Depression for healthcare providers

Malhi GS, Bell E, Singh AB, et al. The 2020 Royal Australian and New Zealand College of Psychiatrists clinical practice guidelines for mood disorders – major depression summary(external link) Bipolar Disord. 2020 Dec;22(8):788-804. doi: 10.1111/bdi.13035.
Clinical practice guidelines for mood disorders(external link) RANZCP, 2016
Management of depression in adults in primary care(external link) BPAC, NZ, 2009
Identification of common mental disorders and management of depression in primary care. An evidence-based best practice guideline(external link) NZ Guidelines Group, 2008
Antidepressants for treatment of depression in primary care – a systematic review and meta-analysis, Dec 2016(external link) Jnl Primary Healthcare
RANZCP clinical practice guidelines for deliberate self harm(external link) RANZCP, 2016
Weiss A, Hussain S, Ng B. Royal Australian and New Zealand College of Psychiatrists professional practice guidelines for the administration of electroconvulsive therapy(external link) Australian and new Zealand Journal of Psychiatry. 2019 April 10;53(7):609-623.

PHQ-9 (Patient Health Questionnaire 9) 
Kessler-10 (K10) depression scale
General anxiety disorder scale (GAD-7)
Assessment of depression(external link) BPAC, NZ, 2009
Emergency department self-harm presentations – clinical audit tool(external link) NZ Guidelines Group, 2012
The assessment and management of people at risk of suicide(external link) Ministry of Health, NZ, 2003
Suicide prevention toolkits for DHBs(external link) Ministry of Health, NZ
HEEADSSS in five minutes(external link) Podcast, Goodfellow Unit, NZ
Adolescent consultation and the HEADSSS assessment(external link) Starship, NZ, 2022
The HEADSSS assessment sample questions(external link) Whāraurau, NZ, 2021

Psychological toolkit – practical resources to assist in the management of mood disorders(external link) Black Dog Institute, Australia
How you can help someone with depression(external link) The Lowdown, NZ
Depression – an overview(external link) BPAC, NZ, 2009
Arroll B, Chin W-y, Martis W, Goodyear-Smith F, Mount V, Kingsford D, Humm S, Blashki G, MacGillivray S. Antidepressants for treatment of depression in primary care: a systematic review and meta-analysis.(external link) J Prim Health Care. 2016 Dec 21;8(4):325–334.
Preventing suicide guidance for emergency departments(external link) Ministry of Health, 2016 
Suicide prevention in Maori youth(external link) Best Practice Journal, NZ, 2010
Square(external link) Suicide questions, answers, videos, training and more. Australian Initiative for Health Provider
Addressing mental health and wellbeing in young people(external link) Best Practice Journal, NZ, 2015
Suicide risk assessment and intervention in people with mental illness(external link) BMJ Learning, UK, 2015
Management of adult depression(external link) Goodfellow Unit, NZ, 2015
Psychological therapies for treatment-resistant depression in adults(external link) Cochrane Review, 2018
Godfrey KE, Muthukumaraswamy SD, Stinear CM, Hoeh NR. An open-label feasibility study of repetitive transcranial magnetic stimulation (rTMS) for treatment-resistant depression in the New Zealand healthcare context(external link) NZ Med J. 2019 Oct 25;132(1504):46-55.

Concerns have been raised about the potential for antidepressants, particularly SSRIs, to cause suicidal thoughts and behaviour especially in adolescents and young adults. These concerns have prompted regulatory authorities in many countries to issue warnings.  Australian and New Zealand Journal of Psychiatry 2015, Vol. 49(12) 1-185.

A consensus statement by the World Psychiatric Association (WPA) (Möller et al., 2008) concluded that in the absence of randomised controlled trial evidence, the risk is difficult to assess but that the available data indicated that there was a small risk of SSRIs inducing suicidal thoughts in patients up to the age of 25. The WPA advised that this risk needed to be balanced against the known benefits of treating depression and in preventing suicide. Clinicians should therefore advise young patients and their families of the small chance of suicidal thoughts emerging during the early phase of treatment with SSRIs and monitor all patients for the emergence or worsening of suicidal thoughts during the first 2–4weeks of treatment. The activation/agitation observed with the initial stages of taking an SSRI can be managed with a low dose of a benzodiazepine prescribed for a limited period of time.  Clinical practice guidelines for mood disorders(external link) Royal Australian and New Zealand College of Psychiatrists, 2015

Systematic review 2018 

A systematic review and network meta-analysis published in 2018 compared the efficacy and acceptability of 21 antidepressant drugs for the acute treatment of adults with major depressive disorder. 

FINDINGS:

"We identified 28,552 citations and of these included 522 trials comprising 116,477 participants.

• In terms of efficacy, all antidepressants were more effective than placebo, with ORs ranging between 2·13 (95% credible interval [CrI] 1·89-2·41) for amitriptyline and 1·37 (1·16-1·63) for reboxetine.
• For acceptability, only agomelatine (OR 0·84, 95% CrI 0·72-0·97) and fluoxetine (0·88, 0·80-0·96) were associated with fewer dropouts than placebo, whereas clomipramine was worse than placebo (1·30, 1·01-1·68).
• When all trials were considered, differences in ORs between antidepressants ranged from 1·15 to 1·55 for efficacy and from 0·64 to 0·83 for acceptability, with wide CrIs on most of the comparative analyses.
• In head-to-head studies, agomelatine, amitriptyline, escitalopram, mirtazapine, paroxetine, venlafaxine, and vortioxetine were more effective than other antidepressants (range of ORs 1·19-1·96), whereas fluoxetine, fluvoxamine, reboxetine, and trazodone were the least efficacious drugs (0·51-0·84).
• For acceptability, agomelatine, citalopram, escitalopram, fluoxetine, sertraline, and vortioxetine were more tolerable than other antidepressants (range of ORs 0·43-0·77), whereas amitriptyline, clomipramine, duloxetine, fluvoxamine, reboxetine, trazodone, and venlafaxine had the highest dropout rates (1·30-2·32).
• Risk of bias: 46 (9%) of 522 trials were rated as high risk of bias, 380 (73%) trials as moderate, and 96 (18%) as low; and the certainty of the evidence was moderate to very low."

