Diagnosing depression

2 downloads 348 Views 138KB Size Report
Sep 7, 2016 - through the release of endorphins that boost wellbeing as well as relieving stress and anxiety. The social
UPDATE Clinical chemistanddruggist.co.uk/update-plus

Module 1795

Diagnosing depression From this module you will learn:

●●What depression is and its prevalence in both adults and children

July Practice: ● Pharmacy counselling

2 July*

Clinical: ● Diagnosing depression

9 July

●●How the condition is diagnosed and potential alternative diagnoses

● Body dysmorphic disorder

16 July

● ADHD

23 July*

●●The role of pharmacy in identifying individuals who have depression and the support that can be provided

● Sleep disorders

30 July

*Online-only for Update Plus subscribers

Asha Fowells MRPharmS

Depression is the most common mental health condition in Britain. Precise figures are hard to come by as not all people with depression seek help, but according to the charity Rethink Mental Illness, around one in 10 people will be diagnosed with depression during their lifetime. This illness is not confined to adults. The National Collaborating Centre for Mental Health estimates that about 1% of prepubescent children and some 3% of postpubescent young people are affected. This module looks at how depression is diagnosed in both adults and children, with the aim of arming pharmacists and their staff with the knowledge to help identify and support those who may have the condition. The treatment of depression is outside the scope of this article, but the module will teach you to empower your patients to seek further help.

What is depression? Everyone feels down from time to time, and while there is often a rational explanation – a bereavement, or difficulties at home or work – sometimes there is not. These feelings of unhappiness soon pass, usually in a matter of days, and life carries on as it did before. However, someone with depression experiences feelings of hopelessness and sadness for weeks and months. Life becomes a struggle, not just in terms of day-to-day living, but also because relationships with friends and family can deteriorate. There is sometimes a trigger for depression – such as a difficult life event, physical illness, or personal circumstances – but in many cases, the individual is unable to pinpoint exactly when and why they started to feel down. For many years, depression was attributed to a chemical imbalance in the brain. The presence of too much dopamine, or too little serotonin, was thought to affect transmission of signals from one nerve cell to another. Although it is now recognised that these neurotransmitters are important, they do not tell the full story. This is well illustrated by the fact that the drugs designed to address this imbalance – the most widely used class being selective serotonin 18 CHEMIST+DRUGGIST 09.07.2016

Depression can present as persistant sadness or low mood, and a marked loss of interest or pleasure

reuptake inhibitors (SSRIs) – are often ineffective at treating depression. The Royal College of Psychiatrists (RCP) estimates that between 3550% of people treated with an antidepressant for depression do not see an improvement.

Diagnosing depression in adults In its recently updated guidance on the recognition and management of depression in adults (CG90), the National Institute for Health and Care Excellence (Nice) highlights the difficulties that exist in diagnosing the condition, stating: “A wide range of biological, psychological and social factors, which are not captured well by current diagnostic systems, have a significant impact on the course of depression and the response to treatment.” In order to diagnose depression, Nice states that five or more of the following symptoms must have been present for most of the time, on most days, during the previous two weeks. This must include at least one of the first two listed below: ●●persistent sadness or low mood ●●marked loss of interest or pleasure ●●significant weight change or an alteration in appetite

●●insomnia or hypersomnia ●●psychomotor agitation (unintentional or purposeless motions suggesting restlessness) or retardation (slowing down of thought and reduction in physical movements) that is noticeable by others ●●fatigue or lack of energy ●●feelings of worthlessness, or excessive or inappropriate guilt ●●diminished ability to think or concentrate, which may manifest as indecisiveness ●●recurrent thoughts of death (not just fear of dying), suicidal thoughts or attempt. The degree of depression in adults can be categorised generally as follows: ●●Mild – if it has some impact on daily life ●●Moderate – if the impact on everyday activities is significant ●●Severe – if the individual is finding it almost impossible to get through each day.

