Feeling down about Depression?

(Cross posted from the ThinkGP blog)

 

Many years ago, coming to general practice from an emergency medicine background, I sat down with a group of trainee GPs. We started to talk about what we would see in general practice. I’d been working as a locum in general practice for a year and I thought I knew everything. ‘Coughs and colds are the bulk of the work’, I confidently declared. Those older and wiser than me set me straight, and told me that general practice is all about depression and anxiety and that it’ll be a rare consult where these won’t play a role. They were wise words then and now, so let’s talk about major depression in general practice.
 

The books would describe major depression as a subjective diagnosis which depends on reported symptoms rather than objective signs. There are cardinal symptoms of depression, rather than signs. Five or more of the symptoms below, present most of the time nearly every day for at least two consecutive weeks. Depressed mood or loss of interest or pleasure must be present. The symptoms cause substantial distress or impair function, and they are not better explained by substance abuse or a general medical problem. They are over and above what the GP thinks would be normal given the patient’s situation.
 

depression

 
The GP who relies on books alone will be well read… and alone. Listen to the patient! It’s a mood disorder. How do they feel? How do they make you feel? Clinical gestalt is the theory that healthcare practitioners actively organise clinical perceptions into coherent construct wholes, or simply put, how experienced GPs can spot depression a mile off. Listen to your gut. Countertransference can be a powerful tool to show you where you need to go. We’ll come back to the Art of General Practice later. Experienced GPs can’t be everywhere, and so we need some other ways to screen for depression.
 

Enter the rating scales for depression. They read like the alphabet – PHQ-9, BDI, HDRS. They can be used for screening and measurement of progress. Perhaps only 50 percent of patients with major depression are identified without screening [1]. Patients may not volunteer depressive symptoms without direct questioning for many reasons including fear of stigma, a belief that depression is not a matter for primary care, or a belief that depression isn’t a “real” illness but rather a personal flaw, as well as concerns about confidentiality and antidepressant medication [2].
 

In Australian general practice, we use the K10 and the DASS21 or 42. These are validated, easy to administer, reproducible, and recognised as part of the Mental Health Care Planning process. This enables patients with diagnosed depression to obtain a Medicare rebate for psychological therapy with a psychologist. American studies show patients are scared of psychiatric referral. Australian GPs are also scared of psychiatric referral, as it can be hard work to access private psychiatry. MBS item number 291 comes to the rescue and many psychiatrists will use this. They also know that depression masquerades as a variety of somatic symptoms. Untreated depression is associated with decreased quality of life and increased mortality. Depression can be successfully treated and treatment is effective. The earlier the better!
 

I recommend non-pharmacological treatment regularly. Exercise, diet, psychotherapy, GP counselling, reducing drug and alcohol use, getting more and better sleep are all options. These take time and effort, both from the patient and the GP. Remember, your time and presence are important to your patients. Ten minutes of education on diet and exercise can be worth months of medication and the effect can be long-lasting. Red flags include significant physical signs (weight loss is the big one in my opinion) or symptoms such as suicidality or psychosis on mental state examination.
 

Depression is not just a chemical imbalance. No pill can defeat the entirety of the patient’s life and circumstances pushing them in the wrong direction. The good GP will consider the patient in their environment and have an awareness of the social determinants of depression. Personality disorders, illicit drug use, and past abuse can lead to poor life choices and situations. Think about these before printing out a script.
 

When selecting an antidepressant, ask the patient what they’ve been on before. Ask about expectations and experiences and how they define success or failure. I tend to use medications that I’m familiar with and can then counsel patients accordingly. I find SSRIs to be an appropriate first line treatment. The side effects that concern my patients are anticholinergic (dry mouth), sexual (decreased libido and prolonged time to orgasm/ejaculation – so common that medications are now marketed for this purpose alone), and changes in sleep (too wakeful and agitated or too sleepy and hungover). I combat these with the advice to drink plenty of water and to time your medication according to how it makes you feel.
 

