Common mental disorders and symptoms

common mental disorders and preventive measures and top 5 most common mental disorders
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Identification of Common Mental Disorders and Management of Depression in Primary Care Evidence-based Best Practice GuidelineAlgorithm 2c Background Management of mild depression in adults in primary care 1 6YjaiYV\cdhZYlibaYYZegZhhdc 1.1 Primary care challenges 6XikZbVcV\ZbZci ™;ghi"acZigZVibZcihVXikZhjeedgi The identification and management of mental disorders in primary care is a VYkXZdcZmZgXhZVcYhZa"bVcV\ZbZci challenging and complex process. Mental disorders are extremely common in this ™:cXdjgV\ZVXikVidcdhdXVahjeedgi cZildg`hVbanlcVj setting, with over one third of adults attending primary care likely to have met the ™GZZgidehnXdhdXVaZaec\V\ZcXZh ® 1 criteria for a DSM-IV diagnosis within the past 12 months. VhgZfjgZYZ\gZaVidcheXdjchZaac\ The identification of common mental disorders is dependent on a number of factors, not least the availability of treatment resources that make identic fi ation worthwhile. There is evidence that identification rates might be improved by encouraging disclosure, fostering continuity of care and having a high index of suspicion with patients who have known 2 risk factors for common mental disorders. However, practitioners rarely address mental 8acXVaVhhZhhbZciVi Yes disorders in isolation from other health problems and must prioritise between competing '¶)lZZ`hcYXViZh igZVibZcigZhedchZ4 clinician, patient and practice needs, often within difc fi ult time and resource constraints. Low identification rates of mental disorders can be attributed partly to a process of prioritisation, whereby practitioners treat only those with marked mental distress and 3 address other more urgent problems in patients with minimal functional impairment. No Presentations of psychosocial distress in primary care often do not correspond well with standard diagnostic criteria, as subthreshold conditions are often associated with 8dchYZgciZchnc\XVc\c\dg Vj\bZcic\bZVhjgZhiV`ZcidYViZ significant functional impairment, while people meeting diagnostic criteria are not 4,5 6,7 always as disabled. There is ongoing debate about diagnostic cut-off points. A high proportion of patients in primary care practice present with medically unexplained symptoms, that is, a mix of physical and psychological symptoms with no 8 identifiable pathology. Although practitioners recognise that in most cases medically Yes unexplained symptoms are an expression of psychosocial distress, it can be difficult HjWhiVciVabegdkZbZci GdjicZbVcV\ZbZci gZedgiZYVi)¶+lZZ`h4 licegbVgnXVgZ to know what approach to take. A sense of frustration (and concern about missing a 8 possible biomedical disease) can make the patient-practitioner relationship difficult. 9 A British Columbia guideline on depression claims that even when depression has been recognised, treatment is often suboptimal. The guideline suggests that this is due to the following problems, several of which may apply in New Zealand: No • patient reluctance to seek and/or comply with treatment, due to the stigma IgZViVhbdYZgViZYZegZhhdc associated with mental disorders • inadequate dosage and duration of antidepressant therapy • failure to educate patients about the nature of depression and to support self-management • failure to recommend evidence-based psychotherapy Identification of Common Mental Disorders and Management of Depression in Primary Care 1• limited access to psychiatrists and other mental health practitioners • lack of ongoing monitoring and maintenance treatment despite high rates of relapse and recurrence. Given competing demands, resource constraints and uncertain diagnostic criteria, it can be difficult for the primary practitioner to allocate intervention thresholds. For more intensive treatments, such as psychological therapies, there is a constant tension between need and treatment availability. It is the intention of this guideline to focus on best practice notwithstanding current resource constraints. 1.2 Cultural perspectives Cultural constructs of mental health 10 The assessment of mental disorders requires culturally sensitive practice. This includes an openness to holistic views of health with a spiritual dimension, though no assumptions can be made about an individual based solely on culture or ethnicity as there is wide 11 diversity within any cultural group. Symptoms described in one cultural group do not necessarily have a counterpart in others. For example, some beliefs regarded as 12 delusional in one culture may be accepted within another. Traditional Mäori and Pacific perspectives challenge some commonly-held assumptions in Western psychological and counselling theory, such as the Western 13,14 focus on developing individuality and self-advocacy. Mäori may question the view that detachment from the family is a sign of strength and likewise query the merits 13,15 of verbalising thoughts and feelings. There is speculation that some counselling therapies that focus on the individual may be less relevant and less acceptable for Mäori and Pacific patients, who place more emphasis on relationships beyond the 16,17 person than on self-searching. Mäori and Pacific models of wellbeing emphasise collectivity over individualism, continuity over the ‘here and now’ and spirituality over the secular. Mäori models 18 19 of wellbeing, such as Te Wheke and Whare Tapa Wha, view the wellbeing of the individual as inseparable from the wellbeing of the whänau, hapü, iwi and family in 14 all its dimensions, as do Pacific models, such as Fonofale. Interventions serve to sustain these various dimensions, rather than to correct 18,20 dysfunction. The wairua or spiritual wellbeing is not only the key to one’s identity but also provides a link to the wider whänau, thus connecting the individual with the 21 wider community that provides strength, support and safety. Medical terminology may be misinterpreted and concepts such as ‘chemical imbalance’ may not be easily understood if they are at variance with beliefs that ascribe mental 22 disorder to wider causes. Similarly, clinicians using restricted interpretations of 2 Identification of Common Mental Disorders and Management of Depression in Primary CareChapter 1 Background 23 psychiatric phenomena are at risk of misinterpreting their