David Kessler1 and Linda Gask2
1 School of Social and Community Medicine, University of Bristol, Bristol, UK
2 University of Manchester, Manchester, UK
This chapter considers the principles of diagnosis and management of depression and anxiety in primary care. Depression and anxiety are predominantly primary care disorders. Most people with these disorders are managed in primary care without reference to specialist help. Both disorders are very common; the estimated point prevalence of depressive episode for adults in the UK is 2.6%; if mixed anxiety and depression is included the figure rises to 11.4%. The most widely used treatment for both disorders is antidepressant drugs; in 2012 there were more than 40 million prescription items for these drugs, and most of them were written in primary care. Psychological treatments are also effective and are preferred by many patients; access to psychological therapies from primary care has been variable, but in the last few years the Improving Access to Psychological Therapies (IAPT) service has been rolled out across England to respond to the needs of patients in primary care and support primary care services.
However, recognition and management of depression is not without its problems. Research over the last 30 years has suggested that a substantial proportion of depression goes undiagnosed in primary care. Depression and anxiety are often associated with other chronic illnesses, and physical needs may seem more pressing to both doctor and patient in the context of relatively brief consultations. Doctors have been described as being ‘not very good’ at following depression treatment guidelines, and even as operating the ‘inverse care law’ when it comes to depression in deprived communities (which means that the availability of good medical care varies inversely with the need for it in the population served). Voices within and outside the medical profession have expressed alarm at the ‘medicalisation of unhappiness’ and the high volume of antidepressant prescribing. Some researchers question the effectiveness of these drugs for mild to moderate disorders, and considerable work has been done to develop psychotherapeutic alternatives to be available in primary care. IAPT has shown encouraging rates of recovery in its first three years but coverage is still limited and it is acknowledged that the service does not provide enough access to high-intensity cognitive-behavioural therapy (CBT) for patients with more severe depression.
Anxiety disorders are also prominent in primary care. There are a range of anxiety disorders, including the phobias, post-traumatic stress disorder and panic disorder. In this chapter we will concentrate on General Anxiety Disorder (GAD), which is characterised by excessive worry for at least 6 months, and will only briefly consider the other anxiety disorders. It will be noted that the emphasis on the management of the common mental disorders in primary care has been on depression rather than anxiety; the drugs most widely used to treat anxiety disorders were developed for depression. The ‘Quality and Outcomes Framework’ (QoF) that rewards good practice in UK primary care is based around the care of depression; anxiety is not mentioned. However, anxiety and depression are often associated, either occurring together or at different times in an individual’s life-course. Anxiety disorders can be chronic and disabling, and when anxiety and depression occur together, response to treatment is poorer.
There are advantages to the care of depression and anxiety being based in primary care where the emphasis is on whole person care. GPs often know their patients, their patients’ families and their social setting. They are more easily accessible to patients and perceived as less stigmatising than mental health services, and have a longitudinal and developmental perspective. They may already be involved in managing the other illnesses that are so often associated with depression.
There are limitations too. Many depressed patients fear that they may be wasting the GP’s time and think that doctors have more important things to do. GPs can offer a series of consultations over time but it is much more difficult to offer longer individual sessions in primary care. The emphasis of formal psychiatric training in GP vocational training schemes has tended to be on the management of psychosis rather than being targeted at depression and anxiety. However, it is not clear how to improve GP training in the management of depression and anxiety; training GPs in the management of depression has not been demonstrated in randomised controlled trials to improve outcomes.
Depression and anxiety can be difficult to diagnose in primary care. Patients often present physical symptoms when they are depressed and anxious, and psychological disorders often find a somatic expression. Presenting a physical symptom to the GP provides a legitimate reason for the consultation for many patients as well as being a way of addressing concerns about possible underlying physical illness. Depression and anxiety both amplify and distort patients’ fears and thoughts about their bodily symptoms. Dealing with these concerns is a complex and demanding process for GPs.
For example, when Maria, whom we met in Chapter 1, talks about her anxiety and low mood (see page 2) she does not separate the symptoms into ‘psychological’ and ‘somatic’. Maria’s story illustrates how depression, anxiety and somatic symptoms occur together. She suffers from both trait and state anxiety and gives a clear description of a panic attack. She refers at the end to her low mood. In this sense the recognition of psychological distress is not difficult. However, it is possible that agreeing such a diagnosis with Maria will be more challenging. Bodily symptoms are as prominent as psychological symptoms throughout her account. They are interwoven with each other and thoughts about her family history and external environment. Her penultimate statement, ‘I don’t know what’s happening to me’ captures her bewilderment in the face of this mix of psychological and somatic distress and environmental hardship, and gives us an idea of the GP’s task. For example, it is possible that Maria might present to her GP with concerns about whether she has a serious disease, perhaps something wrong with her heart. Listed in Box 3.1 are some of the strategies that may be useful when this occurs. Engagement in treatment depends on diagnostic concordance with the patient; the labels of depression and anxiety are not much use if the patient does not agree with them.
