Depression (adults)

Overview

See the BNSSG Guideline for the Management of Depression in Adults (Feb 2023) for detailed advice on assessment and management of depression including advice on medication options.

Prevalence

• Depressive disorders are very common and are among the leading causes of disability worldwide. In people aged 18-44 years, depression is the leading cause of disability and premature death.
• The worldwide prevalence of depression is estimated to be 4.4% and prevalence in the UK is 4.5%.
• Prevalence varies with age and sex, peaking in older adults (7.5% in females and 5.5% among males aged 55–74 years).

Depression in Children and Young People

For advice on managment of depression in in children and young people please see the Mental Health Resources for Children and Young People page.

Depression in Pregnancy and Peri-natal period

For advice on management of depression in pregnancy or the peri-natal period then please see the Perinatal Mental Health page.

Assessment

Clinical Knowledge Summaries (1) has the following advice about recognition and assessment of depressive disorders:

• Be alert to possible depression, particularly in people with a past history of depression or a chronic physical health problem with associated functional impairment.
• Consider asking the person about the two 'core' symptoms of depression. Ask:
  • During the last month have you often been bothered by feeling down, depressed, or hopeless?
  • Do you have little interest or pleasure in doing things?
• If at least one of the two 'core' symptoms have been present most days, most of the time, for at least 2 weeks, ask about:
  • Associated symptoms of depression:
    • Disturbed sleep (decreased or increased compared to usual).
    • Decreased or increased appetite and/or weight.
    • Fatigue/loss of energy.
    • Agitation or slowing of movements.
    • Poor concentration or indecisiveness.
    • Feelings of worthlessness or excessive or inappropriate guilt.
    • Suicidal thoughts or acts.
  • Duration and associated disability, past and family history of mood disorders and availability of support.
• The severity of depression is determined by both the number and severity of symptoms, as well as the degree of functional impairment.
  • Seasonal affective disorder is diagnosed if the person has episodes of depression which recur annually at the same time each year with remission in between (usually appearing in winter and remitting in spring).
• Investigations are not routinely indicated for people with depression, but may be necessary to exclude other causes for symptoms or conditions known to be associated with depression. Tests that may be indicated include:
  • HbA1c, urea and electrolytes, creatinine, LFT, TSH, calcium levels, FBC and erythrocyte sedimentation rate.

PHQ-9 (Patient Health Questionnaire-9) is a tool used to calculate the degree of depression severity. PHQ-9 (Patient Health Questionnaire-9) - MDCalc

Scores ≤4 suggest minimal depression which may not require treatment.

Red Flags

Please see the Self Harm and Suicidal Thoughts pages on Remedy.

What to do before referral

Clinical Knowledge summaries (1) has advice on management of depressive disorders in primary care including non-pharmacological and pharmalogical treatments.

Non-pharmacological treatments

Self help advice - please direct patients to the mental health and wellbeing page on the BNSSG ICB website which has information about local self help resources. There is also a bibliography in the Resources section below.

Psychological therapies - see the Talking Therapies page for further advice on accessing psychological therapies which are available on-line or via self-referral.

Social prescribing - see the Mental Health - Social Prescribing page for advice about local resources

Pharmacological treatments

Please see the BNSSG Guideline for the Management of Depression in Adults in the Formulary section of Remedy for advice on medication use in depression.

The following links about prescribing may also be useful:

• Antidepressants cautions and monitoring requirements
• Switching between anti-depressants
• Antidepressants in pregnancy and breast feeding - see also BUMPS website

Advice and guidance

For patients who are more complex or who are not responding to treatment, you may like to consider discussing at your PCN Mental Health MDT or contacting your link psychiatrist for advice (although may not currently be available to all practices).

There are also email and telephone contact details for mental health teams on the PCLS - AWP page

Services

Please see NHS Talking Therapies page for advice on referral (or self-referral) for psychological therapies.

Please see Primary Care Liaison Service – AWP page for advice on referral of patients needing assessment and/or treatment from the community mental health team.

Anti-depressants

Starting Anti-Depressants

See the BNSSG Guideline for the Management of Depression in Adults for advice on when to consider anti-depressant medication, which ones to use and how to review and follow up patients if they are prescribed.

In less serious depression, antidepressant medication should not routinely be offered as first line treatment, unless that is the patient’s preference 

In more serious depression, consider antidepressant medication and/or non-pharmacological therapies as first line, depending on patient preference (3).

Stopping Anti-Depressants

The guideline above also gives advice about when to consider stopping anti-depressants and how to do it.

This includes a link to the RCPsych patient (and GP) guide to stopping antidepressants.

Resources

References

(1) NICE CKS – Depression (Last revised in March 2021)

(2) BNSSG formulary: Adult Joint Formulary 4.2 Mental Health Disorders 

(3) BNSSG Guideline for the Management of Depression in Adults

Self Help Resources

Mental Health Self-Help Guides page on Remedy

Reading Well Books on Prescription (for adults covering common mental health conditions) are available to borrow free of charge from public libraries including:

• Overcoming Depression and Low Mood: A Five Areas Approach (third edition) by Chris Williams
• Mind Over Mood: Change How You Feel by Changing the Way You Think by Dennis Greenberger and Christine Padesky
• Overcoming Depression by Paul Gilbert
• Reading Well for young people (aimed at 13-18 year olds)
• Am I Depressed and What Can I Do About It? By Shirley Reynolds and Moinka Parkinson
• Can I Tell You About Depression? By Christopher Dowrick and Susan Martin
• I Had a Black Dog by Matthew Johnstone

Efforts are made to ensure the accuracy and agreement of these guidelines, including any content uploaded, referred to or linked to from the system. However, BNSSG ICB cannot guarantee this. This guidance does not override the individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or guardian or carer, in accordance with the mental capacity act, and informed by the summary of product characteristics of any drugs they are considering. Practitioners are required to perform their duties in accordance with the law and their regulators and nothing in this guidance should be interpreted in a way that would be inconsistent with compliance with those duties.

Information provided through Remedy is continually updated so please be aware any printed copies may quickly become out of date.