The essay will explore the NHS guidelines to depression and critically discuss treatment approaches that can be used to alleviate the risk of suicide and help with depression. This will be done using evidence-based practice, for a thirty year old patient (Michael). The patient, a hairdresser, was admitted informally to an acute psychiatric ward complaining of increasing loss of confidence, apathy and a desire to end his life following the break-up of his five year relationship with his live-in boyfriend.
Depression affects an estimated 350,000,000 people globally and contributes greatly to the burden of disease (American Psychiatric Association, 2000). This mental disorder presents with symptoms ranging from mood fluctuations and short-lived emotional responses to severe challenges in every-day living and at worst, depression can lead to suicide (WHO, 2012). Suicidal behaviour is a persistent and lethal public health problem that is among the leading cause of death worldwide (Mitchell et al. 2009). Depression is a important risk factor for suicide (Knapp and Ilson, 2002). It can increase suicidal tendencies four-times higher compared with the general population, this can increase 20-fold in the severely ill (Bostwick & Pankratz, 2000). Suicide accounts for ~ 1% of deaths, while two-thirds of these deaths occur in depressed individuals (Sartorius, 2001).
There are several forms of depressive disorders, including major depressive disorder, which can interfere with everyday living, characterised by an inability to work, sleep, study, eat or take enjoyment in activities , as stated in the Quality Standards (QS8) (NICE, 2001). Minor depression is diagnosed when symptoms have persisted for 2+ weeks as in the case of Michael, but do not meet the total evaluation for major depression (Moussavi et al., 2007). However, without treatment minor depression can develop into major depressive disorder (Nicholson et al. 2006). Furthermore, an estimated 50% of depressed individuals are not recognised in primary care (National Collaborating Centre for Mental Health, 2009).
Depression can be reliably diagnosed and is covered by QS8. Diagnosis of depression is based on its severity and persistence, as well as the occurrence of other symptoms, as well as the extent of functional and social impairment (Kupfer, 1991). The National Health Service (NHS) has a number of models to aid clinicians to diagnose depression. Recognition, assessment and initial administration of individuals presenting with symptoms of depression is covered by the GC90 NICE guidelines, which states that persons presenting with symptoms of depression should be referred to appropriate professionals if the practitioner is not competent in mental health assessments (NICE, 2004, 2007, 2009). Michael’s presentation and the complication of suicide thoughts means that Michael is on step 4 of the stepped care model (figure 1) and was referred immediately to an acute psychiatric ward.
Figure 1: Stepped care model (NICE 2009)
Michael has suicidal thoughts, which means he presents considerable immediate risk to himself and so requires referral to specialist mental health services (DH, 2007). However, referral can result in increased anxiety, agitation and suicidal ideation during initial treatment. As such, medical staff should be vigilant for mood changes, negativity, hopelessness and suicidal ideation, and increased support should be provided such as frequent contact (NICE, 2004).
Evidence-Based Practice and Treatment
There are a number of effective treatments for depression. The recommended treatment options for moderate to severe depression, as stated by the World Health Organisation (WHO), consists of psychosocial assistance in conjunction with antidepressant medication and/or psychotherapy, which includes CBT, interpersonal psychotherapy or problem-solving treatments.
Initial treatment of depression often begins when the patient consults their GP, NICE (2011) states that a comprehensive assessment is required that is more than a symptom tally, but accounts for functional impairment or disability. To ensure this the GP will frequently give the patient a questionnaire to fill in for assessment which may use rating scales such as GAD, PHQ or Whooley. Michael was assessed as significant risk to himself, therefore he was referred to a specialist mental health service.
NICE (2011) states that effective delivery of interventions for depression requires competent practitioners to deliver interventions, which may include psychosocial and psychological interventions. Michael’s treatment would consist of medication, however as he presents with suicidal ideation, medication toxicity as well as the quantities issued, should be assessed stringently (Simon et al., 2006). Antidepressants can be valuable in treating moderate to severe depression, but should not be the primary form of treatment for mild depression (WHO, 1992). The potential side-effects, addiction potential and importance of taking prescribed medication should be explained (Anderson, et al., 2008). Medication support should be provided for at least six months following remission of a depressive episode of (Jick et al., 2004). Michael should be monitored by nursing staff and he should be reassured that he can talk to them, although he must be told that staff have a duty to inform the doctors of any concerns. It is important to remember to not offer false reassurance; problem-solving is the best treatment. If Michael is released into the community, he should be monitored at least weekly (WHO, 1992).
NICE (2011) guidelines suggests that patients with continual sub-threshold depressive symptoms should be offered self-help guides on cognitive behaviour therapy (CBT) either manual or computerised, or structured group activity programmes. Michael (and his family, if he consents) should be advised of the expected symptoms, such as the potential for increased agitation and to be mindful of mood changes, negativity and suicidal ideation (Waraich et al., 2004). He should be offered some form of psychological therapy, especially to help with his feelings of loss, due to his failed romance and any other lifestyle problems that may be affecting him. These could include behavioural activation, cognitive-analytic therapy, cognitive behavioural therapy (CBT) and do-it-yourself CBT, group therapy, counselling (family or relationship), interpersonal therapy or psychodynamic psychotherapy/psychoanalysis (Simon et al., 2004). The use of psychosocial/psychological treatment and medication are beneficial in treating moderate to severe depression, such as Michael’s case.