The other group of patients in whom depression and anxiety may be ‘under-recognised’ is one in which these disorders are more likely to occur – those suffering from other chronic illnesses such as chronic obstructive pulmonary disease (COPD), diabetes and heart disease. In this group, psychological symptoms can be pushed into the background by what appear to be more pressing physical needs. There have been attempts to address this problem by the introduction of screening questions for depression in some of those with chronic illness. In both groups of patients GPs are particularly well placed to make a diagnosis of depression or anxiety and to place it in the context of the patient’s wider life, including physical illness and other comorbidities.
Francis’s story in Chapter 1 (see page 2) illustrates how depression and anxiety can be complicated by alcohol and drug use. Francis began to drink to self-medicate for his social anxiety symptoms (see below) and then became physically dependent on alcohol. Alcohol and other drugs that act as central nervous system depressants (such as benzodiazepines and opiates) will then depress mood further. It can subsequently be difficult to work out which came first, the depression or the dependence.
Until very recently there had been an emphasis in the Quality and Outcomes Framework (QoF) in the UK on the use of symptom scales such as the nine-item Patient Health Questionnaire (PHQ9), the Beck Depression Inventory (BDI) and the General Anxiety Disorder seven-item questionnaire (GAD7) among others, as part of the assessment of depression and anxiety. These scales are generally acceptable to patients, who often value them. They can be used to monitor and illustrate change, and they often provide a basis for discussion. However, none of these questionnaires was designed as a substitute for a wider and deeper conversation. In recognition of this the QoF for depression is now based around the idea of a ‘bio-psychosocial assessment’, which can include symptom scores.
The bio-psychosocial assessment recognises that there are a number of factors that contribute to the onset of depression and that can maintain and prolong an episode. It also encourages GPs to ask about those areas in which recovery can take place. GPs are advised to explore the domains listed in Box 3.2.
NICE (Clinical Guidelines 90 and 91) has also stressed the importance of assessing functional impairment in depression, and not relying on symptom count alone. It may not be possible to cover all these areas in depth in a single GP consultation; it is a strength of general practice that the conversation between patient and doctor can evolve over a number of consultations.The key diagnostic features of depression and generalised anxiety disorder can be found in Boxes 3.3 and 3.4.
In primary care patients, mixed symptoms of generalised anxiety and depression are common, and some patients also show specific features of the other anxiety disorders. Patients with purer forms of the specific anxiety disorders (presenting, e.g., as panic disorder or obsessive-compulsive disorder alone without a mixture of many different anxiety symptoms) tend to have more severe symptoms and are more likely to be seen in specialist settings than in primary care. Panic attacks (see Box 3.5) may commonly occur in a person who also has depression and/or anxiety and/or symptoms of agoraphobia (see Box 3.6) but panic disorder, in which the panic attacks are the primary symptom, is less common. Simple phobias are common in the community and are less likely to be associated with other common mental health problems than agoraphobia or social phobia are (see Box 3.6). Obsessional symptoms may also occur in the context of depression and in obsessive-compulsive disorder. Obsessions are intrusive thoughts, images or urges that are recognised to be irrational or unwanted and are usually resisted. Compulsions are repetitive behaviours or mental acts that the person feels driven to carry out. Some questions that are useful in screening for obsessive-compulsive disorder can be found in Box 3.7. In people who have experienced life-threatening trauma, symptoms of post-traumatic stress disorder (see Box 3.8) may be present, and this may also be complicated by depression and by substance misuse.
Thoughts about suicide and self-harm are common in depression and it is important to ask about such thoughts as patients may be reluctant to volunteer them; they may be ashamed or fear the consequences of disclosure. Urgent referral to specialist mental health services is recommended if a person presents a substantial risk to themselves or others. Assessment of risk of suicide and self-harm is not an exact science, but if clear intent including reference to means is expressed, this should not be ignored (see Box 3.9). Associated alcohol and drug abuse and previous serious attempts should also raise concern. Given Francis’s family history of suicide and use of alcohol his potential risk of suicide is increased.
