MH5

Detecting Depression amongst Hospital, Outpatient and General Community Settings:

Guidance for health professionals

Produced for the intelligent targets for depression service evaluation

Contents

Contents

Introduction

What is depression?

Treatment of depression

Screening for depression

Screening in-patients for depression – FAQs

Screening in-patients for depression - The process

Pathway of action

Patient satisfaction…………………………...……………………………..17

Contact numbers

Introduction

In 2009, the Welsh Assembly Governmentdirected health services to be more proactive in detecting and treating depression. Following on from a pilot project in late 2009 it was agreed that the best way forward would be to look at improving detection of depression by screening for symptoms in high-risk groups such as those hospital in-patients with chronic or disabling medical or surgical conditions.

This booklet aims to set out logically the rationale behind such an approach, including the potential benefits it will offer patients. It will also give an overview of depression as we are only too aware of the confusion and apprehension that this condition can generate in patients and general health professionals alike. Finally, this booklet will look at the screening process itself and give advice on what to do if a patient does have depressive symptoms as well as offering a section on frequently asked questions compiled by consulting with general health professionals who were involved in the pilot study.

Key points:

  • WAG-led initiative
  • Booklet aims:
  • Overview of depressive disorders including treatment
  • Rationale for screening hospital in-patients
  • Guidance on screening process including management of those who screen positive for depression

What is depression?

Depression is best understood as the term used for a range of different mental health problems that tend to impact on one’s ability to feel good about oneself, other people, the future and indeed, when drawing on one’s memories, the past. Depressive conditions can variably affect these emotional responses, as well as perhaps resulting in reduced interest or enjoyment in activities, the subjective awareness of unhappiness or physical symptoms such as poor sleep and appetite or weight loss. Depressive conditions are also commonly accompanied by anxiety, and can cause suicidal thoughts or acts.

Depressive illness is also common. Estimates vary as to the exact population prevalence but are of the order of 4-10%.

Depression carries with it a significant disability burden. Predicted to be the second leading cause of disability worldwide by 2020, it has also been said to cause greater ill-health than angina, arthritis, asthma or diabetes.

There is also significant increased mortality associated with depression. Suicide accounts for 1% of all deaths, and of those suicides, approximately 2/3rds are depressed. The risk of suicide compared with the general population varies between 4-20 times normal depending on the severity of the depressive condition. In addition to suicides, depression has also been shown to contribute towards worsened outcomes in a range of physical health conditions. For example, it has been demonstrated that depression is associated with an 80% increased risk of development of and mortality through coronary heart disease compared with non-depressed individuals.

So by detecting and treating depression, we improve the long-term prognosis for any number of physical health problems.

Key points:

  • Depressive conditions are common and disabling
  • Mortality is increased through elevated suicide risk
  • Mortality is also increased through elevated risk of physical health problems

Treatment of depression

There are various types of treatment available to treat depression. Depending on the severity of the illness some or all of the following may be utilised:

  • Medication e.g. antidepressants
  • “Talking therapies” ranging from counselling to more complex forms of psychological intervention such as cognitive-behavioural therapy
  • Social interventions aimed at identifying and remedying dysfunctional aspects of the individual’s life, be it debt, social isolation or perhaps simply lack of day-to-day activity or occupation
  • Electronic self help forms of therapy such as electronic cognitive behavioural therapy

Very occasionally, depression is so severe and the risk of suicide so acute that in-patient admission to a psychiatric hospital is advisable. This is very much the exception rather than the rule and in fact modern psychiatric services are set up to do everything possible to treat depression outside of the psychiatric ward.

Key points:

  • There are a range of effective treatment options for depression
  • Psychiatric admission is very much the exception, not the rule

Screening for depression

The vast majority of depressive disorders go unrecognised and untreated. One study estimated that only 62% of those with depressive disorders would consult their GP, and that of these less than half will have their depressive illness diagnosed. One thing is clear; even if the detection rate by GPs was 100%, we are still missing over a third of patients with depressive disorders who fail to consult for help in the first place. The reasons given for not consulting their GP included not thinking anyone could help and being afraid of the consequences of asking for help.

So screening of individuals to look for symptoms of depression could seem to offer advantages over simply hoping that they themselves ask for help. But it is not feasible to screen the entire population, and so the focus has been shifted towards those at high-risk of developing depressive illness. The causation of depressive illnesses is complex involving genetic, psychological, social and biological factors but nonetheless we are aware that certain stresses can lead to increased susceptibility. One such important factor in the development of depressive disorder is having chronic physical illness or disability. Thus medical and surgical in-patients tend to be a high-risk population in terms of the development of depression.

By targeting medical and surgical in-patients for screening for depressive disorders we should not only improve detection rates of depression but also improve general health outcomes for those patients by treating the depression which would otherwise have an adverse effect on the outcome of their physical health condition.

Key points:

  • Those with depression often do not seek help
  • Screening for depression can help identify these individuals
  • Chronic physical ill-health predisposes to depression
  • Screening of general hospital in-patients therefore targets those at high risk of developing depression
  • Diagnosis and treatment of depression improves general health outcomes

Screening in-patients for depression – FAQs

Q. Will talking about how bad someone feels make them feel worse?

A:It is common for all of us when we first encounter those with mental illness to feel out of our depth. When dealing with those with depression, common worries are about the reaction that talking to them might elicit, as though the very act of talking about intense negative feelings will make those feelings worse. This is simply not the case. Whilst some may prefer to avoid talking about their feelings, and will doubtless make this clear at an early opportunity, many more will be relieved to have the chance to talk to someone.

