contact with
patients throughout these phases. The schedule will
depend on the severity o the problem, and the phase.
Figures - shows some suggested schedules ocontacts or patients at the dierent steps.
Monitoring response in acute
phase treatment
The goal o acute phase treatment is remission o
symptoms. The denition o remission will depend on
the assessment instruments used. A variety o tools
are available. In Appendix 10 there is a copy o a
questionnaire rom the United States called the PHQ-
9 which can be used reely. Appendix 11 includes
denitions o initial response to treatment and remission
which can be used in urther clinical decision making.
The Clinical Outcome in Routine Evaluation outcome
measure (CORE-OM) is oten used in primary care
in the UK, and may be another useul measure o
progress. Whatever instrument is used, it is important
that there are appropriate and agreed systems or
dening response to treatment and remission, similar to
those in Appendix 11.
Monitoring response may be undertaken by the
GP (e.g. during watchul waiting) or another health
proessional (e.g. practice nurse, graduate primary
care mental health worker, primary care mental health
proessional or a counsellor). In some cases, the
proessional providing the treatment may dier rom the
person monitoring progress. In all cases, inormation is
shared with the GP.
7/29/2019 Managementul Depresiei in Medicina Primara
17/46
17
Decision making about acute
phase treatment
The result o the assessment o response to acute
phase treatment eeds into decision making about
urther care. As the goal is remission, patients who
improve, but do not remit, and those who do not
improve will need their treatment reviewing. Patients
who improve, but do not remit, may simply need
more time on the same treatment. However, patients
who ail to benet at all may be more likely to need an
alternative treatment within a step, or stepping up (see
Figures -).
Periodic monitoring in the continuationand maintenance phases (Steps 3/4 only)
Patients with moderate and severe depression require
longer term monitoring. Some patients who achieve
remission may relapse, while others may have a
recurrent episode. Following remission and during the
continuation and maintenance phases, patients should
be proactively ollowed-up in order to monitor
their status.
Figures - summarise the structure o care at each o
the initial steps, and detail:
The initial treatment
The proposed schedule o contacts involved in the
initial treatment, plus appropriate proessionals to
deliver this treatment
The suggested point at which patient progress
during the acute phase is reviewed, together with
the appropriate proessional to conduct the review
The possible decisions to be made on the basis
o the progress review, and which proessionals
might be involved in the decision making
The proposed schedule o contacts involved in
the maintenance and continuation phases (where
appropriate)
The suggested point at which longer term
patient progress is reviewed, together with the
appropriate proessional to conduct the review
The exact nature o each step, the proessionals
involved and the treatments provided will depend
on local resources and current service structure.
Primary Care Services
or Depression
7/29/2019 Managementul Depresiei in Medicina Primara
18/46
18
Initial treatment Sessions in
acute phase
Progress review Decision making
ollowing review
Treatment contacts
in maintenance and
continuation phase
Long term review
Watchul
waitingNone
2 weeks
GP
I improved
or remitted
no urther
intervention
I not
improved
step upFigure - Clinical pathway or step 1
Initial treatment Sessions in
acute phase
Progress review Decision making
ollowing review
Treatment contacts
in maintenance and
continuation phase
Long term review
Guided
sel-help
CCBT
Exercise on
prescription
Signposting
2-3
sessions
(GW/PN)
Varies
depending
on program
Reerral to
appropriate
scheme
1-2
sessions(GW/PN)
8 weeks
GW/PN
I improved
more o initial
treatmentor another
treatment within
step, inorm GP
I remitted
inorm GP,
discharge
I not
improved
another
treatment within
step or step up,
inorm GP
Figure - Clinical pathway or step
7/29/2019 Managementul Depresiei in Medicina Primara
19/46
19
Initial treatment Sessions in
acute phase
Progress review Decision making
ollowing review
Treatment contacts
in maintenance and
continuation phase
Long term review
Brie therapy
Medication
with case
management
6-8 weekly
sessions
(Therapist)
6 ortnightly
monitoring
sessions
(GW/PN)
12 weeks
GW/PN
I improved
more o initial
treatment or
another treatment
within step, inorm
GP
I remitted
inorm GP,
I not improved
Discuss with GP
or therapist
another treatment
within step, OR
step up, inorm
GP
Figure - Clinical pathway or step Step 4
Every 2
months
or 12
months
GW/PN
6 and 12
months
GW/PN
Primary Care Services
or Depression
7/29/2019 Managementul Depresiei in Medicina Primara
20/46
0
Initial treatment Sessions in
acute phase
Progress review Decision making
ollowing review
Treatment contacts
in maintenance and
continuation phase
Long term review
Figure - Clinical pathway or step
Medication
and case
management
CBT/IPT
12 weekly
sessions
(Gateway,
PwSI, CPN)
16-20
weekly
sessions
(Therapist)
24 weeks
(Experienced
GW, Gateway,PwSI, CPN)
I improved
more o initial
treatment or
another treatment
within step, inorm
GP
I remitted
inorm GP,
I not improved
Discuss with GP
or therapist
another treatment
within step, OR
step up, inorm
GP
Every
month or
12 months
(Gateway,
PwSI, CPN)
6 and 12
months
(Gateway,
PwSI, CPN)
7/29/2019 Managementul Depresiei in Medicina Primara
21/46
1
CHAPTER 6: PATIENTPREFERENCE AND CHOICE
One issue that is oten raised about standardised
systems o care is that they take little account o the
preerences, needs and wishes o individual patients.
