SCE Psychiatry: Navigating Depression Management Guidelines

As medical professionals, understanding the intricacies of mental health conditions is paramount. In the Specialist Certificate Examination (SCE), particularly for specialties like General Internal Medicine or Acute Medicine, presentations of common psychiatric disorders like depression are frequently tested. This blog post aims to distill the essential guidelines for managing depression, ensuring you're well-equipped for your SCE exam and clinical practice.

Depression is more than just feeling sad; it's a complex, multi-faceted illness that impacts millions globally. For the SCE, you'll need a systematic approach to diagnosis, risk assessment, and management, often following National Institute for Health and Care Excellence (NICE) guidelines in the UK context.

1. Initial Assessment and Diagnosis

Your first step is always thorough assessment. This involves:

• History Taking: Elicit symptoms using diagnostic criteria (e.g., DSM-5 or ICD-10/11). Key symptoms include persistent low mood, anhedonia (loss of pleasure), fatigue, changes in sleep, appetite, concentration, feelings of worthlessness/guilt, and suicidal ideation. Always ask about past psychiatric history, family history, and social circumstances.

• Risk Assessment: This is CRUCIAL. Always assess for immediate risk of self-harm, suicide, or harm to others. This includes intent, plan, and access to means. Document this clearly.

• Physical Examination & Investigations: Rule out organic causes of depressive symptoms (e.g., hypothyroidism, anaemia, vitamin B12 deficiency, neurological conditions, medication side effects). Basic blood tests (FBC, U&Es, LFTs, TFTs, B12, folate, glucose) are often appropriate.

• Severity Assessment: Categorise depression as mild, moderate, or severe, as this dictates management pathways.

2. Stepped Care Model: The Cornerstone of Management

NICE guidelines advocate a stepped care model, where the least intrusive but most effective intervention is offered first. Escalation occurs if symptoms don't improve or worsen.

Step 1: Recognition and Initial Assessment

• For all presentations of depression.

• Active monitoring, support, information about depression, and promotion of wellbeing activities (e.g., exercise, sleep hygiene).

Step 2: Mild-to-Moderate Depression

• Psychological Interventions (First-Line):

  • Low-intensity psychological interventions: Guided self-help (e.g., online CBT programmes), individual brief psychological interventions (e.g., counselling, cognitive behavioural therapy (CBT) delivered by a trained professional).

  • Group-based CBT or behavioural activation.

• Pharmacological Interventions (Consider for some): Consider if symptoms are persistent or not responding to psychological interventions, or if the patient prefers medication. Selective Serotonin Reuptake Inhibitors (SSRIs) are generally first-line.

Step 3: Moderate-to-Severe Depression

• Combined Treatment: Usually involves a combination of medication and high-intensity psychological interventions.

  • Pharmacological: SSRIs are typically first-line (e.g., sertraline, citalopram, escitalopram, fluoxetine). Start low and titrate up. Advise on potential side effects (e.g., nausea, agitation, sexual dysfunction) and delayed onset of action (2-4 weeks).

  • High-intensity psychological interventions: Individual CBT, interpersonal therapy (IPT), or psychodynamic psychotherapy delivered by a specialist.

• Referral to Secondary Care: Consider for severe depression, psychotic features, significant risk, treatment resistance, or complex co-morbidities.

Step 4: Severe and Complex Depression; Risk to Life

• Managed by specialist mental health services.

• May involve crisis teams, inpatient admission, electroconvulsive therapy (ECT), or combination of augmentation strategies (e.g., lithium, atypical antipsychotics).

3. Pharmacological Management: Key Principles

• First-Line: SSRIs (e.g., Sertraline, Citalopram). Avoid citalopram/escitalopram in patients with QTc prolongation risk.

• Duration: Continue antidepressant for at least 6 months after symptom resolution to prevent relapse. For recurrent depression, consider 2 years or longer.

• Switching: If no response after 4-6 weeks at an adequate dose, consider increasing dose, switching to another SSRI, or to an SNRI (e.g., venlafaxine, duloxetine) or mirtazapine.

• Augmentation: For partial response, consider adding an atypical antipsychotic (e.g., aripiprazole) or lithium, usually under specialist guidance.

• Withdrawal: Taper antidepressants slowly to avoid discontinuation symptoms (e.g., dizziness, paraesthesia, anxiety, flu-like symptoms).

4. Special Considerations for SCE

• Depression in Pregnancy/Postpartum: Balancing risks to mother and fetus. Consider psychological therapies first. If medication is needed, sertraline is often preferred due to lower placental transfer and breast milk levels.

• Depression in Older Adults: Increased risk of side effects, drug interactions, and comorbidities. Start low, go slow. Consider less sedating SSRIs.

• Comorbidity with Chronic Physical Illness: Depression is common. Management requires integration with physical health care. Explain how depression can exacerbate physical symptoms.

• Seasonal Affective Disorder (SAD): Light therapy can be effective.

5. Monitoring and Follow-Up

Regular monitoring of symptoms, side effects, and adherence is essential. Use validated scales (e.g., PHQ-9, GAD-7) to track progress. Re-evaluate risk frequently. Encourage self-management strategies and social support.

6. SCE Exam Approach

When faced with a depression scenario in SCE, remember to:

1. Systematically assess the patient's symptoms, history, and social context.

2. Prioritise risk assessment and safety planning.

3. Rule out organic causes.

4. Formulate a management plan based on severity, following the stepped care model (psychological, pharmacological, or combined).

5. Discuss prognosis and the importance of long-term management.

6. Consider specific patient factors (e.g., age, pregnancy, comorbidities).

7. Know when to refer to specialist mental health services.

Mastering these guidelines for depression management will not only help you excel in your SCE exam but also equip you with crucial skills for compassionate and effective patient care in your future practice. Stay updated with the latest guidelines, as mental health care is an evolving field!