significance, and might, 22,24 for example, ignore spiritual experiences or regard them as pathological. Models of mental health are now embracing more holistic views, with an acceptance of the significant impact that social, economic and environmental factors have on wellbeing, an awareness of diversity and a recognition that mental distress is part of 25 common human experience. Even so, utilisation of Mäori and Pacific community- based mental health service providers, such as kaumätua (koroua/kuia), tohunga and traditional healers, requires a level of understanding of theoretical and methodological 22,26,27 differences on the part of most New Zealand health practitioners. Cultural barriers to mental health care Mäori As a group, Mäori have poorer health status than non-Mäori, regardless of their 28 level of education, income or occupation. Mäori have a high prevalence of mental 29 disorders and tend to access mental health services at a later stage of illness 28 and with more severe symptoms. Disparities in outcome have been attributed to different variables including historical, economic, cultural and social factors, and 30,31 both interpersonal and institutional racism. There is also evidence that ineffective communication between provider and patient contributes to some of the disparity in 15 Mäori primary mental health outcomes. Although the burden of addressing disparities cannot be taken up solely by health practitioners, they need to be aware of the context within which they are delivering health 11 care to Mäori, and the potential barriers to, and facilitators of, the delivery process. Pacific peoples Pacific peoples in New Zealand are also relatively disadvantaged across most social, economic and health indicators and their health status falls about midway between 32 that of Mäori and non-Mäori groups. Pacific peoples have a high prevalence of mental disorders and suicidal behaviour, compounded by significant underutilisation 33 of health services. Prevalence rates of mental disorders also appear to increase as 34 a function of time spent in New Zealand. Pacific people frequently present late to 33 33 services, and report difficulty accessing culturally appropriate care and information. 35 In addition, Pacific people may face language barriers. Doctors responding to the National Primary Care Medical Survey rated 22% of Pacific people attending primary 36 care as lacking fluency in English. The language used in health care interactions can 37 pose particular difficulties, and there can be difficulty in ensuring confidentiality when 33 interpreters are used. As with Mäori, provision of acceptable and accessible services must be a priority in this vulnerable population. Identification of Common Mental Disorders and Management of Depression in Primary Care 3Asian peoples About 7% of the New Zealand resident population is Asian, the largest ethnic 38 groups being Chinese, Indian and Korean, of whom the vast majority are migrants. This population group is very diverse in religion, culture, language, education and socioeconomic situation, and few generalisations can be made. However, as a group, Asian migrants share a range of risk factors for mental disorders, such as social 38 isolation, language barriers, underemployment and unemployment. There is little evidence on specific ways that social and cultural factors impact on the presentation of mental disorders in this population, but the literature notes that for many Asians there is a strong stigma associated with mental disorders which 39 may delay presentation and treatment. It has also been reported that somatisation (the physical manifestation of mental distress) is more common in this population 39 than in Western societies. Health surveys have identified that Asian patients want better access to more user-friendly services and have identified mental health as a 38,39 priority. The Mental Health Commission report on Asian mental health highlighted, in particular, the high mental health needs of women and refugees within smaller migrant communities (eg, Vietnamese, Indonesian), and of older migrants and refugees suffering from pre-migration trauma, combined with the stress of adapting 39 to a new culture. Refugees often have specific needs associated with the effects of 39-41 trauma and/or torture. There is general recognition of the need for New Zealand practitioners to develop skills in interacting with Asian patients and to increase their awareness of how cultural factors influence the presentation and treatment of mental 38 disorders in this population. 1.3 Epidemiology of common mental disorders Prevalence in different populations All adults 34 The New Zealand Mental Health Survey, undertaken between 2003 and 2004, was a nationally representative face-to-face household survey of nearly 13,000 New Zealanders (aged 16 years and over). The survey provides prevalence data for four groups of major mental disorders: anxiety disorders, mood disorders, substance use disorders and eating disorders. Disorders were diagnosed using a fully-structured ® diagnostic interview which generated DSM-IV diagnoses. The survey revealed that mental disorders are common in New Zealand, with 40% of respondents reporting that they had experienced a disorder at some time in their lives. A total of 21% had experienced a disorder in the 12 months preceding the survey, of which approximately 34 5% were classified as serious, 9% as moderate and 7% as mild. Overall, anxiety 4 Identification of Common Mental Disorders and Management of Depression in Primary CareChapter 1 Background disorders were the most commonly encountered mental disorder (lifetime prevalence rates of 25%), followed by depression and other mood disorders ie, bipolar disorder 34 and dysthymia (20%) and substance use disorders (12%) (see Table 1.1). Data from the Dunedin Health and Development Study showed that most adults with ® a psychiatric disorder had a diagnosable disorder in childhood (any DSM-IV disorder, 42 identified either by structured interview or by self-report of treatment). Similarly, the New Zealand Mental Health Survey found that half of all people who developed a major mental disorder had experienced the disorder by age 18 years and three-quarters by the 34 age of 34 years. Median age of onset was 13 years for anxiety disorders, 32 years for mood disorders, 18 years for substance use disorders and 