Pharmaceutical care

(11) Mood disorders: implications for primary care

By Karen Fraser, MSc, MRPharmS,
Morag Martin, BSc, MRPharmS,
Robert Hunter, MD, MRCPsych,
and Steve Hudson, MPharm, FRPharmS

Mental health problems affect one in six of the population at any one time and the recognition of psychiatric symptoms is important in the delivery of primary health care.¹ Mental health problems frequently complicate other diseases and occur twice as often in people with physical illness as in the general population.¹ The most common psychiatric symptoms are changes in mood and the presence of anxiety, which often co-exist.

Emotional reactions are normal responses to distressing circumstances such as personal loss and physical illness. These reactions form part of the response and adjustment to life events. They are normally self-limiting and are not accompanied by a recognised pattern of other features associated with psychiatric illness.² A clinical pattern of disturbance may affect emotions, mental performance, social behaviour and physical well-being. The spectrum of mental health between emotional reaction and psychiatric illness is not well served by clear diagnostic categories in primary care and this lack of definition limits our understanding of how well these health problems are recognised and treated in the community.²

Recognised symptoms of depression have become increasingly prevalent. About one-third of the population (half of all women and a quarter of all men) will be affected at some time in their lives, and a third of those will have a major depressive episode.²

Patients in primary care with a minor affective disorder that includes depressive symptoms may be diagnosed as suffering a mixed anxiety and depressive disorder. This functions as a "catch-all" category for people showing insufficient features of a separately diagnosed depressive disorder or anxiety disorder. A mixed anxiety and depressive disorder affects 8 per cent of the adult population of working age.¹ Although this disorder needs to be further defined as a diagnostic category, the affected patients can have serious disturbances to their working and social lives. When a mixed anxiety and depressive disorder is related to a life event the term adjustment disorder is used.²

The diagnosis and rational treatment of psychiatric illness seeks, where possible, to distinguish the presence of an underlying primary depressive illness from mixed symptoms of altered mood and anxiety. A lowering of mood produces a decreased capacity for enjoyment and leads to social withdrawal, with loss of interest in activities such as work and hobbies, feelings of detachment, and a tendency to seek solitude. Depressed patients are vulnerable to failure to comply with treatment while also being more likely than non-depressed patients to complain of worsening symptoms of co-existing chronic physical disease. They may also consume excessive amounts of alcohol in an attempt to seek short-term mood elevation. This has the effect of producing an overall worsening of depressive symptoms.³

Over 80 per cent of patients who are diagnosed with depression are treated in primary care, although there is evidence that less than half of cases requiring treatment are recognised in a general practitioner (GP) consultation.^4,5 Many patients with psychological disorders present to their GP with common somatic symptoms. A diagnosis in general practice can be thwarted by patients tending to "normalise" their psychological symptoms, ie, minimising the importance of such symptoms by viewing them as non-pathological extensions of their normal behaviour.⁶

This article will explore the clinical presentation of mood disorders and the public health implications of mood disorders in the community. The pharmaceutical care of depressive disorders and of bipolar disorder will be discussed in two later articles.

Clinical pattern

Mood disorders comprise depression, elation or a combination of the two. These disorders are classified as either unipolar or bipolar disorders.

Unipolar disorders are single or recurrent episodes of lowered mood. Bipolar disorders, which are less common, are episodes of depression alternating with periods of elation. In periods of elation, psychotic symptoms such as delusions and hallucinations, termed mania, and behavioural disturbances such as hyperactivity also occur. Milder forms of mania are known as hypomania. Episodes of elation/delusion occurring alone are also termed bipolar disorders since their first appearance usually heralds a future episode of depression.²

In depression, patterns of cognitive and biological features lead to syndromes in individual patients that are characterised in terms of their psychological and physical manifestations (see Table 1).

