Dealing with Depressionin Rural Australia

Dealing with Depression in Rural Australia

Dealing with Depression in Rural Australia

2

Black Dog Institute

Mission: To advance the understanding and management of the mood disorders through

Research Clinical Services Community Support Education

The Institute is partially funded by NSW Ministry of Health and philanthropic support. No pharmaceutical companies have input to the program.

Clinical Services

Research

Education

Community Support

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Introduction - Materials

Materials for you to keep…

Workshop Workbook 3 Sections

To be handed back… Evaluation form Reinforcing Activity within 2 weeks MAP registration form

For detailed information on GP Mental Health treatment items please go to this link:

www.health.gov.au/mentalhealth-betteraccess

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Housekeeping!

Bathrooms Breaks Phones Adverse Feedback form

Accreditation - 40 QI & CPD Category 1 points

- 30 ACCRM PRPD points

- MHST

Differentiate between the differing sub-types of clinical depression

Recognise the contribution of biological, social and psychological factors to the current depressive episode

Assess and manage risk in the depressed patient Select pharmacological treatment best suited to the individual

patient Develop a comprehensive mental health treatment plan

derived from the formulation of the depressive episode

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Learning Objectives

Online Predisposing Activity

Today’s workshop has been written to compliment the online predisposing activity you have completed prior to attending

The learning from the online Sub-typing Depression program will be assumed in today’s workshop

An overview of this material can also be found on the Black Dog Institute website

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The Experience of Depression

Introduction

Show Marty’s Story

What are the unique challenges/opportunities when managing depression in a rural setting?

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Introduction

Why spend a day talking about depression?

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Depression is common

National Survey of Mental Health and Wellbeing 2007:

Mood disorders affected 6.2% of people aged 16-85 years (7.1% of women and 5.3% of men) in the 12 month period surveyed

In any one year up to one million adults are affected by depression

In 2004-5 overall depression rates were similar for urban and rural areas

However males aged 45-64 living in a non-urban setting were 1.4 times more likely to experience depression.

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Depression is a common general practice presentation

BEACH (Bettering the Evaluation and Care of Health program): psychological problems are treated in 11.5 of every 100 general practice encounters, with depression being the most common presentation.

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Depression is disabling

Depression, one of the leading causes of disability worldwide Depression associated disability costs the Australian economy

$14.9 billion annually More than 6 million working days lost each year Impacts on all relationships particularly within the family unit

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Depression is diverse: a. Culture @

Culture – 2011 - 25% of Australians were born overseas, 15% from a non English background

What impact does cultural background have on the diagnosis and management of depression? Affects how depression is experienced and expressed Affects personal meaning of the depression Affects help seeking behaviours Impact of language/use of translators Adherence to treatment

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Depression is diverse: b. Gender

Gender – Which gender is more likely to develop depression? Why?

Females

(1) Reporting bias

(2) Actual increased risk

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Depression is diverse: c. Age

Age - Which age groups are most likely to suffer from depression? Female incidence peaks in late adolescence Male incidence peaks in 35-45 age group

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Depression is complex @

Which co -morbidities are common with depression?

Psychiatric : Anxiety disorders Substance abuse Personality Disorders

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Depression is complex

Physical: Cancer - recent study confirming high rates of often undetected and

untreated depression in cancer patients

Cardiovascular disease - - high levels of depression in post AMI patient - depression is associated with an increased risk of a

cardiovascular event Diabetes - increased prevalence of depression in diabetes

- depression increases risk of developing diabetes

Chronic Pain

Also a symptom of some illnesses such as MS, thyroid disease, connective tissue disease etc. 16

Today’s program

The aim of today’s program is not only to improve the ability to diagnose clinically significant depression but also to create more effective and meaningful treatment plans by:

identifying the sub- type of depression involved developing a deeper understanding of the context within

which the depression has occurred

Topic 1

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Assessment and Diagnosis

Learning Objectives

At the end of this topic you will be able to: Prioritise key objectives for the first consultation with a

depressed patient Undertake a comprehensive risk assessment Appropriately manage the suicidal patient Utilise the patient formulation as the basis of management

planning Delineate the role of stress and personality in presentations of

non-melancholic depression Use an appropriate outcome tool Provide psycho education best suited to the patient’s situation19

Steve – aged 42

Meet Steve (play DVD)

As you observe this consultation note down any significant information that may help you with your assessment and management of Steve in your workbook.

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Steve

What are some of the key issues in Steve’s presentation?

(We will look at making a specific diagnosis shortly)

21

Steve

Steve has come in at the request of his wife.

What difficulties does this create? What expectations do you think Steve would have of this visit to

the GP? What would Steve think explains how he has been feeling?

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What are your priorities? 7

In the first consultation with a depressed patient there are often numerous issues that require the GP’s attention but limited time to address them all.

What would issues would be some of your priorities for Steve’s first visit?

