De-pathologising depressed mood

So we’ve just learned that Brian, the 81 years old man with chronic knee pain is feeling low in mood. However, should we jump to a diagnosis of depression, or should we initially be taking a step back here?

We know that mental health problems are common, particularly in people like Brian with long-term health conditions¹.

• 20% of people in England have mental health problems (10.2m people)
• 30% of people living with a long term physical condition have a mental health problem (4.6 million people).

If we were to follow NICE guidelines, we would use the case finding questions to identify potential depression, then perform a more detailed assessment using a validated tool such as the PHQ-9 scale.

So, lets say you’ve completed a PHQ-9 score and Brian is classed as having mild/ moderate depression. You explore his preferences for care. He recounts taking citalopram for years, but stopping it recently as it wasn’t helping. He wonders if he’s become “resistant” to this, asking if he could try an alternative.

So, will antidepressants help? What does the evidence tell us?

In the case of Brian, he has had several recent changes in his daily life which have impacted on his mood, so rather than changing his medication, would a better approach be to take a whole-person centred approach to reviewing his mental health?

Should we consider taking a different approach to helping Brian with his depressed mood?

• Psychologist Emmy Gut argues that getting depressed is a ‘universal genetic mechanism for coping with specific problems’⁵.
• Depressed mood forcing us to opt out of everyday routine and work can serve a productive function.
• Rather than taking an antidepressant so we can keep going with more of the same, perhaps we need a different approach.

So how can we help Brian with his mood concern?

We can take a generalist approach, making a whole-person assessment. The flipped consultation approach (week 2) could help us to frame his problem differently, keeping his care on the illness side of the gate (generalist gatekeeper role, week 2).

Furthermore, we can use the exhaustion cycle to help us to engage Brian in using behavioural activation techniques. We can also try to draw on Brian’s creative self, to help him to address his mood concerns.

We will discuss these approaches in more detail within the following steps…

References

1. The Kings Fund. Mental Health: The connection between mental and physical health. Available from: www.kingsfund.org.uk/projects/time-think-differently/trends-disease-and-disability-mental-physical-health [Accessed 17/02/2022]
2. Cipriani A, Furukawa TA, Salanti G, Chaimani A, Atkinson LZ, Ogawa Y et al. Comparative efficacy and acceptability of 21 antidepressant drugs for the acute treatment of adults with major depressive disorder: a systematic review and network meta-analysis. The Lancet. 2018; 391 (10128): 1357-1366. DOI: https://doi.org/10.1016/S0140-6736(17)32802-7
3. Lewis G, Duffy L, Ades A, Amos R, Araya R, Brabyn S et al. The clinical effectiveness of sertraline in primary care and the role of depression severity and duration (PANDA): a pragmatic, double-blind, placebo-controlled randomised trial. The Lancet Psychiatry. 2019; 6 (11): 903-914. DOI: https://doi.org/10.1016/S2215-0366(19)30366-9
4. Kessler DS, MacNeill SJ, Tallon D, Lewis G, Peters TJ, Hollingworth W et al. Mirtazapine added to SSRIs or SNRIs for treatment resistant depression in primary care: phase III randomised placebo controlled trial (MIR). BMJ. 2018; 383: k4218. DOI: https://doi.org/10.1136/bmj.k4218
5. Gut E. Productive and unproductive depression. New York: Basic Books; 1989.