DEPRESSION DECISION AID OPTIONS INFORMATION BOOKLET

Transcription

1 DEPRESSION DECISION AID OPTIONS INFORMATION BOOKLET TABLE OF CONTENTS INTRODUCING THE OPTIONS INFORMATION BOOKLET page 1 Watchful waiting Option - pg 2 Lifestyle medicine Option: Improving Sleep pg 3 Exercise, pg 4 Nutrition pg 5 Internet Psychotherapy Option pg 5-6 Life Stress Support Services Option pg 7-8 Individual Psychological Therapy Option pg 9-10 Prescribed Antidepressant Medications Option pg Referral to a psychiatrist or Community Mental Health Service. pg 13 * Remember Each of these options can work well for many depressed patients and no option is suitable for everybody INTRODUCING THE OPTIONS INFORMATION BOOKLET This Booklet provides unbiased information to answer some basic questions about each of the options. To make good treatment decisions, people need access to enough information about their treatment options but too much information might not help if your depression is severe. Your doctor can provide separate Q & A leaflets that answer more questions and explain how to make good use of that option. Your are welcome to keep the Q & A leaflet/s. If helpful, you could weigh up the advantages and disadvantages for you of the options you ve been considering, using the Decision Grid insert to this booklet. Many combinations of these options are possible Some people will choose a single approach and others will decide on a combination of different self help and/or professional treatments. Some combinations are likely to work much better for you than others, so you may need your doctor s help to find a good combination for you. All options are either cost-free or government supported. 1

2 Self-help options that can be easily used by many people with depression are listed first. Professional depression treatments that may be preferred by patients with more severe or long-term depression are listed later... Watchful waiting Option Q? What are the chances of my depression getting better without treatment? A: Several large studies show that depression will get better just with watchful waiting for about 20% of people during the first week after the diagnosis, but this gets less likely the longer depression lasts. Without any treatment, some people will still be depressed 24 months later. Q? But what does this mean for me? A: The chances of depression improving just with a little time are better for people whose depression is recent and not severe or returning, and who have good relationship support to recover. Does this describe your depression? Look again at your responses on page 10 of the first booklet. If you add your five scores together, the lowest score is 0 and the highest is 50. The lower the total score, the more likely it is that depression will get better with just a little time. Q? How can I know if my depression is getting better? A: Look again at the symptoms you circled on page 5 of the first booklet. When was your mood most depressed during the past two weeks? Has the depression already begun to shift a little with watchful waiting? Is there perhaps one small sign of recovery beginning for you yet? BEFORE worst time RECOVERY.. If you choose this option, your doctor might encourage you to book another appointment in a few week s time, so that you can both be sure your symptoms are improving. 2

3 Lifestyle Medicine Option - Increasing physical activity and improving sleep and nutrition together is often called Lifestyle Medicine. Recent research shows these three changes can be effective for many people with depression because together they help the body and mind cope better with stress and regulate mood. They work best together. Will you be able to use some self-help to recover? Studies have found that even when depression is severe, people are usually able to benefit from the self-help of Lifestyle Medicine, but may need some professional support to find the energy and motivation to make this work well for them, - especially early on in the recovery process. Good news for people with severe depression: If motivated to use Lifestyle Medicine and able to follow through with this option, studies have been finding that, averaged out, depression symptoms decrease more for people whose depression is more severe. (This same effect has also been found for other options.) IMPROVED SLEEP Have you been sleeping a lot less or more than usual? A change in sleep patterns is a common symptom of depression, but insomnia can also cause depression or make other symptoms worse. Most people find their sleep quality improves when they start exercising more. Better nutrition can also assist sleep. There are lots of self-help ways to improve your sleep including psychological and computer assisted programs. The Medicare Local offers a cost-free sleep support group treatment program. Your doctor can provide a Q and A information leaflet about stepped care for improving your sleep. If a sleep disorder is suspected, your doctor can refer you to a sleep disorders clinic. 3

4 INCREASED PHYSICAL ACTIVITY Are you able to exercise? Your doctor will help you answer this question if you are unsure. Exercise helps the human body and mind work as they re designed to work best, and regular exercise has antidepressant effects. If you decide to include this option in your recovery plan, your doctor can write you an exercise prescription, tailored for your own energy and stamina level and prescribing a gradual increase in physical activities you already enjoy. If you have a long-term physical condition (such as diabetes), an exercise physiologist can provide five funded sessions to get you started with these changes through a referral from your doctor. Setting realistic goals for a graded exercise program that gradually increases fitness can help you stay motivated to keep going until you feel the benefits. The Ten Thousand Steps website is a good place to start: You can request a Q & A leaflet about this option from your doctor, or read more about exercise as self-management for depression on the internet at: (team decision needed here) 4