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What are your priorities? The “10 steps”

1. Engage with Steve

2. Make a diagnosis including sub-type

3. Exclude other illness (as appropriate)

4. Assess risk

5. Complete a formulation / Mental Health Treatment Plan

6. Provide psycho-education

7. Decide whether medication is indicated

8. Consider psychological therapies

9. Foster support networks

10. Well being planning/relapse prevention

It will generally require several consultations to work through all these priorities 24

(1) Engage

For many people with depression, the decision to see a health professional has come after considerable deliberation and hesitation

Their experience of this first visit can shape their attitude towards health care professionals for some time

A negative experience may deter them from help seeking into the future

A positive experience may be the turning point in their experience of living with depression

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Engagement strategies @

What are the strategies that you use to engage the depressed patient? An empathic style (i.e., demonstrating the ability to take the

patient's viewpoint) Letting the patient lead the interview Respecting the patient’s pace of delivery, especially when

slowed or having difficulty concentrating Responding to non-verbal cues Listening attentively

…continued26

Engagement strategies @

Tolerating silences Maintaining eye contact Avoiding asking a stream of closed-ended questions (i.e.

Yes/No questions) Avoiding interrupting the patient Occasionally summarising and checking your understanding

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(2) Diagnosis (including sub-type)

Is Steve stressed or depressed?

What are the key features that need to be present in order to diagnose clinical depression?

Depressed mood Increased self-criticism Lowered self-esteem More than two weeks duration Functional impairment

In what domains is Steve experiencing functional impairment?

Is his functional impairment mild, moderate or severe? 28

Diagnosis (including Sub-Type)

What sub-type of depression is Steve experiencing?

What are the features that define non-melancholic depression? Clinical depression where melancholic and psychotic features

are absent Residual group of depressions Diverse group coloured by personality style and stressors Identifying stressors and coping style are key to management Most common (90%) sub-type seen in primary care

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(3) Exclude other illness

Are there any alternate or additional diagnoses to consider? What investigations (if any) would be helpful? Why?

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Using the MAP

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• Free service from the Black Dog Institute • Access by referral from mental health practitioners registered with BDI • Online testing and prompt and secure report delivery direct to the referring clinician• 20 years research and development BDI • Available Australia-wide• Designed to be used in conjunction with clinical assessment• Identifies : depression severity patient functionality probability of bipolar disorder depression sub-type influence of anxiety

vulnerable personality type influence of lifestyle and environmental factors • Supports treatment planning• Enhances communication within the treatment team• To register go to www.blackdoginstitute.org.au/healthprofessionals/map/overview.cfm

(4) Assessing Risk

Assessing the risk of self- harm and suicide is an essential component of any mental health consultation

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About Suicide

What has happened to the suicide rate in Australia over the last decade? Decrease - from 13.2 per 100,000 in 1997 (2723 deaths ) to 11

per 100,000 in 2012 (2535 deaths) although has slightly edged up from 2380 deaths in 2011

What accounts for this change?

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About Suicide

Which gender is more likely to die by suicide? Males

What is the ratio of males to females completing suicide? 2012 - Ratio of 3 :1

By what ratio are suicide attempts more common than completed suicide? Ratio of 30:1

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About Suicide

Which age group is most vulnerable? Statistics vary from year to year. In 2012:

males : Over 80s followed closely by 45 – 49 yr olds

females : Over 80’s followed closely by 50 - 54 yr olds In general, although suicide is responsible for one in five

deaths in the 15 -24 age group the suicide rate in adolescence has dropped dramatically.

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About Suicide @

What is the most common means of suicide in Australia?

In 2012: Hanging accounted for just over half of suicides (54.3%) Poisoning including over-dose 23% Firearms 6.8%

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Suicide in Rural Areas

Australian Institute for Health and Welfare (2007) : men in remotes areas 2.6 x more likely die by suicide than those in metropolitan areas

2005-2007 Queensland Suicide Register : higher rates of male suicide in remote areas (36.32 per 100,000) compared to non-remote areas (18.25 per 100,000)

Rates of male suicide higher in regional areas (21.81 per 100,000) than in non-regional areas (17.27 per 100,000)

There were no significant risk differences for females

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Suicide Risk @

What factors in a person’s history would make you consider them to be at significant risk of suicide? Male

Indigenous (22.4:100,000)

Psychiatric Illness – 90% have mental health diagnosis, 60% with a mood disorder

Higher risk in melancholic and psychotic depression.

Previous attempt

Family history of suicide

Exposure to the suicidal behaviour of others

Chronic Illness (cont……) 38

Suicide Risk @

Isolated - “The more alone you are the more in trouble you are”

Severe hopelessness Access to means Alcohol/drug use Impulsive Aggressive, violent Unemployed Recent losses

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Suicide Protective Factors @

What factors in a person’s history would reduce their risk of suicide? Access to high quality mental health care

Regular ongoing connection with a health service

Restricted access to lethal means

Strong connection to family and community support

Good coping skills e.g. problem solving and assertiveness

Religious beliefs that discourage suicide

Strengthening protective factors has an important role in suicide prevention

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Discussion @

What is it like for a person to experience suicidal ideation?