Table 1: Clinical features of depressive disorders^{2, 3, 10}

Psychological manifestations

Physical manifestations

• Poor concentration and retardation
• Loss of emotional reactivity
• Loss of confidence
• Anxiety
• Change of appetite (usually loss of appetite)
• Bleak and pessimistic thoughts
• Irritability
• Feelings of hopelessness
• Inappropriate feelings of guilt
• Failure to enjoy (anhedonia)
• Delusions (in severe depression)
• Hallucinations (in severe depression)
• Suicidal thoughts (in severe depression)

• Loss of energy or fatigue
• Slowness (of speech and movement)
• Stooping posture
• Sleep disturbance (often insomnia, early morning wakening)
• Change in appetite (usually weight loss)
• Sexual dysfunction (low libido, amenorrhoea)
• Agitation
• Constipation
• Malaise
• Worsening of a physical condition
• Failure in compliance with treatment
• Excessive use of alcohol
• Self-harm

These features include slowness of movement and of speech, with monotonous tone of voice, facial sadness, furrowed brow and a stooping posture.³ Cognitive features include anxiety and lack of concentration, feelings of pessimism and hopelessness, inappropriate feelings of guilt, thoughts of death and suicidal ideas. Other symptoms may include irritability, psychomotor retardation and poor recall but usually without true memory loss. Memory loss does occur where dementia is the underlying cause of the depression and also in severe depression, when it is due to reduced concentration. Biological features include reduced energy, loss of appetite and weight, and sleep disturbances with early morning wakening. A diurnal variation may cause symptoms to be worse earlier in the day and, rarely, vice versa. Other symptoms include constipation, reduced libido and amenorrhoea.³,⁷

Table 2: Diagnostic criteria for depression⁹

Psychological symptoms

Somatic symptoms

• Depression of mood*
• Loss of interest and enjoyment*
• Loss of energy or fatigue*
• Diminished ability to think/concentrate or indecisiveness*
• Loss of self-esteem and self-confidence
• Feelings of worthlessness or excessive/ inappropriate guilt*
• Bleak and pessimistic views of future
• Ideas or acts of self-harm, thoughts of death or suicide*
• Sleep disturbances (insomnia/hypersomnia)*
• Reduced appetite or weight loss*

• Loss of interest or pleasure
• Loss of emotional reactivity to normally pleasurable surroundings and events
• Psychomotor retardation or agitation*
• Loss of libido
• Early morning wakening — more than two hours earlier than usual
• Marked loss of appetite
• Weight loss totalling more than 5 percent body weight in last month

Table 2 lists the psychological symptoms used to diagnose depression, including those that signify a major depressive episode, and also the somatic symptoms that may characterise the more severe forms of depression. The presence of a range of somatic symptoms is termed a somatic syndrome.

Other forms of depression include an atypical presentation, which may be accompanied by over-eating rather than weight loss, restlessness or agitation rather than retardation, and somnolence rather than insomnia.²,⁷ Delusions and hallucinations may accompany severe depressive disorder and this condition is called psychotic depression. Patients with psychotic depression may feel a sense of persecution for which they feel responsible; this contrasts with schizophrenic patients who tend to feel resentful of their persecution.²

Classification

The main approaches to classification of mood disorders are the International Classification of Diseases (ICD 10)⁸ and the Diagnostic and Statistical Manual of Mental Disorders (DSM IV).⁹ The classification of mood disorders given in Table 3 is drawn from DSM IV since later discussion of clinical guidelines cross-refers to this classification.

The classification of major depressive episode remains problematic because it overlaps with other forms. In DSM IV, a major depressive episode is described in terms of severity and whether or not psychotic features are present. A major depressive episode may be mild, moderate or severe, according to the level of incapacitation of the patient's function at work and at home. The episode may also be said to be somatic (characterised by biological features). In its mild form, major depression has fewer somatic and more neurotic features, particularly anxiety, but these can be severe and there may be some overlap into other classifications of minor affective disorders such as adjustment disorder, causing diagnostic difficulty. Mild depressive episodes respond variably to antidepressant medication and resolution of the episode is also dependent on a range of other factors, particularly social circumstances and the doctor-patient relationship.

