Chapter 3 David Kessler1 and Linda Gask2 1 School of Social and Community Medicine, University of Bristol, Bristol, UK 2 University of Manchester, Manchester, UK This chapter considers the principles of diagnosis and management of depression and anxiety in primary care. Depression and anxiety are predominantly primary care disorders. Most people with these disorders are managed in primary care without reference to specialist help. Both disorders are very common; the estimated point prevalence of depressive episode for adults in the UK is 2.6%; if mixed anxiety and depression is included the figure rises to 11.4%. The most widely used treatment for both disorders is antidepressant drugs; in 2012 there were more than 40 million prescription items for these drugs, and most of them were written in primary care. Psychological treatments are also effective and are preferred by many patients; access to psychological therapies from primary care has been variable, but in the last few years the Improving Access to Psychological Therapies (IAPT) service has been rolled out across England to respond to the needs of patients in primary care and support primary care services. However, recognition and management of depression is not without its problems. Research over the last 30 years has suggested that a substantial proportion of depression goes undiagnosed in primary care. Depression and anxiety are often associated with other chronic illnesses, and physical needs may seem more pressing to both doctor and patient in the context of relatively brief consultations. Doctors have been described as being ‘not very good’ at following depression treatment guidelines, and even as operating the ‘inverse care law’ when it comes to depression in deprived communities (which means that the availability of good medical care varies inversely with the need for it in the population served). Voices within and outside the medical profession have expressed alarm at the ‘medicalisation of unhappiness’ and the high volume of antidepressant prescribing. Some researchers question the effectiveness of these drugs for mild to moderate disorders, and considerable work has been done to develop psychotherapeutic alternatives to be available in primary care. IAPT has shown encouraging rates of recovery in its first three years but coverage is still limited and it is acknowledged that the service does not provide enough access to high-intensity cognitive-behavioural therapy (CBT) for patients with more severe depression. Anxiety disorders are also prominent in primary care. There are a range of anxiety disorders, including the phobias, post-traumatic stress disorder and panic disorder. In this chapter we will concentrate on General Anxiety Disorder (GAD), which is characterised by excessive worry for at least 6 months, and will only briefly consider the other anxiety disorders. It will be noted that the emphasis on the management of the common mental disorders in primary care has been on depression rather than anxiety; the drugs most widely used to treat anxiety disorders were developed for depression. The ‘Quality and Outcomes Framework’ (QoF) that rewards good practice in UK primary care is based around the care of depression; anxiety is not mentioned. However, anxiety and depression are often associated, either occurring together or at different times in an individual’s life-course. Anxiety disorders can be chronic and disabling, and when anxiety and depression occur together, response to treatment is poorer. There are advantages to the care of depression and anxiety being based in primary care where the emphasis is on whole person care. GPs often know their patients, their patients’ families and their social setting. They are more easily accessible to patients and perceived as less stigmatising than mental health services, and have a longitudinal and developmental perspective. They may already be involved in managing the other illnesses that are so often associated with depression. There are limitations too. Many depressed patients fear that they may be wasting the GP’s time and think that doctors have more important things to do. GPs can offer a series of consultations over time but it is much more difficult to offer longer individual sessions in primary care. The emphasis of formal psychiatric training in GP vocational training schemes has tended to be on the management of psychosis rather than being targeted at depression and anxiety. However, it is not clear how to improve GP training in the management of depression and anxiety; training GPs in the management of depression has not been demonstrated in randomised controlled trials to improve outcomes. Depression and anxiety can be difficult to diagnose in primary care. Patients often present physical symptoms when they are depressed and anxious, and psychological disorders often find a somatic expression. Presenting a physical symptom to the GP provides a legitimate reason for the consultation for many patients as well as being a way of addressing concerns about possible underlying physical illness. Depression and anxiety both amplify and distort patients’ fears and thoughts about their bodily symptoms. Dealing with these concerns is a complex and demanding process for GPs. For example, when Maria, whom we met in Chapter 1, talks about her anxiety and low mood (see page 2) she does not separate the symptoms into ‘psychological’ and ‘somatic’. Maria’s story illustrates how depression, anxiety and somatic symptoms occur together. She suffers from both trait and state anxiety and gives a clear description of a panic attack. She refers at the end to her low mood. In this sense the recognition of psychological distress is not difficult. However, it is possible that agreeing such a diagnosis with Maria will be more challenging. Bodily symptoms are as prominent as psychological symptoms throughout her account. They are interwoven with each other and thoughts about her family history and external environment. Her penultimate statement, ‘I don’t know what’s happening to me’ captures her bewilderment in the face of this mix of psychological and somatic distress and environmental hardship, and gives us an idea of the GP’s task. For example, it is possible that Maria might present to her GP with concerns about whether she has a serious disease, perhaps something wrong with her heart. Listed in Box 3.1 are some of the strategies that may be useful when this occurs. Engagement in treatment depends on diagnostic concordance with the patient; the labels of depression and anxiety are not much use if the patient does not agree with them. The other group of patients in whom depression and anxiety may be ‘under-recognised’ is one in which these disorders are more likely to occur – those suffering from other chronic illnesses such as chronic obstructive pulmonary disease (COPD), diabetes and heart disease. In this group, psychological symptoms can be pushed into the background by what appear to be more pressing physical needs. There have been attempts to address this problem by the introduction of screening questions for depression in some of those with chronic illness. In both groups of patients GPs are particularly well placed to make a diagnosis of depression or anxiety and to place it in the context of the patient’s wider life, including physical illness and other comorbidities. Francis’s story in Chapter 1 (see page 2) illustrates how depression and anxiety can be complicated by alcohol and drug use. Francis began to drink to self-medicate for his social anxiety symptoms (see below) and then became physically dependent on alcohol. Alcohol and other drugs that act as central nervous system depressants (such as benzodiazepines and opiates) will then depress mood further. It can subsequently be difficult to work out which came first, the depression or the dependence. Until very recently there had been an emphasis in the Quality and Outcomes Framework (QoF) in the UK on the use of symptom scales such as the nine-item Patient Health Questionnaire (PHQ9), the Beck Depression Inventory (BDI) and the General Anxiety Disorder seven-item questionnaire (GAD7) among others, as part of the assessment of depression and anxiety. These scales are generally acceptable to patients, who often value them. They can be used to monitor and illustrate change, and they often provide a basis for discussion. However, none of these questionnaires was designed as a substitute for a wider and deeper conversation. In recognition of this the QoF for depression is now based around the idea of a ‘bio-psychosocial assessment’, which can include symptom scores. The bio-psychosocial assessment recognises that there are a number of factors that contribute to the onset of depression and that can maintain and prolong an episode. It also encourages GPs to ask about those areas in which recovery can take place. GPs are advised to explore the domains listed in Box 3.2.
Anxiety and Depression in Adults
Anxiety and depression in adults in primary care
Introduction
Presentation of depression and anxiety
Assessment
What form does a bio-psychosocial assessment take?
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