Primary care has long prided itsel on being ocussed
on exactly these issues.
However, there is room or patient choice within the
proposed model.
Patients may make choices within steps. For example,
when patients enter step , they may choose rom a
number o equivalent interventions, such as guided
sel-help, exercise on prescription, and computerised
CBT, depending on what is available locally. Patients
entering case management can choose whether or not
to have a combination o medication and psychological
interventions, or medication alone.
Patients may also be able to choose between steps,
and choose to bypass lower level steps, i there is a
good reason that they are inappropriate.
However, it is important that patients decisions are
made on the basis o good inormation. Patients who
initiate treatment or depression should be oered
inormation on the services currently available, as
discussed in the section on patient assessment.
Patients treatment preerences should be part o
the initial assessment, and patients should also
be encouraged to discuss their evolving treatment
preerences with the case manager or primary care
proessional during treatment.
Primary Care Services
or Depression
7/29/2019 Managementul Depresiei in Medicina Primara
22/46
CHAPTER 7: ROLES FORPROFESSIONALS
While the clinical pathways described above identiy
proessionals to undertake specic roles, this will
depend on local availability. No proessional should
take on any role or which they have not received
training or which they do not eel competent to
undertake.
The ollowing recommendations maybe useul:
GPs
Initial assessment
Patient education
Initial medication prescription
Practice nurse, graduate primary care
mental health worker
Screening
Patient education
Follow up and monitoring o progress
Guided sel-help
Signposting
Group psycho-education
Assisting with computerised cognitive
behaviour therapy
Case management in moderate depression
Primary care mental health
proessionals, counsellors
Brie CBT
Brie counselling
Gateway workers, practitioner with a special
interest, mental health nurses
Supervision or primary care proessionals
Training or primary care proessionals in the
recognition and management o depression
Strengthening links between primary and
secondary care interace
Case management in severe depression
Mental health specialist (psychiatrist,
psychological therapist, mental health nurse)
Diagnosis where dicult in primary care
Specialist medication advice
Specialist longer term psychological therapy
Consultation, support and supervision or primary
care proessionals and case manager
7/29/2019 Managementul Depresiei in Medicina Primara
23/46
CHAPTER 8: INTERFACE ISSUES
As well as improving primary care mental health
services, eective management o depression in
primary care will require improvements at the primary-
secondary care interace. To achieve this, proessionals
working in both primary and secondary care will need
to work together and have agreed mechanisms or
communication.
Protocols between primary and specialist mental health
services can be written which enable patients who
have been successully treated by specialist services
to be urther treated and/or monitored in primary care.
An example might be a patient who makes an almostull recovery ollowing a short inpatient stay and may
only require brie intervention or case management by
a primary care proessional.
The new incentives to screen patients on the diabetes
and coronary heart disease registers means there is
potential or increased case-nding o people with
complex co-morbid problems at moderate severity and
above. Dealing with these sorts o problems requires
close working between primary care and mental
health teams. Research examining interventions to
improve outcomes or both diabetes and depression
have shown mixed results, and have shown it is
generally easier to impact on depression symptoms
than diabetes outcomes. The same is broadly true
or coronary heart disease - treating depression
improves the signs and symptoms o depression in
these patients, but there is less compelling evidence
at present that it improves the morbidity and mortality
associated with coronary heart disease.
As well as eective interace between primary and
secondary care, the employment agenda highlighted
by Lord Layard also suggests the need or more
eective working between health and employmentagencies, or example the services o Job Centre Plus
and condition management programmes run by the
Department o Work and Pensions (DWP).
Primary Care Services
or Depression
7/29/2019 Managementul Depresiei in Medicina Primara
24/46
CHAPTER 9: CASE STUDIES
Case study 1 - Mild depression
Week 0 - Initial/screening appointment (GP)
Mr Clarkson presents to the GP with a recent history
o headaches and stiness in his joints which has
been aecting his sleep or the past weeks. Physical
examination does not indicate any physical cause. The
screening questions are positive, and assessment o
severity indicates that Mr Clarkson is suering rom mild
depression. Treatment options in steps 1 and are
discussed and Mr Clarkson says that he does not eel
he needs anything specic at this time. The GP gives thepatient some materials on depression and suggests Mr
Clarkson make another appointment in weeks time to
review the situation.
Week 2 - Review appointment (GP)
Two weeks later, the assessment indicates no symptoms,
and it is agreed that no urther action is required.