May fear they are going crazy May fear they are dangerous to others May feel ashamed of their thoughts May begin to dwell on the suicidal thoughts giving them

increasing power

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About Suicide

How accurately can we predict someone’s risk of suicide?

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Steve’s Risk

On history alone how would you rate Steve’s level of risk of self-harm or suicide?

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Assessing Risk

Every patient with a depressive illness needs to be asked about suicide What difficulties do you encounter when taking a suicide

history? Are there any drawbacks of taking a suicide history? How do you go about discussing suicide with your patients? What are some key phrases that you use?

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Suicide History 6

What are the key components of a suicide history? Ideation Intent Planning Means Previous attempts Protective factors

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Skills Practice

Form a group of 3 - clinician, Steve and observer.

The roles will rotate through the day - everyone will be the clinician at some time

The clinician wishes to raise the issue of suicide with Steve and assess his level of risk

If you are Steve: On page 77 in your workbook there is a guide for as to how answer questions on this subject

Try and respond authentically to doctor rather than reading out the answers

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Skills Practice

Observer : Note any useful questions and comments that encourage Steve

to open up and confide in the clinician Note any unhelpful questions and comments that discourage

Steve from confiding in the clinician In view of Steve’s responses, how do you now rate his risk of

self harm or suicide?

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Managing suicide risk 7

How would you manage this in your practice?

(a) Involving family and friends:

Who would you involve in Steve’s care?– How do you assess the capacity of friends/family to be involved

– How would you negotiate their involvement?

– How would this impact on your appraisal of the level of risk?

(b) Use of crisis teams and hospitalisation – – What services are available in your area?

– When are these useful/when are they not useful?

…continued 48

Managing suicide risk 6

(c) Access to 24 hr support services – use of a crisis card

(d) Strengthening the therapeutic relationship– Eliciting reasons to live

– Instilling hope

– Provide psycho-education and treatment for the underlying condition Involving other professionals /services

– Frequent assertive review and monitoring – a directive approach to follow up.

(e) Linking to other services– What referrals would you make for Steve? When?

No evidence that safety contracts on their own act as a deterrent.49

Managing suicide risk

Helpful websites: www.suicidecallbackservice.org.au (crisis counseling 24/7)

(1300 659 467 ) www.livingisforeveryone.com.au (health professionals and

consumers) www.square.org.au (health professionals)

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Priorities

So far we have:

1. Engaged with Steve

2. Made a diagnosis including sub-type

3. Excluded other illness

4. Assessed risk of suicide

Next we will continue with

5. Complete a formulation / Mental Health Treatment Plan

6. Provide psycho-education

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(5) Complete the Formulation

When taking a mental health history, it is often useful to organise the information you elicit into a formulation.

This has four components often known as the 4 Ps Predisposing factors – factors that predate the depression Precipitating factors – factors that triggered the depression Perpetuating factors – factors that prevent the depression from

remitting Protective factors – factors that increase the likelihood of

recovery and decrease the likelihood of relapse

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Formulation

The formulation can be added to in subsequent sessions as new information comes to light. It can then be used as a foundation for the Mental Health Treatment Plan

A formulation grid can be helpful in organising the information for management planning

Exercise (in pairs) : Complete Steve’s formulation (see grid on following slide)

(Refer to Steve’s story on page 76)

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Steve’s Formulation @

Predisposing: anxious-worrier personality, high expectations of self as man/provider, flood and drought, financial stress,

Precipitating: wife working in town Perpetuating: insomnia, social isolation, alcohol, beliefs about

help-seeking Protective: caring partner, children, wife in employment

What is the value of completing the formulation for:

(a) Steve (b) the clinician

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Formulation

Which factors in the formulation can be addressed in the management plan?

Predisposing: anxious-worrier personality, high expectations of self as man/provider, flood and drought, financial stress,

Precipitating: wife working in town Perpetuating: insomnia, social isolation, alcohol, beliefs about

help-seeking

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Formulation

Which protective factors in the formulation can be drawn from to assist in recovery?

Protective: caring partner, children, wife in employment

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Mental Health Treatment Plan

There are many templates available for GP MHTP We have included the Department of Health and Aging

proforma in your work book How would your formulation assist in developing a MHTP

together with Steve? Let’s review the completed plan on page 18 of your workbook.

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Stress and depression sub-types

Steve is currently facing numerous stressors

He also has an anxious worrier personality style

Non- melancholic depression arises from a combination of: Stressors and Personality vulnerabilities that may reduce resilience in the

face of stress

in varying measure

The personality style may also colour the presentation of the depression e.g. an anxious worrier will present with an anxious depression.