Chronic depression may take several forms.⁹ It may be mild but persistent (lasting longer than two years) which is termed dysthymia. Chronic depression may occur alone or in combination with major depressive episodes (sometimes referred to as double depression). Antidepressants are of most benefit in patients with major depressive episodes and/or dysthymia.

The occurrence of repeated depressive episodes is termed recurrent major depressive disorder. When recurrence is frequent and occurs in short cyclical episodes (usually lasting up to a week at a time), the condition is termed recurrent brief depression. Some patients develop depression at changes of season, known as seasonal affective disorder. This most commonly occurs in autumn/winter, with atypical symptoms of increased appetite and hypersomnia.

Bipolar disorders tend to occur in early adulthood and are mostly diagnosed before the age of 50 years. If mania has occurred, the condition is termed bipolar I, and if only hypomania has occurred, it is known as bipolar II. The identification of mild hypomania, and diagnosis of a bipolar II disorder, has treatment implications for patients with recurrent major depression who may require treatment for bipolar disorder.

Rapid cycling occurs when episodes in bipolar disorders alternate, or frequently remit, in cycles of more than four episodes a year. Rapid cycling is more common in females and may be triggered by antidepressant drugs.

Cyclothymia is persistent mood instability with mild episodes. It may progress to more severe forms of mood disorder, including bipolar disorder.

Refinement in the classification of mood disorders awaits better understanding of the aetiology of depression.⁴ Although the cause of depression is unknown, depressive syndromes may also be differentiated as secondary to a physical illness, to alcohol or to other drugs. Some of the factors associated with susceptibility to mood disorders are given in Panel 1.

Panel 1: Factors associated with mood disorders

Genetic

• Family history of mood disorder
• Ethnicity (eg, Asians are more susceptible than other populations¹)

Personality types

• Neurotic characteristics
• Perfectionist
• Obsessional
• Anxious

Medical history

• Physical illness (general and specific)
• Postnatal period
• Drug treatment
• Alcohol abuse

Family history

• Abuse during childhood
• Parental discord

Social history

• Recent stressful life events
• Isolation
• Social deprivation
• Unemployment
• Single parenthood
• Living alone
• Old age
• Older patients receiving home care

Public health implications

Mental health problems are often associated with social circumstances. Statistically, mental health problems are diagnosed more frequently in victims of past/current abuse and domestic violence, the prison population, black and ethnic minority groups and refugees. Mental health problems often co-exist with drug abuse and alcoholism which affect about 2 per cent and 5 per cent of the population, respectively.¹

Affective disorders, in general, are more common in particular patient groups such as people with physical illness, patients who are hospitalised, and patients receiving drugs for musculoskeletal disorders.¹¹ Depressive illness affects 10 per cent of women in the postpartum period.¹²

Depressive symptoms occur in about 10 to 15 per cent of the population at any one time. About 5 per cent of the population are diagnosed with a depressive disorder and, among adults under 65 years of age, about 2 per cent are affected by major depression, 2 per cent by chronic mild depression (dysthymia) and about 8 per cent by a mixed anxiety and depressive disorder.¹ Unemployed people are twice as likely to suffer depression as those who are in work. There is a similar prevalence of major depression throughout middle and late adult years, although prescribing for anxiety and depression markedly increases with age — from just under 10 per cent in those aged 45–74 years to over 15 per cent in those aged over 74 years.¹³

Panel 2 provides a profile of depressive and anxiety disorders in a population served by a typical community pharmacy.

