Depression & Anxiety

Treatment Guidelines

Document Control Summary

Version

2.0

Ratified By:

Compliance and Clinical Practice Standards Group

Date of Publication:

January 2016

Author:

Principal Clinical and Deputy Chief Mental Health Pharmacist, South West London & St Georges NHS Trust

Accountable Director:

Trust Medical Director

Date Issued

January 2016

Review date

January 2018

Responsible committee:

Drugs and Therapeutics Committee

SWL Mental Health Interface Prescribing Forum

Target audience:

Clinicians treating depression & anxiety in primary care, mental health or acute care services

Policy Number

TWC21a

Version Control Summary

Version

Date

Status

Comment/Changes

1.6

2014

Authors, to previous versions inc: Sedina Agama, Chief Pharmacist, Merton CCG

Gursharon Bains, Primary Care Pharmacist, Kingston CCG

Carl Holvey, Principal Clinical and Deputy Chief Mental Health Pharmacist, South West London & St Georges NHS Trust

Hetal Naik, Pharmacist, Merton CCG

Shaistah Qureshi, Senior Pharmacist Richmond CCG

Dr Nova Hart, Consultant Psychologist

Fiona White, Nurse Practitioner, Merton CCG

Dr Chris Keers, Sutton CCG

Dr Andrew Otley, Merton CCG

Dr Anthony Hughes, Kingston CCG

Dr Shubra Rao, SWLStG, Adult & ID Psychiatrist

Dr Alice Lomax, SWLStG, Psychiatrist

Dr Jim Bolton, SWLStG, Liaison Psychiatrist

Dr Maurice Zwi, SWLStG, Child & Adolescent Psychiatrist

Dr Sim Roy-Chowdhury, East London NHS FT, Consultant Clinical Psychologist and Psychotherapist

1.7

September 2015

DRAFT

Joseph Wilson changed name from Depression & anxiety disorder treatment guidance for primary care or acute care health providers to Treatment for depression and anxiety guidelines.Reviewed and reformatted.

1.8

Dec 2015

DRAFT

Reviewed at DTC and comments regarding changes to IAPT service names included.

2.0

January 2016

Approved

Ratification body updated to CCPSG. Title changed

ContentsPage

Executive Summary

1. Introduction4

2. Purpose4

3. Duties4

4. Ratification process4

5. Consultation process4

6. Training needs5

7. Monitoring compliance with the policy5

8. Associated documents5

9. Screening questions6

10. Diagnosis6

10.1. Assessment of depression6

10.2. Assessment of anxiety6

10.3. Assess the risk of suicide7

10.4. Rating scales7

10.5. Consider co-morbidities, social and cultural factors7

11. Treatment8

11.1. Mild depression or sub threshold symptoms8

11.2. Moderately severe depression or anxiety8

11.3. Considerations when initiating an anti-depressant9

11.4. Severe, chronic or resistant depression10

11.5. Children & young people (under 18 years)10

12. Switching & stopping antidepressants10

13. Mental health service contacts11

Appendix 1:Depression & Generalised Anxiety Disorder Treatment Summary

(Primary and acute care)12

Appendix 2Equality impact assessment & Governance15

Appendix 3References16

Executive Summary

This guidance has been developed to aid clinicians working in South West London and St Georges Mental Health NHS Trust as well as in primary care and acute care organisations to prescribe for patients with a diagnosis of depression and/or generalised anxiety disorder (GAD).

1.0 Introduction

This guidance is intended to aid clinical decisions concerning the treatment of depression and anxiety in line with local prescribing policy and formulary advice, national treatment and technology appraisals and guidance.

2.0 Purpose

This document is to be shared across healthcare organisations in South West London, including those working in primary and secondary care and acute care organisations to ensure there is consistency and a shared understanding of the treatment of depression and anxiety.

3.0 Duties

In the event of changes to national guidance or current best practice the DTC will ensure that this policy and Trust prescribing procedure are informed and updated accordingly.

4.0 Ratification process

Key Area

Lead Director

Working Group

(where appropriate)

Ratification Body

Clinical

Medical Director

Drugs and Therapeutics Committee

SWL Mental Health Interface Prescribing Forum

Compliance and Clinical Practice Standards Group

5.0 Consultation Process

This guide has been informed by patient and care representatives from South West London and St Georges NHS Trust. The Mental Health Interface Prescribing Forum proposes joint education meetings in depression and physical health of those with severe and enduring mental illness between primary and secondary care to aid dissemination of this guide.

Key groups:

Drug and Therapeutics Committee

Chief Pharmacist and Clinical Pharmacy Staff across the Trust

Medical Director

Director of Nursing

Mental Health Interface Prescribing Forum

6.0 Training Needs

In order to ensure the health, safety and well-being of our service users and staff, the Trust aims to address the needs and impact of its procedural documents on its corporate, mandatory and statutory training, with a comprehensive and robust training needs analysis procedure. All Trust procedural documents which have mandatory training requirements for permanent staff are included in the Training and Development Policy as managed by the Training and Development Department. This document is available on the Trust intranet, under Training and Development.

