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Depression - Coggle Diagram
Depression
Management: New/Initial
For people with mild depression who do not want an intervention, or people with subthreshold depressive symptoms who request an intervention, consider a period of active monitoring, and discuss presenting problems/concerns, provide information and arrange follow up (usually within two weeks).
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Manage suicide risk. Contacting the Crisis Resolution and Home Treatment (CRHT) team for an urgent assessment or Voluntary/Compulsory admission and Reviewing a person frequently in primary care. If the person is unwilling to go voluntarily. Compulsory admission may be arranged under sections 2, 3, or 4 of the Mental Health Act.
For people with persistent subthreshold depressive symptoms or mild-to-moderate depression: consider offering low-intensity psychosocial intervention — this is accessed by referral or self-referral or group-based CBT. Avoid use of routine antidepressants but consider in those with a history of moderate/severe depression, subthreshold that has persisted for a long period, subthreshold or mild which persists after other interventions or mild which is complicating the care of a chronic physical health problem.
Consider the use of a validated measure to inform and evaluate treatment such as a depression questionnaires such as PHQ-9
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Assess for any comorbid conditions associated with depression, including: alcohol or substance abuse, Anxiety, eating disorders or dementia and manage appropriately.
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Identify any safeguarding concerns for children or vulnerable adults in the care of someone with depression. Follow local safeguarding procedures if appropriate.
For people with moderate or severe depression — offer an antidepressant and a high-intensity psychological intervention.
Be aware of any learning disabilities or acquired cognitive impairments, and if necessary consider consulting with a relevant specialist when developing treatment plans and strategies.
For those starting an antidepressant: consider suicide risk and toxicity in overdose, explain that symptoms of anxiety may initially worsen, medication may take time to work, should be continued for at least 6 months following remission of symptoms.
Consider any factors which may affect the development, course and severity of depression.
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Risk factors
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Psychosocial issues such as divorce, unemployment, poverty, homelessness
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Diagnosis
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If at least one has been present most days, most of the time for at least two weeks, enquire about associated symptoms.
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Ask about the two 'core' symptoms of depression: During the last month have you often been bothered by feeling down, depressed or hopeless? ; Do you have little interest or pleasure in doing things?
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Be alert to the possibility of depression especially in people with a past history of depression or chronic physical health problem with functional impairment
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Duration and associated disability, past and family history of mood disorders and availability of support
Ongoing Management
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If there has been a poor response to treatment reassess for further option as per severity eg subthreshold, mild-to-moderate, moderate or severe.
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Arrange regular follow up to assess response to treatment and ongoing management and adverse effects of any medication. The review period for follow up should be determined by the risk of suicide/need to assess the tolerability and effectiveness of any treatments started or changed
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Differential diagnosis
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Neurological conditions such as Parkinson's, MS, Dementia
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Severity - determined by the number and severity of symptoms as well as the degree of functional impairment
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Severe depression is diagnosed if the person has most symptoms and they markedly interfere with functioning – they can occur with or without psychotic symptoms
Mild depression is diagnosed if the person has few, if any, symptoms in excess of five symptoms and they only result in minor functional impairment
Persistent subthreshold depressive symptoms (sometimes termed dysthymia) is diagnosed if the person has Subthreshold symptoms for more days than not for at least 2 years, which is not the consequence of a partially resolved 'major' depression.
Subthreshold depression is diagnosed if the person has at least two, but fewer than five symptoms of depression
Seasonal affective disorder is diagnosed if the person has episodes of depression which recur annually at the same time each year with remission in between (usually appearing in winter and remitting in spring).
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Investigations are not routinely indicated for people with depression, but may be necessary to exclude other causes for symptoms or conditions known to be associated with depression (see Differential diagnosis).
Biochemistry: blood glucose, urea and electrolytes, creatinine, liver function tests, thyroid function tests, calcium levels.
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Depression is characterised by persistent low mood and/or loss of pleasure in most activities and a range of associated emotional, cognitive, physical, and behavioural symptoms.