How can I effectively screen for and manage depression in my primary care patients?

To effectively screen for and manage depression in primary care patients, a systematic approach is recommended, starting with recognition and moving through a stepped-care model ¹.

• Screening and Recognition
  • Be alert to possible depression, particularly in individuals with a past history of depression or a chronic physical health problem with associated functional impairment ³.
  • Consider asking two key questions: "During the last month, have they often been bothered by feeling down, depressed or hopeless?" and "During the last month, have they often been bothered by having little interest or pleasure in doing things?" ³.
  • If a patient answers 'yes' to either question and the practitioner is competent, review their mental state and associated functional, interpersonal, and social difficulties ³. If not competent, refer the person to an appropriate professional and inform their GP ³.
  • Consider using a validated measure, such as the PHQ-9, to assess symptoms, functional impairment, and/or disability, which can also help inform and evaluate treatment ³,². A comprehensive assessment should not rely solely on a symptom count but also consider the degree of functional impairment and duration of the episode ¹.
• Management: Stepped-Care Model
  • The stepped-care model provides a framework for organising services, ensuring the least intrusive, most effective intervention is offered first ¹. If a patient does not benefit or declines, an appropriate intervention from the next step should be offered ¹.
  • Step 1 (All known and suspected presentations): Focus on assessment, support, psychoeducation, active monitoring, and referral for further assessment ¹.
  • Step 2 (Persistent subthreshold depressive symptoms or mild to moderate depression): Consider low-intensity psychosocial interventions, psychological interventions, medication, and referral for further assessment ¹.
  • Step 3 (Persistent subthreshold depressive symptoms or mild to moderate depression with inadequate response to initial interventions; moderate and severe depression): Options include medication, high-intensity psychological interventions, combined treatments, collaborative care, and referral for further assessment ¹.
  • Step 4 (Severe and complex depression; risk to life; severe self-neglect): This step involves medication, high-intensity psychological interventions, electroconvulsive therapy (ECT), crisis service, combined treatments, multiprofessional, and inpatient care ¹.
• Initial Management in Primary Care (Steps 1 & 2)
  • Information and Support: Provide up-to-date, evidence-based verbal and written information about depression and its treatment, tailored to the patient's language, cultural, and communication needs ³. This includes advice on the nature and course of depression, recovery, and sources of information and support such as The Royal College of Psychiatrists (RCPsych), MIND, Depression UK, The Samaritans, SANEline, and the NHS website ².
  • Wellbeing Activities: Advise on activities to improve a sense of wellbeing, including physical activity (e.g., walking, jogging, gardening) and maintaining a healthy lifestyle through diet, alcohol intake, and sleep ². Offer advice on sleep hygiene, such as establishing regular sleep and wake times, avoiding excess eating, smoking, or drinking alcohol before sleep, creating a proper environment for sleep, and taking regular physical exercise where possible ¹.
  • Active Monitoring: For patients who may recover without formal intervention, those with mild depression who do not want an intervention, or those with subthreshold depressive symptoms who request an intervention, discuss their concerns, provide information about depression, arrange a further assessment (normally within 2 weeks), and make contact if they do not attend follow-up ¹.
  • Shared Decision-Making: Discuss treatment options and develop a treatment plan based on the person's wishes, any physical or mental health comorbidities, experiences with previous treatments, and expectations, involving family/carers where appropriate ². Patients have the right to be involved in decisions about their care ¹.
• Specific Considerations
  • Chronic Physical Health Problems: Patients with chronic physical health problems are at high risk of depression, especially with functional impairment ¹. If a physical health problem restricts engagement with preferred psychosocial or psychological treatment, consider alternatives like antidepressants or telephone delivery of interventions ¹. Advise patients and their families/carers to be vigilant for mood changes, negativity, hopelessness, and suicidal ideation, and to contact their practitioner if concerned, particularly during high-risk periods ¹.
  • Depression with Anxiety: The first priority should usually be to treat the depression ¹. However, if the patient has an anxiety disorder with comorbid depression, consult the relevant NICE guideline for the anxiety disorder and consider treating the anxiety disorder first, as this often improves the depression ¹.
  • Risk of Suicide/Self-Harm: If a patient is assessed to be at risk of suicide, consider toxicity in overdose if prescribing an antidepressant (limiting the amount if necessary), increasing the level of support (e.g., more frequent contacts), and considering referral to specialist mental health services ¹. Urgent referral to specialist mental health services (e.g., crisis resolution and home treatment team) is needed for severe depression with significant risk of self-harm, suicide, harm to others, or self-neglect ².
  • Psychotic Symptoms: Urgent referral to specialist mental health services (e.g., crisis resolution and home treatment team or specialist psychiatry) is required ².
  • Pregnancy and Postnatal Period: Urgently refer to a secondary mental health team (ideally with a special interest in perinatal mental health) if a woman is severely depressed with immediate risk of harm, shows severe self-neglect, cannot fulfil caring duties, has a possible bipolar disorder diagnosis, or a history of severe mental illness ⁴,⁵. Antidepressants can be used at any stage of pregnancy if clinically indicated and should not be withheld due to pregnancy ⁴,⁵. Discuss the risks and benefits, weighing the benefits of treatment to the woman, her unborn baby, and her family against any possible adverse maternal and fetal effects ⁴,⁵. SSRIs have the most pregnancy safety data ⁴,⁵.
• Monitoring and Follow-up
  • Arrange to review and monitor patients with depression in primary care ².
  • Assess ongoing symptoms, their impact on daily functioning (including work, relationships, and any carer role), and the response to any psychosocial intervention or antidepressant treatment, including adherence and adverse effects ². Consider using a validated depression questionnaire like PHQ-9 to assess severity and response ².
  • Assess any thoughts, plans, or intent to self-harm or commit suicide, and any other risks to others or risk of self-neglect, ensuring the person has a crisis plan ².
  • Ask about any new symptoms of other mental health disorders (e.g., anxiety, eating disorders, bipolar disorder, psychosis) ².
  • Address any new or ongoing personal, social, or environmental factors that may impact symptoms and recovery ².
  • Follow local safeguarding procedures if the person is a carer for a child or vulnerable adult and there are safeguarding concerns ².
  • Offer support to the family and/or carers, particularly if symptoms are severe or chronic ².
  • If there is no improvement in symptoms after 4 weeks of antidepressant medication at a recognised therapeutic dose, or after 4–6 weeks of psychological therapy or combined treatment, assess and manage any modifiable risk factors, address issues affecting concordance, consider an alternative diagnosis or comorbid condition, and discuss options for further-line treatment ².