Aiming for recovery for patients with severe or persistent depression a view from secondary care Chrisvan Koen Kent and Medway NHS and Social care Partnership trust
Persistent depressive disorder F34 Persistent mood [affective] disorders Persistent and usually fluctuating disorders of mood in which the majority of the individual episodes are not sufficiently severe to warrant being described as hypomanic or mild depressive episodes. Because they last for many years, and sometimes for the greater part of the patient's adult life, they involve considerable distress and disability. In some instances, recurrent or single manic or depressive episodes may become superimposed on a persistent affective disorder. F34.0 Cyclothymia A persistent instability of mood involving numerous periods of depression and mild elation, none of which is sufficiently severe or prolonged to justify a diagnosis of bipolar affective disorder (F31.-) or recurrent depressive disorder (F33.-). This disorder is frequently found in the relatives of patients with bipolar affective disorder. Some patients with cyclothymia eventually develop bipolar affective disorder. High rate of Personality disorder F34.1 Dysthymia A chronic depression of mood, lasting at least several years, which is not sufficiently severe, or in which individual episodes are not sufficiently prolonged, to justify a diagnosis of severe, moderate, or mild recurrent depressive disorder (F33.-).
Current treatments for depression leave a significant minority (20%-40%) of patients with persistent depressive symptoms Individual episodes are often prolonged, there is a high rate of progression to chronicity and relapse and recurrences are frequent. In addition, the illness is associated with pronounced psychosocial and physical impairments and a high suicide rate (Angst, 1999) Severity of depression and high neuroticism scores were the best predictors of persistent depressive symptoms Other characteristics often associated with chronic depression, but without definite evidence of a causal relationship were: anxiety disorders, personality disorders, unspecified comorbid substance abuse and a range of social problems. The latter included low social integration, low social support, and negative social interaction
Drugs with strong efficacy and good tolerability included the antidepressants moclobemide (not approved for use in the US) and sertraline as well as the antipsychotic amisulpride (not licensed in the US or Canada). Imipramine also had strong efficacy supported by a large body of evidence, but it was less well tolerated 2014 Persistent depression will require a combination of antidepressant medication and highquality, structured psychotherapy to achieve good long-term outcomes. A collaborative approach involving both a psychiatrist and clinical psychologist or CBT therapist in the care of the same patient is essential for delivery of effective treatment.
Severe Depression Severe depressive episode without psychotic symptoms An episode of depression in which several of the depressive symptoms are marked and distressing, typically loss of self-esteem and ideas of worthlessness or guilt. Suicidal thoughts and acts are common and a number of "somatic" symptoms are usually present. Agitated depression Severe depressive episode with psychotic symptoms An episode of depression as described as above, but with the presence of hallucinations, delusions, psychomotor retardation, or stupor so severe that ordinary social activities are impossible; there may be danger to life from suicide, dehydration, or starvation. The hallucinations and delusions may or may not be mood-congruent.
Psychotic depression is, however, rare, with a lifetime risk of only 0.35%. In other words, less than one in 100 people with depression will have psychotic symptoms. psychotic depression needs treatment to avoid the risks of dehydration, starvation, and suicide Complex medication regime which may and should include ECT as treatment option Evidence suggests that the combination of an antidepressant plus an antipsychotic is more effective than antidepressant monotherapy, more effective than antipsychotic monotherapy and more effective than placebo Higher incidence of relapse, recurrence and prolonged treatment of the illness
Recurrent depression The more severe forms of recurrent depressive disorder (F33.2 and F33.3) have much in common with earlier concepts such as bipolar depression, persistent depression. The first episode may occur at any age from childhood to old age, the onset may be either acute or insidious, and the duration varies from a few weeks to many months/year. Female sex, a longer depressive episode, more prior episodes, and never marrying were significant predictors of a recurrence Adhering to Antidepressant guidance reduce relapse and recurrent episodes Results of this meta-analysis indicate that Mindfulness Based Cognitive Therapy is an effective intervention for relapse prevention in patients with recurrent MDD in remission, at least in case of three or more previous MDD episodes.
Patient profile Complex and high risk presentation Complex Social, psychological and physical health needs Acute and longer term care plans to address needs, risk and recovery of the patient Given the nature and degree of the illness, multidisciplinary medical, psychological and social support essential for recovery Given high risk profile easy, fast, effective and efficient access to Crisis care and home treatment Nature of presentation has impact on prognostic outcome of the illness
STEP 3/4 The assessment of a person with depression referred to specialist mental health services should include: their symptom profile, suicide risk and, where appropriate, previous treatment history associated psychosocial stressors, personality factors and significant relationship difficulties, particularly where the depression is chronic or recurrent associated comorbidities including alcohol and substance misuse, and personality disorders. Use crisis resolution and home treatment teams to manage crises for people with severe depression who present significant risk, and to deliver high-quality acute care. The teams should monitor risk as a high-priority routine activity in a way that allows people to continue their lives without disruption
Medication in secondary care mental health services should be started under the supervision of a consultant psychiatrist. Teams working with people with complex and severe depression should develop comprehensive multidisciplinary care plans in collaboration with the person with depression (and their family or carer, if agreed with the person). The care plan should identify clearly the roles and responsibilities of all health and social care professionals involved develop a crisis plan that identifies potential triggers that could lead to a crisis and strategies to manage such triggers be shared with the GP and the person with depression and other relevant people involved in the person's care. The full range of high-intensity psychological interventions should normally be offered in inpatient settings. However, consider increasing the intensity and duration of the interventions and ensure that they can be provided effectively and efficiently on discharge. Consider crisis resolution and home treatment teams for people with depression who might benefit from early discharge from hospital after a period of inpatient care.
Recovery Model provides a holistic view of mental illness that focuses on the person, not just their symptoms believes recovery from severe mental illness is possible is a journey rather than a destination does not necessarily mean getting back to where you were before happens in 'fits and starts' and, like life, has many ups and downs calls for optimism and commitment from all concerned is profoundly influenced by people' s expectations and attitudes requires a well organised system of support from family, friends or professionals requires services to embrace new and innovative ways of working.
Commissioning Prevention of severe/persistent depressive disorders Understanding of prescription guidelines for lower risk/clinical demanding depressive illnesses Robust assessments in Primary care identifying risk profile and risk factors indicating possible persistent and severe clinical picture Clinically effective and efficient psychological therapies in primary care Psychological support essential in minimising relapse, recurrence and persistence Psycho-pharmacological education to primary care Importance of social support given nature of depression. Secondary Community mental health services Effective multidisciplinary working with focus on Risk management and relapse prevention Consultant and medical workforce medication and care pathway monitoring Well resources Psychological workforce Integrated social care pathway safeguarding
Crisis and inpatient pathways Easy, fast interfaces between services Short and effective admissions Access to Acute and Crisis pathways by all providers Mental Health Act provision Transfer of care Rehabilitation services Interfaces between primary and secondary care pathways Education/training in management of longer term comorbid mental and health care conditions Mental and Physical health monitoring Positive message
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