Case study 2 - Mild depression
Week 0 - Initial/screening appointment (GP)
Mrs Jones is a year-old teacher who presents to
her GP complaining o poor sleep and appetite and
tearulness or the past our or ve weeks. A physical
examination indicates no abnormalities. The GP asks
the patient the two screening questions and ollowing
a positive response asks specic questions about
symptoms, impact and risk and completes the ICD-10.
The patient is asked to complete the screening tool (PHQ-
9). Both scores are indicative o mild depression and this
is discussed with the patient. The patient agrees she
has been eeling a little ed-up and drinking slightly more
alcohol than normal but isnt at risk and has no previous
history. The patient shows some interest in psychological
therapy, and the GP gives the patient an inormation
leafet on available therapies, and suggests the patient
might wish to use some sel help materials in the rst
instance. An appointment is made to see the graduateworker to discuss some guided sel-help in more detail.
Week 2 - Guided sel-help session 1 (graduate primary
care mental health worker)
The graduate primary care mental health worker briefy
discusses the nature o the patients problems and
possible materials that may be o use. They decide on
a depression sel-help book, and the graduate primary
care mental health worker suggests scheduling pleasant
activities more regularly, and shows the patient how themanual can help with this. They make an appointment
or weeks. This inormation is ed back to the GP by
addition in the medical records.
Week 4 - Guided sel-help session (graduate primary
care mental health worker)
The patient and worker discuss the patients use o
the manual and any diculties that have arisen. Other
activities are also discussed. The patient continues to be
concerned about her alcohol consumption so the worker
gives her contact details or the local voluntary alcohol
support service. This inormation is added to the medical
records.
Week 6 - Guided sel-help session (graduate primary
care mental health worker)
The patient and worker continue to discuss the patients
use o the manual. The patient did contact the voluntary
alcohol service and has signed up or a support group.
Week 8 Monitoring session (graduate primary caremental health worker)
The worker gets the patient to complete the PHQ-9.
Scoring the questionnaire indicates that the patients
7/29/2019 Managementul Depresiei in Medicina Primara
25/46
problems have remitted. The patient is happy to continue
using the manual and attending the voluntary support
group. The results o the assessment are ed back to the
GP and entered onto the medical record. The patient isremoved rom the workers caseload.
Case study 3 - Moderate to
severe depression
Week 0 - Initial/screening appointment (GP)
Mr Allen attends surgery complaining o not eeling right
since being made redundant months ago. Unable to
establish any specic physical complaints the GP asks
Mr Allen what he is doing with his time and discovers that
the patient is spending most o his time in the house just
watching TV. He has stopped going to his darts matches
as it all seems like too much eort. Completion and
scoring o the ICD-10 and PHQ-9 indicates a moderate
level o depression. The patient also discloses that he
had a similar depression when his wie let him years
ago. He has never posed a risk to himsel or others but
on this occasion has thought his amily would be better
o without him. The GP probes into this urther and
using the recommended risk questions asks i the patient
has made any plans to act on his thoughts. Having
established that Mr Allen has no plans to harm himsel
because he would leave too much debt or his daughter,
the GP discusses the treatment options with the patient.
The GP and the patient agree to try medication. The GP
prescribes an anti-depressant which has minimal risk in
overdose and explains side-eects, the time required or
medication to work and any possibility o increasing the
dose in the uture to therapeutic levels. The GP explains
to the patient that he will be assigned a practice nurse
to manage his case and support and assist him over the
next ew months, who will contact him by telephone in
the next week to discuss the medication. The patient is
given a patient inormation leafet on depression and an
appointment to be seen in the clinic at the practice held
by the local Citizens Advice Bureau regarding his debt
problems.
Week 1 Initial ollow up (Practice nurse)
One week later the practice nurse contacts Mr Allen to
discuss his medication, answer any queries he has, and to
give support. The nurse establishes that he orgot about
his CAB appointment and reschedules him another one
and agrees to remind him by telephone the aternoon
beore the appointment.
Weeks 3, 5, 7, 9 Follow up (Practice nurse)
The practice nurse continues to contact Mr Allen to
discuss his medication, answer any queries he has, and to
give support. Mr Allen did attend his appointment and is
being supported by the CAB worker to deal with his debts.
Week 12 Progress review session (Practice nurse)
The PN sees Mr Allen to conduct a review o his progress
with the PHQ-9. Scoring the questionnaire indicates that
Mr Allen has had a partial response to the medication.
Further discussion indicates some problems with
loneliness Mr Allen is assisted to increase his social
support through activity scheduling/behavioural activation
and using local support groups. Mr Allen is happy with this
and does not wish to change his medication at present.
This inormation is discussed with the GP and added to
the medical records.
Months 2, 4, 8, 10 post acute phase (Practice Nurse)
The PN conducts telephone ollow-up, checks progress is
maintained and discusses medication.
Months 6 and 12 (Practice Nurse)
The patient is invited or an appointment with the Practice
Nurse to review progress and the PHQ9 is completed.
