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17.02.2014

Diagnosing depression nice, brain related diseases symptoms - Try Out

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Depression is the most common mental disorder presenting in primary care and community settings.
However, the prevalence of depression varies considerably and is influenced by gender and a wide range of social, ethnic and economic factors. NICE commissioned the guideline entitled Depression: management of depression in primary and secondary care from the National Collaborating Centre for Mental Health, which was established by the Royal College of Psychiatrists and the British Psychological Society. However, only an estimated 60% of community cases of depression present in primary care;7 and of these, approximately 60% are unrecognised. This is mainly because most of these patients consult for a somatic symptom and do not consider themselves mentally unwell, despite the presence of symptoms of depression. In developing a treatment approach for depression, the group encountered significant challenges in identifying the most effective treatments and organisational structures in which to deliver those treatments.
The care and management of depression starts with effective recognition and diagnosis, as Figure 1 shows. The guideline also offers advice on other important factors that can influence the classification of depression and the choice of intervention to offer.
A greater number of symptoms, history of depression, limited social support, greater social disability and the presence of suicidal thoughts argue for more active interventions such as formal psychological therapies and antidepressant medication.
Poor response to two or more interventions, recent recurrence of depression and self-neglect argue for the involvement of mental health specialists. Most patients presenting with depression in primary care will have mild depression, and the guideline recommends several approaches to treatment (Box 3, below). The guideline does not recommend antidepressant medication as the primary treatment for mild depression.
Another important consideration for the development group in moving away from recommending antidepressants as an initial treatment for mild depression was the emerging evidence on the risks associated with the use of antidepressant medication, in particular SSRIs.
The effective treatment of mild depression in primary care will require a significant restructuring of the current organisation and delivery of care.
Guided self-help, which may in time see GPs writing prescriptions for self-help manuals from the local library, structured exercise programmes and computerised cognitive behavioural therapy are all cost-effective alternatives to both antidepressants and therapist-delivered psychological therapies for mild depression. Perhaps only 20% of individuals who present with depression in primary care will meet the criteria for moderate depression. When considering individual psychological treatments for moderate, severe and treatment-resistant depression, the treatment of choice is CBT.
Severe depression often has a poor outcome, and it is therefore important that the patient receives effective treatment as soon as it is recognised.
The psychological treatment recommended for severe depression often involves 16 to 20 sessions, considerably more than for the psychological treatments usually delivered in primary care, where the number is often nearer to six or eight. However, the total number of individuals who require combination treatments represents less than 10% of patients identified with depression in primary care; and those requiring combined treatments in primary care are relatively few.
As many as 30% of depressed patients develop depression that is chronic in nature and often responds only partially to treatment.
In addition to recommendations on treatment, the guideline makes a number of recommendations for further research, on the nosology of depression, the underlying biology and, importantly, the social and personality factors that interact with treatment response.
Depression is a treatable disease but, unfortunately, it is not always treated appropriately.This guideline should help clinicians in primary and secondary care to change that situation.
Successful implementation depends on better recognition of depression, the increased availability of a range of nonpharmacological interventions including self-help, exercise and computerised treatments as well as psychological therapies.
The guideline is available in several formats: the NICE guideline, a quick reference guide, a version for patients and carers and the full guideline, published by the National Collaborating Centre for Mental Health. Von Korff M,Goldberg D.Improving outcomes in depression – the whole process of care needs to be enhanced. The unpredictable, variable nature of MS and the possibility of accumulating disability means that diagnosis can have significant psychological and psychosocial consequences for the patient and their significant others (Thomas et al., 2006).
Individuals respond to diagnosis and disease progression in many different ways, both positive and negative. The psychological and psychosocial impact of MS has been highlighted in both the MS NICE guidelines (2003) and in the NSF for long-term conditions (DoH, 2005). Ideally, newly diagnosed individuals will be seen by the MS nurse specialist for initial and subsequent consultations to provide advice, support and education to enable the patient and their family to adjust to the diagnosis (Burgess, 2002). A diagnosis of MS, the onset of new symptoms, or increasing disability can trigger a wide range of emotions, which range from grief, shock, fear and denial, anger and frustration, acknowledgement, accommodation and adaptation. When investigating the role of the MS Specialist Nurse in the UK, Johnson (2003) examined patients’ experiences of receiving their MS diagnosis. Depression is the most common emotional consequence and can cause considerable distress for people with MS and their families.
Given the prevalence of depression and anxiety within the MS population, it is important that all health professionals are aware of depression and anxiety, and how to identify and treat it appropriately.


