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Managing People with Depression in Primary Care – Key Questions Answered

Did you attend our virtual event covering Women’s Health, Dermatology and Long Term Conditions from 21 – 23 November 2023? Professor Carolyn Chew-Graham, General Practitioner in Manchester and Professor of General Practice Research at Keele University, answers some of the questions about managing people with depression in primary care that we didn’t have time to answer on the day.

Managing People with Depression in Primary Care – Key Questions Answered

In a normal GP consultation how do you fit in history, PHQ9, gad-7 and management? Is there a practical approach you find helpful? I find it extremely tricky to do all of this without falling far behind.

I don’t think you need to do both PHQ9 and GAD7 in every consultation – a good history usually makes the diagnosis, and PHQ9/GAD7 can be used selectively to negotiate a management plan (e.g. an older adult who is not keen on the label of depression, or a young person who wants antidepressants but actually have few symptoms of depression). And remember – we can assess people across a number of consultations – PHQ9/GAD7 can be done as part of ‘active monitoring’ in step 1 of matched care/stepped care models. You can give people a paper copy of PHQ9 / GAD7 to complete and return at the next consultation.

How do you choose the best type of talking therapy for a patient as there are so many to choose from?

GPs don’t make the choice – if a patient is referred/self-refers to IAPT (NHS Talking Therapies) they undergo an assessment and negotiate a plan and therapy with them. If a person wants to go privately, I talk through the evidence – CBT has the most evidence and I would suggest that first. Again – patients can be shown the schema of options in the NICE guidelines and they can make the choice of what might suit them…. In practice, options offered by NHS Talking Therapies may be limited.

Most of the patients I find are not keen on psychological therapies and unfortunately the waiting list is too long so we end up using medication.

I think we need to remember that there is no evidence for the use of antidepressants in less severe depression and patients need to be informed of that – and that NICE recommend talking treatments. We can advise about alcohol, drugs, activity and exercise, social interactions, yoga, mindfulness and online Apps. Yes, waiting lists can be long for more intensive therapy – I advise people to write to their MP about waiting times…

Why ESR with the depression blood test request?

In an older adult, low mood may be a presentation of a physical illness (renal failure, diabetes, hypothyroidism, Ca) – so worth doing bloods if not done recently.

I noticed bone profile wasn’t included in the blood test for a medical cause of depression. Was that left out on purpose or an omission?

Omission! Thank you!

Is BA, individual CBT and counselling accessible through IAPT or is it a separate referral?

All through IAPT (NHS Talking Therapies).

Writing guidelines is good enough but what about the workforce issues. Any guidelines how to hold on to clinicians?

Interesting question – I am absolutely aware that GP workforce is under pressure. You might find this article helpful.

Is QT prolongation with citalopram dose dependent?

Yes – problematic at doses above 40mg. Check out the Citalopram and escitalopram: QT interval prolongation and the Citalopram/escitalopram & QTc prolongation reminder.

If someone is already on citalopram and they have AF which is well controlled, would you switch to a different SSRI?

I would review whether the antidepressant is needed. If patient is stable and on <20mg citalopram (for someone over 65years) then continue – but do discuss whether withdrawal might be an option.

What do you think about trazadone for the patient who cannot sleep but should avoid the weight gain of mirtazepine. Works very well for my ADHD patients (who are not on a stimulant as well).

Yes (although all antidepressants have the potential for weight gain).

What are your thoughts about Escitalopram?

In my experience it can be better tolerated by people who have had s/e with Citalopram and Sertraline. Check out this resource.

Re: Panorama earlier in year suggesting SSRIs are not effective and cause side effects that last. Royal College of Psychiatry representatives appear in the documentary. Any comments/advice?

SSRIs are effective for more severe depression. Do look at this for further information on discontinuation symptoms.

Can you tell me how to change or switch antidepressant from one to another?

Check out this resource.

Can we start venlafaxine in primary care if SSRI not suitable for patient? Do we need ECG before initiating venlafaxine?

Yes you can start venlafaxine and no you do not need ECG.

How would you deal with Depression in an adult with Dementia e.g. Alzheimer’s? What if their memory is not good and they can’t have behavioural therapy? NICE guidelines ask us to stay away from antidepressants?

I think I would ask for a specialist opinion. Behavioural Activation would be appropriate – delivered in-person by skilled practitioner. Antidepressants can be used – but I suggest liaison with Old Age Psychiatry.

Would you consider Clomipramine for anxiety with predominant OCD ahead of SSRI in primary care?

Check out this resource and this resource too.

Managing sleep difficulty & particular Rx where anxiety is a feature?

Mirtazepine could be tried.

Can we combine SSRI with mirtazapine?

Yes, but check out these resources:

I always find it hard changing anti-depressants in patients who present with worsening symptoms – to come down off one before starting next and then delay in therapeutic action – any advice on how to manage this?

Check out this resource.

Where does mirtazepine fit on the list of medications?

Check out this resource.

What is the incidence of depression among psychiatrists, therapists and psychologists?

Sorry – I am not sure, it’s but an interesting question. Note – therapists, psychologists and psychiatrists all receive supervision – unlike GPs.

How soon can wean swap antidepressants, can the different ones overlap?

Check out this resource.

Can primary care add on second antidepressants (e.g. adding mirtazepine to sertraline)?

Yes – with care and proactive follow-up. Check out these resources:

Which antidepressants are better with lower side effects with ED/wt. gain?

All antidepressants have side-effects – and it not easy to predict which patients will experience which side-effects. The key is to warn a patient of possible side-effects, make sure they know what to do/how to contact practice if they get s/e, and to always arrange follow-ups when starting antidepressants.

What about dual treatment, some of them on 2 antidepressants?

Check out these resources:

How do you manage those who have anxiety and present with perceived physical health problems but completely deny issues with stress/depression/anxiety?

I think that this would be a presentation on it’s own! Check out these resources:

Are obese people more prone to depression? And are depressed people prone to depression?

Evidence varies, but it does seem that obesity may be associated with an increased risk of depression. Depression is often a recurrent illness – so if a person has had one episode of depression, they are more likely to get further episodes.

Check out these resources:

Would you ever combine antidepressants such as sertraline and low dose amitriptyline or mirtazepine for resistant depression?

NICE suggests that TCAs should not be used for depression. NICE does support addition of Mirtazepine to SSRI.

Check out these resources:

Any advice on Antidepressant use and management of anxiety/panic attacks in those less than 18 years of age?

Avoid antidepressants in children under age 18years. Check out resources on the McPin website. Sign-post children to Kooth. Sign-post parents to resources such as:

Please can we have the references?

If you would like to find out more about managing people with depression in primary care, you can watch the full session by clicking here.