Primary Care Services
or Depression
7/29/2019 Managementul Depresiei in Medicina Primara
26/46
CHAPTER 10: AUDIT AND MONITORING
Patients on a practice list with depression will need
to be identiable through the clinical record keeping
system (oten reerred to as registers). For audit
purposes it would also be benecial to classiy the
depression (i.e. mild, severe, atypical etc).
It is recommended that this identication record
should be separate rom any Severe Mental Illness
(SMI) registers.
It is recommended that audit involves checking the
ollowing are being undertaken:
Primary care has protocols in place or the
screening o high-risk groups and that these
protocols are adhered to
Screening tools are used to aid diagnosis
Standard questionnaires are used to monitor
progress
Patients are oered the appropriate number o
monitoring and review appointments
Medication is prescribed appropriately andmonitored regularly:
Not used or mild depression
Inormation is given to the patient
Prescribed in accordance with NICE guidelines
Maintenance prescribing is monitored regularly
Appropriate psychological therapies are available
and oered to the patient
Patient satisaction is monitored (using a standardpatient satisaction questionnaire)
APPENDICES
Appendix 1: Screening or Depression in
High Risk GroupsDuring the last month, have you oten been bothered
by eeling down, depressed or hopeless?
and
During the last month, have you oten been bothered
by having little interest or pleasure in doing things?
I the patients response to BOTH questions is no, the
screen is negative.
I the patient responds yes to EITHER question, use arecommended screening tool (Appendix and ).
7/29/2019 Managementul Depresiei in Medicina Primara
27/46
7
Appendix 2: Assessing the severity o
depression (ICD-10 Primary Care Version)
KEY SYMPTOMS
Have any o the ollowing occurred most o the time or two weeks or more:
A. Persistent sadness or low mood.......................................
B. Loss o interest or pleasure.......................................
C. Fatigue or low energy.....................................
ASSOCIATED SYMPTOMS1. Sleep disturbance.. ....................................
Diculty alling asleep
Early morning wakening
. Appetite disturbance......................................
Appetite loss
Appetite increase
. Poor concentration or indecisiveness.......................................
. Agitation or slowing o movement ....................................
. Decreased libido......................................
. Low sel condence....................................
7. Suicidal thoughts or acts....................................
8. Guilt or sel-blame...................................
I YES to any o the above, continue below
Conclusion:
Positive to A,B or C and:
o the associated symptoms above = MILD- o the associated symptoms = MODERATE
7 or more o the associated symptoms = SEVERE
Primary Care Services
or Depression
7/29/2019 Managementul Depresiei in Medicina Primara
28/46
8
Appendix 3: Other scales or the
assessment o severity and outcome
Patient Health Questionnaire (PHQ-9). Developed
specically or primary care and used widely in the US.
Items relate closely to the criteria or depression in the
DSM-IV. Copyright Pzer Inc. Details are provided in
Appendix 9 and 10. Can be downloaded ree rom:
www.depression-primarycare.org/clinicians/toolkits/
materials/orms/phq9/questionnaire/
General Health Questionnaire (GHQ) (1 items). Easy
to complete and well validated. Available in several
languages. Available rom NFER-Nelson Publishing Co
Ltd Tel: 08 0197).
Hospital Anxiety and Depression Scale (HADS) (1
items). Used requently in primary care, especially
useul with patients who also have physical illness.
Available rom NFER-Nelson Publishing Co Ltd Tel:
08 0197.
Beck Depression Inventory (BDIII) (1 items) Copyright
belongs to the Psychological Corporation and can be
purchased at www.pnotebook.com
Geriatric Depression Scale (GDS) is used or screening
with the elderly. Not subject to copyright. Can be
downloaded rom www.miahonline.org
Edinburgh Postnatal Depression Scale (EPDS) is
commonly used by health visitors to screen or
postnatal depression. Not subject to copyright and can
be downloaded rom www.priory.com/psych.htm
See also Cox, J. and Holden, J. (199) Perinatal
Psychiatry: use and misuse o the Edinburgh Postnatal
Depression Scale. London: Gaskell.
The CORE-OM is a patient completed outcome
measure and part o the CORE System. It is a -item
questionnaire designed to measure clients global
distress, including subjective well-being, commonly
experienced problems, unctioning, and risk. Although
protected by copyright, no charge is made or the
CORE-OM and practitioners who are interested inusing it can photocopy materials i their content is not
changed in any way. Further inormation on training,
support systems and sotware are available at
www.coreims.co.uk/index.php
These questionnaires can be used to assess severity
and monitor progress.
Most scales can be completed by patients whilst in
the waiting area. Patients who have diculty reading
or are non-English speakers may require additionalhelp. Minimal sta input is required or the scoring o
responses.
Appendix 4: Asking About Risk
Intention - thoughts
Do things ever eel that bad that you think about
harming or killing yoursel?
Do you ever eel that lie is not worth living?
Plans
Have you made plans to end you lie?
Do you know how you would kill yoursel?
