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Interventions for depression, what causes ringing in your right ear - Review

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Depression is approximately two-to-three times more common in patients with a chronic physical health problem than in patients who have good physical health.1 It occurs in around 20% of people with a chronic physical health problem,2 such as cancer, heart disease, diabetes, musculoskeletal disorders, respiratory conditions, or neurological disease.
Depression can exacerbate the pain and distress associated with physical illnesses and adversely affect outcomes, including shortening life expectancy. Depression often has a remitting and relapsing course, and symptoms may persist between episodes.
The NICE guideline contains a stepped-care model that provides a framework in which to organise the provision of services for patients with a chronic physical health problem and a diagnosis of depression (see Figure 1).
The NICE Guideline Development Group did not find sufficient evidence to recommend the routine use of antidepressants to treat sub-threshold depressive symptoms or mild depression in patients with a chronic physical health problem because the risk–benefit ratio is poor. There is no evidence to support the use of specific antidepressants for patients with particular chronic physical health problems,10 however, it is worth considering using citalopram or sertraline in the first instance because their cost–benefit ratio appears favourable,12 and they have less propensity for interactions. The need for careful and comprehensive assessment of patients with a chronic physical health problem who may have depression is clear, but the time involved in such an assessment may sometimes be problematic for busy GPs.
The availability of specified psychosocial interventions, and of collaborative care programmes, is patchy across England and Wales.
The GP retains a central role in the diagnosis of depression in the context of physical illness. NICE has developed the following tools to support implementation of Clinical Guideline 91 on Depression in adults with a chronic physical health problem.
The slides are aimed at supporting organisations to raise awareness of the guideline and resulting implementation issues at a local level, and can be edited to cater for local audiences. Despite the effectiveness of pharmacological treatments in the acute phase of late-life depression, symptom remission is achieved in fewer than 40% of elderly depressed patients with cognitive impairment, with or without dementia.8-11 Therefore, effective psychosocial interventions for this population are needed.

Depressive symptoms below standard threshold criteria can be distressing and disabling if persistent. When assessing a patient with a chronic physical health problem who may have depression, the guideline emphasises the need to conduct a comprehensive assessment that does not rely simply on a symptom count.
Selective serotonin reuptake inhibitors should be the first-line drug treatment for depression associated with physical illness. Therefore it may not always be possible for GPs to refer patients to the most appropriate intervention according to the stepped-care model. The NICE guideline gives the GP valuable information about what interventions are likely to be helpful in ongoing management, and hence should increase the confidence of both GP and patient in the likelihood of successful outcomes.
Major depression in individuals with chronic medical disorders: Prevalence, correlates and association with health resource utilization, lost productivity and functional disability.
Depression, chronic disease, and decrements in health: Results from the World Health Surveys.
Collaborative Depression Trial (CADET): multi-centre randomised controlled trial of collaborative care for depression—study protocol. Therefore, to effectively treat late-life depression, clinicians need to evaluate the presence and degree of the patient’s cognitive deficits and level of disability. The clinician must conduct a thorough evaluation that includes a review of the current depressive symptoms, past history of depression, history of pharmacological and psychosocial treatments and their effectiveness, and an evaluation of suicidal ideation. To treat depressed older patients with comorbid cognitive impairment and disability, psychosocial interventions need to be modified to include involvement of a caregiver, home delivery of the interventions, and environmental changes to help improve everyday functioning.
In addition to the assessment of depression and cognitive impairment, the clinician needs to evaluate the patient’s functional, behavioral, and physical limitations (eg, hearing, visual, mobility problems).

PST-ED is a 12-week outpatient treatment for ambulatory depressed elders with mild executive dysfunction. For most cognitively impaired elders, the clinician needs to interview the caregiver and obtain information that may not be available with the patient self-report. Because geriatric depression may be comorbid with other illnesses, symptoms that are caused by depression must be differentiated from those of another illness. With these modifications, psychosocial interventions may provide relief to a large group of elderly patients with depression who may not respond to antidepressant medication treatment.
The following interventions have been designed for depressed older patients with varying degrees of cognitive impairment.
Instruments that have been validated in the assessment of depression in cognitively impaired elders may help in the evaluation (Table 1). Sometimes this differentiation is extremely difficult, because depression may exacerbate existing physical symptoms. However, most psychosocial interventions for the acute treatment of geriatric major depression are designed for “young-old,” cognitively intact, ambulatory patients who can follow outpatient treatment plans.

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