Traditionally, antidepressants are taken in the morning, but for those with a significant anxiety component, evening dosing is best. Trial and error will determine the optimal time for a good night’s sleep with no morning hangover. Sexual issues often require a change in medication. The newer medications promise fewer sexual issues, but often an older alternative can achieve the same goals at much lower cost.
 

depression2

 
The literature tells us the most resistant symptoms to treatment are insomnia, followed by sad mood, and decreased concentration. Depression is more likely to reoccur if these symptoms are persistent. I find that fatigue, anhedonia, guilt, worthlessness, and poor concentration are the hardest symptoms to treat successfully. It can be a long road for the patient (and the GP) back to wellness, and it can be hard to stick with treatment over time.
 

GPs have used many strategies to improve treatment adherence and all of us will remember pre-contemplators from our studies. We all get frustrated when patients don’t take our advice but providing information and warning of future consequences doesn’t always work. However, a solution is in clear sight. GPs have a fantastic and privileged therapeutic relationship with their patients, and can use this to capitalise on the essential window of time before you deliver your medical advice. This “privileged moment for change” prepares people to be receptive to a message before they experience it. Robert Cialdini has coined the term ‘pre-suasion’ to describe this. The therapeutic relationship allows pre-suasion, and therapeutic change can then be addressed, with consideration of the patient’s motivation, opportunity, and ability.
 

You can see the themes above of time and a relationship as potent therapy for the management of major depressive disorder in general practice. The initial clinical gestalt and the ongoing therapeutic relationship can be powerful tools for change. Depression is subjective and has been part of the human condition throughout history. This gives us all we need to move forward. Focus on the whole person sitting in front of you. Give them your time and expertise, be thorough, be kind, and be present. It therefore seems fitting to end with the words of a doctor from another time:

 

“The three grand essentials of happiness are: Something to do, someone to love, and something to hope for.”


Alexander Chalmers (29 March 1759 – 29 December 1834)




If you are worried about depression, anxiety, or have any other mental health concerns, reach out:

ACIS 131465 (South Australia – Acute Crisis Intervention Service)

Your GP at Partridge Street General Practice

Dr Gareth Boucher
Dr Ali Waddell
Dr Emmy Bauer
Dr Nick Mouktaroudis
Dr Nick Tellis

Beyond Blue & Beyond Blue New Access (free mental health coaching)

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Reach Out

References

  1. Mitchell AJ, Vaze A, Rao S. Clinical diagnosis of depression in primary care: a meta-analysis. Lancet. 2009 Aug;374(9690):609-19
  2. Bell RA, Franks P, Duberstein PR, Epstein RM, Feldman MD, Fernandez y Garcia E, Kravitz RL. Suffering in silence: reasons for not disclosing depression in primary care. Ann Fam Med. 2011 Sep;9(5):439-46.

Thanks to Klarem for the beautiful picture above, Marcia Vernon for the Beyond Blue link, and the guys at ThinkGP for their editing and help. 

 

 

Welcoming Dr Gareth Boucher to Partridge Street General Practice

 

Partridge Street General Practice is very happy to have Dr Gareth Boucher with us long term.

 

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Dr Gareth completed his undergraduate medical studies in Auckland and all of his post-graduate training has been in Adelaide. His medical areas of interest include:

 

  • babies and kids (neonates and paediatrics)
  • emergency medicine,
  • chronic disease management
  • palliative care

 

Outside of work Dr Gareth enjoys cycling, skiing, and photography.

 

 

dr-gareth-boucher-cycling

 

He is a GP Palliative Shared Care Provider, as are Dr Tellis and Dr Mouktaroudis. We’ll let Dr Gareth explain this:

 

 

What is palliative care?

Palliative care is holistic care of people with life-limiting illnesses.  Holistic care means we focus on them, not their illness!

Their goals and ambitions

Their mental, physical, and spiritual well-being

Their symptoms

Their dignity

 

We provide care in the community and co-ordinate service providers. We support patients and their families to maintain quality of life and achieve the outcomes important to them.