17 years for eating disorders. Generalised anxiety disorder and major depressive disorder had the highest median onset ages (32 years). However, a r fi st episode of depression, one of the most common disorders, can occur at any time of life, with one quarter of first episodes reported in the 34 New Zealand Mental Health Survey experienced at age 50 years or older. Women have slightly higher overall lifetime prevalence rates of mental disorder (42%) 34 than men (37%). Women have higher rates of major depressive disorder (9% higher than men), specific phobia (7% higher), post-traumatic stress disorder (4% higher) and generalised anxiety disorder (3% higher). Men have higher rates of alcohol abuse (9% higher than women), alcohol dependence (3% higher), drug abuse (4% higher) 34 and drug dependence (1% higher). The Mental Health and General Practice Investigation (MaGPIe) survey of mental 1 health in general practice reported rates of common mental disorders in the preceding Table 1.1 Lifetime prevalence of common mental disorders in New Zealand adults Anxiety disorders Mood disorders Substance use disorders Specific phobia 11% Major depressive 16% Alcohol abuse 11% disorder Social phobia 9% Drug abuse 5% Bipolar disorder 4% Post-traumatic 6% Alcohol 4% stress disorder Dysthymia 2% dependence Panic disorder 3% Any mood disorder 20% Drug dependence 2% Agoraphobia 1% Any substance use 12% disorder Obsessive 1% compulsive disorder Any anxiety disorder 25% Includes those with more than one disorder Source: Oakley Browne MA, et al. (eds). Te Rau Hinengaro: The New Zealand Mental Health Survey. Wellington: Ministry of Health; 2006. Identification of Common Mental Disorders and Management of Depression in Primary Care 512-month period amongst adults attending general practice. Substance use disorders were found to be more common in men than women (17% vs 8%). Depressive disorders (depression and dysthymia) and anxiety disorders were approximately twice as common 1 in women compared with men (22% vs 12% and 26% vs 12%, respectively). Mäori The New Zealand Mental Health Survey found that mental disorders were common among Mäori with at least half (50.7%) of adults experiencing at least one disorder over their life before interview and 29.5% experiencing at least one disorder in the 29 previous 12 months. These findings are consistent with evidence from the MaGPIe study that showed a relatively high prevalence of common mental disorders among 43 Mäori primary care patients. Many disorders experienced within the previous 12 months were considered serious (29.6%) or moderately serious (42.6%), and analyses of comorbidity found that multiple disorders were common, suggesting that such 29 disorders have a considerable impact among Mäori. Anxiety disorders were the most common disorder (lifetime 31.3%; previous 12 months 19.4%), and mood and substance disorders were also common, especially major depressive disorder (lifetime 15.7%; previous 12 months 6.9%). Alcohol disorders were the most prevalent substance use disorder (lifetime 24.5%; previous 12 months 7.4%). Drug disorders were also common (lifetime 14.3%; previous 12 months 4.0%), 29 particularly marijuana abuse and dependence. Disorders were more prevalent among Mäori women than men (previous 12 months 33.6% vs 24.8%), partly due to an increased rate of anxiety and mood disorders. Disorders were also more prevalent among young people, with a disorder occurring in the previous 12 months in about one-third of 15- to 44-year-olds. When the relationship between household income and mental disorder was examined, the prevalence rates for mental disorder were highest among Mäori with the lowest income and supported the view that socioeconomic position contributes to mental 29 disorders among Mäori. Pacific peoples The New Zealand Mental Health Survey found high rates of mental disorders among Pacific adults, with an overall prevalence of 25% for the previous 12 months compared 34 with 21% for the total New Zealand population. There were also higher rates of suicidal ideation (4.5%) and attempts (1.2%) for the previous 12 months than among the general population. Only 25% of Pacic fi people who had experienced a serious mental disorder had visited any health service for mental health reasons, compared with 58% for the general population. The prevalence of mental disorders was lower among 44 Pacific people born in the Pacific Islands than among those born in New Zealand. 6 Identification of Common Mental Disorders and Management of Depression in Primary CareChapter 1 Background Asians There have been few studies of the prevalence of mental disorders among Asian ethnic groups in New Zealand. The limited evidence suggests that the prevalence of mental disorders among Asians does not differ significantly from that of the general 39 population. However, there are indications of high levels of depression among older Chinese immigrants and of a high prevalence of post-traumatic stress disorder among 39 Cambodian refugees. Young people The most prevalent childhood and adolescent mental disorders among young people in New Zealand are anxiety disorders, mood disorders, conduct disorder and 45 substance abuse. The overall and gender-specific prevalence of various disorders changes over time (see Table 1.2), with an overall increase up to the age of 18 years. In childhood and early adolescence, males are at greater risk, with higher rates of conduct disorder, attention-deficit hyperactivity disorder, and de pressive disorder (depression and dysthymia) in boys. In adolescence, the rates of depression/dysthymia and anxiety disorders increase dramatically in females. However, the rate of substance 45 abuse is higher in males. New Zealand rates of mental disorders for young people are commonly taken from two long-term South Island studies of a 1972 to 1973 birth cohort of 1037 children 46 (Dunedin Health and Development Study ) and a 1977 birth cohort of 1267 children 45,47 (Christchurch Health and Development Study). The Dunedin study found that in 11-year-olds there was an 18% 1-year prevalence rate of mental disorders in their cohort, rising to 35% in 18-year-olds. Prevalence in 18-year-olds in the Christchurch study was similarly high at 42%. A limitation of these epidemiological data on the prevalence of mental disorders is that the extent of functional disability is not described. The disorders identie fi d are likely to range from relatively mild and adolescent-limited conditions, to severe and chronic illness. The data from these studies should therefore be taken to represent an upper limit estimate of the number of young New Zealanders 48 with significant psychiatric problems. Overall, the studies showed that rates stabilised 49 from the age of 18–21 years and new cases began to decline. 