Q. Why ask about depression at all when they are in for a different condition?

A: Because, as mentioned earlier, detection and treatment of depression in certain disease groups will improve the prognosis of those conditions. Additionally, because those same disease groups predispose to depression, screening tools will generate a higher “yield” when targeted this way compared to screening the population at large.

Q. What shall I do if they say that they do feel like ending their life?

A: Thoughts of self harm and suicide are common amongst those with depression. They do not automatically mean that they will act upon them, and asking further whether they do have any plans to end their life or any intent to go through with it will help decide how much risk there is. We would certainly consider there to be more risk if there were plans and intent.Regardless of this, if there are suicidal ideas and you are unsure it would be wise to speak to a mental health professional, either from the psychiatric liaison team within the hospital or the area-appropriate community mental health team outside the hospital. If you are really worried about the risk, then the psychiatric liaison team can carry out assessments on the wards so referral directly to them would be appropriate in such a case.

Q. This person is terminally ill and bound to feel low. Should I bother screening them too?

A: Terminal illness can trigger depressive illness. This can cause significant distress to the patient over and above that which they may be undergoing because of their terminal illness. This distress, if caused by depression, may be treatable. If a patient does not wish to be asked the questions that is their right, but assuming that there is no role for screening for depression just because someone is dealing with end of life issues is wrong. They can benefit as well as anyone from detection and treatment of any depressive illness.

Screening patients for depression - The process for inpatients, outpatient clinics and community patients

On admission to hospital, the patient will be given the patient-specific booklet by the admitting nurse. The patient will be asked to read the booklet in their own time.

On arrival at an outpatient clinic, the patient will be given the booklet by the receptionist and asked to read it whilst waiting to be seen by their doctor.

Community patients will be given the booklet by their visiting nurse and asked to read it in time for their next visit.

In the booklet, the patient will be introduced to concepts of depression and asked firstly the following 2 questions:

  • During the past month, have you often been bothered by feeling down, depressed or hopeless?
  • During the past month, have you often been bothered by having little interest or pleasure in doing things?

Only if they answer no to both questions is the screening negative for depression.

If they answer yes to either, they are asked to continue to complete the PHQ-9 self-rated questionnaire.

The PHQ-9 is a validated tool which asks patients to rate how often they have been bothered by a range of 9 different depressive symptoms. It is easily self-scored and then the score used to give a symptom severity as follows:

<10Mild or minimal depressive symptoms

10-14Moderate depressive symptoms

15-19Moderately severe depressive symptoms

>20Severe major depression

The score relates directly to the actions that should be taken by ward staff to ensure follow up of the mental health problem (see pathway of action).

Key points:

  • Booklet to be given to all patients on admission
  • Patients answer the 2 question prompt
  • If they answer yes to either question they are encouraged to complete PHQ-9
  • This gives a score which will rate the severity of their depressive symptoms
  • The symptom severity dictates the action taken

Pathway of action

Ward nurses, community nurses and outpatient doctors will collect the booklet from the patient near the point of discharge from hospital or the at the end of the outpatient clinic or home visit and go to the section containing the 2 question screen and the PHQ-9. The ward nurse, community nurse or outpatient doctor nurse will count up the score on the PHQ-9.

The ward nurse and outpatient doctor will follow the course of action from the score arising from the PHQ-9.

<10Mild or minimal depressive symptoms – refer to GP on discharge through discharge summary

10-14Moderate depressive symptoms – ask the patient if they have any suicidal thoughts and if the patient says yes, discuss the case with psychiatric liaison team; otherwise refer to GP on discharge

15-19Moderately severe depressive symptoms – ask the patient if they have any suicidal thoughts and if the patient says yes, discuss the case with psychiatric liaison team; otherwise refer to GP on discharge through discharge summary

>20Severe major depression - refer to psychiatric liaison if any suicidal thoughts: otherwise refer to area-appropriate CMHT – use contact numbers on contacts page.

Patient satisfaction

This service evaluation is interested in the views of all patients who have been screened for depression.

The first few questions of the patient satisfaction feedback form (question 1-6) ask about who is filling it in, whether they have a long term condition and specifically what they thought about the ‘how are you feeling’ booklet.

If patient has had a past history of depression, the patient satisfaction form asks the patient to carry on with answering the satisfaction questions. If the patient does not have a history of depression, the patient does not need to answer any more questions. This is likely to be around 70% of the time.

It is really important that the patient is asked to fill out the satisfaction questions. Information from the satisfaction questions is useful to receive feedback about the service.

Useful contact numbers

If the patient is in hospital and scores over 10 on the PHQ and is expressing suicidal thoughts you should ask the psychiatric liaison service to see the patient.

The numbers for the psychiatric liaison services are

WrexhamMaelorHospital

Ysbwty Glan Clwyd

LlandudnoHospital

If the patient is in clinic at the hospital or at home and scores over 10 on the PHQ and is expressing suicidal thoughts, you should ask the patient to go to the local Accident & Emergency Department.

27/10/2018