5 IMPROVED NUTRITION Do you eat lots of colourful vegetables, enough nutritious protein and some healthy fats (such as avocado and olive oil)? Poor nutrition can worsen symptoms of depression because brains need certain nutrients to regulate mood properly, but many people who are depressed find it difficult to eat well. The Q & A patient information leaflet for this option includes tips for managing depression through improving your nutrition. Also, if you have a long-term medical condition, a dietician can provide five funded sessions through your doctor s referral to support your changes. Internet Psychology Option - Q? What is this option about? A: There are many depression treatment programs on the internet. Most help people practice changing depressing thoughts using a type of psychology called cognitve behaviour therapy (CBT). Other programs help people improve their relationships or learn to control their body s stress response. Most programs are free. Q? How well does this option work to treat depression? A: Some studies show that, for people who are motivated enough to complete a program, internet CBT can treat depression just as well as face-to-face CBT. Q? How do I find a well-designed, no-cost internet psychotherapy program to try? A: The Australian Government have set up a Web Portal to help people find different programs to choose from: (You can select resources then search under online programs for a list of 29 programs) Other web portals can be found at: and: 5

6 This example is a page from a depression prevention program: Q? How do I decide if internet psychotherapy is suitable for me? A: As internet psychology is still new, it is not clear yet which people are more likely to benefit from this treatment option. Internet psychotherapy seems to suit people who: are familiar with computers and feel comfortable with writing their feelings and thoughts and are able to review and reflect on their thinking patterns without face-toface support This option might especially suit people who are living in isolated rural communities or who like the privacy provided by using the internet. 6

7 Life Stress Support Services and Depression Support Groups Q? What are the benefits? A: Depression isolates people. People who ve been badly hurt by life often isolate themselves, blame themselves and feel shamed by what they ve suffered. Connecting with the right support network can help people recover more easily from depression. This option can be added to the self-help of Lifestyle Medicine or Internet Psychotherapy as well as the options that follow in this booklet. Q? What are the risks? A: Some groups are not helpful, and some people may find themselves taking on too much responsibility for caring for others in a self-help group. Community forums and groups that are moderated by trained people generally limit these risks. Q? How strong is the evidence that this option can support depression recovery? A: Life stress supports for depression generally show good recovery outcomes, especially when people chosen this for themselves. Q? What kinds of support are available? A: There are lots of different kinds of support services, so you may need to search for one just right for you. Your Medicare Local or local council websites can be good places to look for local depression support groups and life stress support services. The Q and A patient information leaflet about this option lists locally available face-toface support services for your area. For example: Local Grow Groups - nsw@grow.org.au Listed below are some other suggestions for online and face-to-face support groups that are moderated, well established and available from most regional and rural areas: ANONYMOUS COMPUTER-BASED DEPRESSION SUPPORT FORUMS For example: - and BlueBoard s Depression Support Forums 7

8 LiFE STRESS SUPPORT SERVICES (Australia-wide) For example: au au/ org.au (03) home.html Support and respite for carers Mental health support Support for friends and families of problem drinkers Help for problem gambling Help for problem drug use Advocacy and support for survivors of child abuse Support following the death of a child Suicide prevention service (professionally-staffed service) 1800RESPECT - National Sexual Assault, Domestic and Family Violence Counselling Line Relationships Australia - Couples and relationship counselling Living well support services for men who have experienced childhood sexual abuse or sexual assault FASSTT - Forum of Australian Survivors of Torture and Trauma (especially for refugees) Links to support services for older people Could you make use of support of this kind? Do you need more information to decide if this recovery option might be helpful for you? Your doctor can provide the Q & A leaflet for this option that gives more information about: face-to-face depression support groups in your local area other life stress services available across Australia computer-based depression support forums 8

9 Individual Psychological Therapy Option Q? How might just talking with a therapist treat depression? A: Psychological therapy can help people change learned patterns of thought, behaviour and emotional response that depress mood, and the many links between these that often cause or worsen depression. It can also be used to treat specific symptoms of depression like not being able to sleep, inappropriate guilt and feelings of worthlessness. People with strong beliefs about what has made them feel depressed may have good ideas about what kind of psychological help is needed for recovery. Q? Is there a risk that my depression could be made worse by psychological treatment? A: There is always some risk that your depression could worsen with or without any active treatment. There is evidence to suggest that a small percentage of people may get worse following time-limited psychological treatment, while most people (around two thirds) reliably improve or recover. It s important to remember that it is always the therapist s responsibility to make sure that their treatment techniques and skills are right for you and most likely to assist, not harm your recovery. You can help by telling them what is not working for you, right away, so that the therapist can change their approach to better suit your needs. Q? How long would it be before I d be ready to stop psychological treatment, and what are the risks of my depression later returning? A: While many people will feel better after the first session, on average, at least 18 sessions may be needed for longer-term recovery. Some people will need only a few sessions to achieve their recovery goals. Other people are more likely to recover well over time only with many more psychology sessions if their depression story is more like John s. Are you considering this treatment option? Do you understand enough about the pros and cons for you to make an informed decision? Your doctor can provide the Q&A Patient Information Leaflet for this option that also answers these questions: Q How well does psychological therapy work to treat depression? Q I ve had life experiences that I don t want to talk about with anyone Can I still benefit from psychological treatment? Q If someone is depressed because they are in a violent relationship, how could psychological treatment help? Q If I've felt depressed all my life, and had lots of stressful life experiences that I need to talk about, can I still be helped with a short-term treatment program? Q "What psychological programs are Government funded?" 9

