Supporting people with depression and anxiety A guide for practice nurses

Supporting people with depression and anxiety A guide for practice nurses


This guide has been developed for GP practice nurses following a three year research study called ProCEED (Proactive care and its evaluation for enduring depression), conducted by Dr Marta Buszewicz and a research team at University College London.

 The study involved a large number of practice and research nurses working in general practices throughout the UK. It was run in collaboration with the mental health charity Mind and funded by a grant from the Big Lottery fund.



Dr Mark Haddad RGN RMN

Clinical  Research Fellow,  Institute of Psychiatry at King’s College London and South London & Maudsley NHS Trust

Dr Marta Buszewicz

GP in North London and Senior Lecturer in Primary Care  at University College  London

Beth Murphy

Information Manager, Mind



We would like to thank Kate O’Brien and Elaine McMahon for their very helpful contributions to the written materials in this guide.

We would also like to thank all the nurses, patients and practices involved in the study and the Medical Research Council GP Research Framework (MRC GPRF), without which the trial would not have been able to run successfully.

Dr Marta Buszewicz and Beth Murphy



The Royal College of Nursing is delighted that nurses working in general practice are able to develop their skills and  knowledge  of  depression  by  having  access to this excellent guide. While the vast majority

of practice nurses do not hold mental health nursing qualifications, there is no doubt they are able to make a positive contribution to improving mental health care, when given the learning opportunities to enhance their confidence in this field.

Around 20,000 nurses are currently working  in  general  practice  and  all  of them will at some time be in contact with people whose health is impaired and  quality  of  life  reduced  as  a  result  of  depression.  While  this  guide cannot enable nurses to become experts on diagnosing and  managing  the care of patients with depression, it will ensure they are better equipped to:

  • identify the signs and symptoms of depression
  • have the confidence to ask the right questions
  • enter into, what many nurses would call, ‘difficult conversations’ with their

General practice continues to be the core business of health care and the setting where most people who experience depression can be effectively cared for – in terms of both prevention and management.

20,000 practice nurses are a wonderful resource, in terms of the management of long-term conditions and minor illness and this guide  could, potentially, help them be as skilled in the management of depression, as they are other chronic and long-term conditions such as diabetes and hypertension.

The RCN is committed to ensuring that all nurses working in primary care have  easy access to this  excellent  guide.

Lynn Young, Primary Care Adviser, Royal College of Nursing



Is this relevant to me?

 Depression can be deeply distressing and without proper care and treatment it can severely damage the lives of those affected and the people close to them.

As a practice nurse you will already be involved in caring for people with chronic physical conditions such as diabetes or asthma and, as you know, people with these conditions are more at risk of also having problems with depression and anxiety. Depression and anxiety are very common – at any given time there are around 2.3 million people in the UK experiencing symptoms of depression.

However, there is limited training to help you to support people with  mental  health  problems,  and  the  result  is that people with depression and anxiety do not always routinely get the comprehensive level of care they are entitled to.


2.3 million

Depression and anxiety are very common – at any given time there are around 2.3 million people in the UK experiencing symptoms of depression.

This guide has been designed to support you to work more effectively  with  people  who  experience depression and anxiety, and will be particularly useful for you if you answer ‘yes’ to any of these questions:

  • Do you feel uncertain about how to recognise and assess depression and anxiety?
  • Do you worry that you don’t have the skills needed to talk to people about their feelings?
  • Do you think that depression is a life-sentence that people can’t recover from?
  • Do you worry that if you start to talk about depression people will become  suicidal  or  it  will open  up a can of  worms  that  you  can’t  help with?
  • Are you unsure of the difference between low mood and clinical depression?
  • Do you think that mental health problems should be treated by  specialists only?

If  you  have  any  of  these  worries  you  are  not  alone, and it is natural to be unsure about how you can help. However, you will be seeing patients who experience depression and anxiety already,  and if you feel unable   to support them or that aspect of their health you are missing  out  an important  part of  their care.