Competence frameworks should ensure the patient receives regular supervision, reviewed treatments with monitoring and evaluation of those treatments that may include video or audio tapes and external scrutiny (NICE, 2011) .Collaborative care ought to consist of case management, which should be administered by a senior mental health professional. Care of depressed individuals also requires close cooperation between primary and secondary health services and/or specialist mental health services. Finally, long-term coordination of care and good follow-up with Michael will reduce the risks associated with recurrence of depression.
The best clinical practice for depression in adults has been defined in QS8, which discusses the measures, audience descriptors, and assessment and clinical management of depression required to provide to patient. The current guidelines for depression ensure that patients are no longer simply given antidepressants in the long-term without psychosocial/psychological treatments which ensure the patient is involved in their recovery. However, while best practices are derived from the best research evidence available, they are not a replacement for professional acuity and clinical judgement (NICE 2011).
American Psychiatric Association (Ed.) (2000) Diagnostic and statistical manual of mental disorders: DSM-IV-TR. 4th edn. Washington, DC: American Psychiatric Association.
Anderson, I.M., Ferrier, I.N., Baldwin, R.C. et al. (2008) Evidence-based guidelines for treating depressive disorders with antidepressants: a revision of the 2000 British Association for Psychopharmacology guidelines. Journal of Psychopharmacology 22(4), 343-396.
Bostwick, J.M. and Pankratz, V.S. (2000) Affective disorders and suicide risk: a reexamination. American Journal of Psychiatry 157(12), 1925-1932.
DH (2007) Best practice in managing risk: principles and evidence for best practice in the assessment and management of risk to self and others in mental health services. Department of Health. www.dh.gov.uk. Accessed Jan 2013.
Jick, H., Kaye, J.A. and Jick, S.S. (2004) Antidepressants and the risk of suicidal behaviors. Journal of the American Medical Association 292(3), 338-343.
Knapp, M. and Ilson, S. (2002) Economic aspects of depression and its treatment. Current Opinion in Psychiatry 15(1), 69-75.
Kupfer, D.J. (1991) Long-term treatment of depression. 52(Suppl), 28-34.
Mitchell, A.J., Vaze, A. and Rao, S. (2009) Clinical diagnosis of depression in primary care: a meta-analysis. Lancet 374(9690), 609-619.
Moussavi, S., Chatterji, S., Verdes, E. et al. (2007) Depression, chronic diseases, and decrements in health: results from the World Health Surveys. Lancet 370(9590), 851-858.
National Collaborating Centre for Mental Health (2009a) Depression in adults (update): full NICE guideline. National Institute for Health and Clinical Excellence. www.nice.org.uk. Accessed Jan 2013.
National Collaborating Centre for Mental Health (2009) Depression in adults with a chronic physical health problem: treatment and management (full NICE guideline). National Institute for Health and Clinical Excellence. www.nice.org.uk. Accessed Jan 2013.
NICE (2004) Depression: management of depression in primary and secondary care (NICE guideline) [Replaced by clinical guideline 90 (CG90)]. Clinical guideline 23. National Institute for Health and Clinical Excellence. www.nice.org.uk. Accessed Jan 2013.
NICE (2007) Depression (amended): management of depression in primary and secondary care (NICE guideline). [Replaced by clinical guideline 90 (CG90)]. NICE clinical guideline 23 (amended). National Institute for Health and Clinical Excellence. www.nice.org.uk. Accessed Jan 2013.
NICE (2009) Depression. The treatment and management of depression in adults (NICE guideline). National Institute for Health and Clinical Excellence. www.nice.org.uk. Accessed Jan 2013.
NICE (2011) Quality standard on depression in adults. National Institute for Health and Clinical Excellence. www.nice.org.uk. Accessed Jan 2013.
Nicholson, A., Kuper, H. and Hemingway, H. (2006) Depression as an aetiologic and prognostic factor in coronary heart disease: a meta-analysis of 6362 events among 146 538 participants in 54 observational studies. European Heart Journal 27(23), 2763-2774.
Sartorius, N. (2001) The economic and social burden of depression. Journal of Clinical Psychiatry 62(Suppl 15), 8-11.
Simon, H.C., Bruce, M.L., Lee, P.W. et al. (2004) Preventing suicide in primary care patients: the primary care physician’s role. General Hospital Psychiatry 26(5), 337-345.
Simon, G.E., Savarino, J., Operskalski, B. and Wang, P.S. (2006) Suicide risk during antidepressant treatment. American Journal of Psychiatry 163(1), 41-47.
Waraich, P., Goldner, E.M., Somers, J.M. and Hsu, L. (2004) Prevalence and incidence studies of mood disorders: a systematic review of the literature. Canadian Journal of Psychiatry 49(2), 124-138.
WHO (1992) The ICD-10 classification of mental and behavioural disorders. Clinical descriptions and diagnostic guidelines. World Health Organization. www.who.int. Accessed Jan 2013.
WHO http://www.who.int/mediacentre/factsheets/fs369/en/index.html. Accessed Jan 2013.