51 Childhood anxiety commonly precedes adolescent depression and studies comparing anxiety and depression have revealed a common genetic predisposition for these 53 disorders. In the presence of both anxiety and depression, there is an increased risk of developing a comorbid substance disorder and treatment responsiveness is 54 45 reduced. Forty percent of 18-year-olds met the criteria for more than one disorder. Identification of Common Mental Disorders and Management of Depression in Primary Care 7Table 1.2 Prevalence of common mental disorders in children and adolescents Disorder (in order of prevalence) Estimated population prevalence (%) Total Boys Girls Preschool † Preschool behaviour problems (parent rated) 16 17 14 ‡ Hyperactive behaviour disorder 2 2 2 Primary school age § Attention-deficit hyperactivity disorder 14 19 9 Anxiety disorder (esp. separation anxiety) 5 n/a n/a § Conduct disorder 3 5 2 § Depression/dysthymia 3 4 2 Pre-adolescence (11 years) Conduct/oppositional disorder 9 12 5 Attention-deficit hyperactivity disorder 7 11 2 Separation anxiety 4 2 5 Overanxious disorder 3 4 2 Depression/dysthymia 2 3 1 †† Any mental disorder 18 20 17 Mid adolescence (15 years) Anxiety disorder 13 7 19 Conduct disorder 5 7 3 Depression/dysthymia 6 3 9 ‡‡ Any mental disorder 22 16 28 Late adolescence (18 years) Alcohol or substance abuse/dependence 24 29 20 Depression/dysthymia 18 10 27 Anxiety disorder 17 12 22 ‡‡ Any mental disorder 42 39 45 New Zealand data have been used where available † New Zealand. 2.5- to 5-year-olds, current prevalence in Pavuluri MN, et al. J Paediatr Child Health 50 1996;32:132–7. ‡ New Zealand. 3-year-olds, current prevalence from Dunedin Health and Development Study in McGee R, et al. Mental Health. In: Silva PA, Stanton WR, editors. From child to adult: the Dunedin Multidisciplinary Health and Development Study. Auckland: Oxford University Press; 1996. p. 150–62. § Australian. 6- to 12-year-olds, 1-year prevalence from Sawyer MG, et al. Mental health of young people in australia: child and adolescent component of the National Survey of Mental Health and Wellbeing. Canberra: Commonwealth Department of Health and Aged Care; 2000. continued over... 8 Identification of Common Mental Disorders and Management of Depression in Primary CareChapter 1 Background Table 1.2 Prevalence of common mental disorders in children and adolescents continued... US Great Smoky Mountains Study. 9- to 10-year-olds, 3-month prevalence from Costello EJ, et al. 51 Arch Gen Psychiatry 996;53:1137-43. Dunedin Health and Development study. 1-year-olds, prevalence from Anderson JC, et al. Arch Gen 52 Psychiatry 1987;44:69-76. 1-year prevalence, Christchurch Health and Development Study from Fergusson D, et al. Aust N Z 47 J Psychiatry 2001;35(3):287-96. †† Any common DSM-III disorder (attention-deficit hyperactivity disorder, conduct disorder, oppositional disorder, depression, dsythymia, separation anxiety, overanxious disorder, avoidant disorder, phobia, panic disorder, obsessive-compulsive disorder, psychosis). ‡‡ Any common DSM-III–IV disorder (anxiety disorder, conduct disorder, depression/dsythmia, alcohol/ substance use disorder). Late puberty is associated with widespread and common experimentation with drugs (usually alcohol and marijuana) and also with a three-fold increase in substance 55 abuse. Most 12- to 17-year-olds in New Zealand have access to alcohol and over 12% consume large amounts weekly (6 and 4 standard drinks for males and females, 56 57 respectively). About 38% of 15- to 17-year-olds have tried marijuana. Multiple substance abuse is also common. Two-thirds of New Zealand adolescents with 58 marijuana dependence are also alcohol dependent. Clinicians tend to underestimate adolescent substance-related pathology and this is probably the most commonly 59 missed diagnosis in this age group. Mental disorders in young people lead to emotional distress, impaired functioning, 34,60,61 physical ill-health and increased suicide risk. They also carry a high risk of a pattern of recovery and recurrence (more likely in females) or unremitting persistence 42,62,63 (more likely in males) into adult life. Follow-up data from the Dunedin Health and Development Study found that young men who were antisocial and aggressive in childhood and delinquent in adolescence were highly maladjusted at 26 years, with mental health problems, psychopathic personality traits and histories of drug-related and violent crime (including domestic violence). Problems among those with a history of adolescent-onset delinquency were less extreme but included mental health and financial problems, and property offences. A third group who were aggressive as children but not very delinquent as adolescents were anxious, depressed, and had financial and work problems. These findings reinforce the need for effective intervention with aggressive children 64 and delinquent adolescents, in an effort to prevent very serious problems in adult life. Identification of Common Mental Disorders and Management of Depression in Primary Care 91.4 Etiology of common mental disorders The etiology of common mental disorders is multifactorial and complex. It involves the interaction of differing susceptibilities, environmental exposures and stressful life 65,66 67 68 69 events, and encompasses a range of genetic, developmental, biochemical, 70 71 72 endocrine, nutritional and psychosocial factors. Moreover most risk factors, whether genetic or environmental, involve probabilistic rather than deterministic 67 effects. This complexity explains the heterogeneity of presentations and may account 53,67 for differential responses to treatment. There is strong research interest in genetic 73-76 and biochemical vulnerabilities and their influence on mental health, including the 77,78 potential for biochemical prevention and/or treatment of depression. There is widespread acceptance that mental disorders can be triggered by the 66,79 interaction of individual