See discussions, stats, and author profiles for this publication at: https://www.researchgate.

net/publication/285904492

Managing depression in primary care

Article  in  Practice Nursing · December 2015

DOI: 10.12968/pnur.2015.26.12.594

CITATIONS READS

0 125

1 author:

Sheila Hardy
The Charlie Waller Memorial Trust
28 PUBLICATIONS   147 CITATIONS   

SEE PROFILE

All content following this page was uploaded by Sheila Hardy on 25 May 2016.

The user has requested enhancement of the downloaded file.

 Clinical mental health

Managing depression in
primary care
D
Depression is epression is a commonly seen
condition in primary care. In this
commonly seen in article, the prevalence of depression,
its signs and symptoms, risk factors,
primary care, and consequences and barriers to diagnosis are
the majority of described. The way practice nurses can
promote the prevention of depression,
people with identify it and enable treatment is defined.
depression who Prevalence
seek treatment will Depression is a common mental disorder
causing human distress and large costs to
receive it in primary society. The World Health Organization
(WHO) projections suggest that by 2020
care. Sheila Hardy depression will be the leading cause of disease
describes how burden in developed countries (WHO, 2001).
Approximately, two thirds of adults will at
nurses can identify some time experience some degree of
depressed mood sufficient to negatively
and help those with impact on their day-to-day lives (Stewart et
depression al, 2004) and each year 6% of the adult
population will develop a depressive illness
(NHS Information Centre, 2009).
In order to measure the number of people
who have different types of mental health
problem in England each year, a survey is
carried out every 7  years. It only includes
those who are living at home, so people in
prison or hospitals (where there is a high
incidence of mental health problems) are not
included. The last survey showed that
approximately 17.6% of the adult population
(21.0% of women and 11.9% of men) has a
common mental health problem such as
anxiety or depression (NHS Information
Centre, 2009) and 17% has sub-threshold
mental illness. Not all of these people will
seek treatment; of those who do, 90% receive
it from primary care (Gask et al, 2009).
Signs and symptoms
Sheila Hardy, Northamptonshire The definition of depression is often described
Healthcare NHS Foundation Trust as loss of hope, poor concentration, lethargy,
sleep problems, changes in appetite and
Submitted 22 October 2015; accepted for irritability (Cassano and Fava, 2002). The
There are nine criteria for diagnosis (Table 1).
The severity of depression is assessed as:
➤➤Sub-threshold depressive symptoms:
fewer than five of the diagnostic criteria
➤➤Mild depression: five or more of the
diagnostic criteria, and the symptoms
result in only minor functional impairment
➤➤Moderate depression: symptoms or
functional impairment are between ‘mild’
and ‘severe’
➤➤Severe depression: most of the diagnostic
criteria, and the symptoms markedly
interfere with functioning. This can occur
with or without psychotic symptoms.
When making the diagnosis, consideration
needs to be given to the degree of associated
functional impairment and/or disability and
the duration of the episode.
The symptoms of depression can be divided
into physical and psychological (Table 2), but
each person has an individual experience of the
condition and a variable pattern of symptoms.
Their family history, personalities, premorbid
difficulties (for example, sexual abuse),
resilience and current relational and social
problems can significantly affect outcomes.
Depression is often accompanied by
anxiety, and in these circumstances one of
Table 1. Diagnostic criteria for
depression
1. Depressed mood most of the day, nearly every day
2. Markedly diminished interest or pleasure in all, or
almost all, activities most of the day, nearly every day
3. Significant weight loss when not dieting or
weight gain
4. Insomnia or hypersomnia nearly every day
5. Psychomotor agitation or retardation nearly
every day
6. Fatigue or loss of energy nearly every day
7. Feelings of worthlessness or excessive or
inappropriate guilt nearly every day
© 2015 MA Healthcare Ltd

publication following peer review
11 November 2015
Key words: Depression, primary care,
practice nurse, recognition, treatment
National Institute for Health and Care
Excellence guideline update (National
Institute for Health and Care Excellence
(NICE), 2009a) uses the DSM–IV (since
updated to DSM-V) to define depression.
8. Diminished ability to think or concentrate, or
indecisiveness, nearly every day
9. Recurrent thoughts of death (not just fear of
dying), recurrent suicidal ideation
Adapted from: American Psychiatric Association, 2013