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Stress in other depression sub-types

In melancholic and psychotic depression, although a stressor may be present it is not necessarily so

The association with stressors appears to lessen over the years and with subsequent episodes

This means at times there will be no apparent trigger

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Non-melancholic depression

In the assessment of non-melancholic depression it is therefore necessary to identify:

1. Stressors (acute and chronic) and2. Any ‘key and lock’ effect (see next slide)

3. Personality vulnerabilities

(1) We have listed Steve’s stressors in the formulation

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(2) Stress and “Key and Lock”

For some patients it is the enormity or nature of the stress that overwhelms them rather than a lack of effective coping skills that leads to depression

For others it is the meaning they place on a stressor that underpins their reaction to that stressor which to the observer may seem out of proportion to the stressor

This is often known as the “Key and Lock” Model Insight into the “key and lock” is helpful for patients in

understanding their own reaction to the stressor

Is there any “key and lock” effect that you can identify in Steve’s story?

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(3) Personality and non-melancholic depression

What personality traits do you think would make a person more likely to become depressed when stressed?

• Anxious Worrying Social Avoidance

• Personal Reserve Rejection Sensitivity

• Perfectionism Self-criticism

• Irritability Self-focused

• Clearly there is considerable overlap of personality styles and one person may have a number of these traits in varying measure

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Personality and Temperament

The 109 item personality and temperament questionnaire (TAPQ) can be completed on the BDI website.

TAPQ is also incorporated into the MAP. Steve’s MAP report is in your workbook (page 20) (next slide)

Teaching Steve specific skills to manage stress and address his personality vulnerabilities will both assist his recovery and prevent relapse

We will look at this in greater detail this afternoon

64

65

Coping well with stress7

What coping skills are helpful in the face of increased stress? Eliciting support of others Prioritising Problem solving Assertive communication Time management Delegating Time for self and self-care

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Impact of personality style on coping with stress @

How does Steve’s personality style effect his ability to cope with stress?

How do anxious worriers typically respond to stress? Autonomic arousal Ruminate and catastrophise Increased self doubt Become helpless Seek reassurance from others Use distraction, avoidance Improving skills for coping with stress will be discussed further in

management planning 67

(6) Psycho-education

a. Why is psycho-education important when managing patients with depression?

b. What important messages do patients need at this early stage?

c. What resources do you commonly use for psycho-education in your practice?

Black Dog Institute website has printable fact sheets on a range of issues of concern for people with depression and carers

Psychological Toolkit for use by health professionals additional resources

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Psychological Toolkit

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Psycho-education

(a) Outcome tools What is the role of using outcome tools in depressed patients? What outcome tools do you use in your practice? Which outcome tool would you use for Steve? Look at the completed DASS for Steve (Page 23 in workbook).

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Using the Psychological Toolkit

(b) Mood chart ( page 25)

Would it be useful to give Steve a mood chart to complete? What instructions would you give him?

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Summary: Topic 1

The initial assessment of a depressed patient needs to include: Successfully engaging the patient Making a diagnosis of clinical depression including sub-type Assessing the patient’s level of risk to self and others Developing a formulation inclusive of personality style and

stressors Completing a Mental Health Treatment Using an outcome tool as a baseline for monitoring progress Psycho-education for patients and their families

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The Carer Experience

Jessica’s Story / Carer presentation

Discuss

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Carer

Carers need: encouragement to acknowledge their own needs and reach out to be

supported themselves

to negotiate communication pathways with health professionals

to be pointed to resources such as books and websites to learn more about depression and become more educated in their loved one’s condition

to maintain connection with the rest of the family, health professionals, other carers and the wider community rather than risk insularity

to learn to delegate

…continued 74

Carer

help to recognise priorities and organise tasks into a manageable load

help negotiating the system opportunities to vent and off load their frustrations and distress to adjust their own work load in response to the demands

placed on them eg. shorter hours or light duties at difficult times

to at times participate in exercise, stress management and relaxation with the sufferer

to balance being helpful with taking over and not allowing space for the sufferer to regain autonomy and self esteem. 75

Topic 2

Management

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Learning objectives

Initiate antidepressant medication when pharmacological treatment is warranted

Effectively manage pharmacological treatment in the depressed patient

Select appropriate psychological strategies that most effectively address stressors and personality sub – types.

Assist patients in fostering an effective support network Recognise the importance of regular monitoring and review

consultations for the depressed patient.

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Ellie

Let’s listen to Ellie as she talks to her GP about how she has been feeling

Meet Ellie 24 yrs (play DVD)

(script is also in your workbook)

Note down any significant information in the history and your observations of Ellie in your workbook.

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Ellie

What are the key issues in Ellie’s presentation? What is the symptom that Ellie is complaining of?

Depression is common in primary care patients but many people with depression do not openly present with mental health concerns

What other presentations may indirectly alert you to the possibility that a person may be suffering from depression?

How will that impact on the consultation?

79

Rural presentations

Australian Journal Primary Health July 2013

• 1375 rural men

• 212 in farming and agricultural occupations

“ almost half of the farming and agriculture group (48.0%) had

contact with a GP in regard to physical health issues in the

3 months before their death by suicide”

• average age of death 43Figures are from Queensland Suicide Register which have recorded suicides in Qld since 1990

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Ellie

In pairs discuss:

1. What would be the challenges engaging with Ellie? How would you overcome these?

2. What is the diagnosis for Ellie?

3. What other diagnoses are possible?

How would you exclude these?

