GP and mental health lead Dr Peter Bagshaw provides an update on current best practice in the diagnosis and management of depression in primary care, including discussion of the latest NICE guidelines recommendations and some new and emerging therapies.
Learning objectives
This module aims to extend knowledge of:
- Current diagnostic approaches for depression.
- Recommended treatment options for mild depression and more severe depression, including both drug and non-drug interventions.
- The relative benefits of psychological (talking) therapies and their place in management, including use of online versions.
- Considerations when discussing drug treatment options, including withdrawal symptoms.
- Advances in potential new treatments and how to explain these to interested patients.
Introduction
Thinking around depression has shifted in recent years as more evidence has accumulated about the benefits of non-drug interventions, such as cognitive behavioural therapy (CBT), exercise and mindfulness.
In tandem with this there have been growing concerns over medication side-effects such as emotional blunting, and a recognition of withdrawal problems in people coming off antidepressants.
In addition, the trialling of new non-invasive treatments such as recurrent transcranial magnetic stimulation (rTMS) have changed the landscape, recognised in the 2022 updated NICE guidelines (NG222) which looks at the evidence around treatment options and makes clear recommendations for cost-effective interventions.1
There is access to psychological therapies on the NHS across the UK, for example in England through NHS Talking Therapies (formerly known as IAPT), although waiting lists can be a significant issue in some areas. The success rates of different interventions have been studied just as drug interventions are, allowing us to recommend specific options for different conditions.
We now have a deeper understanding around the causes of depression. For instance, adverse childhood events (ACEs) significantly increase the risk: indeed, they are believed to be directly related to around a third of all mental health problems.
Some studies have now cast doubt on the serotonin hypothesis of depression, which underpins the rationale for selective serotonin reuptake inhibitor (SSRI) antidepressants,2 and this is another factor that has contributed to the swing away from drug therapy as the mainstay of treatment options.
This article will look at the latest evidence and recommendations we should now be adopting in primary care, as well as touching on some options which patients may be aware of but are not yet available, or not recommended, as we are often asked our advice on these.
To read and complete the full module visit the Nursing in Practice 365 website.
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Dr Peter Bagshaw is a GP and NHS Somerset ICB mental health and dementia clinical lead