Actions
Have you made any actual preparations to kill yoursel?
Have you ever attempted suicide in the past?
Prevention
How likely is it that you will act on such thoughts
and plans?
What is stopping you killing or harming yoursel
at the moment?
7/29/2019 Managementul Depresiei in Medicina Primara
29/46
9
Risk Factors or Suicide:
Recent marital confict
Currently untreated severe mental illness
Alcohol abuse
Previous suicide attempts
It is also important to ask about risk to others,
especially where patients are not known to the primary
care practice. An example question might be Have you
ever been in trouble with the police?
Categorising risk
Appendix 5: Asking About Alcohol
Problems the CAGE Questionnaire
Have you ever elt you ought to Cut down
on your drinking?
Have peopleAnnoyed you by criticising your drinking?
Have you ever elt bad or Guilty about your drinking?
Have you ever had a drink rst thing in the morning
to steady your nerves or get rid o a hangover (Eye-
opener)?
Two or more Yes responses yield a positive screen
test or alcohol.
Risk Description Action
Low risk No current
thoughts, or
inrequent
thoughts
Continue ollow-up
visits and monitor.
Normalise thoughts
and dierentiate
between thoughts
and actions.
Intermediate
risk
Frequent
currentthoughts but no
plans or intent
Assess risk careully
at each visit. Liasewith specialist
mental health
service. Ensure
patient knows how
to access services.
High risk Current
thoughts with
plans and
preparations
Reer to specialist
mental health
service and engage
in collaborative
approach to
treatment and
monitoring.
Primary Care Services
or Depression
7/29/2019 Managementul Depresiei in Medicina Primara
30/46
0
Appendix 6: AUDIT Questionnaire: Screen
For Alcohol Misuse27
Please circle the answer that is correct or you
1. How oten do you have a drink containing alcohol?
Never
Monthly or less
times a month
times a week
or more times a week
. How many standard drinks containing alcohol do
you have on a typical day when drinking?
1 or
or
or
7 to 9
10 or more
. How oten do you have six or more drinkson one occasion?
Never
Less than monthly
Monthly
Weekly
Daily or almost daily
. During the past year, how oten have you ound
that you were not able to stop drinking once you
had started?
Never
Less than monthly
Monthly
Weekly
Daily or almost daily
. During the past year, how oten have you ailed to
do what was normally expected o you because
o drinking? Never
Less than monthly
Monthly
Weekly
Daily or almost daily
. During the past year, how oten have you needed
a drink in the morning to get yoursel going ater a
heavy drinking session?
Never
Less than monthly
Monthly
Weekly
Daily or almost daily
7/29/2019 Managementul Depresiei in Medicina Primara
31/46
1
7. During the past year, how oten have you had a
eeling o guilt or remorse ater drinking?
Never
Less than monthly
Monthly
Weekly
Daily or almost daily
8. During the past year, have you been unable
to remember what happened the night beore
because you had been drinking?
Never
Less than monthly
Monthly
Weekly
Daily or almost daily
9. Have you or someone else been injured as a
result o your drinking?
No
Yes, but not in the past year
Yes, during the past year
10.Has a relative or riend, doctor or other health
worker been concerned about your drinking or
suggested you cut down?
No
Yes, but not in the past year
Yes, during the past year
Scoring the audit
Scores or each question range rom 0 to , with the
rst response or each question (e.g. never) scoring 0,
the second (e.g. less than monthly) scoring 1, the third
(e.g. monthly) scoring , the ourth (e.g. weekly) scoring
, and the last response (e.g. daily or almost daily)
scoring . For questions 9 and 10, which only have
three responses, the scoring is 0, and .
A score o 8 or more is associated with harmul or
hazardous drinking. A score o 1 or more in women,
and 1 or more in men, is likely to indicate
alcohol dependence.
Primary Care Services
or Depression
7/29/2019 Managementul Depresiei in Medicina Primara
32/46
APPENDIX 7: RELEVANT PATIENTINFORMATION RESOURCES
Many GPs have the variety o leafets available at
www.patient.co.ukon their computers or printing or
individual patient use.
Below are some o the other web-sites and
organisations rom where patient inormation leafets
can be accessed or purchased.
MIND produces a variety o leafets, some o which are
available in languages other than English. They can be
printed by individuals or ordered on-line or a cost to
organisations www.mind.org.uk
The Royal College o Psychiatrists produce leafets on
depression, anti-depressants and psychotherapy in a
variety o languages which can be printed rom
www.rcpsych.ac.uk
The British Association o Behavioural and Cognitive
Psychotherapies (BABCP) have leafets on depression,
sel-help which are printable or available to order at a
cost www.babcp.com
Depression Alliance have a number o on-line patient
inormation leafets on depression and available
treatments www.depressionalliance.org/
The Mental Health Foundation have leafets available to
order at cost and can be printed rom the web-site by
individual patients www.mentalhealth.org.uk
The Department o Health has produced a ree leafet
with inormation on dierent psychological therapies
www.doh.gov.ukand search or talking therapies.