10 Antidepressant Medication Option - Q? What might be the benefits? A: All commonly used antidepressant medications are intended to increase brain chemistry involved in mood and/or the stress response. Any improvement in mood might help people cope better with specific problems or life stresses. People who prefer antidepressant medication as a single treatment option might value its benefits of privacy and time-saving convenience. Q? How do I know if antidepressant medication will work for me? A: It isn t yet possible to tell who will benefit, so if you choose this option, it s very important to let your doctor know if the medication does not seem to be working for you after you ve given it enough time (at least 2 weeks, and sometimes up to 8 weeks). If most of the following are TRUE for you, your chances increase for being able to give antidepressant medication a long enough try: o I usually remember to take medication regularly o Medications usually work well for me o Medication side effects don t usually bother me o My doctor and I agree that my depression could be caused by a brain chemical imbalance that antidepressants might correct o I expect that the right antidepressant medication will improve my mood o If an antidepressant doesn t seem to be helping after 2-6 weeks, I d ask my doctor to change my antidepressant o I think people should always talk to their doctor before stopping medications 10

11 Q? Will I experience unpleasant physical side-effects from antidepressant medication? A: Different antidepressant medications can have different side effects. The most common side effects are listed below: Losing sexual function Feeling sleepy Gaining weight Dry mouth Not being able to sleep Always feeling tired Feeling sick Dizziness Tremors Feeling agitated If you decide on this option, let your doctor know which of these are most important for you to avoid. Your doctor may then be able to prescribe an antidepressant medication with the least bothersome side effects for you. NOTE: Antidepressant medications may increase the risk of having a car accident, so more care may be needed when driving. Antidepressant medications may also increase the risk of suffering heart rhythm problems. Q? How would I feel when on antidepressants? - Would I still feel things like grief, or might my feelings be dulled so that I feel emotionally empty? A: Antidepressants do seem to cause these common emotional effects that may cause people to stop taking them as often as physical side effects. For someone with very severe depression, it s possible that these effects might be welcomed or even experienced as potentially life-saving. It s also possible that these effects might make someone care less about acting on suicidal thoughts. Q? If I start antidepressant medication and it does seem to be helping, how likely is it that I will need to take it for the rest of my life? A: Studies do not answer this question clearly. People often stop antidepressant medication suddenly when they feel better, but then suffer antidepressant discontinuation syndrome and feel worse again. This can make the decision more confusing. Shared decision making with your doctor may help you decide. Q? Are there any risks to my health if I take antidepressant medication for a long time? A: Longer-term health risks are still being studied in particular patient groups, such as antidepressants taken in pregancy. Some studies seem to show that long-term use of antidepressant medications may increase the likelihood of getting depression again. 11

12 Are you considering this treatment option? Do you understand enough about the possible benefits and risks of this option for you to make an informed decision? Your doctor can provide the Q&A Patient Information Leaflet for this option that also answers these questions: Q Are antidepressants addictive? Q How well does antidepressant medication work to treat depression or prevent future depression? Q Might I feel worse before I feel better? How long should I wait to feel better? Q If I start medication and it doesn t seem to be helping, what are my chances that a different medication might work better for me? Q Would there be any risks if I were to suddenly stop taking my medication? Q "What is the most I should expect to pay for antidepressant medication?" Referral to a Psychiatrist Q? What is the difference between a psychiatrist, a psychologist and a psychotherapist? A: Psychiatrists are registered medical doctors with specialist training in medications for thought and mood disorders. Psychologists also need to be registered in order to practice, and are trained in psychology for at least six years. They are not trained in medicine, and do not prescribe medications. Psychotherapists do not need to be registered professionals to practice. Q? When might a psychiatrist be the best professional to help treat depression? A: A doctor and patient might make a shared decision to involve a psychiatrist in depression care for a range of different reasons, such as: The patient has a chronic medical condition that requires multiple medications, and there is uncertainty about risks for that person of interactions between these medications and an antidepressant medication. The person s depression is extremely severe and they are afraid they might act on suicidal thoughts and need hospital care. The doctor and patient both want to be sure there is a correct diagnosis when there is a lot of uncertainty about a complex medical and mental condition with depression. The patient requests a referral to a psychiatrist who is recognised as having particular expertise Q? How would I consult a psychiatrist? A: Patients can be referred to a psychiatrist for up to 50 consultations each year, subsidised through Medicare. (Medicare subsidises only 10 visits per year with a psychologist.) Some psychiatrists charge a large gap fee, but community health centres usually have psychiatrists visiting regularly and this is a free service. Doctors in regional and rural parts of Australia are often able to link their patients with a psychiatrist using an internet program called Skype from the privacy of their own practice rooms. 12