risk factors with stressful situations. However, this sequence of events does not invariably apply; further, there are factors that appear to protect 65 against depression following a stressful life event. For a first episode of depression, the commonly encountered risk factors are detailed in Table 1.3, along with a short list of protective/resilience factors. Table 1.3 Risk factors and resilience factors for depression Common risk factors Resilience factors (which could lead to vulnerability) (protective in the presence of risk factors) § Parental history of depression Good parenting † Difficult temperament as a child Easy temperament as a child Attachment difficulties/parental neglect Good peer relationships ‡ Family discord Stability in love relationships Previous depression/anxiety in adulthood Has coped with past difficulties well Ruminating over negative circumstances Displays behaviour such as impulsiveness, shyness, difficulty in concentrating, easily upset, poor task persistence, irritability. † Displays behaviour such as adaptability in novel situations, sociability; has a low intensity of reactions. ‡ Tension between parental figures, arguments or fighting (often preceded by financial problems). § Research indicates that good parenting includes emotional warmth and cognitive stimulation 82 (Kim-Cohen 2004). Sources: 80 Bruder-Costello B, et al. Psychiatry Res 2007;153(2):145–51. 81 Brown GW, et al. J Affect Disord 2007;103;(1-3):225–3. 10 Identification of Common Mental Disorders and Management of Depression in Primary CareChapter 1 Background A history of depression in one or both parents puts offspring at a three-fold increased 80 risk of depression. Furthermore, a history of parental depression increases the risk that a child will have a difficult temperament, which is itself a risk factor for depression. A child with a difficult temperament is two to three times more likely to develop 80 depression than a child with an easy temperament. Parental maltreatment or experiencing family discord as a child provide a two- to four- 83 fold increased risk of recurrent or chronic adult depression and if the individual is 84 maltreated while siblings are not, that risk increases to 12-fold. Emotional neglect and abuse, including physical or sexual abuse during childhood, can also act as precursors to mental disorders, given a lack of protective factors (see Table 1.3), as can attachment 85 problems. However, there is nothing inevitable about the development of mental 84 disorders, particularly in the presence of protective factors of resilience. 86 Low socioeconomic status in childhood does not appear to predict psychopathology 82 unless accompanied by family discord or lack of maternal responsiveness. However, socioeconomically disadvantaged adults appear to be less likely to receive effective 86 treatment. Vulnerability and resilience Resilience can be viewed as a collection of personal qualities that enable one to thrive in 87 the face of adversity, that is, possessing innate stress-coping abilities. High resilience has biological validity given the correlations with specific genetic markers and sympathetic/ 88 parasympathetic balance. Vulnerability has correlations not only to the presence of 89 certain genetic markers but also to childhood adversity and attachment difficulties. It has been reported that insecurely attached 15-month old babies can have problems 90 with anxiety by 5- to 6-years of age if affected by stress, unlike securely attached babies. 91 A secure maternal attachment style is also associated with raised social maturity in girls. Differences in basic patterns of reaction towards unhappy and traumatic circumstances are found in all humans and are relatively stable characteristics. Resilience is related to having at least one caring parent, good peer relationships in adolescence, the quality 92 of adult friendships and the stability of marital and other love partnerships. Knowing (or asking) whether a person is able to adapt easily to stress and has a tendency to ‘bounce back’ after illness or hardship gives an indication of the risk of mental health 88 consequences when a person is exposed to new stressful life circumstances. The concept of resilience, once regarded as a personal trait, is more recently viewed as a dynamic developmental process, and the focus in research has shifted towards 93 resilience-based intervention and prevention programmes. 79 The ‘stress-vulnerability model’, also known as the ‘diathesis-stress model’ takes into account both biological and psychological factors in explaining mental disorders. This theory predicts that an underlying vulnerability can be triggered or exacerbated 66 by current stressful conditions. Identification of Common Mental Disorders and Management of Depression in Primary Care 1194 The ‘hopelessness theory’ concentrates on hopelessness as the core characteristic of depression, the presence of which signifies the need for further exploration of depressive symptoms. Stresses and vulnerabilities combine to exacerbate hopelessness, especially when the person attributes stress to global and stable causes (eg, ‘It’s always like that’ or ‘You can’t do anything about it’), or catastrophises thoughts, or views her 95 or himself as deficient or incapable. These two theories and others coalesce under the umbrella of ‘developmental psychopathology’, which takes into account vulnerabilities, contexts and timing. In this theory, mental health is conceptualised as a consequence of intra-individual 96 and extra-individual circumstances, which fits in with the stress-vulnerability model. 97 Obvious signs of stress in children are associated with later mental health problems. Some personality types are particularly vulnerable to depressive tendencies. Depressive symptoms in 18-year-old boys are often associated with a pattern from early childhood 98 of antisocial, aggressive and outwardly-directed behaviour. Girls are more likely to 98 have a history of overly-compliant, self-blaming and inwardly-directed behaviour. Anxiety is a risk factor for developing substance dependence (1.3 – 3.9 times more likely) among young people in New Zealand. The association appears to be largely non-causal, reflecting adverse factors that increase individual susceptibility to both anxiety disorders and substance use, such as family adversity, parental psychopathology, 99 child abuse, personality factors and behavioural adjustment in childhood. 