Panel 2: Profile of affective disorders in the population of a pharmacy serving 5,000 patients¹,²,¹⁷,^19-23

750 people with mental health problems
   (500 women, 250 men)
130 with symptoms of generalised anxiety disorder
   (70 women, 60 men)
300 with symptoms of mixed anxiety and depression
   (200 women, 100 men)
500 with symptoms of depression
   (300 women, 200 men)
250 with undiagnosed symptoms of depression
Eight attempted suicides annually
One suicide every two years

1,000 general practitioner consultations annually specifically relating to depression
325 patients with depression and/or anxiety being treated
   (225 women, 100 men)
   (90 are aged over 64 years, 70 women, 20 men)

200 patients diagnosed with a depressive disorder
   (130 women, 70 men)
60 with chronic mild depression (dysthymia)
60 with recurrent brief depression
25 aged over 64 years receiving home care

90 patients suffering a major depressive episode
   (60 women, 30 men)
25 will have a single episode without recurrence
25 will recur within a year
30 patients have a severe depressive episode
20 patients have combined major depression/dysthymia
20 patients treated by psychiatrist
Five cases are directly induced by physical disease or drugs
Five hospital admissions with major depressive episode
(one recurrent episode)

20 patients have bipolar disorder
One hospital admission with bipolar disorder

Remission is a period of reduction of symptoms, while recovery is a sustained period of remission. A relapse is an episode occurring during remission and a recurrence is a new episode during a period of recovery.^15,16 Three-quarters of all patients with major depression have a recurrence; in one-third, symptoms recur within a year. Recovery between episodes may only be partial and about a quarter of patients go on to develop dysthymia. In about 5 to 10 per cent of patients with major depression, the episode persists for more than two years.

Severe mental illness is associated with social isolation where patients may pose a risk to themselves. About one in 20 patients with major depression attempt suicide. There are about 5,000 suicides each year in the United Kingdom and, although the true relationship between suicide and depression is unclear, 10 per cent of suicides involve the use of antidepressants, with 4 per cent involving the use of antidepressants alone.17 Scales used to rate the severity of depression are shown in Panel 3.

Panel 3: Depression rating scales¹⁹

Hamilton rating scale for depression (HRSD) 1967²⁰

Administered during unstructured interview
Measures severity of syndrome rather than symptoms

Beck depression inventory (BDI) 1961²¹

Patient self-completed questionnaire of 21 items
Patients offered four to six statements in each item to ascertain symptom profile

Montgomery-Åsberg depression rating scale (MADRS) 1979²²

Administered during unstructured interview
Rates psychological symptoms in 10 items, each on a four-point scale

National Service Framework In England and Wales, public health targets include a reduction in suicides and the use of protocols for diagnosing and treating depression is recommended as a first priority. The National Service Framework for mental health requires that patients with severe mental illness be treated using the Care Programme Approach where a written care plan is used to optimise engagement with the patient.¹⁸ Care co-ordinators are identified and information is shared with professional and family carers. The aim is to manage the risks to the patient and to prevent or anticipate a crisis by providing the patient with access to psychiatric support services. In Scotland, the requirement for Care Programmes differs in being more focussed on specific groups.

An informational media campaign ("Defeat Depression Campaign", 1992 to 1996) was aimed at enhancing public awareness about depression and providing professional education. Research during the campaign found public attitudes tended to link depression to life events and inappropriately to view antidepressants as addictive.¹⁴ The campaign involved an extensive programme of general practice education and included consensus conferences and statements, recognition and management guidelines, training videotapes, and other publications.

Role for pharmacists There is a clear role for community pharmacists in health promotion and pharmaceutical care of depressed patients. The use of medication is central to the management of depressive illness.

The contribution of pharmaceutical care to the support of patients with mood disorders will be considered in subsequent articles.

ACKNOWLEDGMENTS
The authors would like to thank Dr Chris Prior (department of physiology and pharmacology, University of Strathclyde) and Dr Ian Aston (department of occupational medicine, Queen's Medical Centre, Nottingham) for helpful discussions in the preparation of this article.

• Ms Fraser is medicines information and research pharmacist, Greater Glasgow primary care NHS trust
• Ms Martin is principal pharmacist (clinical services), Greater Glasgow primary care NHS trust
• Dr Hunter is consultant psychiatrist and director of research and development, Greater Glasgow primary care NHS trust
• Professor Hudson is Boots professor of pharmaceutical care, pharmaceutical care health service unit, department of pharmaceutical sciences, University of Strathclyde, Glasgow, and Scottish Executive national specialist in pharmaceutical care