4. What is your level of concern for Ellie’s safety?

Discuss in larger group81

Diagnosis (including sub-type)

What features of melancholic depression are evident in Ellie’s

presentation?

(1) Presence of psychomotor changes: Retardation Cognitive impairment (concentration, memory difficulties)

(Some melancholic depression will present with agitation rather

than retardation)

82

Diagnosis (including sub-type)

(2) Additional Features Loss of “light in the eyes” Mood and energy lowest in the morning Pervasive anhedonia Complete non-reactivity Profound anergia Early morning waking

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Diagnosis

Psychomotor features become more observable with age.

In younger people these are more likely to be elicited in the history than observed.

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Diagnosis

Given Ellie’s age and presentation is there any other diagnosis we need to consider? Melancholic depression in a younger person is moderately

suggestive of a bipolar disorder. 80% of depression in bipolar illness is melancholic or psychotic.

What features in Ellie’s story are suggestive of a possible bipolar disorder?

How would you explore this possibility?

85

What are the common features of mania or hypomania?

A discrete period uncharacteristic of normal personality style Energised and wired Talk more and over people Spend more money Are indiscrete Require less sleep and do not feel tired Increased libido Creative and grandiose plans And can be irritable, argumentative or aggressive

86

Highs

What is the most significant difference between mania and hypomania?Mania has psychotic features.

Mania is consistent with a diagnosis of Bipolar 1Hypomania with a background of depressive episodes is

consistent with Bipolar 2

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88

Self assessment test

89

Highs

Why is it important to distinguish whether Ellie has ever had a “high”? Impact on management Impact on prognosis

90

Ellie

Which outcome tool would you use for Ellie? Let’s look at Ellie’s completed DMI 10 in your workbook (pge 30)

Is this information useful?

91

(7) Deciding on Medication

Clearly medication is only one aspect of treating depression and we will look at other modalities of treatment in the next unit.

Would you prescribe medication for Ellie? Why?

The treatment of a melancholic depression always necessitates the use of antidepressant medication

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Medication - melancholic

Which neurotransmitter pathway dysfunctions contribute to melancholic depression?

Therefore, which medication would you prescribe for Ellie? For a melancholic depression, a dual action antidepressant is

more likely to be effective than an SSRI However, in young people there may be some initial success

with an SSRI incurring a lower side effect burden This is less likely to be effective in future episodes

93

Medication - melancholic

Broad spectrum antidepressants (such as tricyclic antidepressants) are also effective in treating melancholic depression but have a higher side effect burden

With age, tricyclics antidepressants become increasingly more effective than SSRIs so that by age 60 they are 4 times more likely to be effective than an SSRI in successfully treating a melancholic depression.

Given the degree of Ellie’s functional impairment it may be reasonable to start with a dual action medication from the outset.

94

Medication - non - melancholic

Would you prescribe medication for Steve? Why? Only 50% of non-melancholic depression will respond to

medication Psychological therapies are the main stay of treatment

Consider medication when: Severe functional impairment Anxiety is a key symptom Previous response to medication Inadequate response to non-pharmacological treatment

95

Which neurotransmitter pathway dysfunction contributes to non-melancholic depression?

Therefore, which medication would you prescribe for Steve? There is generally no value in moving to broader acting anti-

depressants when treating non-melancholic It can be helpful to trial a second SSRI where the first has not

been helpful or side effects have been dose limiting

96

Medication - non - melancholic

SSRIs

Which medications are in the SSRI class? (see also Antidepressant Regimes section 3)

Prozac/Lovan - Fluoxetine Aropax - Paroxetine Zoloft - Sertaline Luvox - Fluvoxamine Cipramil - Citalopram Lexapro - Escitalopram

97

Dual action antidepressants @

Which medications are dual action antidepressants? Efexor - venlafaxine Pristiq - desvenlafaxine Cymbalta - duloxetine Avanza - mirtazapine

98

Broad Spectrum antidepressants

Which medications are broad spectrum antidepressants? Tricyclic antidepressants: amitriptyline, nortriptyline, dothiepin,

imipramine MAO Inhibitors

99

Agomelatine (Valdoxen)

MT1/MT2 melatonergic agonist 5-HT2C serotonergic antagonism Restores circadian rhythm and sleep-wake cycle Less sexual side effects Baseline LFT’s – repeat week 6,12 and 24 Place in treatment still to be determined

100

Antidepressant Classes

Serotonergic Noradrenergic Dopaminergic

Selective

SSRIs Dual Action

SNRIs

Mirtazapine Broad Action

TCAs MAOIs

What dose would you use?

SSRIs Start with a half dose and increase if tolerating side effects Effective dose varies with rate of metabolising

Tricyclic antidepressants Start 25mg titrate up to 150mg

(note: watch for QT prolongation)

102

What dose would you use?