The Team at Partridge Street General Practice is able to help you and your family with any Palliative Care needs.

 

 

Partridge Street General Practice is an accredited General Practice and is further accredited by our Regional General Practice Training Provider GPEx and our local Medical School at Flinders University.

 


This means that the GPs at Partridge Street General Practice are teaching the Doctors and Medical Students who will be the future of medicine in Australia. It’s a big responsibility and a privilege we take very seriously.

 

 

Award Winning Responsibility!

 

 

All of our doctors here at Partridge Street General Practice are fully qualified ‘Fellows’ holding a specialist qualification with either the Royal Australian College of General Practitioners (FRACGP) or the Australian College of Rural and Remote Medicine (FACRRM) or both (3-4 years of full time study and 3 exams on top of an undergraduate university medical degree and supervised trainee ‘intern’ year in a hospital) or are studying towards these qualifications. This is our minimum specialist standard and we may have other qualifications and skills.

 

 

Our Fellows provide supervision and advice to our Registrars and you may find that they are called in to consult with the Registrar on your case. ‘Registrars’ are qualified doctors who have completed their hospital training and are now embarking on their General Practice training. Some may already have other qualifications in medical or other fields.
We also supervise and teach Medical Students from Flinders University. They are still studying to become doctors. All of us – Fellows, Registrars, and Medical Students – make up the Clinical Team here at Partridge Street General Practice with our excellent Practice Nurses. We all uphold the highest standards of privacy, confidentiality, professionalism, and clinical practice.

 

 

Dr Gareth Boucher is a key part of our growing Clinical Team.

 

Dr Gareth Boucher

Dr Penny Massy-Westropp

Dr Monika Moy

Dr Katherine Astill

Dr Nick Mouktaroudis

Dr Nick Tellis

Driving. Dementia. Decisions. 

General Practice is the greatest vocation there is. Every day GPs are proud to use their skills and training to help their patients have better health and better lives. It’s incredibly rewarding for us and our patients (and the statistics!) show that it’s rewarding full stop.

 

 

Recently, Dr Tim Senior answered the question ‘Do we even need Doctors?‘. He concluded that GPs ‘know what to do when we don’t know what to do. And I can’t think of any other profession we can say that about’. So let’s have a look at a topic where GPs have to make hard decisions when we don’t know what we have to do.

 

 

Big Australia!

 

Australia has an aging population and Australia is big. Really big! Driving and Australia go together like Vegemite and Toast! What do we do when aging drivers see their GP and we make a diagnosis of Mild Cognitive Impairment or Dementia?

 

 

What are the GP’s responsibilities?

 

 

Here is the excellent Dr Genevieve Yates with a very personal and professional view on the matter.

 

 

 

 

 

Here is another excellent video from Professor Joe Ibrahim.

 

 

 

 

In South Australia we have clear(er) guidelines on Fitness to Drive, with Mandatory Reporting and the associated safeguards for GPs who report patients they believe to be impaired. It’s still a hard decision. For example, just look at Kate Swaffer who has been diagnosed with dementia. What would you do?

 

 

Tough Decisions

 

 

 

What would I do? I’m not sure. Every patient is different and that’s one of the reasons why General Practice is, as I said above, the best vocation in the world. GPs will keep learning every day of their professional lives to serve their patients better. My advice to patients is to See Your GP, your best source of information, advice, and support for all of those hard decisions, when you don’t know what to do.

We’re Here to Help.

 

 

Here to Help

 

 

NEW: We can now refer for sub-specialist driving assessments!

 

DR NICK TELLIS

Your Specialist In Life

DR NICK MOUKTAROUDIS

DR GARETH BOUCHER

Dr Gareth’s Cycle of Care

DR PENNY MASSY-WESTROPP

Dr Penny Massy-Westropp

DR MONIKA MOY

Dr Monika Moy

DR KATHERINE ASTILL

Dr Katherine Astill 1

Superpowers and The new Advance Care Directives Act 2013 (SA)

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Just revisiting an old post after listening to a great podcast – ‘The Good GP‘. It got me thinking. We know that General Practice is a good thing and reduces hospitalization rates (and hence healthcare costs) – but how can we measure this in our own practices?