How will it help me?

This guide has been designed to help practices nurses working in primary care teams. It focuses on recognising and supporting adult patients who show signs of depression and anxiety.

It will  help  you to:

“It focuses on recognising and supporting adults who show signs of depression and anxiety.”


The ProCEED trial

This guide was developed from a research trial called ProCEED. This was a randomised controlled trial which involved practice nurses from 42 general practices throughout  the  UK working with patients who had chronic or recurrent depression  over  a two year  period.

In many ways the  model used was  similar to that used in other long-term conditions such  as  asthma  or diabetes.

Practice nurses met with patients every three months to review the management of their depression and whether the treatments prescribed (medication, psychological therapies or lifestyle interventions) had been helpful  or needed  to  be reviewed  and  changed

– if necessary this  would  involve  a GP consultation.

Before taking part in this  study  the  majority  of  the nurses reported feeling  very  unconfident  about  the idea of  working  with  patients  who  were  depressed and felt wary about raising the issue of depression in their clinical practice in case they were unable to deal effectively with the issues  raised.  They all mentioned   a distinct lack of  relevant  training  in  working  with people with mental health problems in primary care. This was despite the fact that practice nurses are increasingly  being  expected  to  broach  the topic of depression and anxiety as part of their standard workload, for example screening for depression in diabetes or cardiovascular disease as part of the QOF (Quality  and  Outcomes  Framework).

“Sometimes you ask the question and you think, oh please don’t have a problem because if you have you know. Which is awful to say it, but it’s a reality sometimes. You’re almost relieved that everything is fine. I don’t think that’s right, but that’s how you sometimes  feel.”

After taking part in the trial all the nurses interviewed reported an  increase  in  their  confidence  in  asking patients about  possible  depression  and  having  a sense of what to do if they identified  this.  It is  this  response from the nurses, as well as the current lack of relevant training materials for practice nurses in this field,  which led to  us  producing  this guide.

“I was always confident to chat to people before but,  and maybe I know more  of  the,  you  know,  sort  of things that are available or a little bit more about the medications and things,  so  maybe  happier  to  lead them  through  the  right pathway.”

As well as conducting the main trial we carried out two qualitative studies to get more detailed information from both nurses and patients who had been involved. From the interviews with the nurses we established that all the nurses felt more confident at the end of the trial in identifying people with depression during their day to day work and following up on this where appropriate. However, not all the nurses wanted to develop a special interest in working with people with mental health problems.

This guide covers the range of information about depression and anxiety, its detection and management in primary care which we think will be relevant and of interest to all practice nurses in their routine contact with patients in primary care settings.

We hope that these materials will be of interest and use to you. If you would like to get a further understanding and knowledge about mental health issues, information on a variety of other resources can be found in

Further information on  page 44.

“Caring for patients with depression is challenging and consequently extremely rewarding.”


Case study

Working with depression and anxiety as a practice nurse

This guide has been developed from a three year project which provided support and training to practice nurses who had limited experience of working with mental health problems. This is the experience of one of the nurses involved in the project. It explains how she found the process, both the positives and the challenges.

“Caring for patients with depression is challenging and consequently extremely rewarding. I found that I needed to develop new skills to enable me to feel that I could be of benefit to my patients. The most important was listening, really listening to pick up what patients were trying to tell you, this often meant identifying what they weren’t saying and finding a way of allowing them to talk comfortably.

“Many patients really valued someone listening to them, often when an appointment was over I realised I had actually done very little, except listen.

“Lateral thinking became useful, as some patients felt that they were unable to see a way out of a certain difficulty and so were receptive to different ideas and another perspective. There is a skill in persuading patients that the situation can improve, but it takes work on their part to bring this about, and for them to recognise the need for their input. This again can take many forms, remembering to take medication, going out for walks, going to see a Relate or Cruse counsellor.