538 Practice Nursing 2015, Vol 26, No 12

 three diagnoses can be made (NICE, 2009a):
➤➤Depression
➤➤Anxiety
➤➤Mixed depression and anxiety.
In primary care, each GP practice receives
payment through the Quality and Outcomes
Framework (QOF) to provide care for
patients with long-term conditions. The QOF
contains groups of indicators, against which
practices score points according to their level
of achievement (British Medical Association
and NHS Employers, 2015). Unlike the other
long-term conditions, there is no register
indicator for the depression indicator; instead
it is defined as: all patients aged 18 or over,
diagnosed on or after 1 April 2006, who have
an unresolved record of depression in their
patient record (this includes mixed depression
and anxiety).
Risks factors
Depression can be a reaction to life events
such as physical illness, bereavement,
relationship or financial problems, moving
house or redundancy (NICE, 2009a).
However, there are many people who become
depressed without any of these events
occurring (NICE, 2009a).
Some groups of people are more likely to
develop depression than the rest of the
population, they include those who are: in low
paid work; single; lesbian, gay or bisexual;
elderly, caring for people with long-term illness
and disability (Office for National Statistics,
2002; NHS Information Centre, 2007;
Wahlbeck and Mäkinen, 2008; McManus et
al, 2009; Chakraborty et al, 2011) and those
who have a learning disability or a chronic
physical illness (Smiley, 2005; Miovic and
Block, 2007; NICE, 2009b).
Regarding the increased likelihood of
depression in people with long-term conditions,
the evidence for this is strong for cardiovascular
diseases, diabetes, chronic obstructive
pulmonary disease and musculoskeletal
disorders (King’s Fund, 2012), but there is also
some evidence for poorer mental health in
people with other conditions such as asthma,
arthritis, cancer and HIV/AIDs (Chapman et
al, 2005; Sederer et al, 2006).
© 2015 MA Healthcare Ltd
Consequence of depression
The worst consequence of depression is
suicidal behaviour, especially if other
predisposing factors exist. Figures released by
Practice Nursing 2015, Vol 26, No 12 539
Table 2. Symptoms of depression
Physical Psychological
• Change in appetite: not eating resulting in • Depressed mood, feelings of sadness, feeling
weight loss; eating excessively resulting in weight low or flat
gain; unhealthy eating resulting in poorer physical • Attitude: feeling fed up, indecisive,
wellbeing preoccupation with physical symptoms,
• Bowel changes: constipation; diarrhoea; or indifference, denial or lack of awareness of
preoccupation with bowel function symptoms
• Participation in daily life: the patient lacks vitality • Loss of interest in life: withdrawal from the
and may sit and brood. Everyday tasks such as outside world, reduced awareness of current
washing and dressing may be difficult to perform. events, lacking interest in what is going on
Generally the patient’s actions are slowed down around them
• General appearance: sad and miserable, often • Speech: slow monotonous, monosyllabic
unkempt (or badly dressed) answers. Incessant negative talk often about
death, dying and the futility of life
• Sexual function: partial or total loss of libido
(sex drive) • Thought: slow and difficult, poor
concentration, preoccupation with morbid
• Amenorrhoea (partial or complete stopping of
periods) may be experienced by some women thoughts (death/suicide)
• Sleep disturbance: difficulty in getting to sleep.
The sleep maybe broken with excessive dreaming;
the patient wakes up unrefreshed and then feels
tired and unable to get going in the morning.
Some people wake up 2 or 3 hours before usual
waking time and do not get back to sleep
• Other physical symptoms: dry mouth,
indigestion, palpitations, headaches, giddiness, tight
band round chest and head, skin-picking, hand-
wringing, general aches and pains
Adapted from: Hardy and Gray, 2012
the Office for National Statistics (2015) show
that in 2013, 6233 suicides were registered in
the UK; a rate of 12 per 100 000 (19 per
100 000 for men and 5 per 100 000 for
women). It is important to raise awareness
that depression is a treatable disorder and
suicide is a preventable act. People with
untreated (or treatment-resistant) depression
are more likely to engage in risky behaviours
such as drug or alcohol addiction. Their
relationships may be adversely affected; they
may have problems at work, and experience
more physical illnesses.
Barriers to diagnosing depression
In a study carried out by Docherty in 1997
looking at the specific barriers to diagnosing
depression in primary care, three types of
barriers were found: system-, patient- and
clinician-related. System-related barriers
included financing of care, other
reimbursement issues, time available to care