Diagnosing depression in children Nice has published guidance on the identification and treatment of depression in children aged five to 11 years, and young people aged 12-18 years (CG28). In this case, the three core symptoms are:

Looking for tips to get the most out of your MURs? Try C+D’s popular MUR Zone ▶▶ chemistanddruggist.co.uk/mur-zone

●●persistent sadness or low mood (which may present as irritability) ●●loss of interest or pleasure ●●fatigue or low energy. The above core symptoms require the first and either the second or third to be present for a diagnosis to be considered. Below is a list of associated symptoms, which can be combined with the core symptoms to give an indication of the severity of the depression: ●●poor quality of, or an increased need for, sleep ●●impaired concentration or indecision ●●low self-confidence ●●altered appetite ●●agitation or lethargy ●●guilt or self-blame ●●suicidal thoughts or acts. The symptoms should persist for at least two weeks and be present for most of each day. Much like adult depression, episodes of depression in children are classified as: ●●Mild – two associated symptoms in addition to the core symptoms, ie four in total ●●Moderate to severe – two core symptoms plus three or more associated symptoms, ie a minimum of five in total ●●Severe with psychotic symptoms – core symptoms plus seven or more associated or psychotic symptoms such as hallucinations, delusions, confused and disturbed thoughts and lack of insight and self-awareness. Depression is widely recognised as being more difficult to diagnose in children and adolescents than in adults. This is because: ●●it has a more gradual onset ●●symptoms may fluctuate in severity ●●other behavioural disorders may co-exist. ●●younger people may be more reluctant to volunteer information about how they feel. A further complication is that abuse can be a possible cause of the signs and symptoms of depression. If you come into contact with children through work who you suspect are being abused, then it is your duty to ensure their safety and protection, and to report any evidence of abuse appropriately. For further advice on safeguarding children, read the CPPE learning documents at tinyurl.com/ CPPEsafeguarding.

What else could it be? There are several differential diagnoses that should be considered if someone – either old or young – presents with symptoms of depression: Grief shares many characteristics of depression, most notably the biological symptoms such as loss of sleep, appetite and concentration. However, the psychological aspects – for example, a sense of hopelessness or guilt – are generally absent. Grief also comes in waves, whereas depression is often unremitting, and the sense of loss is specific rather than generalised distress about all facets of life. In addition, suicidal thoughts are rarely part of the grieving process.

Staying active, such as gardening regularly, can be as effective as antidepressants at reducing symptoms

Dementia often includes depressive symptoms, and hence distinguishing the two can be difficult as both can affect orientation, memory and the ability to concentrate. But depression is more likely if: ●●the individual’s memory seems reasonable ●●there is a personal or family history of the condition ●●the symptoms respond to conventional depression treatments. Chemicals may alter mental state, whether by means of deliberate substance misuse (including alcohol, steroids, cannabis, opioids and cocaine), or unintentionally in the form of carbon monoxide poisoning or an adverse drug reaction. Common medications that may affect mental state include: ●●lipid-soluble beta-blockers, such as propranolol ●●CNS depressants, eg benzodiazepines ●●centrally acting antihypertensives, eg methyldopa ●●isotretinoin ●●opioid analgesics. Hypothyroidism can also cause symptoms of depression, but is easily excluded by conducting thyroid function tests.

What can pharmacists and their staff do? Being at the forefront of primary healthcare, pharmacy is perfectly placed to help identify individuals who may be suffering from depression but who are unwilling to seek help. Gentle, open questioning can help detect those who are experiencing one or both of the core diagnostic symptoms, and it can be done in such a way as to not feel intrusive. For example, you could ask: “During the past month, how often have you felt down?” or: “How has your interest in doing things that you would usually enjoy changed?”

The responses to this simple questioning, as well as the patient’s general demeanour, may give a good indication of whether they should be referred to their GP for a full assessment. Pharmacy also has a vital role to play in breaking down some of the barriers that people have to seeking help. Chief among this is a sense that depression is a form of weakness, or an inability to cope. In a leaflet on the condition, the RCP states: “There comes a point when depression is much more like an illness than anything else. It can happen to the most determined of people – even powerful personalities can experience deep depression. Winston Churchill called it his ‘black dog’.” Explaining to the patient that they have not had a choice in the matter, in the same way that they would not if they were diagnosed with diabetes or cancer, can give some valuable perspective. Another area in which pharmacy has much to contribute is in providing advice on lifestyle measures that can make a difference. This can touch on a range of areas: Encouraging discussion of feelings, whether with loved ones, within a support group or with a counsellor. Socialisation is vital to minimising isolation. Staying active – research has shown that, in some cases, exercise can be as effective as antidepressants at reducing symptoms, through the release of endorphins that boost wellbeing as well as relieving stress and anxiety. The social interaction that it can provide may also be beneficial. But hitting the gym is not necessary – simply going for a walk or doing some gardening can make a difference. Eating healthily is now regarded as crucial for physical health, but it is just as important for good mental health. 09.07.2016 CHEMIST+DRUGGIST 19