“Patience is a virtue is certainly necessary. It can be very frustrating when a patient does not act on an agreed plan, but again it is then important to find out why this is happening and recognising that this is not failure. However, accepting failure is also relevant; nurses care about helping their patients and it is troubling

when you feel you are not succeeding in this. Recognising that depression is a condition with peaks and troughs enables you to cope with these times.

“A tendency I have developed since becoming involved in working with depression is the magpie effect. I collect information in case it is useful to my patients. I am a fountain of knowledge about the courses available through the University of the Third Age (U3A), what is available at the local library, where the nearest Mind branch is, how to contact the local volunteer service and where to go for a yoga class. I have found it important to get feedback on this, so that if something is not useful, or details change I am aware. I recognise that one of my roles is that of a signpost, pointing to where help is available rather than offering it directly.”


Feelings I had during the study


“Identifying  a  problem  and  trying  to  work  out  a solution with the patient was challenging. Each patient was an individual with completely differing needs, as opposed  to  trials  in  diabetes  or  hypertension  where the pathways are identified and structured. I enjoyed  the  challenge  and  mental stimulation.”


“Sitting in front of the computer waiting for a patient who had just joined the study, seriously depressed following a complete breakdown. There was either no eye contact, or a fixed stare, hands continually folding paper, little verbal communication. The sick feeling with the realisation I was now expected to do something.”


“The nature of the consultations led to a position of trust, with patients feeling able to discuss their fears and anxieties. I felt very privileged that people had the confidence to share this with me. I felt that their family  members  acknowledged  a  positive  benefit, for example if I had to phone a patient at home. I was recognised and given a friendly reception as ‘Kate from the surgery’ – this meant that I felt as though I knew these people although we had never met.”


“The study may have finished over a year ago, but if I bump into one of the subjects either at the practice or in the town centre they always say ‘hello’ and stop for a chat. This is never negative but to let me know how they or their family members are doing, and to ask how  I am.”


“The patient who does not accept that there is help available and refuses to recognise that there is even a way forward. All you can do is keep the communication channels open, listen and don’t give up.”

Continued benefit

“If I am checking notes for any  reason and the person   is someone I worked  with during the study it is such    a  positive  feeling  to  see  that  they  have  not  needed to restart their antidepressants or that they have only had a couple of GP consultations in the last year.

It reinforces the impression of making a difference.”


“Despite all the advice you offer, the patient is the only one who can act on it. They may choose not to action     a plan, even though they have happily agreed that it is what they need to do, often offering this as a solution themselves. Frustration sets in when they attend for a series of appointments without initiating an agreed change. Take a deep breath and try to establish why this is the case and try to look for alternative solutions.”


“The feeling when a patient thanks you saying that they can now see a way forward and a return to their normal life. Just observing the change in appearance, the return of confidence and the ability to smile this makes it all worthwhile!”


Section 3 Depression and anxiety


What are depression and anxiety?

Depression and anxiety are common mental health problems. This means that they occur relatively frequently in the population. They are thought to affect about 1 in 10 people in the general population at any time, and are the third most common reason for people visiting the GP.

Other common mental health problems include phobias, obsessive compulsive disorder and alcohol and substance misuse problems.

Common mental health problems do not usually involve what are termed as ‘psychotic symptoms’ when some people lose touch with reality, for example hearing voices or hypomanic episodes. Those symptoms are present in disorders such as schizophrenia and bipolar disorder, which affect approximately 1 in 100 people.

Common mental health  problems  are  mostly  managed in primary care  – and  it is  almost  inevitable  that  a number  of  the  patients  you  care  for  have  these problems  alongside  the  other  physical conditions

that you help them to manage. Many people with depression  are  reluctant  to  consult  their  GP  due  to the stigma associated with depression, as well as the perceived  lack  of  appropriate  treatments available.