13 If you are feeling suicidal please stay safe and seek help. Depression can make it harder for people to stay well connected to their reasons for living and make good decisions when feeling severe distress, emptiness or emotional pain. Most people who ve had some suicidal thoughts are sure they would never act on these thoughts, and never do so, but continuing suicidal thoughts can be dangerous. Suicidal thinking is not uncommon, but it is always a warning sign for the need to get skilled professional help. Do you have any red flag warning signs for suicide risk in the danger zone? The risk of acting on suicidal thoughts is increased by any of the following red flags: past suicide attempts not having supportive relationships recent life crisis, trauma or important loss long-term childhood rejection or mistreatment feeling hopeless, feeling despair or feeling worthless Feeling suicidal includes wanting not to be alive as well as wishing to die. Suicide risk increases if these feelings are not well connected with clear thinking. This is more common and dangerous when people who are feeling suicidal also have: alcohol issues or drug use dissociative experiences, such as hearing inner voices urging suicide, feeling not real or as if the outside world is not real severe or long term sleep problems, especially nightmares severe anxiety, panic, mood swings, agitation, or racing/crowded thoughts unusual reactions to antidepressant medication impulsive behaviour (acting suddenly before being able to think clearly about effects for self and others over time) If you are feeling at all suicidal, it s most important to remember that support is there for you - you do not have to cope alone. You can get crisis help, your doctor s help or ask for a referral to a mental health professional to make a plan to live. If you 13

14 are safe to wait for an urgent appointment with your doctor, make a long consultation to discuss professional treatment options most likely to help you be able to keep yourself safe in the future. If you have any actual suicide plans, please ensure your safety by referring yourself straight to the emergency department of your local hospital. Even if that decision limits your choices for a while because others are then responsible for caring for you, you will be making a decision to stay safe. Suicide means that someone suffering emotional pain gave up all future options for a better quality of life. This is a tragedy, never an option for dealing with emotional pain. Never give up hope for a better future - There are always life supporting options In case of crisis, please contact: * Your local hospital emergency department Lifeline (24 hour crisis telephone line) Mensline Suicide Call Back Service (Free nationwide suicide prevention counselling) Telphone crisis support can also help you find the courage to talk with your doctor about any suicidal thoughts, feelings or red flags warning signs You do not need to wait for a crisis to reach out for support. Some life stress supports are listed on page 7 & 8 of this booklet, and the telephone suicide prevention services listed above, are also there for support. 14

15 FINALLY Never give up on finding options that are likely to work well for you: Depression can make it feel impossible for people to keep trying different treatment options, but in recovering from severe and chronic depression, not giving up truly pays off. If the treatment you ve chosen doesn t seem to be helping when you have given it a fair go, talk again with your doctor about trying something else. Also, when your depression changes over time, your doctor can help you add, drop or replace different treatment options with those more suitable. Remember, within each of the treatment options, there are still more possibilities and your doctor is there to help. For example: If you choose Internet therapy there are many websites to choose from, and you will probably find that some suit you much better than others. If you decide to start antidepressant medication, you can make a shared decision with your doctor about the medication with the side effects you can accept. If you choose talk therapy, you might need to keep trying until you find a good match between the therapist s approach and the approach that suits you best. If you choose supported self-help, with a referral from your doctor there is also the opportunity to step up the support to professional help from a dietician, exercise physiologist, the Medicare Local sleep program or the sleep disorders clinic. Even after making a shared treatment decision with your doctor, remember that you always have a choice. Your recovery is too important for you to stay silent if the treatment you decided on is not working for you after you have given it a good enough try. You can always choose to discuss your concerns about your treatment with your doctor and you are always free to change your mind and try a different treatment strategy. There are always good recovery options that can help you move forward with your life The development of this patient decision aid has been funded by three research grants generously provided by ISML and the City Coast Country General Practice Training Grant through ISPRN. No funders, literature reviewers, authors or their affiliations stand to gain or lose by choices patients make after using this patient decision aid. No funding to develop or exclusively distribute the patient decision aid has been received from commercial, for-profit entities that sell tests or treatments included as options in this patient decision aid. REFERENCES 15