APPENDIX 8: TREATMENTS AT STEP 2
Guided sel-help
Sel-help involves providing patients with both
inormation about a condition and skills and techniques
to overcome symptoms and assist with problems. These
skills and techniques are oten based on cognitive-
behaviour therapy (CBT). Guided sel-help is appropriate
or mild depression.
There is some evidence rom the UK that pure sel-
help through written materials improves outcomes or
patients in primary care,1,8 and that guided sel-help
can be conducted by non-mental health specialists suchas practice nurses.9,0
A comprehensive sel-help booklet or depression can
be ordered rom the Oxord Cognitive Therapy Centre at
www.octc.co.uk/html/sel-help.html
Overcoming Depression is written by Chris Williams,
and two o the chapters on Problem Solving and Being
Assertive are available ree o charge at
www.calipso.co.uk
Newcastle, North Tyneside and Northumberland MentalHealth Trust sel-help booklets are available ree to
download at www.nnt.nhs.uk/mh/
Computerised CBT
Computerised packages may be designed to unction
with very little guidance, although monitoring o outcome
is still recommended. There is evidence rom the UK that
computerised CBT (with brie guidance) is clinically and
cost-eective in primary care.1
The National Institute o Clinical Excellence has reviewed
the evidence or computerised packages and provided
guidance. www.nice.org.uk/page.aspx?o=ta097
7/29/2019 Managementul Depresiei in Medicina Primara
33/46
Reerral acilitation (signposting)
Reerral acilitation involves assessing a patient and
helping them nd appropriate local or national voluntary
organisations. On occasion, statutory organisations
may be suggested or new support groups established.
Reerral acilitation is based on the availability o local
groups, up to date inormation on their scope, and
agreement rom these groups concerning reerral. It is
recommended that a proessional such as a graduate
worker visits groups in order to gather inormation on a
pro-orma concerning each group, which allows easy
and rapid sharing o inormation about
available resources.
Reerral acilitation is appropriate or mental health
problems o mild to moderate severity, and may be
relevant or patients with depressive symptoms who
are acing particular psychosocial diculties or which
there are relevant groups available.
There is one study in the UK that suggests that reerral
acilitation improves patient outcome.17 There is one
ongoing UK trial that is examining the eects o reerral
acilitation specically by graduate primary care mental
health workers.
Group psycho-education
Group psycho-education or depression is group
treatment which involves providing inormation about
depression, issues that aect mood, how to identiy
and change thoughts, activities and interactions that
aect mood, relaxation training, and goal planning.
Groups o -10 people are ormed on a locality basis
and each group meets or 8, hour sessions.
Because o the educational nature o the intervention,
it can be used in a variety o settings, including
those outside health such as adult education. The
intervention can be used in a preventive capacity (i.e.in patients at risk o developing depression) or with
patients with specic depressive problems.
Group psychoeducation is appropriate or mild
depression. There is evidence rom UK primary care
that group psychoeducation is eective.18
Exercise on Prescription
Exercise on Prescription (EoP) can be used as a non-
drug treatment in the treatment o depression and aims
to help people increase their physical activity.
Being physically active can assist in the recovery
o depression and can also prevent against re-
occurrence. However, seven in ten adults are not
active enough to get the health benets. The EoP
Government schemes aim to tackle health inequalities
by improving access to sport and exercise.
Many o the schemes already in operation have
established links with local leisure centres and patients
can access the equipment and receive regular advice
and monitoring rom qualied registered tness
proessionals. National standards or EoP have
been published by the Department o Health which
encourage the development o new and eective high
quality projects nationwide.
There is some evidence that exercise is eective in
improving depression. Guidance is available at
www.dh.gov.uk/PolicyAndGuidance/HealthAndSocialCareTopics/HealthyLiving/s/en
Primary Care Services
or Depression
7/29/2019 Managementul Depresiei in Medicina Primara
34/46
APPENDIX 9: WEBSITES WITHINFORMATION ON THECOLLABORATIVE CARE AND CASE
MANAGEMENT APPROACH
Helping the Chronically Ill through Quality Improvement
and Research (a national program o the Robert Wood
Johnson Foundation)
www.improvingchroniccare.org
The MacArthur Initiative on Depression in Primary Care
www.depression-primarycare.org
The Health Disparities Collaborative
www.healthdisparities.net
APPENDIX 10: PHQ-9MONITORING TOOL(COPYRIGHT PFIzER)
The Patient Health Questionnaire (PHQ-9) is a brie
9-item patient sel-report questionnaire specically
developed or use in primary care and used extensively
in the United States. The PHQ-9 has acceptable
reliability, validity, sensitivity and specicity as an
assessment tool or the diagnosis o depression in
primary care. The questionnaire can also be used to
monitor progress with possible scores ranging rom
0 to 7 with higher scores indicative o
increasing severity.