Rates of depression and anxiety are much higher in the MS population than in the general population, although the reasons are often unclear.
Depression is very common in MS with up to 50% of people thought to experience a major depressive episode in their lifetime (Sadovnick et al, 1996). Within the MS population, there is a suggestion that depression has biological origins which interact with psycho-social factors. It is also possible that medical treatments provided to people with MS can also impact on depression. Certain emotional and behavioural characteristics may be a blueprint for the individual’s personality, and may have been present prior to the diagnosis of MS. Despite the profound effects of mental health issues, current evidence suggests that many people with MS are not screened for depression and consequently do not receive adequate treatment for depressive symptoms (Feinstein, 2002). Various hypotheses such as clinicians not routinely screening patients for depression, patients not adhering to medication recommendations (Goldman Consensus group, 2005), clinicians focusing primarily on medical symptoms as opposed to emotional symptoms, patients not seeking treatment, difficulties in accessing services and viewing depression as a natural consequence of MS (Sollom & Kneebone, 2007) are all suggested as possible reasons for poor uptake of treatment.
The Goldman Consensus Group (2005) conclude that clinicians working regularly with people with MS should routinely screen them for depressive symptoms, should ensure they are treated with either a pharmacological or psychotherapeutic or integrated approach and that a clinical algorithm should be developed so as to standardize a treatment approach. Many people with MS will loosely use the word ‘depression’ to describe periods feeling ‘down’ or ‘low’; however, clinical depression is much more severe. Within the UK, psychiatrists are encouraged to use the World Health Organisation’s ICD-10 for diagnosing clinical depression and other mental health issues. If all three symptoms of depression are present then it is possible that a person may be experiencing a severe depressive episode.
It is important when assessing depression that the context of the depression is taken into account. The NICE Guidelines (2003) recognize that if depression is suspected, the person with MS should be assessed by asking them whether they feel depressed, or by using a screening method. There are a number of different assessment scales available to measure severity of depression that have been validated for use in MS, these being the Beck Depression Inventory (BDI-II) and the Centre for Epidemiological Studies (CES-D) (Goldman Consensus Group, 2005). Another scale that is valid in physically unwell populations but as yet is not validated within the MS population is the Hospital Anxiety and Depression Scale. Management of depression in the UK should follow the NICE Guidelines for Depression (amended, NICE, 2007). When depression is suspected by the MS nurse specialist, the patient should be referred (as a matter of urgency) to their GP and their neurologist informed.
The NICE guidelines for MS management (2003) recommend that specific antidepressant medication, or psychological treatments such as CBT, should be considered, but only as part of an overall programme of depression management. The NICE Guidelines for MS Management (2003) recognize that any person with MS whose function or happiness is being aversely affected by anxiety should be offered specialist assessment and management (either psychological or psychiatric).
The NICE guidelines for MS management (2003) have made the following recommendations for emotionalism. The high incidence of depression among the MS population highlights the need for MS specialist nurses to be competent in the recognition and assessment of depression.
I asked the psychologists for advice and they also use the Beck depression Inventory (BDI-II) which is very widely used and easy to fill in. The estimated point prevalence for major depression among those aged 16 to 65 years in the UK is 21 per 1000.1 However, if the less specific and broader category of mixed depression and anxiety is included, the figure is much higher (see here).
The guideline development group felt that these were most likely to reduce the variation in the availability of effective interventions for depression or to bring about a significant improvement in patient outcomes.
The presence of personal support, lack of a family history of depression or of suicidal thoughts, coupled with limited disability and relatively recent onset of symptoms favour the use of limited interventions such as watchful waiting. It is perhaps in this area that the guideline presents the most significant challenge to current practice in the management of depression in primary care. Implementing the guideline will demand greater availability of psychological therapies, but they are not the only alternatives to antidepressant drug therapy for the management of mild depression.
However, these individuals are at greater risk of long-term problems, and the recommended approaches to management differ from those for mild depression. This is in part because many patients with severe depression who do not respond to treatment will be referred to secondary care mental health services.
These are the individuals whose lives are most often blighted by depression and who place a considerable demand on the healthcare system.
For the full benefits of this enhanced range of options to be really cost effective the systems for the delivery of care in depression will need to be restructured. In addition, NICE provides a guide to the potential cost impact of the guideline and simple costing tools for use by commissioners and managers; separate costing tools are provided for both England and Wales.
North of England evidence-based guideline development project: summary version of guidelines for the choice of antidepressants for depression in primary care. The treatment of depression: prescribing patterns of antidepressants in primary care in the UK.