1.5 Special issues Depression in the antenatal and postnatal period Depression in the antenatal and postnatal period is common, although estimates 100 of prevalence vary. A systematic review of prevalence and incidence suggests that about 13% of women have an episode of major or minor depression during 100 pregnancy, of which up to 6% meet the diagnostic criteria for major depression. Similarly, up to 19% of women have an episode of major or minor depression within 100 3 months of childbirth, of which approximately 7% are major depression. The etiology of mental disorders in the antenatal and postnatal period is complex and reflects the profound social, psychological and biological changes occurring in this 101 period. Genetic, biochemical, endocrine, and social factors may all play a part. Although the course and prognosis of depression in the antenatal and postnatal period is similar in many respects to depressive disorders experienced at other times, there may be distinct causative factors for postnatal depression occurring in women with no history of a mood disorder (ie, de novo), possibly associated with postnatal 102,103 neuroendocrine changes. Women with de novo postnatal depression appear 102 to recover more quickly than those with a history of a mood disorder. It has also 12 Identification of Common Mental Disorders and Management of Depression in Primary CareChapter 1 Background been suggested that such women may have specific vulnerability to the relationship 104 74 demands of early motherhood or may have predisposing physiological traits. Women with de novo postnatal depression appear to be at increased risk of further 102 episodes of postnatal depression, but not for non-post partum episodes. The potential impact of a maternal mental disorder early in an infant’s life favours urgent identification and intervention. Postnatal mental disorders have been associated with a wide range of negative outcomes affecting both mother and child, including 105 106 obstetric and perinatal difficulties, poor mother-child interaction, long-term 107,108 developmental and mental health problems in offspring, and mental disorders 109 in male partners. A systematic review of literature on risk factors for postnatal depression found that potentially important factors were the mother’s level of social support, life events and 101 psychiatric history. Depressed mood or anxiety during pregnancy were the strongest 101 predictors of depression in the antenatal and postnatal period. However, it has been reported that many women presenting in primary care in New Zealand with depression in the postnatal period do not have identifiable risk factors, such as poor social 103 support or partner relationship problems. Depression in older adults Overall, the 12-month prevalence of depressive disorders among community-dwelling older adults aged over 65 years in New Zealand primary care is about 2% for men 1 and 5% for women. Older adults in residential care are at much higher risk of 110 depression, with a prevalence of about 18% in low-level care residential facilities. 111 A study from the Netherlands reported that the best predictors of depressive symptoms in the very old (75–85 years) were the fear that they were declining cognitively, difficulties in daily functioning, fear of falling, and being alone during part of the day, followed by the presence of chronic physical disease. Depression in older adults is often missed by practitioners, as older adults appear reluctant to report mental health problems and when reported, practitioners tend to attribute the 112 problems to normal aspects of aging or disease. Chronic medical conditions 113 Mental and physical illness commonly coexist. The course of disease is altered, disability is increased, quality of life is reduced, treatment is more complex, and mortality 114 risks higher when physical disease is comorbid with mental disorders. A chronic medical condition combined with a mental disorder can lead to a less than optimum medical response unless both conditions are treated. Identifying and treating the mental 113 disorder can thus improve health outcomes and reduce health care utilisation. Identification of Common Mental Disorders and Management of Depression in Primary Care 13Sexuality Data from the Christchurch Health and Development Study indicated that lesbian, gay and bisexual young people are at significantly increased risk of mental health problems. The risk of a disorder between 14- and 21-years-old is increased approximately four- to six-fold for major depression, suicidal ideation and suicide attempts, conduct disorder, 115 nicotine dependence and multiple disorders. These adolescents are highly vulnerable to bullying and verbal assault at school, with negative effects on educational attainment 116 and on satisfaction with a lesbian, gay or bisexual identity. There is also evidence of increased vulnerability to mental disorders, psychological distress and/or alcohol abuse among lesbian, gay and bisexual adults in comparison 117,118 to heterosexuals. There is evidence that lesbian women who have identified with their sexual orientation for a long period of time are less likely to have mental 118 disorders than those who have more recently identified as lesbian. Mental health issues related to sexuality will go unaddressed unless the health provider is aware of the patient’s sexual identity, yet most health providers assume that patients 119 are heterosexual and do not provide them with an opportunity to disclose otherwise. Suicide Prevalence 120 Suicide and attempted suicide are important health problems in New Zealand. Each year there are approximately 500 deaths by suicide and 10 times as many 120 hospitalisation events for intentional self-harm (5400 events in 2006). Suicide rates are high in young people aged 15–24, among whom New Zealand has one of the 120 highest rates out of comparable OECD countries. The prevalence of suicidal ideation (thinking about committing suicide), suicide plans 121 and suicide attempts were reported in The New Zealand Mental Health Survey. Among the general population aged over 16 years the 12-month (lifetime) prevalences were 3.2% (15.7% ) for suicidal ideation, 4.1% (5.5%) for making a suicide plan and 1.6% (4.5%) for attempted suicide. Risk factors 120 Suicide rates are higher in the following sociodemographic groups: • males (age-standardised rate: 20.3 per 100,000 versus 6.5 per 100,000 in females) i • Mäori (age-standardised rate 17.9 per 100,000 versus 12 per 100,000 for non-Mäori) i Most Mäori who die by suicide are aged under 35 years (Ministry of Health, Suicide Facts: 120 2005–2006 Data. 2007). 