Dual acting Venlafaxine start low and can increase to 225-300mg according

to response. Others start at one tablet – – desvenlafaxine 50mg (up to 200mg) ,– duloxetine 30mg (up to 120mg) – mirtazapine 30mg (up to 60mg).

103

Instructions

What do you need to tell Ellie when prescribing an antidepressant?

(a) Side effects – which side effects would you warn her about?

104

Drug interactions and serotonin syndrome @

(b) Drug interactions and serotonin syndrome

Which medications can interact to cause serotonin syndrome? SSRIs, SNRIs,TCAs, MAOI Opioid analgesics: pethidine, tramadol, fentanyl,

dextromethorphan St John’s wort Amphetamines Methylenedioxymethamphetamine (MDMA; ecstasy)

105

Serotonin Syndrome @

What are the symptoms of serotonin syndrome?

106

Neuromuscular Autonomic Mental state•Hyperreflexia•Clonus•Myoclonus•Shivering•Tremor•Hypertonia/rigidity

•Hyperthermia:mild, < 38.5°C;severe ≥ 38.5°C•Tachycardia•Diaphoresis•Flushing•Mydriasis

•Agitation•Hypomania•Anxiety•Confusion

Time until it starts working

(c) How long will Ellie need to wait to get any positive benefit from the medication? In melancholic depression it may take 2-3 weeks to respond to

medication In a non-melancholic depression a response may be seen earlier

107

Abrupt cessation of treatment @

(d) What withdrawal symptoms can occur if an antidepressant is ceased suddenly?

Discontinuation syndrome: flu-like symptoms, insomnia nausea imbalance, dizziness sensory disturbances, hyperarousal, insomnia vivid dreams, irritability

108

Discontinuation

Symptoms last one to two weeks

Which antidepressants are more likely to cause severe discontinuation?

Those with shorter half lives such as paroxetine, venlafaxine.

109

Length of treatment

(e) How long would Ellie need to stay on the medication?

– 6 months for first episode of non-melancholic depression

– 1 year for a first episode of melancholic depression.

– Longer for subsequent episodes.

110

Medication and alcohol @

(f) What about alcohol? Alcohol can worsen depression Intoxication symptoms may occur more readily Increase in side effects experienced may occur Serious interaction with MAOIs

111

Changing medications

What do patients experience when changing from one antidepressant to another?

What do we need to tell them?

– Give a clear written change over schedule

– Combination of discontinuation effects, early side effects of the new medication and loss of antidepressant effect can be very challenging

– Prepare extra support, reduced responsibility and frequent contact through this period

See Changing Antidepressant medication fact sheet page 90

112

Feeling much better

You prescribed an antidepressant for Ellie and within 4-5 days she is feeling much better. She is energetic, alert and motivated. She has some new ideas for managing the main desk differently at work.

What do you make of this? How would you respond?

Ellie may be switching into a hypomanic state. Options are:

– stop the antidepressant and monitor her progress or

– continue the antidepressant at a low dose and observe her closely 113

or… Not getting better

At 4 weeks, despite gradually increasing the dose, Ellie is still not responding to the antidepressant you prescribed.

What would you do next? In a melancholic depression, augmentation with an atypical

antipsychotic may be helpful A low dose of olanzapine (2.5 -5 mg) or quetiapine (25-50mg)

for 2- 4 weeks can often accelerate improvement Prolonged treatment with these medications is best avoided

due to their side effect profile If she is still not responding it may be necessary to change the

antidepressant Aim of treatment is full remission of symptoms.

114

Jack - aged 57yrs

You have already been introduced to Jack in your online predisposing activity

You will recall that Jack has a psychotic sub-type of depression

115

What are they key features of psychotic depression?

• Mood congruent delusions• Pathological guilt• Severe psychomotor changes• Pseudo-dementia

Psychotic depression is a psychiatric emergency

Treating psychotic depression

116

5%Placebo

25%Antidepressant alone

33%Antipsychotic alone

80%Antidepressant and antipsychotic

80%ECT

Response Rate

Treatment

Medication Fact Sheets

See:

Treatment for Unipolar Depression for information regarding treatment approach to the various sub-types of depression (pages 92-95)

Antidepressant Regimes for more information regarding the different antidepressants, their dose and side effect profile (pages 88-89)

117

Priorities

We have looked at:

1. Engagement

2. Make a diagnosis including sub-type

3. Exclude other illness (as appropriate)

4. Assess risk

5. Complete a formulation / Mental Health Treatment Plan

6. Provide psycho-education

7. Decide whether medication is indicated

After the break we will:

8. Consider psychological therapies

9. Foster support networks

10. Wellbeing planning/relapse prevention 118

(8) Psychological Strategies

Psychological strategies are the main stay of treatment for people with non-melancholic depression and may be a useful adjunct to medication for patients with other sub-types of depression as their cognitive ability improves

Psychological strategies aim to both improve stress management skills and reduce personality vulnerabilities

Patients who have a completed mental health treatment plan can currently access a Medicare rebate for 6 + 4 sessions of focused psychological therapies in a calendar year

ATAPS – 12 sessions for low income groups funded through Medicare local

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Internet based mental health assistance

There are also several options online to support management of mild to moderate depression and anxiety

e-Mental Health can fill the gap in services where face to face therapy is not available or accessible and can also be used to augment face to face therapy

Training in the use of e-Mental Health Programs in primary care is available for GPs through the Black Dog Institute eMHPrac project

See information leaflet in your pack 120

www.mindhealthconnect.org.au (resource portal)

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On line psychological therapies

On Track - www.ontrack.org.au

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Mental Health On line

www.anxietyonline.org.au

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Psychological strategies in Primary Care

Several basic behavioural strategies are readily initiated in primary care

What are some of the behavioural techniques you employ when treating patients with depression?