DefinitionPostnatal depression is a type of depression some women experience after they have had a baby. Their study, which included 174 people with MS, identified four stages of adjustment to a diagnosis of MS, these being; denial, resistance, affirmation, integration. There have been a variety of studies that have focused on attempting to establish the pathology of depression using MRI and other imaging techniques (Siegert & Abernathy, 2005). Corticosteroids are known to cause mood changes, with some people experiencing increased energy, euphoria and a decreased need for sleep whilst using steroids and depressive symptoms upon discontinuation (Patten et al, 1996). Clinical depression prevents people from functioning normally on a daily basis, interferes with their relationships and can seriously impair their ability to function adequately in a work environment.
Behavioural and cognitive psychotherapies are psychological approaches that are based on scientific principles, which research has shown to be effective for a wide range of problems, including post-traumatic stress, depressive disorders, anxiety disorders, bulimia, chronic fatigue and chronic pain (Davis-Smith, 2006). Depression in Multiple Sclerosis as a function of length and severity of illness, age, remissions and perceived social support. Self-reported depressive symptoms following treatment with corticosteroids and sedative-hypnotics. During the first phase, denial, patients might be unwilling to accept the diagnosis and might seek a second opinion. The context and consequences of communicating the diagnosis of MS: some brief findings from a survey of 900 people. There was also some suggestion that treatment with Interferon-beta 1b was associated with an increase in depression and increased risk of suicide attempts Lublin et al (1996). It is estimated that 60% of individuals relapse within five years of an index depressive episode. Actute treatment of moderate to severe depression with hypericum extract WS 5570 (St John’s Wort): randomised controlled double blind non-inferiority trial versus paroxetine. There are many symptoms of postnatal depression, such as low mood, feeling unable to cope and difficulty sleeping, but many women are not aware they have the condition. However, there is a suggestion that there may be an association between depression and lesions occurring in the left anterior temporal and parietal regions of the brain (Siegert & Abernathy, 2005). However, more recent reports suggest that increased risk appears to be linked to pre-treatment levels of depressive symptomatology than to interferon-beta 1b itself (Mohr & Goodkin, 1996).
To minimize the risk of relapse, it is recommended that antidepressant therapy be continued for at least six months after recovery from the first episode of depression.
Over time they accept the diagnosis and move towards pursuing activities aimed at controlling the disease. Half the patients studied talked about their suspicions of MS diagnosis prior to having it confirmed by the neurologist. It has also been suggested that Modafinil, a drug commonly used for treating fatigue can cause anxiety or depression; and baclofen (used for spasticity), can cause hallucinations, agitation or altered mood when stopped suddenly(Goldman Consensus Group, 2005). A greater recognition of depression in MS patients will no doubt lead to more effective interventions and will prevent the tragic loss of life from a treatable disorder (Sadovnick and Remick, 1996). Feelings of abandonment and isolation following diagnosis may be particularly heightened in MS. 6Postnatal depression is more common than many people realise and cases can often go undiagnosed. It is estimated around one-in-seven women experience some level of depression in the first three months after giving birth.
15Local health visitors also routinely measure mothers according to the Edinburgh postnatal depression scale between 5-8 weeks after their birth, in order to identify individual needs. 16Numbers of local health visitors are increasing and therefore there is an expectation that they will have a greater capacity to support mothers with postnatal depression. 17 However, there is an awareness that there are limited services available for women once they have been identified as suffering from postnatal depression. It delivers a Mental Health Creative Support Service in Bath and North East Somerset includes working with women with postnatal depression. 20Creativity Works project My Time - My Space has helped hundreds of women and their families in Bath and North East Somerset to cope with postnatal depression. The programme has been through research trials in Australia which demonstrated that it could be effective in helping mothers overcome depression.



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