14 Identification of Common Mental Disorders and Management of Depression in Primary CareChapter 1 Background • age 15–24 (rate 18.1 per 100,000 versus 13.1 per 100,000 overall) • socioeconomically disadvantaged people (age-standardised rate 15.6 per 100,000 versus 9.1 per 100,000 in most deprived versus least deprived areas). The same sociodemographic groups are at increased risk of attempted suicide, except that for this outcome rates are higher among females, with twice as many 120 hospitalisations for intentional self-harm occurring among females as among males. Although the determinants of suicide and suicide attempts include a wide range 122 of influences, including biological, psychological, social and macro-social factors, 123 the overwhelming majority of cases are associated with mental disorder. In the 121 New Zealand Mental Health Survey people with a mental disorder had increased risks of suicidal ideation (12-month prevalence: 11.8%), suicide plan (4.1%) and attempted suicide (1.6%) compared with those without mental disorder. Specific mental disorders associated with increased risk of suicidal behaviour (ideation, plan or attempt) were mood disorder (depression, dysthymia or bipolar disorder), substance use disorder and anxiety disorder. Major depression was the specific disorder most strongly associated with suicidal behaviour. Less than half of those who reported suicidal behaviours within the past 12 months had seen a health professional during that time. 122 The profile of individual risk factors for suicidal behaviour varies across the life span. Suicidal behaviour in young people is often associated with a disturbed or unhappy family background, educational or social disadvantage, mental health or behavioural problems, and/or experience of a recent stressful life event, such as relationship 124 break-up, court appearance or family crisis. In adults the contribution of current mental disorders becomes more prominent, and factors such as childhood adversity become relatively less important, with recent interpersonal or legal problems also 28 adding to risk. Among older people, current mental illness, particularly depression, 120 remains the most important risk factor. In all age groups, social isolation confers additional risk, and negative life events may act as immediate precipitants in those 125 already at risk. The association of socioeconomic factors with suicide is complex and may vary across time. For example, the ratio of inequality in suicide between the least deprived and most deprived areas of New Zealand rose from 1.68 in 1980–1982 to a high of 1.94 in 1990–1992, a period in which New Zealand experienced rapid social and 126 economic change. Prevention and postvention 127 The recently published New Zealand Suicide Prevention Action Plan provides direction on suicide prevention initiatives. It emphasises the role of improved recognition and management of mental disorders, particularly depression, in the prevention of suicide. Identification of Common Mental Disorders and Management of Depression in Primary Care 15Since those who are affected by suicidal behaviour in others are also at increased personal risk of suicidal behaviour, support services need to be available for family and friends after a suicide bereavement or suicide attempt. This applies particularly where there is a risk of suicide contagion, which can result in a cluster of suicides. A postvention support initiative is currently being developed by the Ministry of Health to guide programme development in this area, which may from time to time involve 128 participation by primary health organisations. 16 Identification of Common Mental Disorders and Management of Depression in Primary CarePrinciples of intervention 2 in the primary care setting 2.1 Rationale for intervention The high prevalence and morbidity of common mental disorders such as depression and the potential for effective treatment provide a strong rationale for identification, 65,101 active management and follow-up in primary care. Likely benefits include ease 129 of access for patients, early intervention and a holistic and integrated approach. 2.2 Recognising potential mental disorders A routine check of psychosocial health is the first step in recognising potential mental disorders and the most vital assessment tools are the communication and observational skills of the practitioner. A structured approach to assessment ensures that the relevant domains are addressed and enables the practitioner to identify risks, protective factors and any issues of cultural context and identity. Functional disability should be considered carefully, as many patients with modest or subthreshold symptoms have significantly impaired occupational or social 4,73,130 Substance use disorder can be difficult to recognise because functioning. 131 it is relatively less disabling than some other disorders. Formal assessment tools may have a supplementary role in diagnosis, but can be time-consuming and are less versatile than global clinical assessment. Tools may also be useful to help assess severity and monitor response to treatment. Although many people with mental disorders present with physical complaints, the 132,133 majority will divulge psychological problems if asked directly. A nonjudgmental 134 manner and assurance of confidentiality increase the likelihood of disclosure. The involvement of family/whänau in the assessment process may also encourage disclosure. Sometimes problems take several sessions to ‘unravel’ in the clinical setting and 135 may involve an assessment process of ‘trial and error’. For all patients with mental distress it is therefore vital to negotiate active follow-up. There may only be sufficient time to address urgent concerns within the course of a 15-minute primary care appointment. In the opinion of the Guideline Development Team (GDT), many patients would benefit from an extended consultation to allow 136 time to explore their personal perspectives and promote self-management goals, though it may be