UPDATE Clinical chemistanddruggist.co.uk

Advising on quitting smoking, particularly cannabis, as there is a significant body of research linking the drug to adverse mental health outcomes. Promoting good sleep hygiene can help the patient get a better night’s sleep, which in turn will help them cope better with the next day. For more information on tiredness see C+D Update Module 1777 at tinyurl.com/CDtiredness and read the follow-up module on sleep later this month. Supporting adherence to prescribed medication, advising on interactions and withdrawal from antidepressants when appropriate. Alcohol is used by many as an emotional crutch, but is best avoided. It is important to remember the relationship that pharmacists and their staff have with these patients. A pharmacist may be the first person the patient discusses their feelings with, or when collecting their medication for the first time, they may want to understand their condition more and seek advice from the pharmacist. It means you need to be aware of the common symptoms that these patients present with and how they can empower themselves to deal with their condition.

For more information

DIAGNOSING DEPRESSION QUIZ 1. Depression is the most common mental health condition in Britain. True or false? 2. It is estimated that around 3% of pre-pubescent children are affected by depression. True or false? 3. Triggers for depression include difficult life events, physical illness, or personal circumstances. True or false? 4. Drugs that correct chemical imbalances in the brain have a relatively high failure rate in the treatment of depression. True or false? 5. Depression is considered severe if the individual is finding it almost impossible to get through each day. True or false? 6. The three core symptoms for depression in children are persistent sadness or low mood, low self-confidence and poor quality of sleep. True or false? 7. Depression is widely recognised as being more difficult to diagnose in children and adolescents than it is in adults. True or false? 8. Grief shares many characteristics of depression, including psychological aspects such as feelings of hopelessness and guilt.

Clinical Knowledge Summaries pull together a range of resources to provide information on conditions and their management. Depression is dealt with separately for adults and children at: cks. nice.org.uk/depression and cks.nice.org.uk/ depression-in-children respectively.

True or false?

NHS Choices is a good source of information for patients and carers, as is the website of the Royal College of Psychiatrists at: tinyurl. com/depression36 and tinyurl.com/depression37.

True or false?

Nice has a care pathway on depression, which includes links to more detailed guidance for adults and children, at: tinyurl.com/depression38. The Mental Health Foundation is a UK charity that informs and influences the development of evidence-based policies, and empowers people to manage their condition. Its website also has links to a number of other organisations, such as Samaritans, Rethink Mental Illness and Mind: tinyurl.com/depression39. Time to Change is an anti-stigma campaign and social movement, aiming to end the discrimination faced by people with mental health problems in England. It is funded by the Department of Health, Comic Relief and the Big Lottery Fund. Its information on depression can be accessed at: tinyurl.com/depression40.

20 CHEMIST+DRUGGIST 09.07.2016

9. Common medications that may affect mental state include propranolol, methyldopa and CNS depressants. True or false? 10. Exercise can help in depression.

Diagnosing depression CPD Reflect How is depression diagnosed and classified? What are the symptoms of depression in children? What lifestyle measures can help patients cope with the condition?

Plan This article contains information about what depression is, its prevalence in adults and children, how it is diagnosed, and potential alternative diagnoses. The role of pharmacy in identifying individuals who may be suffering from depression and the support that can be provided is also discussed. Act Read more about depression on the Royal College of Psychiatrists website at: tinyurl.com/depression30

Find out more about depression in children and adolescents on the Patient website at: tinyurl.com/depression31 Find out about the patient health questionnaire (PHQ-9), which can be used to monitor the severity of depression and response to treatment, on the Patient website at: tinyurl.com/depression34 Read more about mindfulness and how it can help with depression and anxiety on the NHS Choices website at: tinyurl.com/depression35

Evaluate Are you now confident in your knowledge of depression and how it is diagnosed? Could you spot at-risk patients? Are you able to provide advice and resources about depression to patients?