They may be apprehensive that their concerns and preferences will not be taken into account and have low expectations of getting any benefits  from treatment. Effective treatment helps with  both  first and later episodes of depression, reducing the time someone is affected  by  their  symptoms  and minimising  their  impact.


What  is depression?

In its mildest form, depression can mean just being in low spirits. It doesn’t stop people from leading a normal life, but makes everything harder to do and may make things seem less worthwhile. At its most severe, clinical depression can be life-threatening, because it can make people suicidal, simply give up the will to live or have a major and lasting impact on a persons life, work and relationships.

It is important to remember that the experience of depression can vary from person to person, as can the words people use to describe their problems. Many people are uncomfortable using the term ‘depression’, possibly because they associate this with serious mental illness or a sense of personal failure. It is common for people to deny feeling depressed, but to admit to feeling unhappy, sad or low. Likewise, some people  may deny feeling depressed but admit to losing interest in things, or to feeling tired most of the time.   It  can  sometimes  be  difficult  to  decide  if  someone who has  some  symptoms  of  depression is ‘clinically  depressed’.

To classify depression  clinically,  and  distinguish  it from other mood problems as well as from normal experiences and life problems, we focus on the symptoms  experienced  by  the person.


1: Core features

Although there are a range of symptoms, the presence of core features is essential for diagnosis.

  • A lowered
  • A lack of interest  or pleasure  in usual

Either one or both of these must be present for a person to be diagnosed as depressed.


2: Associated features

As well as these two core features, additional symptoms characterise depression. Some of these relate to physical aspects  of  function  (sometimes  referred  to  as  somatic or biological features of depression) and some to emotional/psychological  and  social aspects.

The features of depression

Physical features

  • Disturbed sleeping – waking in the night, or earlier than usual, or sleeping too
  • Loss of appetite or
  • Tiredness or persistent  loss of
  • Aches and pains not fully explained by medical

Psychological features

  • Feeling sad or unhappy or having a ‘low’
  • Feeling unable to enjoy things like you used
  • Loss of confidence and/or loss of self-esteem.
  • Feeling particularly  guilty  or self-blaming.
  • Feeling that things won’t get better in the
  • Thoughts of self-harm or

Social features

(features affecting social function)

  • Poor concentration  or
  • Not wanting to see people or do
  • Irritability or more frequent arguments with people  around
  • Difficulties managing work, family responsibilities or other  usual

3: Making a diagnosis of clinical depression and its severity

It is often difficult to decide if someone who has some symptoms of depression is ‘clinically depressed’. You can decide whether an individual is experiencing a ‘clinical’ episode of depression by applying the diagnostic criteria set out in the ICD 10 (the International Classification of Disease) on page 13.

You may also have heard of another classification system – the DSM IV (the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders). This provides a similar list of the features of depression.

We have listed the possible symptoms, and questions to ask on page 13, together with a description of how many symptoms someone would need to have to be diagnosed as having mild, moderate or severe depression.

The length of time that a person experiences the symptoms is another key distinction between depression, and general low mood. For a diagnosis of depression, these features must persist for most days, for much of each day, for a minimum of two weeks.


Questions to ask

—   Have you been bothered by feeling down depressed or hopeless?

—   Have you lost interest in things?

—   Do you get less pleasure from things you used

to enjoy?

—   If ‘yes’  to the above  – i.e.

the two core questions, please prompt  further  about individual symptoms as in the questions below. (See also the assessment  box.)

—   Have  you  noticed  any  change in  your  normal  sleep patterns?

—   Appetite? Weight?

—   Have you noticed difficulties in concentrating?

—   Have you lost confidence in yourself?

—   Are you feeling guilty or blaming yourself for things?

—   Have you found yourself to be more physically restless/ or  moving  more  slowly than usual?

—   Have you felt that life is not worth living, or that you would be better off dead? (See Assessing the risk on page 21.)

Mild Depression

At least two core symptoms and at least two additional symptoms.

The person has some difficulty with ordinary activities but does not cease to function.