1. Sleep hygiene

2. Exercise prescription

3. Alcohol and substance reduction

4. Activity scheduling

5. Pleasant events

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Psychological Strategies - Steve

Steve’s formulation: Predisposing: anxious-worrier personality, high expectations of

self as man/provider, flood and drought, financial stress, Precipitating: wife working in town Perpetuating: insomnia, social isolation, alcohol, beliefs about

help-seeking Protective: caring partner, children, wife in employment

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Addressing personality vulnerabilities

What psychological strategies could assist Steve to address his anxious - worrier personality style?

What would motivate Steve to undertake psychological therapies?

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Treating the anxious worrier

2 components of the anxious worrier experience: Anxiety – physical experience Worry – cognitive experience

2 common psychological approaches (next 3 slides) : Cognitive Behavioural Therapy Mindfulness-based therapy

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Treating the Anxious worrier

CBT:

Anxiety? relaxation techniques (eg. PMR, breathing techniques) to

reduce hyperarousal

Worry? challenge unhelpful thoughts, reality testing, behavioural

experiments, graded exposure

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Treating the Anxious worrier @

Mindfulness based therapies

What is your understanding of the term ‘mindfulness’? In the present Non judgmental Awareness

“Consciously bringing awareness to the here and now experience with openness, receptiveness and interest”. (Dr Russ Harris)

Experiential therapy that requires commitment to practice

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Mindfulness for the anxious worrier

Anxiety - Accepting the physical sensations that accompany anxiety without struggle, reducing the need to avoid or get rid of these sensations

Worry - Looking at worried thoughts and ruminations without getting caught up in them, challenging them or giving them attention

Focusing on the present and living meaningfully rather than living a life governed by anxious sensations and worried thoughts

Mindfulness handouts in PTK (Section 3 of your workbook)

Dealing with Anxiety Disorders workshop

Stress management skills

The psychological toolkit contains many useful worksheets to improve skills to better manage stress.

Learning structured problem solving is particularly useful for the anxious worrier.

Let’s look at the problem solving templates in the toolkit

• Define the problem

• Generate solutions

• Consider Pros and cons

• Choose the best option

• Plan

• Review

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Skills Practice

Steve has identified that financial stress is a very significant contributor to his distress.

In your group of 3- clinician, Steve and observer, use the PTK worksheets on problem solving pages 37 and 38 to work on this issue.

You will need to first define the problem more specifically before exploring possible solutions and working through these

Allow Steve to generate his own solutions rather than attempting to ‘fix’ the problem for him

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Psychological Strategies - Steve

Steve’s formulation:Predisposing: anxious-worrier personality, high expectations of self as man/provider, flood and drought, financial stress, Precipitating: wife working in townPerpetuating: insomnia, social isolation, alcohol, beliefs about help-seekingProtective: caring partner, children, wife in employment

These can be listed in the issues/needs component of the MHTP and form the basis for ongoing treatment planning (see next slide)

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Steve’s Mental Health Treatment Plan

Jason (aged 38)

Let’s listen to Jason who has been returned to have some sutures removed from a laceration to his scalp sustained after a fall one week ago

Meet Jason (play DVD )

(script is also in the workbook)

Note down any significant information in the history and your observations of Jason in your workbook.

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Jason

In small groups discuss: What are the key issues for Jason? What stressors are currently impacting on him? Can you see any “key and lock” effect in these stressors? What personality style does Jason have? What is the diagnosis for Jason ?

Discuss in large group

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Social and Emotional Wellbeing

Health and Welfare of Australia's Aboriginal and Torres Strait Islander Peoples, Oct 2010

Social and Emotional Wellbeing:

• Most (70%) Aboriginal and Torres Strait Islander adults reported being happy

• Around one third of adults reported high/very high levels of psychological distress

• Many Aboriginal and Torres Strait Islander people experienced discrimination

• Around one in twelve Aboriginal and Torres Strait Islander adults have personally experienced removal from their natural family.