www.depression-primarycare.org
7/29/2019 Managementul Depresiei in Medicina Primara
35/46
1. Over the last 2 weeks, how oten have you been bothered by any o the ollowing problems?
Read each item careully, and circle your response.
a. Little interest or pleasure in doing things
Not at all Several days More than hal the days Nearly every day
b. Feeling down, depressed, or hopeless
Not at all Several days More than hal the days Nearly every day
c. Trouble alling asleep, staying asleep, or sleeping too much
Not at all Several days More than hal the days Nearly every day
d. Feeling tired or having little energyNot at all Several days More than hal the days Nearly every day
e. Poor appetite or overeating
Not at all Several days More than hal the days Nearly every day
. Feeling bad about yoursel, eeling that you are a ailure, or eeling that you have
let yoursel or your amily down
Not at all Several days More than hal the days Nearly every day
g. Trouble concentrating on things such as reading the newspaper or watching television
Not at all Several days More than hal the days Nearly every day
h. Moving or speaking so slowly that other people could have noticed.
Or being so fdgety or restless that you have been moving around a lot more than usual
Not at all Several days More than hal the days Nearly every day
i. Thinking that you would be better o dead or that you want to hurt yoursel in some way
Not at all Several days More than hal the days Nearly every day
2. I you checked o any problem on this questionnaire so ar, how difcult have these problems made
it or you to do your work, take care o things at home, or get along with other people?
Not Dicult at All Somewhat Dicult Very Dicult Extremely Dicult
Scoring the PHQ-9 when used to measure severity involves counting one point or each o the 9 items in
question 1 ticked several days, two points or each ticked hal the days and three points or those ticked
nearly every day. Sum the total or a severity score.
Patient Name Date
Primary Care Services
or Depression
7/29/2019 Managementul Depresiei in Medicina Primara
36/46
APPENDIX 11: RECOMMENDED
CATEGORIES FOR RESPONSE AND
MONITORING WITH THE PHQ-9
Defnition o improvement
Improved A reduction o or more points
on the baseline score
Not improved Drop o 1 point or no change or
increase
Defnition o remission
A PHQ-9 score o less than is the eventual goal o
acute phase treatment. When this goal is achieved,
patients enter the continuation phase o treatment.
Changes o treatments within steps and stepping up
are considered or patients who do not meet this goal.
SCORE SEVERITY CLINICAL PATHWAY
0 Severe depression Step or
7/29/2019 Managementul Depresiei in Medicina Primara
37/46
7
REFERENCES
1 LAYARD R. The case or psychological treatment
centres. BMJ 00;:100-10.
HARKNESS E, BOWER P, GASK L, SIBBALD B.
Improving primary care mental health: survey
evaluation o an innovative workorce
development in England. Primary Care Mental
Health 2006;(in press).
USTUN T, AYUSO-MATEOS J, CHATTERJI
S, MATHERS C, MURRAY C. Global burden
o depressive disorders in the year 000. Br J
Psychiatry 2004; 18:8-9.
GOLDBERG D, HUXLEY P. Common MentalDisorders: A biosocial model. London:
Routledge, 199.
KATON W, VON KORFF M, LIN E, ET AL.
Population-based care o depression: eective
disease management strategies to decrease
prevalence. Gen Hosp Psychiatry 1997;19:BMJ
00;:100-10.
FREELING P, KENDRICK T. INTRODUCTION.
IN: T KENDRICK, A TYLEE, P FREELING, EDS.
The Prevention o Mental Illness in Primary Care.
Cambridge: Cambridge University Press,
1997;1-18.
7 PAYKEL E, PRIEST R. Recognition and
management o depression in general practice:
consensus statement.
BMJ 1992;0:1198-10.
8 THOMPSON C, KINMONTH A, STEVENS L, ET al.
Eects o a clinical practice guideline and practice-
based education on detection and outcome o
depression in primary care: Hampshire Depression
Project randomised controlled trial.
Lancet 2000;:18-191.
9 KATON W, VON KORFF M, LIN E, SIMON G.
Rethinking practitioner roles in chronic illness: the
specialist, primary care physician and the practice
nurse. Gen Hosp Psychiatry 2001;:18-1.
10 GILBODY S, WHITTY P, GRIMSHAW J, THOMAS R.
Educational and organisational interventions
to improve the management o depression
in primary care: a systematic review.JAMA
2003;89:1-11.
11 GASK L. Role o specialists in common chronic
diseases. BMJ 2005;0:1-.
1 DEPARTMENT OF HEALTH. Treatment Choice
in Psychological Therapies and Counselling:Evidence based clinical practice guideline.
London. Department o Health, 2001.
1 PRIEST R, VIZE C, ROBERTS A, ROBERTS M,
TYLEE A. Lay peoples attitudes to treatment
o depression: results o opinion poll or Deeat
Depression Campaign just beore its launch. BMJ
1996;1:88-89.
1 ANDERSON L, LEWIS G, ARAYA R, ET AL. Sel-
help books or depression: how can practitioners
and patients make the right choice? BritishJournal o General Practice 2005;:87-9.