INTERPRETATION:

"All antidepressants were more efficacious than placebo in adults with major depressive disorder. Smaller differences between active drugs were found when placebo-controlled trials were included in the analysis, whereas there was more variability in efficacy and acceptability in head-to-head trials. These results should serve evidence-based practice and inform patients, physicians, guideline developers, and policymakers on the relative merits of the different antidepressants."  [1] Lancet, 2018

The role of medicines in the management of depression in primary care(external link) BPAC, NZ, 2017
Drug interaction chart(external link) BPAC
NZ Formulary(external link) 

Podcast

Improving treatments for depression - Pim Cuijpers(external link) (Goodfellow podcast, 2019)
Pim Cuijpers talks about the challenge of improving treatments for depression. Pim is Professor of Clinical Psychology at the Vrije Universiteit Amsterdam (The Netherlands), and Head of the Department of Clinical, Neuro and Developmental Psychology. He is the world’s leading expert in the meta-analyses of reviews of psychotherapies.

Video series

Stress, anxiety and depression: new approaches to diagnosis and treatment

In this webinar, Professor Bruce Arroll looks at how we label patients with stress, anxiety, and depression by considering transdiagnostic labels. He will deal with the why and how, and highlight the dangers of labels in primary care.

(Goodfellow Unit Webinar, NZ, 2020)

Goodfellow Unit Webinar: Antidepressants in primary care

Depression in primary care: The evidence base for first consultation Bruce Arroll

Become a PND Recovery Course Facilitator

Mothers Helper’s(external link) PND Recovery Course training is now available to all qualified counsellors, social workers, psychologists and mental health nurses interested in becoming a facilitator. Learn more(external link).

Goodfellow Seminars

Perinatal mood and anxiety disorders – Dr Mark Huthwaite

(Goodfellow Unit Webinar, NZ, 2019)

Moana Research webinar series

Episode 1: Pacific maternal mental health

(Moana Research, NZ, 2020)

Exercise is effective for treating post-partum depression

This evidence comes from a review of exercise for post-partum depression from 12 studies. It was found that exercise interventions during and after pregnancy had a large effect size which translated to 41% of participants improving (numbers needed to treat of 2.5). The types of exercise ranged from stretching and breathing exercises, a walking programme, cardiovascular exercises, mixed cardiovascular and strength exercises, Pilates, yoga and home-based programmes.

Session frequency varied from 1–5 days per week and intensity levels included low, moderate or moderate to high. Physical activity interventions were individualised in 3 studies. Kelly McGonigal from Stanford suggests that for stress in general, exercise done with others gets an additional benefit from the social connection.

References:

1. Effects of exercise‐based interventions on postpartum depression – a meta‐analysis of randomized controlled trials(external link) Birth (2017) 
2. How to use stress for your own benefit(external link) RNZ Interview, Dr Kelly McGonigal (2020) 

From: Antenatal depression symptoms in Pacific women – evidence from Growing Up in NZ(external link) Journal of The Royal New Zealand College of General Practitioners, July 2019

Further attention is required to providing appropriate primary health care for Pacific women of child-bearing age in NZ. Better screening processes and a greater understanding of effective antenatal support for Pacific women is recommended to respond to the multiple risk factors for antenatal depression among Pacific women.

From: Addressing the burden of perinatal depression in NZ through innovative mobile health (mHealth) solutions(external link) Winston Churchill Memorial Trust Fellowship Report July 2018 

Depression during or after pregnancy, known as perinatal depression, is widespread in NZ; and the consequences are significant. Postnatal depression is the most common postpartum mental disorder, and recent findings suggest antenatal depression is even more common. Suicide is the leading indirect cause of perinatal death in New Zealand (Perinatal and Maternal Mortality Review Committee (PMMRC) report, 2017).

Early identification and treatment of perinatal depression is intuitive and important. It leads to better outcomes for women and their children and whānau, and is more cost-effective than picking up the pieces later on.

This report focuses on the role of mobile health (mHealth) technology, such as mobile phones, tablets and applications (‘apps’), to better detect perinatal depression and to deliver prevention interventions, follow-up, treatment and support.

From: Perinatal mental health care in NZ – the promise of beginnings(external link) Carol Cornsweet Barber, University of Waikato, NZ

Pregnancy and the postnatal year represent a critical time in the health and development of families, and a time when psychologists can play an important role in the primary health care team. This paper discusses some key issues of interest in perinatal mental health care, encouraging clinicians and researchers to broaden the focus beyond postnatal depression to perinatal emotional disorders, and to become informed and involved in promoting recognition of, and appropriate treatment for, parents who are struggling with psychological distress

From: Postnatal depression in NZ – findings from the 2015 New Mothers’ Mental Health Survey(external link) May 2016

The purpose of this report is to add to current knowledge around postnatal depression (PND) in New Zealand by providing an indication of PND prevalence as well as an overview of the social and life experiences, as well as help-seeking knowledge and attitudes, of women who might be experiencing PND. To this end, the current report uses data from the New Mothers’ Mental Health Survey (NMMHS), a cross-sectional survey conducted between July and September 2015. 

Depression topics