The world has seen a pandemic of depression long before the Covid-19 pandemic. Depression is the second largest cause of disability worldwide after ischaemic heart disease. It results in a high number of lost working days and reduced GDP in developed nations. Suicide is a leading cause of death in young and middle-aged people, men especially. We all have a responsibility to “start listening” and “save lives”.
Depression is a common mental illness. It affects approximately one in four people across the lifespan. At any point in time, between five and ten percent of the population are suffering from depression. Depression is the underlying problem in between one third and one half of all GP consultations. Around fifty percent of suicide victims consult their GP within a month of death. In contrast, only 25% of suicide victims are under secondary care mental health services in the 12 months before death. This means that among healthcare providers, GPs are well placed to make an important contribution to suicide prevention.
I would like to make something clear to my readers. Depression is a mental illness. Depression is not the same as stress, human distress, bereavement, or normal human suffering.
I often draw analogies with diabetes. Diabetes is a physical disorder due to malfunctioning of the pancreas. It has a complex aetiology. Genetic factors, physiological factors and lifestyle choices interact to precipitate the disease. Once present it cannot be reversed but can be controlled. The precursor to diabetes is pre-diabetes. There is much interest in this state as it is reversible unlike full blown diabetes.
So too depression. There is often a family history of depression or other mood disorder. Psychosocial factors such as childhood trauma, personality type, substance misuse and stress can interact to precipitate the illness. Stress is the equivalent precursor state which is potentially reversible. Major depression is not. I would pose the question why do we agonise over the causes of depression when there is no such debate about diabetes? Why is diabetes a more “legitimate illness”.
Depression presents with certain core symptoms. These include persistent low mood unresponsive to life circumstances, loss of interest in usual activities, loss of motivation, low energy, and impaired biological functions such as appetite, sleep, libido, and memory. In 50% of depressed people, suicidal thoughts occur although completed suicide is rare. Depression can occur as a standalone illness or it can be associated with anxiety, psychotic symptoms or occur in the context of bipolar affective disorder. It is often a recurrent illness, and the risk of recurrence increases according to how many previous episodes a person has had. Relapse prevention is a key intervention in preventing long-term disability.
What does the current landscape look like in the treatment of depression? A lot of depression is not treated at all. This is because either the sufferers do not recognise that they have depression or if they do, they are reluctant to seek help. This is particularly the case among men, people from an ethnic minority and people who are socially isolated.
Most depressive illness is treated in primary care. The more difficult to treat depressive illnesses were routinely referred to a psychiatrist, however this has changed over the last ten years or so and it is now rare for a depressed patient to be assessed by a psychiatrist unless they are treatment-resistant or at high risk of suicide. Most depressed patients who are referred to mental health services by their GP are assessed by a mental health practitioner. Many MHPs are very experienced however they are not trained in the use of medication other than simple antidepressant regimes and they are in many instances less knowledgeable than the GP that referred to them. This can lead to treatment delays and chronic symptoms.
I believe that this is a concerning and unsustainable situation and one which I doubt would be tolerated in physical medicine. Depressed patients are numerous however seem to be increasingly finding themselves at the “bottom of the pile”. Psychiatrists are under increasing pressure to manage the severely mentally ill which usually means severe psychotic illnesses.
The burden of untreated and inadequately treated depressive illness is huge. It leads to increased care seeking, secondary physical illness, job loss, relationship loss, and substance misuse. In chronic depressive illness the risk of suicide long-term is 15 to 20%.
The aforementioned discussion has mostly focused on treatment of adult depression. There is also a crisis of depression among children and adolescents. This is compounded by CAMHS services in most areas unable to cope with the volume of referrals from GPs. At the last estimate there were almost 400,000 children and adolescents waiting to be assessed by their local CAMHS. This does not take account of many others who are simply not referred due to the resource deficit.
As a general adult psychiatrist, what do I think the treatment of depression should look like over the next decade? As with many multi-faceted problems, the solutions are necessarily broad. There needs to be a public education programme based around stress, its causes, how it manifests and how it can be managed. The same applies to depression itself. I have started to produce a series of short videos on my business Facebook page and Instagram account addressing stress, what it is, how to recognise it, and how to manage it.
