Identification of Common Mental Disorders and Management of Depression in Primary Care Evidence-based Best Practice Guideline Identification of Common Mental Disorders and Management of Depression in Primary Care Evidence-based Best Practice Guideline Statement of intent Evidence-based best practice guidelines are produced to help health care practitioners and consumers make decisions about health care in specific clinical circumstances. Research has shown that if properly developed, communicated and implemented, guidelines can improve care. The advice in this guideline is based on evidence from epidemiological studies and other research. Where no evidence is available, but guidance is needed, recommendations for best practice are developed through a systematic consensus process based on the experience of the Guideline Development Team. While guidelines represent a statement of best practice based on the latest available evidence (at the time of publishing), flexibility will be required in local interpretation and they are not intended to replace the health practitioner’s judgment in each individual case. Copyright The copyright owner of this publication is the Ministry of Health, which is part of the New Zealand Crown. Content may be reproduced in any number of copies and in any format or medium provided that it is not changed, sold, used to promote or endorse any product or service, used in any inappropriate or misleading context, and a copyright acknowledgement to the New Zealand Ministry of Health is included. For a full copyright statement go to http://www.moh.govt.nz/copyright Citation: New Zealand Guidelines Group. Identification of Common Mental Disorders and Management of Depression in Primary Care. An Evidence-based Best Practice Guideline. Published by New Zealand Guidelines Group; Wellington: 2008. Published: July 2008 Review Date: 2011 ISBN (Print): 978-0-473-13683-3 ISBN (Electronic): 978-0-473-13684-0 Hard copies of this guideline are available free from: Wickliffe: 04 496 2277 Order Nos. HP: 4597 (full); HP: 4619 (summary) This guideline is also available online at: New Zealand Guidelines Group (http://www.nzgg.org.nz) and the Ministry of Health (http://www.moh.govt.nz) Ministry of Health PO Box 5013, Wellington 6145, New Zealand © 2008 Ministry of Health Ehara täku toa i te toa takitahi, ëngari he toa takitini Mine is not the strength of an individual, but the strength of many Endorsements Te Ao Maramatanga New Zealand College of Mental Health Nurses (Inc.) Partnership, Voice, Excellence in Mental Health Nursing Contents Purpose .........................................................................................................v About the guideline ......................................................................................vii Summary ..................................................................................................... xv Key messages ......................................................................................................xv Algorithms ..........................................................................................................xvi 1 Management of depression in young people in primary care ..........................xvi 2 Management of depression in adults in primary care .................................... xvii 2a Management of severe depression in adults in primary care ......................... xviii 2b Management of moderate depression in adults in primary care ......................xix 2c Management of mild depression in adults in primary care ...............................xx 1 Background .......................................................................................... 1 1.1 Primary care challenges ............................................................................... 1 1.2 Cultural perspectives ................................................................................... 2 1.3 Epidemiology of common mental disorders ................................................... 4 1.4 Etiology of common mental disorders ......................................................... 10 1.5 Special issues ............................................................................................ 12 2 Principles of intervention in the primary care setting ............................ 17 2.1 Rationale for intervention ........................................................................... 17 2.2 Recognising potential mental disorders........................................................ 17 2.3 Managing depression: the stepped care model ............................................ 18 2.4 Practitioner roles ....................................................................................... 18 2.5 Managing depression: shared decision-making ........................................... 19 2.6 Goals of treatment for depression ............................................................... 20 2.7 Culturally competent care .......................................................................... 20 3 Recognition and assessment of common mental disorders in young people/rangatahi/tamariki ................................................... 23 3.1 Applying strengths-based and biomedical models ........................................ 24 3.2 Screening young people/rangatahi/tamariki for common mental disorders..... 25 3.3 Psychosocial assessment of young people/rangatahi/tamariki ....................... 26 3.4 Further assessment where there is concern ................................................... 30 3.5 Assessment tools: evidence review .............................................................. 31 Identification of Common Mental Disorders and Management of Depression in Primary Care i 3.6 Clinical features of common mental disorders in young people/ rangatahi/tamariki .............................................................................................34 3.7 Reaching a diagnosis................................................................................. 38 3.8 Determining severity and when to refer ........................................................ 39 3.9 From assessment to management ............................................................... 40 4 Management of depression in young people/rangatahi/tamariki ......... 43 4.1 Clinical management ................................................................................ 45 4.2 Specific interventions: review of the evidence ............................................... 49 5 Recognition and assessment of common mental disorders in adults/pakeke ................................................................................. 55 5.1 Psychosocial assessment of adults/pakeke ................................................... 56 5.2 Targeted screening of high-risk groups ........................................................ 57 5.3 Further assessment where there is concern ................................................... 59 5.4 Assessment tools: evidence review .............................................................. 61 5.5 Reaching a diagnosis................................................................................. 63 5.6 Determining severity and when to refer ........................................................ 64 5.7 From assessment to management ............................................................... 66 6 Management of depression in adults/pakeke ...................................... 67 6.1 Clinical management ................................................................................ 69 6.2 Prevention of relapse or recurrence ............................................................. 79 6.3 Specific interventions: evidence review ........................................................ 80 7 Special issues: women with mental disorders in the antenatal and postnatal period .......................................................................... 91 7.1 Mental disorders in the antenatal and postnatal period ................................. 93 7.2 Screening of women in the antenatal and postnatal period ........................... 94 7.3 Screening and assessment tools: evidence review ......................................... 95 7.4 Further assessment where there is concern ................................................... 97 7.5 Management of antenatal and postnatal depression .................................... 98 7.6 Specific interventions: evidence review ...................................................... 103 8 Special issues: older adults/koroua/kuia ........................................... 109 8.1 Psychosocial assessment of older adults/koroua/kuia ................................. 111 8.2 Assessment tools for older adults: evidence review ..................................... 111 8.3 Assessing an older adult with cognitive impairment .................................... 112 8.4 Management of depression ...................................................................... 113 8.5 Interventions for depression in older adults/koroua/kuia: evidence review .... 115 8.6 Depression with dementia ........................................................................ 116 ii Identification of Common Mental Disorders and Management of Depression in Primary Care Contents 9 Models of care .................................................................................. 119 9.1 Introduction ............................................................................................ 119 9.2 Generic models: