1. Mental Health Promotion, social inclusion and combating stigma and discrimination.
2&3 Primary care and access to services.
4&5 Effective services for people with severe mental illness
6. Caring about carers
7. Preventing suicide
it was expected that local health and social care agencies would organize Local Implementation Teams (LITs) to follow the remit. The Local Implementation Officer (LIO) was accountable for delivering the framework at local level.
What causes depression
There is no specific cause of depression and varies from person to person and can happen for a combination of factors. Depression often runs in families, suggesting a genetic component. It is also believed to be caused by disturbances in body chemistry. The physical change can be triggered by disease and illness, by traumatic stressful events such as bereavement, illness and retirement, or by work, relationship and financial problems. The lifetime rate of depression is 8 per cent for men and 12 per cent for women, and these figures seem to be rising. This trend is worrying and has been much discussed. Depression is now more frequently diagnosed in younger people than it was previously, this change could well be a result of the increasing social fragmentation, including family breakdown, seen over recent decades. Unfortunately, according to the Agency for Health Care Policy and Research, depression is under diagnosed and under treated by primary care and other non-mental health practitioners. High levels of depressive symptoms are most common among those with a lower socio economic status. In addition individuals who are under educated and unemployed are at a higher risk of depression (Trowler 1991).
When an individual becomes depressed family dynamics become strained. Husbands, wives, children, work colleagues will almost certainly become affected. , loved ones may feel they are walking on egg shells, children may feel guilty for their parents sadness and wife’s, husbands, may loose physical contact because of lack of libido. They may be “snappy” therefore arguments may become a regular occurrence. Depression affects the whole family and can have a profound and detrimental effect. It is therefore imperative for the depressed person to be understood and have as much family support as needed. They should be encouraged to talk through their difficulties with friends and loved ones. Voluntary services such as “The Samaritans” and MIND provide help and advice 24 hours a day 365 days of the year for people suffering depression, and family, friends can also receive advice on how to help. Within the waiting room of our surgery, leaflets are displayed in a variety of languages, with telephone numbers for self help and voluntary groups for people in need of them.
Assessment
There are a vast range of treatment options available for patients suffering with depression. It is therefore imperative for any clinician, when diagnosing depression that a thorough assessment is carried out to determine the severity of the presenting symptoms. There are a number of rating scales which enable a person’s depression to be measured. One of the most widely used is the Beck Depression Inventory (Beck 1967). Beck believed that depression was associated with certain ways of thinking and perceiving the world. Within general practice a Patient Health Questionnaire (PHQ-9) is used as a tool for determining severity. (See appendix 1). The PHQ consists of 9 questions and depending on the patients overall score a grading system will determine whether the depression is mild, moderate or severe. It is equally important to rule out any physical cause for depression by performing certain blood tests. Anaemia, (a lack of iron in the blood) and Thyroid disorders (causes weight gain, loss, and tiredness) and can cause symptoms similar to depression.
Management of depression
The National Institute for Clinical Excellence (NICE) state that no drug treatment is recommended for mild depression as patients often recover without intervention but patients should be offered another assessment if they do not. (Healy, 2005) suggests that physical activity and structured routines along with a healthy diet, plenty of sleep may be enough to clear up the depression. Book therapies are widely used in general practice which teaches self relaxation techniques and coping mechanisms. Of paramount importance for any healthcare professional when dealing with a potentially depressed person is to firstly ask the patient “how are you”, this open ended question is usually enough for the patient to engage in converstaion. The SOLER technique summarises how to use good body language when actively listening to a patient.
S Face the patient
O Adopt an open posture
L Lean towards the other
E Maintain good eye contact
R Relax (Power 1998).
For the treatment of Moderate and severe depression, antidepressant medication alone, or together with Cognitive Behaviour Therapy (CBT) may be beneficial. The drugs which are used for treating depression affect the level of a brain chemical called seratonin which is a chemical messenger that relays impulses from one nerve to another. Anti-derpessant drugs increase the amount of seratonin in the brain (Blows, 2003). It should be noted that anti-depressants can take up to three weeks to start having an effect and this should be fully explained to any patient being prescribed them. CBT is a structured psychological intervention in which the therapist works with the patient to identify thoughts, beliefs, interpretations and behaviours and their effect on current depressive symptoms. They learn new and helpful ways of addressing and coping with thoughts, and learn new ways of behaving that may aleviate their symptoms (NICE 2007).
Community Psychiatric Nurses are widely used in the community and any GP can access this service if they feel it would benefit the patient. In house counselllors are also commonly used, as access to the Primary Care Trust (PCT) Psychology Service, has a waiting list which currently runs at 9-12 months before a patient is seen. If a patient presents at the surgery with suicidal intentions or in severe crisis, they are immediately refferred to the Crisis Team situated within the A&E department at the local hospital where specialist psychiatric help can be given. If deemed appropriate a patient can be sectioned under section 17 of the Mental Health Act for their own safety.
Suicide is a significant risk factor in depression (Inskip et al, 1998) and certain people are at greater risk of suicide than others. Gender, age and social circumstances influence the risk of suicide, the five major factors are:
1 Men
2 Those under 35 or over 65 years of age
3 Single people
4 Those who are separated, divorced or socially isolated
5 Those with a history of previous self-harm with insomnia, self neglect or agitation (Barker, 2004)
.Stigma
Unfortunately many sufferers of depression will not seek help from a healthcare professional for fear of being labelled “mentally ill”. The stigma of being labelled as such can have detrimental effects on not just the individual but also their families. People with experience of mental distress face stigma and discrimination on a daily basis. Worryingly MIND in a recent survey state that fewer than four in ten employers say they would recruit someone with a mental health problem. Over 900,000 adults in England alone claim sickness and disability benefits for mental health conditions, with particularly high claimant rates in the North.
Insurance companies, when requesting medical notes for patients wishing to purchase life insurance, have a section within their questionnaires entirely dedicated to mental health problems and It is evident that there is an increase in patients being refused life insurance because they have, or are suffering with depression. Although for some patients it could be a single isolated episode, premiums are often doubled compared to those patients with no history of mental illness. The media also paint a bad picture of mental health as only the bad things that happen are ever reported which further alienates individuals, and further stigmatises them as “nutters”. Negative and unbalanced media coverage of mental health issues, over the last three years, has increased mental health problems and social exclusion amongst people with psychiatric diagnoses claims a new Mind report published in 2008.
Conclusion
It seems apparent while researching all the evidence, that people with mental health issues are treated equally and have the same privileges as people without mental illness’s within general practice. My research suggests that discrimination, with employees preferring not to employ a person diagnosed with a mental illness, further stigmatising and socially isolating people. The media play a huge part in informing the general public of the dangers of the mentally ill.
Barker PJ, (2004) Assessment in Psychiatric and Mental Health Nursing (2nd ed). Nelson Thornes, Cheltenham
BBC News on Health (2007) available at Last accessed 14/05/2007
Beck AT, Ward CH, Mendelsohn M (1961) An Inventory for measuring depression Archives of General Psychiatry 561-71 Cited In Barker P.J. (2004) Assessment in Psychiatric and Mental Health Nursing (2nd ed) Nelson Thornes, Cheltenham
Blows W, (2003) The Biological Basis of Nursing: Mental health Routledge, London
Healy D (2005) Psychiatric Drugs Explained (fourth edition) Elsevier, Edinburgh
http://
Inskip HM, Harris EC, Barraclough B (1998) Lifetime risk of suicide for affective disorder, alcoholism and schizophrenia. British Journal of Psychiatry 172:5-37
Mind (2005) Mens Mental Health Mind, London
Mind (2008) News Policy and Campaigns London
National Association for Mental Health (2008) available at
Power M (1998) Working Through Communication available at
Shah A, The Burden of psychiatric Disorder in Primary Care. Int Rev Psych 1992; 4: 243-50
Singleton N, Bumpstead R, O’Brien M, Lee A, Meltzer H (2001) Psychiatric Morbidity Among Adults living in Private Households 2000
The Office for National Statistics Psychiatric Morbidity Report (2001)
Trowler, P. (1991) Investigating Health, Welfare and Poverty’ Collins Educational; London.
