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Short Notes on Depression 2017 - Dr Mark Burgin

12/09/17. Dr. Mark Burgin BM BCh (oxon) MRCGP considers the elements that should be included in a primer for clinical negligence cases involving Depression.

Depression is part of a complex of unpleasant feelings associated with sadness, the type of depression is characterised by the symptoms associated with these feelings.

NICE guidance focuses on the feeling of low mood and the lack of interest as the core symptoms and does not consider the associated symptoms as important to management.

NICE says that the mental health assessment should include an assessment of the disabling effects of the depression which the DSM V describes as impairment in social, work or other.

The DSM V asks for 5 or more symptoms including low mood and loss of interest symptoms include weight change, fatigue, insomnia, guilt, poor concentration, agitation and thoughts of dying.

There is significant degree of controversy in the management of depression with significant funding increases and political efforts such as IAPT.

Immediate Access to Psychological Therapies IAPT

The NICE guidance does not discuss the role of GPs in the management of depression and refers to low-intensity psychosocial interventions delivered by trained professionals.

In the UK the IAPT service has been audited and found to deliver the recommended number of sessions to only 30% of the service users many having one session or none. (3)

Whilst over 40% who were treated had recovery from their symptoms this was less than one in 6 of the total referred with many of the rest not considered suitable.

The psychologists delivering the service have raised concern about overwork, difficulty in delivering effective treatment to complex cases and in 2016 about half were showing signs of burnout. (4)

Referring a patient to the IAPT service does not absolve the GP from further responsibility as 5 out of 6 patients will require further assistance.

Role of GP

It appears likely that the General Practitioner will remain the primary deliverer of psychological therapy to patients with depression for the foreseeable future.

Whether GPs are sufficiently trained to perform a mental health assessment or not. failure to attempt to assess a patient with depression would be in breach of their duty.

There are no formal examinations for GPs to demonstrate that they can perform an assessment based upon the biopsychosocial model or that they have undergone further training for a diploma in psychiatry or psychological medicine.

Failure of a GP to ask about each of the following -the patient’s symptoms, their thoughts and disabling effects of the depression is likely to be in breach.

Whilst NICE guidance suggests that anti-depressant treatment is not to be used first line in mild depression for the first 12 weeks a GP is not likely to be in breach when prescribing if they record the reasoning.

GPs who manage complex cases without referring to the mental health team may not be in breach unless the patient has active suicidal thoughts.

Combination therapies

NICE states that few combinations are not allowed and confirms that little research is available but then states that GPs should prescribe in consultation with a consultant psychiatrist.

The problem for GPs is that few consultant psychiatrists would be happy discussing a case that they are not involved with, in effect creating a ban for GPs prescribing combination therapies.

The guidance does not differentiate between high dose combinations where both drugs are used at the top of their range and low dose where the risk of adverse effects is low.

The recent work on short term low dose painkillers to reduce suicidal ideation is likely to be both safe and save lives, the average dose was 0.4mg per day less than a tenth of the normal dose for pain. (5)

Unusual combinations are not likely to be in breach per se but if there is no record of why the practitioner has used that combination particularly when high doses are chosen then breach is likely.

Conclusions

IAPT Psychological therapies is having problems with delivering an alternative to primary care so the GPs will remain liable for most adverse events even when the patient has been referred.

The GP can be in breach for not making an appropriate assessment of the patient and for not recording the rationale behind the therapy used.

Patients may be found to have been vulnerable due to their mental health problems which can increase the GP’s responsibility for issues such as did not arrive (DNA), GPs behaviour and consent.

Whilst specialists can refuse to accept referrals for alcohol dependant patients with depression GPs are in breach if they cannot offer an urgent appointment.

A primer in depression will need to differentiate between high and low risk management of patients and consider whether failure to assess a psychological patient by a GP is professional issue.

Doctor Mark Burgin, BM BCh (oxon) MRCGP is on the General Practitioner Specialist Register.
Dr. Burgin can be contacted This email address is being protected from spambots. You need JavaScript enabled to view it. and 0845 331 3304 website drmarkburgin.co.uk

  1. NICE 2009 Depression in adults: recognition and management nice.org.uk/guidance/cg90

  2. American Psychiatric Association 2016 Diagnostic and Statistical Manual of Mental Disorders (DSM–5)

  3. Royal College of Psychiatrists (2013). Report of the Second Round of the National Audit of Psychological Therapies (NAPT) 2013. London: Healthcare Quality Improvement Partnership.

  4. British Psychological Society 2016 Psychological therapies staff in the NHS report alarming levels of depression and stress – their own

  5. Yovell 2016 Ultra-Low-Dose Buprenorphine as a Time-Limited Treatment for Severe Suicidal Ideation: A Randomized Controlled Trial Volume 173, Issue 5, May 01, 2016, pp. 491-498

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