GPs need to see fewer people with mild depression and more people with moderate and severe depression where they can add the most value. To this end, I believe the public education programme should include information on self-diagnosis of depression which is remarkably easy and therefore accessible to those people who feel stigmatised by having a mental health problem and who would not necessarily consult their GP. This approach would reach more people with diagnosable depression.
Depression can be reliably diagnosed using a tool such as the PHQ-9 (Patient Health Questionnaire). This involves 9 questions about common symptoms of depression and generates a score out of 27 and sub-categories of mild, moderate, moderately severe, and severe depression.
Using this tool, any potential patient can determine whether they are depressed and the degree of the illness. Those with mild illness would not need to see a GP initially but could embark on a programme of CBT and exercise given the lack of evidence for the usefulness of antidepressants. Those with mild illness who failed to respond to treatment after a certain time, e.g., 6 months, would need to consult their GP.
The next essential cog in the wheel of depression management is to revisit the training of GPs in the identification and treatment of depression. GPs should undergo basic training or attend a refresher course on diagnosis and treatment of depression. GPs should be empowered to better manage depression and to become more skilled in using a range of drugs to treat depression rather than antidepressants alone. To support this process, they should have access to the expertise of a psychiatrist in case of difficulty. Psychiatrists need to adapt to the changing needs of their GP colleagues and may opt to provide telephone, video, or email consultation services. This is the old fashioned “liaison service” that used to exist between GPs and psychiatrists, but on a larger scale, using modern technology and without the sandwiches!
The next controversial proposal that I have relates to the treatment of adolescents with depression. Currently NICE guidelines stipulate that a child under the age of 18 cannot be started on an antidepressant by their GP rather the input of a specialist is required, so a Consultant Psychiatrist usually from CAMHS. This leaves 1000s of depressed adolescents “out in the cold” and chronically unwell due to the resource crisis affecting CAMHS. Some GPs will prescribe for these patients out of desperation, others adhere strictly to protocol.
I fully understand the concerns that relate to prescribing antidepressants for under 18s however I believe it would be better if an experienced and educated GP were able to prescribe for 13- to 17-year-olds with clear cut depression. I believe that the potential benefits of promptly treated illness, less substance misuse, better life chances and reduced suicides in this age group would far outweigh risks of over prescribing and adverse effects of antidepressants in younger adolescents. At the very least I would like to open a debate on this issue.
Effective treatment of depression in the population and suicide prevention cannot be delivered by one or two healthcare sectors, rather a broad and inclusive approach is needed. There needs to be a public health campaign to educate the public about stress and depression. I am reminded of the “Act FAST” campaign on television a few years ago designed to reduce disability from stroke. Everyone in the population needs to become familiar with symptoms and signs of depression and be able to use a simple tool such as the PHQ-9 to make a diagnosis. Mild depression can be self-treated with CBT/ counselling/ physical therapy. CBT needs to become much more widely available in different formats to support this process and negate current waiting times which can be up to 12 months in some cases.
Alongside this, GPs need to be re-educated in diagnosing and treating depression including more severe illnesses requiring drugs previously reserved for a “specialist”. Psychiatrists need to reclaim their expertise in managing depression and treating the most high-risk cases. They need to be prepared to offer their GP colleagues advice and support in a responsive and creative way.
The question of large numbers of depressed adolescents who cannot access treatment remains. This has been the focus of a recent media campaign by Dr Alex George (GP) as well as others who are promoting Early Support Hubs to improve access to care among this group. My concerns include who will staff the Early Support Hubs and what will their level of expertise be? There is talk of CAMHS professionals dedicating clinical time to the Early Support Hubs but how realistic is this given their existing workload? There is a real danger that Early Support Hubs will simply provide an added layer of complexity which will delay access to expert help in the same way that MHP assessments do for adult patients. What will be needed is a triage process that will detect people with more severe depressive illness, those that require pharmacotherapy and those at moderate or high risk of suicide. These individuals will then need urgent treatment by their GP, CAMHS, or adult psychiatrist. The public and the third sector have vital roles to play in increasing their knowledge of depression and can therefore feed into the triage process and reduce the burden on mental health services which are already over-stretched. Let us all “Act Fast” and “Prevent Suicide”.
11th February 2022