for patients, and continuity of the physician–
patient relationship. Some patients were
ashamed to admit to psychological symptoms
of depression and feared the stigma attached
to it or, they lacked awareness and
understanding of the nature of the disease
 Clinical mental health
Table 3. Barriers preventing
practice nurse participation in
training courses (n=390)
Barrier Percentage
of nurses
Gaining agreement to attend may 34
be difficult
The course may not be available 25
Too far to travel 26
Employers would not pay 28
Employers would not release me 16
from practice
Hardy, 2014
and its symptoms so could not accurately
report them. Barriers relating to the clinician
included a lack of knowledge about the
disease and lack of training in its recognition
and management. Docherty (1997)
recommended a variety of tools to assist
primary care clinicians in the recognition,
accurate diagnosis, and effective management
of depression. Today, the barriers are still the
same but there is now clear guidance and
validated tools for primary care clinicians to
use. A survey of 420 primary care clinicians
showed that those with mental health training
were more positive in their attitudes toward
depression and their treatment of these
patients (Richards et al, 2004). However, in a
survey regarding the mental health training
needs of practice nurses, participants reported
a number of barriers to attendance (Table 3).
What can the practice nurse do?
Practice nurses are in a position to promote
mental health and wellbeing, encourage
preventive measures, recognize depression
early and ensure adequate treatment. These
elements are key in avoiding depression and
its complications such as suicide (Wahlbeck
and Mäkinen, 2008).
Promote mental health and wellbeing
Primary care clinicians and staff can work
together to create a culture where the mental
health and wellbeing of their patients is
actively promoted. Some examples of how
this can be achieved are listed below.
➤➤Empower patients: provide them with
relevant and up-to-date written and
verbal information
➤➤Reduce patient anxiety and prevent
symptoms worsening: allow prompt access
to an appropriate health professional
540 Practice Nursing 2015, Vol 26, No 12
➤➤Give the patients a sense of ownership:
find out what the patient population
wants from the practice
➤➤Enable patients to connect with others:
provide or signpost to patient support
groups
➤➤Promote healthy lifestyle behaviour:
advertise local groups, provide accessible
general information and appropriate
individual counselling
➤➤Prevent the patients from becoming
frustrated and increase their trust: give
consideration to their experience of
attending and make adjustments
➤➤Consider the wellbeing of the staff
➤➤Educate all staff in mental health awareness
➤➤Get leaflets/posters for your practice:
www.actionforhappiness.org/poster-great-
dream
Prevention of depression
The first objective of the Department of
Health mental health strategy is that more
people will have good mental health
(Department of Health, 2011). In order to
achieve this, it is vital for prevention, risk
stratification, and early intervention to take
place in primary care (The Joint Commissioning
Panel for Mental Health, 2012). Psychological
interventions for people at risk of depression
could reduce the risk of development of a
depression by a third (Cuijpers et al, 2005).
However, very few countries have implemented
prevention programmes (Jané-Llopis et al,
2003; Garber, 2008).
There are three different levels of
prevention:
➤➤Primary (preventing illness from
occurring in the first place)
➤➤Secondary (early identification and
treatment)
➤➤Tertiary (promotion of recovery and
relapse prevention).
Primary prevention
There are two general methods for the
primary prevention of depression (Rose,
1992). The first is the population approach
where population-wide changes in risk
factors are made. It works on the assumption
that making small reductions in the most
© 2015 MA Healthcare Ltd
important depression risk factors throughout
the whole population could lead to large
reductions in depression. In the UK Health
and Wellbeing Boards have been set up to
make it easier for everyone to get the care
 Table 4. Suicide questions
• Have you made a suicide attempt in the past?
• Do you think that life is not worth living? Do you think about harming or killing yourself?
• Have you got a plan to kill yourself? How would you do it?
• Do you aim to carry out this plan?
• Have you got access to (the necessary tools to) carry out the plan? For example, a supply of medication if planning
an overdose
• What would stop (or what is stopping) you from carrying out your plan? For example, they wouldn’t want to
abandon their children
Adapted from: Hardy and Gray, 2012
they need to feel well (Department of Health,