 

 

Professor Barbara Starfield’s work clearly demonstrates that countries with a strong GP-centred system have much better health outcomes than countries that don’t.

 

 

Maybe utilization of Advance Care Directives could be part of this?

 

 

Read on!

 

 

We have all wished for superpowers – I know I have! Flying, changing the past, and predicting the future would all be fantastic abilities to have. I can’t promise the ability to fly, nor can I give you last weeks winning Lotto numbers prior to last weeks draw. However, I can predict the future for you. At some point in the future, all of us will be unable to make decisions for ourselves. We may be unlucky enough to be in an accident, have a severe illness, or we may just be facing the final stages of a long life well lived, but the time will come. I was lucky enough to hear Dr Chris Moy speak eloquently on some changes to the law here in South Australia that will give all of us the power to have decisions made for us, according to our wishes, if we cannot express them at the time.

 

 

Why is this important?

 

 

This is why.

 

 

 

 

From SA Health:

 

From 1 July there will be a clear decision-making framework and new protections for health practitioners when they find themselves in the difficult position of trying to determine what someone in their care might want, at a time when their patient’s ability to make decisions is impaired.

 

 

Plan Ahead

The new Advance Care Directive Form replaces the existing Medical Power of Attorney, Anticipatory Direction and Enduring Power of Guardianship with a single Advance Care Directive Form (however any of these existing forms will continue to have legal effect post 1 July 2014).

The Advance Care Directive Form allows individuals to appoint substitute decision-makers and/or to clearly document their values, wishes and instructions with respect to their future health care, living arrangements and other personal matters.

 

 

Make the Decisions They would want!

 

 

You can find the form here:

 

 

And you can find some further information here:

Or you can complete it online here:

 

Use your new power wisely!

 

 

Remember, if you have any questions, ask Your GP!

 

 

 

Dr Gareth Boucher

Dr Penny Massy-Westropp

Dr Monika Moy

Dr Katherine Astill

Dr Nick Mouktaroudis

Dr Nick Tellis

 

 

We can Help

 

UPDATE:

From David Coluccio of Senexus Aged Care Solutions!

Hi there,
http://www.linkedin.com/pulse/two-small-pieces-paper-guaranteed-save-your-family-time-coluccio 
Kind regards, David

UPDATE 2:

What are the costs of aged care?

Read here and any questions? Partridge Street General Practice are Here.

UPDATE 3:

Some further reading on end of life care!

 

 

 

And there’s more…

 

 

Most nursing home residents want CPR if their heart stops in the belief they’ll have a good outcome, a national survey reveals.

While survival rates after cardiac arrest are as low as 5% for older people receiving CPR, a survey of more than 2000 nursing home residents found 44% believed they had a good chance of recovering.

“This view is perhaps not surprising given that opinions about the likely outcomes from CPR are often informed by television medical dramas,” said researchers from Monash University.

The misplaced perceptions likely explained why 53% of residents expressed a desire to receive CPR in the event of cardiac arrest, they added.

“These findings highlight the need for older people to be better informed about cardiopulmonary resuscitation, including a clear understanding of what is involved … and a realistic perception of outcomes,” they suggested.

The researchers said the wide gap between expectations and reality also showed the need for novel approaches to end-of life planning in nursing homes.

A new ‘Goals of Care’ model had been developed to replace the old ‘Not For Resuscitation’ orders, they noted.

Under this system, the doctor could assign a patient to curative, palliative or terminal phases of care, based on an assessment of their likely treatment outcomes.

“This transfers the technical medical decision-making responsibility to a physician, who can work with the preferences of the patient or resident, but has an understanding of how likely it is for victim to achieve their previous health state,” the authors explained.