difficult to provide this within current resource constraints. Identification of Common Mental Disorders and Management of Depression in Primary Care 172.3 Managing depression: the stepped care model Management options for depression in primary care sit on a continuum from simple advice and monitoring to intensive multidisciplinary intervention. Most individuals with depression present with relatively mild disorders, which are of recent onset and are amenable to treatment in a primary care setting. The minority with severe or chronic 65 disorders require more intensive management, with secondary mental health care input. A ‘stepped care’ approach to management entails choosing the least intrusive intervention required to achieve clinical change for an individual. It is often possible to ‘do more with less’, by starting with a low-intensity therapy, monitoring patient response and moving to more intensive treatments only if the problem persists. The stepped care model guides treatment using a combination of evidence-based principles and continuous clinical assessment. Progression through levels of care is 137,138 determined on the basis of patient response. Support for self-care is a major 139 feature of this approach. The choice of initial therapy will inevitably depend not only on the individual’s needs and preferences but also on service availability. Minimum intervention should not be used as a triaging device as this would risk delaying access to therapy to those with serious need, or loss to follow-up for some who fail to respond at the lower level of input. There also needs to be a clear plan on how to decide whether a treatment is 137,138 effective and when to employ another approach. 2.4 Practitioner roles The term ‘practitioner’ in this guideline is used to refer to any health care practitioner in the primary care or community setting. However, practitioners involved in targeted screening for common mental disorders in primary care will, in most cases, be health professionals working in a general practice setting (eg, GP, practice nurse, nurse practitioner), an educational setting (eg, school nurse or guidance counsellor), or a maternity setting (eg, midwife). Other health care practitioners working in first-point-of contact settings could also undertake this role, if supported to do so by local protocols (eg, public health nurses, occupational health nurses, iwi and Pacific providers, district nurses, Plunket nurses, counsellors, social workers and psychologists). Any practitioner administering screening for common mental disorders needs to have a high standard of communication skills, to be educated in the use and limitations of the screening questions, be aware of the appropriate management of individuals who screen positive, and to be able to action referral for further assessment and treatment. Practitioners involved in the diagnosis and treatment of depression in primary care are likely to be members of the general practitioner/practice nurse team, or therapists 18 Identification of Common Mental Disorders and Management of Depression in Primary CareChapter 2 Principles of intervention in the primary care setting providing psychological therapies who are members of a recognised professional organisation with documented ethical guidelines, professional conduct procedures and requirements for supervision. In New Zealand, general practitioners often focus on the diagnosis and treatment of illness, while the practice nurse role has evolved to include preventative activities, 140 health maintenance and management of long-term disorders. In the general practice setting, there is no good evidence that outcomes differ according to whether 65,141 care is led by the general practitioner or the practice nurse. General practitioners and practice nurses working collegially and collaboratively could share the management of patients with depression and utilise their differing skills to the benefit 140,142 of patients. The literature strongly advocates the use of interdisciplinary team- based models of care as a cost-effective way of improving primary care outcomes for patients with depression. The practice nurse and general practitioner working together could share the tasks involved in the management of patients with depression, such as screening, diagnosis, treatment intervention, patient education, self-management support, monitoring of progress and concordance with treatment, relapse-prevention planning and liaison with other team members. These activities can be undertaken by 142 a mix of face-to-face and other means (eg, telephone, text or email). Structural changes arising from the implementation of the Primary Health Care Strategy are increasing the potential for New Zealand practice nurses to undertake an expanded role. Despite ongoing challenges concerning funding and employment arrangements, a professional infrastructure is now developing and there are growing opportunities for professional development. These changes will increase the capacity for practice nurses 140 to work effectively and collaboratively within a general practice team. 2.5 Managing depression: shared decision-making Successful management of depression is far more likely if the patient is an active 143 participant in the care process. A collaborative partnership between the practitioner 144-147 and the patient is a consistent predictor of outcome regardless of the therapy used. Integral to this partnership is an understanding between practitioner and patient on the 136,145,148,149 significance of depression and the tasks and goals of treatment. The needs, resources and cultural preferences of family and whänau should also be integrated into the care plan, as they can provide the support networks that help facilitate patient 150,151 lifestyle changes and meet treatment goals. In the view of the GDT, treatment for depression is generally ‘preference-sensitive’: there is no one treatment that is clearly superior and so the best choice of treatment depends not only on the benefits and risks of treatment options, but also on the person’s lifestyle, values and preferences. In this situation the practitioner’s aim should be shared decision-making, with an emphasis on informed patient choice as opposed Identification of Common Mental Disorders and Management of Depression in Primary Care 19

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