2012). The second is the high-risk approach,
in which individuals at high risk of disease
are identified and targeted for preventive
treatment. There is currently no strategy for
this in primary care because the health care
system is set up to pay providers for treatment
and there are no arrangements to pay
providers for the prevention of mental
disorders (Muñoz et al, 2012).
Secondary prevention
There is no current policy for the secondary
prevention of depression in primary care, i.e.
targeting individuals who are at risk of
developing mental health problems. The Joint
Commissioning Panel for Mental Health
(2012) recommends that these patients can be
identified from computer ‘Read Codes’.
Patients can be screened for depression by
asking them two simple questions, the
so-called Whooley or two-question test
(Whooley et al, 1997). Patients simply answer
‘Yes’ or ‘No’.
➤➤‘During the last month have you often
been bothered by feeling down,
depressed, or hopeless?’ Yes/No
➤➤‘During the last month have you often
been bothered by having little interest or
pleasure in doing things?’ Yes/No
An answer of ‘Yes’ to either of the questions
should trigger a more detailed assessment,
using the Patient Health Questionnaire
(PHQ-9). The form can be downloaded from:
www.phqscreeners.com/terms.aspx
Tertiary prevention
Tertiary prevention involves actual treatment
© 2015 MA Healthcare Ltd
for depression. This includes giving support
and encouragement to a patient who has
benefited from taking an antidepressant to
continue medication for at least six months
after remission of an episode of depression to
Practice Nursing 2015, Vol 26, No 12 541
reduce the risk of relapse (NICE, 2009a).
Patients with depression who are considered
to be at significant risk of relapse despite
antidepressant treatment or who choose not
to continue taking medication should be
offered a psychological intervention.
When the patient is identified as
being depressed
If a person is depressed they should be asked
directly about current suicidal ideas and
intent and asked if they feel hopeless or that
life is not worth living (Table 4). A family
history of suicide and past attempts are
significant risk factors. If suicidal ideation is
present, it is essential to establish whether the
patient has a current suicide plan and their
determination to carry out the plan. Patients
who are intent on carrying out their plan
should be seen by a mental health professional
as an emergency. If a patient does have
suicidal ideas, it is also necessary to assess
whether they have adequate social support
and are aware of sources of help. Patients
with depression and their carers need to be
vigilant for changes in mood, negativity and
hopelessness, and suicidal intent, particularly
during high-risk periods (such as initiation of,
or changes to, antidepressant medication or
at times of increased stress). They should be
advised to contact an appropriate health
professional if they are concerned or if their
situation deteriorates.
Current guidance for depression uses a
‘stepped approach’ for the care of people
with mental health problems (NICE, 2009a).
People with mild-to-moderate problems
should be treated in primary care with the use
of: self-help books; computerized cognitive
behavioural therapy (cCBT) websites;
increased exercise; improved diet; reduction
in alcohol and smoking; and support from
their GP and/or practice nurse. The choice of
treatment should take into account patient
preference. Patients may be referred to
 Clinical mental health
Improving Access to Psychological Therapy
Key Points (IAPT) services. Each service have their own
referral criteria, but they have been set up to
offer first-line treatment to patients with
➤➤ The World Health mild, moderate and moderate-to-severe
Organization (WHO) symptoms of anxiety or depression. Some
projections suggest that patients may benefit from counselling or help
by 2020 depression will from a voluntary organization. Those who
be the leading cause of have severe depression should be assessed by
disease burden in a mental health specialist in secondary care.
developed countries
➤➤ Practice nurses are in a Summary
position to promote Practice nurses are in a position to help
patients in the prevention of depression,
mental health and
wellbeing, encourage identify signs and symptoms early and to
preventive measures, enable the appropriate treatment. However,
recognise depression in order to do this they need access to suitable
early and ensure training and to be supported in this role.
adequate treatment Clinical Commissioning Groups can
arrange free training for practice nurse
➤➤ Practice nurses need trainers from the Charlie Waller Memorial
access to suitable Trust by contacting the author.
training in mental
health and wellbeing American Psychiatric Association (2013) The
