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Research on Depression in the Workplace.

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Mental Health Matters Journal for Psychiatrists & GP's

MHM Volume 7 Issue1 small

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How GPs recognise and treat depression
It's shocking there's still a stigma about depression when one in seven adults is depressed enough to need treatment.

But some people still worry about the implications of consulting their doctor about depression. This is a great shame because GPs can offer really useful help nowadays. My frustration is that the help on offer - particularly access to talking therapies - could be so much better.

Is it depression?
We all feel down sometimes, it's a normal reaction to everyday life. Clinical depression is quite another beast. So my most crucial task is to recognise the difference between the two.

GPs see about one depressed patient every surgery
There are some key features of depression on my radar, in particular lack of pleasure in doing ordinary things, lack of energy, weight loss (or gain), sleep problems and suicidal thoughts. But the list of possible symptoms can be as long as your face.

GPs see about one depressed patient every surgery, but they don't all walk in saying they're feeling depressed. People often mention lack of energy, or focus on a very physical symptom, which usually alerts GPs to the need for more specific questions about the patient's mental health.

Key questions
There are two particular questions your GP may ask you: "During the past month, have you often been bothered by feeling down, depressed or hopeless?" and "During the past month, have you often been bothered by lack of interest or pleasure in doing things?"

If you answer yes to both, it's likely you're depressed. Research suggests that out of 100 patients with depression, these two questions should pick up 96.

Your doctor may also ask you to complete a more formal questionnaire, which helps with the diagnosis and can be useful in grading your depression as mild, moderate or severe.
Your GP will probably want to check there's no physical cause for your problems, probably with a blood test, because physical conditions such as thyroid disorders or anaemia can cause symptoms similar to depression.

Will I be given antidepressants?
I meet many people who worry they'll be fobbed off with antidepressants, and that they'll then become addicted to them, turn into a zombie, or become suicidal.

If you have mild depression you almost certainly won't need antidepressants
The first thing to say is that if you have mild depression you almost certainly won't need antidepressants.

The latest guidance for doctors from the National Institute for Health and Clinical Excellence (NICE) says the side-effects may outweigh the benefits in cases of mild depression and patients are likely to do better with regular exercise (at least 45 minutes three times a week), reading self-help books and following online programmes, or having some form of talking therapy, such as counselling.

But if you have more severe symptoms, your doctor's likely to suggest you try an SSRI (selective serotonin reuptake inhibitor), the most commonly prescribed antidepressants.

This policy - again advised by NICE - is based on evidence from good quality clinical trials. Members of the SSRI family include fluoxetine (Prozac) or citalopram (Cipramil). SSRIs work by increasing levels of a chemical called serotonin in the brain, which is thought to influence mood.

What about side-effects?

In my experience, used properly, SSRIs rarely cause serious side-effects, but of course all medicines have some side-effects.

Possible side-effects of SSRI antidepressants
· Nausea and vomiting
· Insomnia – in particular not being able to get to sleep
· Sexual problems - loss of desire or difficulty achieving an orgasm
Less common
· Drowsiness
· Headache
· Loss of appetite
· Diarrhoea
· Restlessness and anxiety
· Rashes
· Itching
· Dry mouth
· Tremors or stiffness
· Bleeding disorders have been reported

Apart from nausea, SSRIs generally have fewer side-effects than the older antidepressants (such as the tricyclics).

Many people say they put on weight while taking SSRIs, but it's often hard to tell if this is caused by the pills. As you recover from depression, your appetite's likely to return and so you may start to gain weight.

Depression itself can also increase appetite
Talk to your doctor if you're concerned about these symptoms. If one drug doesn't suit you, it may be possible to try another.

Starting with a lower dose for a week or so may help you to tolerate the drugs and experience fewer side-effects.

SSRIs take a little while to work - you may not see much improvement for a couple of weeks after starting - and although it may be tempting to stop taking them as soon as you feel better, it's usually better to stick with them for several months after you begin to feel better because this reduces your likelihood of relapsing back into depression.

Are they addictive?
No, they don't cause cravings or tolerance (where you need to take more and more of the drug to get the same effect). But there's no doubt you can get unpleasant, sometimes serious, flu-like symptoms if you stop taking them suddenly.

So the advice is not to miss doses and to come off them very gradually under your doctor's guidance.

Do they make you suicidal?
Most people won't have problems such as this, but there has been research linking SSRIs with an increase in suicidal thoughts or behaviour.

This is why your doctor is likely to want to monitor you pretty closely, especially during the first few weeks of treatment, or when changing your dose.

Pill pushers?
Despite the fact NICE advises against antidepressants for mild depression, GPs in England issued more than 31 million prescriptions for them in 2006 (6 per cent up on 2005).

But uncaring doctors aren't doling out antidepressants like sweeties. The real story is lack of access to talking therapies on the NHS, for which patients have to wait many months in some areas.

GPs, in wanting to help you, find themselves in a sticky position: do they stick to the guidance and offer you nothing for several months, or do they stick their necks out and offer you an SSRI while you're waiting for therapy?

Talking therapies
There's evidence the so-called talking therapies can be very effective in treating depression, either on their own or, if the problem's more severe, in combination with antidepressants.

The main ones are cognitive behaviour therapy (CBT), problem-solving therapy and counselling. These are all more about practical ways to change your thinking patterns than delving into the recesses of your childhood.
For milder depression, I often recommend either self-help books based on the cognitive behaviour approach, or online programmes, such as Mood Gym, offering a form of CBT.

There's no waiting list, you can take it at your own pace, and it's often enough to help you out of the depression pit without resorting to pills.

Dr Graham Easton works in a London GP practice with around 10,000 patients. It has three GP partners, three salaried doctors and fully computerised medical records. His medical training was at The Royal London Hospital. He's also an experienced medical journalist who has worked for BBC Radio Science and the British Medical Journal.

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