Assessment (ICD-10)

Clinical Symptoms

Core Symptoms (at least two)

—   Depressed  mood, and/or

—   Loss of interest.

Additional Symptoms

—   Poor concentration.

—   Reduced self-esteem and self-confidence.

—   Disturbed sleep.

—   Change  in appetite or weight.

—   Feelings of guilt or worthlessness.

—   Agitation/slowing.

—   Pessimism/hopelessness.

—   Suicidal thoughts or acts.

Much of the day, most days for at least two weeks.



Mild depression for more  than  two years.


Moderate  Depression

At least two core symptoms and at least three or four additional symptoms.

The person usually has considerable difficulty continuing with normal work and social activity.

Other clinical signs which may be associated with depression

—   ‘Tired  all  the time.’

—   Irritability.

—   Loss of libido.

—   Medically unexplained symptoms.

—   Depression associated with physical illness.

—   Frequent attendance at the surgery.

Severe Depression

Two core symptoms and at least four or five additional symptoms, some of which are severe.

The person shows considerable distress and agitation (or retardation) and is unlikely to be able to continue with their normal  activities.

An episode of major depression (moderate/severe depression) is disabling by definition and lasts at least two weeks, but often much longer. Increasingly,  it  is being recognised that some people may have several episodes of major depression in their lifetime – which can  be  termed  recurrent  depression.  In  between these episodes the person may feel well and function completely normally, although sometimes major depression  is  more enduring.

A further description sometimes used is that of Dysthymia, which means a chronically low mood over a period of time (at least two years but often much longer). Dysthymia features other symptoms which can include sleep disturbance, low energy, low self-esteem, indecisiveness and hopelessness, but the symptoms are generally less severe than in major depression.

Effects on function

In addition to the symptoms and their duration,  the impact  that  the  depression  has  on  a  person’s  ability to  take  part  in  their  life,  or  their  function,  is  a  key part  of  reaching  a  diagnosis.  Significant  limitations on the person’s ability to function in work or in their relationships may be associated with being depressed and this in itself will be distressing.

It is at least as important to assess the impact being depressed has on someone’s ability to  function normally  as the severity of their   symptoms.

What  is anxiety?

As with depression, anxiety is something we all experience from time to time. Most people can relate to feeling tense, uncertain and possibly fearful at the thought of things like sitting an exam, going into hospital, attending an interview or starting a new job. You may worry about feeling uncomfortable, appearing foolish or how successful you will be.

In turn, these worries can affect your sleep, appetite and ability to concentrate. If everything goes well, the anxiety will go away.

However, if the anxiety does not go away, and becomes a regular part of a person’s life then it might said to be an anxiety disorder. Anxiety disorders are very common in the general population and almost certainly under- recognised in those attending UK primary care.

Diagnoses exist  for  a  number  of  different  types  of anxiety disorder, including generalised anxiety disorder, panic disorder, phobias, obsessive-compulsive disorder and  post-traumatic  stress disorder.

Within primary care, the most common anxiety  disorders are:

  • generalised anxiety disorder
  • panic

It is common for people to experience both depression and generalised anxiety disorder, and this is associated with a poorer prognosis. As with depression, it is also common  for  anxiety  to  be  associated  or  co-morbid with  various  long-term  physical  health conditions such as COPD or cardiovascular problems.

Generalised anxiety disorder (GAD) is characterised by persistent  excessive  worry that  the  person  finds difficult to control. This is accompanied by some of the physical and/or psychological symptoms listed on page 15 which, in order to fit this definition the person should have experienced on more days than not for a period of at least six months.