Chief Pharmacist

To inform the Training and Development Department of amendments to policy training needs.

Management

Responsibility

To ensure all permanent staff are adequately trained as appropriate to the employees duties and work location and to follow up on refresher training needs.

Staff Responsibility

To ensure they attend all relevant training as detailed in their induction and annual development Performance Appraisal and Development Review (PADR).

Training and Development Department Responsibility

To provide access to training for all permanent staff. To maintain monitoring, reporting and review systems as per the Training and Development Policy.

7.0 Monitoring Compliance with the Policy

Element to be monitored

Lead

Tool

Frequency

Reporting arrangements

Acting on recommendations and Lead(s)

Change in practice and lessons to be shared

The CCGs receive prescribing review information on prescribing antidepressants as part of the London wide QIPP initiative

Each CCG will have their own lead.

See London Procurement Partnership website.

QIPP data is sent quarterly by the London Procurement Partnership to CCGs and NHS Provider Trusts.

Each CCG and organisation is responsible for reviewing and reporting to their prescribing lead group.

The Mental Health Interface Prescribing Forum will suggest possible actions required for CCGs or acute provider organisations to aid compliance with this policy.

Each CCG and organisation is responsible for acting on their own results from compliance with this policy.

The medicines ratification body in each organisation is responsible for ensuring action s identified and carried out from review of compliance of this policy.

8.0 Associated Documents

South West London Mental health formulary

SWLStG Shared care of psychotropics & discharge of patients

Physical monitoring of Mental health medicines for GPs summary

All shared mental health prescribing policies for South West London are available:

http://www.swlstg-tr.nhs.uk/for-health-professionals/

9.0 Screening questions (See summary Appendix 1)

Screening questions are useful tools to assess whether a patient should be further investigated for depression and anxiety. Those with long term physical health conditions should be targeted as these are associated with higher levels of depression than the general population.

10.0 Diagnosis

10.1Assessment of depression:

Severity of depression is likely to be greater when more symptoms are present with functional and social impairment, and a longer duration of symptoms.

Assess for these symptoms to make a diagnosis of depression using the ICD 10:

Core Symptoms:

1. Persistent pervasive low mood

2. Anhedonia loss of interest in pleasurable activities

3. Decreased energy

Additional Symptoms:

1. Reduced attention and concentration

2. Reduced self-esteem and self confidence

3. Ideas of guilt and unworthiness

4. Negative image about self and the future

5. Ideas/acts of self-harm or suicide

6. Disturbed sleep

7. Disturbed appetite

Mild Episode

At least 2 core symptoms and 2 other additional symptoms

Moderate Episode

At least 2 core symptoms and 3 other additional symptoms

Severe Episode

All 3 core symptoms and 4 or more additional symptoms with severe intensity

2

Both mild and moderate episodes can be present with/without somatic symptoms.

10.2Assessment of Anxiety disorder:

The symptoms must be present for most days for at least several weeks at a time and usually for several months.

Generalised and free floating anxiety.

Persistent symptoms of apprehension, motor tension and autonomic over activity.

Frequent need for reassurance and recurrent somatic symptoms may be prominent.

However, if the person does not fulfil these criteria (sub-threshold symptoms), they should not be dismissed as they may still have potential for considerable morbidity.

10.3Assessment of the risk of suicide

Ask all patients with depressive symptoms about suicidal ideation and current intent at assessment, follow-up and on initiation and dose changes of antidepressants. Suggested questions are below. In depression the more actions a patient has taken to attempt suicide and the fewer barriers there are to stop them undertaking the act, the higher risk of suicide (in personality disorder the clinical picture may be more complicated). Those depressed with a diagnosis of bipolar disorder are known to have a higher risk of suicide than those with depression alone.

Do you ever think about suicide?

Have you made any plans for ending your life?

Do you have the means for doing this available to you?

What has kept you from acting on these thoughts?

Risk factors for suicide1

Social characteristics

History

Clinical/diagnostic features

Male gender

Young age (0.4mmol/L), an antipsychotic i.e. risperidone (1-2mg/day), olanzapine (2.5-5mg/day ) or quetiapine (150-300mg/day) or liothyronine. Prescribing in children should be initiated by a specialist.

1st line: sertraline 200 mg/day (unlicensed) or paroxetine 20 mg/day

2nd line : If no response consider switching to an alternative SSRI or venlafaxine 75mg/day

3rd line: Pregabalin 200 to 450 mg/day in 2 divided doses

Pharmacologic treatment of generalised anxiety disorder