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.
 

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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. 

 

 

The Golden Month

A guest post by the excellent Dr Kar Loong Ng of Next Generation Occupational Medicine – NGOM.

Time. Timing. Such a critical aspect of Medicine. When a patient is in VF (Ventricular Fibrillation) the medical team has seconds, tens of seconds to act before the probability of successful resuscitation decreases exponentially. Act too fast (not yelling ‘CLEAR’) whilst activating the defibrillator and they risk hurting a team member and losing further precious seconds whilst the machine recharges. Act too slow and the patient is lost forever.

The same principles apply for non-emergency musculoskeletal workplace injuries. More often than not, I encounter patients, employers and insurers who request for MRIs at early stages of injury when there is no medical indication. The fact of the matter is, there is very little correlation between most MRI findings and the patient’s current injury or problem. Kind of like seeing all the imperfections on footy player’s faces on a 4K TV during a game. Additionally there are quite a large number of studies that show that early spinal MRIs that are not medically indicated often result in poorer outcomes and disability. I once saw a worker who was in such severe pain due to his belief that his ‘discs are squashed, bulged and spinal cord and nerves crushed’. When viewed I his MRI scans and told him that there is mild bulging of his lower 2 lumbar discs , his immediate response was “That’s where my pain is !! Between my shoulder blades……..”

Another example is that of shoulder impingement syndrome. A subacromial injection early on the injury is not going to be of benefit if the patient is not aware of how to perform rotator cuff exercises. An injection too late will also have less chance of success.

It is all about timing. Right, Roger Federer?

I previously wrote about Specialised Early Intervention and Second Opinion Medicine. With both services, we have been able to successfully rehabilitate a good proportion of complex worker injuries to normal work, alternative work, new employment or community restoration. Unfortunately some patients do not do so well. Being a sub-specialist practice, all our patients are referred from GPs. Despite extensive communication to the GP community, employers, insurers and rehabilitation providers emphasising the importance of early referrals, our earliest referral over the past few years has been 7 weeks post injury. This was an outlier, with the average referral being 6 to 9 months old. Well…….it beats my record a few years back when I saw a 50 year old man (with a six-pack) who had been on benefits since 19 and could not remember which leg his sciatica was on………..

Successful Early Intervention requires implementation at 2 to 3 weeks post injury. Some people refer to it as ‘The Golden Month’. For complex worker injuries, there is now good evidence that screening and intervention at day 1 of injury result in a significant reduction in disability and cost.

We are now in the process of implementing this with the introduction of services to GPs. The aim is to provide patients, workers and employers with a personally tailored comprehensive suite of medical and allied health care, as well as quick but well-timed access to medical sub-specialists.

I feel like I have been playing the game of RISK over the past few years. Disability is the enemy. I hope this strategy contains it.

Thanks Kar – it’s inspiring to see the passion you have for returning injured workers to work! Getting you better is what we’re about at PartridgeGP and so we’ll be working together with NGOM whenever we see injured workers.

Here to Help

Our Doctors at PartridgeGP are Here to Help Injured Workers – you can meet them here.