Physical symptoms of generalised anxiety disorder

  • Feeling restless and being ‘on edge’.
  • Rapid
  • Rising blood pressure and a pounding
  • Tense muscles which can cause pain and
  • Sleep
  • Nausea, sickness  or urgent  need to use the

Psychological symptoms of generalised anxiety disorder

  • Feeling worried all the
  • Feeling
  • Being unable to
  • Feeling low or


Panic disorder involves  recurring  and  unexpected panic attacks. A panic attack is an exaggeration  of  the body’s normal response to  fear,  stress  or  excitement. When faced with a situation  seen as potentially threatening, the body automatically gears itself up for danger by producing quantities of adrenalin for ‘fight or flight’. This happens very quickly, usually in less than 10 minutes,  and  brings  about  the  symptoms  outlined above.  In addition  people  may feel:

  • that they’re going to die
  • frightened of ‘going crazy’ or losing control
  • short of breath
  • that they’re

These attacks may often lead to avoidance of situations due to fear of developing symptoms and being unable to escape.

Alongside these recurrent unexpected panic attacks, someone with panic disorder also experiences one or more of the following symptoms.

  • Persistent worry about having further panic
  • Worry about the implications or consequences of the panic attacks (such as having a heart attack, or losing control).
  • Significant change in behaviour related to the panic

Panic disorder is often accompanied by agoraphobia  – which  is  anxiety  about  being  in  places  from  which escape might be  difficult  or  embarrassing  (typical situations include being in a crowd,  being outside alone  or  travelling  in  a  car  or  public  transport).  These situations are either avoided or endured with marked distress  or worry about  having  a panic  attack.

Alternatively, the person affected always needs a companion with them.


Causes and triggers for depression and anxiety

The exact causes of mental  health  problems  are  not known, and are likely to vary between different people. Different theories suggest that a family (genetic) history  of the disorder, brain chemical  imbalances,  major  life events and social factors (such as bereavement or unemployment)  and,  in  some  cases,  a history  of  abuse or other  childhood  difficulties  have  a role  to play.

In some cases there is no apparent cause or trigger for  someone’s  depression.


“The exact causes of mental health problems are not known, and are likely to vary between different  people.”

There does appear to be increased risk of depression  and  anxiety  in  certain groups:

  • Gender: depression and all anxiety disorders are around twice as commonly diagnosed in women, but this could be because women are more likely to  seek
  • Socioeconomic factors: mental health problems are more commonly diagnosed  among  people  at the  lowest  socio-economic
  • Ethnicity: South Asian women in England are more likely to experience depression, panic and anxiety disorder than the general population.
  • Medical illness: there is an increased risk of depression and anxiety disorders linked to chronic physical health problems such as coronary heart disease, diabetes, asthma or chronic obstructive pulmonary
  • Past history of depression and anxiety: there is a high risk of relapse and recurrence if people have experienced depression  and  anxiety
  • Alcohol misuse: this is particularly linked with anxiety
  • Antenatal and  postnatal  period:  there is an increased risk for depressive symptoms around
  • Psycho-social factors: people who have experienced or are experiencing difficult life events such as homelessness, poverty,  debt or abuse  have  a higher  risk  of

Probably the most important factor is a past history of depression and anxiety. It is now recognised that someone who has had one or two episodes of major depression is at high risk of having further such episodes, so it is essential to discuss this with people who you think may be at risk or who have some clinical features. The person’s past history also provides important indications of the types of support  and treatment that are most likely to be acceptable and effective  in  the future.


Talking about mental health problems

It can be difficult for people to talk about mental health problems for a variety of reasons, including:

  • Stigma and discrimination: many people don’t want to receive a diagnosis of  depression  and anxiety because of the stigma that still surrounds mental  health
  • Cultural or peer pressure: people from certain groups or  communities  can  find  it  difficult  to admit  to  feeling  low,  or  not  coping  because  of the attitudes of their
  • Confidence of professionals: it is difficult to encourage people to open up if you or they feel you do not have the skills to support
  • Nature of depression: if people are feeling depressed their outlook is generally negative, and  it can be difficult to believe that there is anything which  can

Factors such as these can result in interactions with patients that are unsatisfying and don’t fully address the problem. You might find the following tips help you to talk about mental health problems more easily.