Aboriginal Mental Health

Cultural awareness and sensitivity training is recommended for health professionals working within Aboriginal communities

This training is not within the scope of this program Recognition of the cultural and historic context of connection to

land, family and community together with multi- generational trauma and loss is integral to managing Aboriginal social and emotional wellbeing

Where possible services that have been developed specifically to meet the unique needs of Aboriginal people are preferred but at times this may not be possible

Aboriginal Mental Health

However, the skills of assessment, diagnosis, risk management and developing a management plan that addresses the mental health needs of the person are still required albeit modified to acknowledge the unique culture and context in which the episode has occurred

Australian Indigenous Health Infonet provide excellent resources in SEWB including fact sheet series

Mental Health First Aid – Aboriginal and Torres Strait guidelines And key and lock

Irritable personality style

Questions in the TAPQ that look for irritable personality style I am very snappy when I’m stressed

I can become quite grumpy and grouchy

At times, I can get very cross with other people

I have an excitable and quick temper

I tend to be hot tempered

I tend to get angry and lose my cool when stressed

Under pressure I tend to get snappy

Under pressure, I can get cranky with others and myself

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Irritable personality style @

When stressed, people with an irritable personality style: Outbursts of anger Snappy at other people Lash out at others Impatient with self Distracted by reckless/pleasurable pursuits eg drinking,

gambling

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Jason - diagnosis

What is the diagnosis for Jason?

Management Planning

In small groups discuss: Would you prescribe medication(s) for Jason? Why Which medication(s) would you prescribe? Complete the formulation grid for Jason ( see next slide)

Which of these can be addressed in the management plan? How would you collaborate with others in helping Jason? Complete the assessment component of the Mental Health

Treatment Plan Which psychological strategies would be helpful for Jason?

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Formulation

Predisposing: Mother from stolen generation, absent father unemployment, eldest brother deceased, alcohol use, irritable personality style

Precipitating: Expecting second child, relationship stress Perpetuating: Frequent fights, increased alcohol use, insomnia

Which protective factors in the formulation can be drawn from to assist in recovery?

Connection with family and community, willing to assist others, invested in wellbeing of partner and child

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Jason

Medication? Collaboration? What psychological strategies could assist Jason to address his

irritable personality style? Narrative therapy is recognised by Medicare as a form of FPS

useful for assisting ATSI people with psychological distress

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Jason

Frustration is a hybrid emotion composed of both anxiety and anger

We have discussed the use of CBT/ Mindfulness in managing anxiety. These could also be beneficial for Jason

Let’s focus now on anger management How would you motivate Jason to learn some anger

management skills?

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Anger management

(1) First step is recognising the physical signs of anger in the body and noticing these early:

Think about a situation where you felt extremely angered Notice where in your body you feel the sensation of being angry

(2) When these sensations are extreme:

– STOP! (can use visualisation – e.g. stop sign, flashing lights)

– BREATHE (reduce arousal through slow diaphragmatic breathing)

– LEAVE (or count to 10)

to defuse immediate situation…147

Anger management

(3) Identify unhelpful cognitions -

What unhelpful thoughts would be fuelling Jason’s anger?

(4) Mindfulness and relaxation exercises can help reduce overall arousal

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Stress Management Skills

What resources from the toolkit could help Jason better manage stress?

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Skills Practice:Assertive Communication

Jason needs to talk his cousin about some tools he borrowed months ago that Jason now needs him to return so he can help Jules’ father with some work on the family home. He would like your help to communicate more effectively with his cousin.

In your groups of 3, using the Honest Communication worksheet, page 103-104 , help Jason prepare for this conversation

» Describe objectively

» Express how you feel

» Specify what you want

» State Consequences150

Priorities

1. Engage

2. Make a diagnosis including sub-type

3. Exclude other illness (as appropriate)

4. Assess risk

5. Complete a formulation / Mental Health Treatment Plan

6. Provide psycho-education

7. Decide whether medication is indicated

8. Consider psychological therapies

9. Foster support networks

Fostering Support 7

What are the characteristics of good support? Non-judgmental Listening Assisting with appointments and referrals Encouraging to exercise, eat well and socialise Fostering hope Balancing encouraging autonomy with providing assistance Notice signs of relapse

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Support

Where can support be found?

What are some of the supports available in your community?

Discuss

Support groups:

www.blackdoginstitute.org.au/public/gettinghelp/supportgroups.cfm

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Relapse

Once the depression has remitted our focus can move helping our patients stay well and reducing the risk of relapse

What factors can help our patients stay well and reduce the risk of relapse?

These can be formalised in a written wellbeing plan which will assist in maintaining wellness and decrease the likelihood of relapse.

It can be useful to involve carers in some aspects of the wellbeing plan.

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Relapse

Despite our best efforts and the patient’s best efforts relapses still occur. Helpful for patients identify their relapse signature Educate friends and family to recognise signs of relapse Be clear that you expect them to contact you when the early

warning signs occur so that their management plan can be adjusted.

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Summary

Comprehensive management of clinical depression requires working through the 10 steps delineated in the program today

The management plan, however, will be unique for the individual person depending on their bio-psycho-social-spiritual context, depression sub-type and the risk issues in their presentation

Managing depression in rural areas can be more challenging than in urban areas however there are strengths in rural communities that can be mobilised to better assist people living with depression

Thank you!

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