Even in the absence of suicidal thinking it is worth advising patients, families and carers on how to seek help if the symptoms worsen; agitation and anxiety often increase in the early stages of treatment.
The management of depression and anxiety in primary care is based around the ‘stepped care model’. The principle of this model is that the intervention offered should be the least intrusive and most appropriate to the level of severity (see Box 3.10). The stepped care model is useful in guiding response to different levels of severity. Specific stepped care models have been described for depression and the anxiety disorders by NICE but we will review the basic principles here.
Presentations of depression and anxiety in primary care can be relatively mild. An initial assessment and recognition of the symptoms by the GP is often experienced as supportive. Psycho-education includes an explanation of the links between mental experiences and physical symptoms, for example autonomic symptoms of arousal in anxiety disorders. Advice about sleep hygiene, diet and exercise, and the establishment of regular routines can be helpful. Many patients experience a sense of relief that they have been listened to, and are reassured that they are not ‘going mad’.
It is important to offer to review even those with apparently mild symptoms within a few weeks. They may fail to improve or feel worse. In addition, it is not always appropriate to respond to an initial presentation of depression or anxiety with ‘active monitoring’ and psycho-education; the need for immediate treatment may be apparent. In both depression and anxiety, persistent or worsening symptoms should trigger the offer of a ‘low-intensity psychological intervention’. Such interventions include access to self-help materials, often based on CBT principles. These materials are available in books or online, and there is evidence that they are more effective when supported by a professional. Improving Access to Psychological Therapies services run self-help and psycho-educational groups in many areas. Individual psychological wellbeing practitioners (PWPs) can also offer simple behavioural interventions (see Chapter 10) that may be effective at this level of severity. The routine use of antidepressants is not recommended in this group.
Some patients will not respond to low-intensity interventions. These include those whose depression is more severe, and can also include patients with ‘subthreshold depressive symptoms’ that have been present for a long period (typically at least 2 years). The term ‘subthreshold symptoms’ is used for those with fewer than five of the symptoms of depression. For patients in these groups, treatment with an SSRI (selective serotonin reuptake inhibitor), antidepressant or ‘high-intensity’ psychotherapy such as individual CBT should be considered. Treatment choice is influenced by patient preference, and in the case of CBT, by availability. There is no reason why these treatments cannot be combined.
A proportion of patients do not respond to either first-line antidepressants or individual psychotherapy, or to both. Those with depression and a chronic physical health problem may also require additional therapeutic input. Specialist mental health advice is important in these groups. Options include pharmacological strategies for treatment-resistant depression, such as combining antidepressants or adding additional psychotropic drugs, and direct referral for specialist mental health care for day case or inpatient care. Specialist psychological treatments such as EMDR (Eye Movement Desensitisation Reprocessing) should also be available for people with PTSD.
For people such as Francis who misuse alcohol, it is usual to manage the alcohol misuse problem first, as this may lead to significant improvement in symptoms. If the anxiety and depression then persist for 3 or 4 weeks, treat as above.
Depression and anxiety can both be chronic relapsing conditions. Patients who have responded to antidepressants should be encouraged to continue their medication for at least 6 months. They can be reassured that antidepressants are not addictive, but also advised about the need to withdraw under supervision to avoid a discontinuation syndrome. This occurs in approximately 20% of patients after abrupt withdrawal of medication that has been taken for at least 6 weeks, and is characterised by flu-like symptoms, insomnia, nausea, sensory disturbance and hyperarousal. It is more likely for drugs with a shorter half-life.
Drug treatment may be prolonged if there is a history of recurrent depression or anxiety, but must be evaluated regularly. Individual CBT should be offered to those who relapse despite antidepressants; it can be argued that it teaches skills that are of value in the long term. There is also increasing evidence that mindfulness-based cognitive therapy is of value in preventing relapse and maintaining wellbeing.
Most depression and anxiety can be managed in primary care. People commonly present with physical symptoms, and anxiety and depression commonly occur alongside chronic physical health problems. Engagement in treatment depends on diagnostic concordance with the patient; the labels of depression and anxiety are not of much use if the patient does not agree with them. Assessment should always including checking for thoughts of suicide or self-harm. A stepped care approach to management is very useful in tailoring treatment to severity of symptoms. Both can be chronic relapsing conditions and therefore attention should be paid to relapse prevention.
Free downloadable leaflets from the Royal College of Psychiatrists available at: www.rcpsych.ac.uk/expertadvice.aspx
Depression Alliance: www.depressionalliance.org
Anxiety UK: www.anxietyuk.org.uk