1 LOVELL K, RICHARDS D. Multiple Access Points
and Levels o Entry (MAPLE): Ensuring Choice,
Accessibility and Equity or CBT Services.
Behaviour Cognitive Psychotherapy
2000;8:79-91.
1 PROUDFOOT J, RYDEN C, EVERITT B, ET AL.
Clinical ecacy o computerised cognitive-
behavioural therapy or anxiety and depression in
primary care: randomised controlled trial.
British Journal o Psychiatry 2004;18:-.
Primary Care Services
or Depression
7/29/2019 Managementul Depresiei in Medicina Primara
38/46
8
17 GRANT C, GOODENOUGH T, HARVEY I, HINE C.
A randomised controlled trial and economic
evaluation o a reerrals acilitator between
primary care and the voluntary sector. BMJ2000;0:19-.
18 DOWRICK C, DUNN G, AYUSO-MATEOS J-L, ET AL.
Problem solving treatment and group
psychoeducation or depression: multicentre
randomised controlled trial. BMJ 2000;321:1-6.
19 SCOGIN F, HANSON A, WELSH D.
Sel-administered treatment in stepped-care
models o depression treatment.Journal o
Clinical Psychology 2003;9:1-9.
0 SOBELL M, SOBELL L. Stepped care as a
heuristic approach to the treatment o alcohol
problems.Journal o Consultant Clinical
Psychology 2000;8:7-79.
1 DAVISON G. Stepped care: doing more with
less?Journal o Consultant Clinical Psychology
2000;8:80-8.
ANDREWS G. Should depression be managed as
a chronic disease? BMJ 2001;:19-1.
KENDRICK T. Depression management clinics ingeneral practice? BMJ 2000;0:7-8.
VON KORFF M, GOLDBERG D. Improving
outcomes in depression. BMJ 2001;:98-99.
KATON W, VON KORFF M, LIN E, ET AL.
The Pathways study: a randomized trial o
collaborative care in patients with diabetes and
depression.Archives o General Psychiatry
2004;1:10-109.
VIEWEG W, JULIUS D, FERNANDEZ A, ET AL.
Treatment o depression in patients in coronary
heart disease.American Journal o the Medical
Sciences 2006;119:7-7.
7 SAUNDER J, AASLAND O, BABOR T.
Development o the alcohol use disorders
identication test (AUDIT): WHO collaborative
project on early detection o persons withharmul alcohol consumption II.Addiction
1993;88:791-80.
8 BOWER P, RICHARDS D, LOVELL K. The clinical
and cost-eectiveness o sel-help treatments or
anxiety and depressive disorders in primary care:
a systematic review. British Journal o General
Practice 2001;1:88-8.
9 RICHARDS D, RICHARDS A, BARKHAM M,
CAHILL J, WILLIAMS C. PHASE: a health
technology approach to psychological treatmentin primary mental health care. Primary Health Care
Research and Development 00;:19-18.
0 RICHARDS A, BARKHAM M, CAHILL J,
RICHARDS D, WILLIAMS C, HEYWOOD P.
PHASE: a randomised, controlled trial o
supervised sel-help cognitive behavioural
therapy in primary care. British Journal o General
Practice 2003;:7-770.
1 PROUDFOOT J, GOLDBERG D, MANN A,
EVERITT B, MARKS I, GRAY J. Computerized,
interactive, multimedia cognitive-behavioural
program or anxiety and depression in general
practice. Psychol Med 2003;:17-7.
COOPER H, LESTER H, FREEMANTLE N,
WILSON S. A cluster randomised controlled trial
o the eect o primary care mental health workers
on satisaction, mental health symptoms and
use o services: background and methodology.
Primary Care Psychiatry 2003;9:1-7.
LAWLOR D, HOPKER S. The eectiveness o
exercise as an intervention in the management
o depression: systematic review and meta-
regression analysis o randomised controlled
trials. BMJ 2001;:7
7/29/2019 Managementul Depresiei in Medicina Primara
39/46
9
USEFUL RESOURCES
Books & Reports
Department o Health (1999) National service
ramework or Mental Health: Modern Standards and
service models. London, Department o Health.
Department o Health (1999). Saving Lives: Our
Healthier Nation. London, HMSO.
www.dh.gov.uk/assetRoot/0/0/9/9/0099pd
National service ramework or mental health: modern
standards and service models.
www.dh.gov.uk/assetRoot/0/07/7/09/007709.pd
Executive Summary: Saving lives: Our Healthier Nation
is an action plan to tackle poor health.
Department o Health (000) The NHS Plan ~ A plan
or investment, A plan or reorm. London, Department
o Health.
www.dh.gov.uk/assetRoot/0/0/7/8/0078.pd
Department o Health (001). The Mental Health Policy
Implementation Guide. London, Department o Health.
www.dh.gov.uk/assetRoot/0/0/89/0/00890.pd.
This policy guidance supports the delivery o adult
mental health policy locally.Department