Diagnostic and Statistical Manual of Mental
Disorders. 5th edn. Arlington (VA): APA
British Medical Association and NHS Employers (2015)
2015/16 General Medical Services (GMS) contract
Quality and Outcomes Framework (QOF). http://
tinyurl.com/nunnt86 (accessed 10 November 2015)
Cassano P, Fava M (2002) Depression and public
health. An overview. J Psychosom Res 53: 849–57
Chakraborty A, McManus S, Brugha T, Bebbington P
(2011) Mental health of the non-heterosexual
population of England. Br J Psychiatry 198: 143–8.
doi: 10.1192/bjp.bp.110.082271
Chapman D, Perry G, Strine T (2005) The vital link
between chronic disease and depressive disorders.
Prev Chronic Dis 3(2): 1–3
Cuijpers P, Van Straten A, Smit F (2005) Preventing the
incidence of new cases of mental disorders: a meta-
analytic review. J Nerv Ment Dis 193(2): 119–25
Department of Health (2012) Joint Health and
Wellbeing Strategies—draft guidance: Proposals for
consultation London: Department of Health. http://
tinyurl.com/nss566p (accessed 10 November 2015)
Docherty J (1997) Barriers to the diagnosis of
depression in primary care. J Clin Psychiatry
58(Suppl 1): 5–10
Department of Health (2011) No health without
mental health: a cross-government mental health
outcomes strategy for people of all ages. www.gov.
uk/government/uploads/system/uploads/
attachment_data/file/213761/dh_124058.pdf
(accessed 10 November 2015)
Garber J (2008) Prevention of depression: Are we
there yet? Clin Psychol Sci Practice 15: 336–41
Gask L, Lester H, Kendrick T et al (2009) Primary
Care Mental Health. Royal College of Psychiatrists,
London
Hardy S (2014) Mental health and wellbeing: snapshot
of practice nurses’ views regarding responsibility
and training. Practice Nursing 25(8): 525–9. doi:
10.12968/pnur.2014.25.8.395
Hardy S, Gray R (2012) The Primary Care Guide to
Mental Health. M&K Publishing, Keswick
542 Practice Nursing 2015, Vol 26, No 12
View publication stats
Jané-Llopis E, Hosman C, Jenkins R et al (2003)
Predictors of efficacy in depression prevention
programmes. Meta-analysis. Br J Psychiatry 183:
384–97
Joint Commissioning Panel for Mental Health (2012)
Guidance for commissioners of primary mental
health care services. www.rcpsych.ac.uk/pdf/
JCP-MH%20primary%20care%20(March%20
2012).pdf (accessed 10 November 2015)
The King’s Fund, Centre for Mental Health (2012)
Long-term conditions and mental health: The cost
of co-morbidities. www.kingsfund.org.uk/sites/files/
kf/field/field_publication_file/long-term-conditions-
mental-health-cost-comorbidities-naylor-feb12.pdf
(accessed 13 November 2015)
NHS Information Centre (2009) Adult psychiatric
morbidity in England, 2007: results of a household
survey. NHS Information Centre for Health and
Social Care, Leeds
McManus S, Meltzer H, Brugha T et al (2009) Adult
psychiatric morbidity in England, 2007: results of a
household survey. NHS Information Centre for
Health and Social Care, Leeds
Miovic M, Block S (2007) Psychiatric disorders in
advanced cancer. Cancer 110(8): 1665–76
Muñoz R, Beardslee W, Leykin Y (2012) Major
depression can be prevented. Am Psychol 67(4):
285–95. doi: 10.1037/a0027666
NHS Information Centre (2007) Health Survey for
England 2005: Health of Older People. NHS
Information Centre, Leeds
National Institute for Health and Clinical Excellence
(2009a) CG90 depression in adults. www.nice.org.
uk/guidance/cg90 (accessed 10 November 2015)
National Institute for Health and Clinical Excellence
(2009b) Depression in adults with chronic physical
health problem: recognition and management.
www.nice.org.uk/guidance/cg91 (accessed 10
November 2015)
Office for National Statistics (2002) The mental health
of carers. ONS, London
Office for National Statistics (2015) Suicides in the
United Kingdom, 2013 Registrations. www.ons.gov.
uk/ons/dcp171778_395145.pdf (accessed 13
November 2015)
Richards J, Ryan P, Mccabeb M et al (2004) Barriers
to the effective management of depression in general
practice. Aust N Z J Psychiatry 38(10): 795–803
Rose G (1992) The Strategy of Preventive Medicine.
Oxford University Press, Oxford
Sederer L, Silver L, McVeigh K et al (2006) Integrating
care for medical and mental illnesses. Prev Chronic
Dis 3(2): 1–3
Smiley E (2005) Epidemiology of mental health
problems in adults with learning disability: an
update. Advances in Psychiatric Treatment 11:
214–22
Stewart D, Gucciardi E, Grace S (2004) Depression.
BMC Womens Health 25(4 Suppl 1): S19
Wahlbeck K, Mäkinen M, Eds (2008) Prevention of
depression and suicide. Consensus paper. European
Communities, Luxembourg
Whooley M, Avins A, Miranda J, Browner W (1997)
Case finding instruments for depression. Two
questions are as good as many. J Gen Intern Med
12(7): 439–45
© 2015 MA Healthcare Ltd
World Health Organization (2001) Mental health:
World health ministers call for action. WHO,
Geneva