Language and tone

It is important to use words and a manner that are appropriate and demonstrate sensitivity to background and spoken language. Try to consider gender and cultural differences. For example, many men prefer more physical and active language rather than more emotional language. Some cultures may use different expressions to explain feelings or mental health problems. Allow yourself to be led by the person and use the phrases and words they are using, and use terms like ‘low’, ‘down’ and ‘on edge’ rather than overtly psychological terms.

Showing empathy and sensitivity by means of your posture, eye contact and gestures are a key part of the non-verbal communication that will assist people in talking about their mental state. Using open questions, offering prompts and repeating or paraphrasing the patient’s statements can also be useful.

It is important to set your own experiences aside and focus on the experience and feelings of the patient. Don’t jump to conclusions because you think a situation sounds familiar. Give them the space to talk about how they feel.

Stay with painful, distressed feelings. Simply being heard can be of great value in itself, particularly for people whose thoughts, feelings and wishes may have been rushed when talking to their GP, or who haven’t opened up about their experiences before.

Don’t be afraid of silences. Often when people are trying to make sense of difficult feelings they need time to process their own thoughts. If you fill the silence with a question or comment you can take people away from this and close down the conversation.


Start with physical symptoms

People are often more at ease describing physical symptoms and problems when they first open up about how they are feeling. It may therefore be easier for the patient if you initially consider areas such as sleep, appetite and energy levels.


Your role

Remember that as a nurse there are limits to what you can and can’t offer to a patient. People who experience depression or anxiety are likely to have a number of other concerns in their lives which can include financial worries, housing problems or relationship issues. It will not be your role to support them with all these issues, although you may be able to suggest other agencies or organisation which can provide appropriate advice and this can be very helpful.

A person who is very distressed may wish to be able to pass on all of  their  issues  to  another  person  and  hope that  they  can  sort them  out,  so you  need to  be clear with yourself and with them where your boundaries lie. Finding out from a person about  the  multiple  issues  in their lives  will allow  you to offer  them the best options to seek further support (see Further information on page 44). It will also help you to gain a fuller understanding of their life circumstances and how they may be impacting on them both physically and mentally.


Section 4 Recognising depression and anxiety


Assessing patients for depression and anxiety

Correctly  recognising  depression  and anxiety is the essential first step to any ongoing assessment, monitoring,  support and treatment. An important part of recognising depression or anxiety disorders involves  knowing  the  symptoms that make up these conditions (see What are depression and anxiety?).


Rating scales to recognise and monitor depression

Several tools are available to assist  identifying depression and anxiety. Two of the most commonly used  are  described here.

The ‘Whooley  questions’  (named  after  the  researcher who initially tested it) use a ‘yes’ or ‘no’ response format  to screen for  the two core  features  of  depression.

A positive response to either or both of these questions identifies a person as having possible depression with further assessment required to identify if this is present. As you’ll see the questions are based on the ‘core questions’ for an ICD-10 diagnosis of depression described on page 13.

It can be used as a self-report where the person completing the responses themselves. Alternatively, the questions can be asked within a clinical consultation or during  a  telephone conversation.

Whooley questions

  1. During the past month, have you often been bothered by feeling down, depressed or hopeless?
  2. During the past month, have you often been bothered by little interest or pleasure in doing things?


Asking these two  questions  as  a  screen  for  depression and recording the answer is  part of  the  current requirement for the care of people with Diabetes  or Coronary Heart Disease under QOF (the Quality and Outcomes Framework). Practice nurses are quite often tasked to do this,  but  may  be tempted  to  ask  the questions in a way which is unlikely to lead to a positive answer  if  they  feel  unconfident  about  how  to  provide the relevant  further assessment  and effective  support if the patient answers ‘yes’ to both questions.

If the person answers ‘yes’ to  both  these  screening questions another more detailed symptom identification tool called  the  PHQ-9  is  recommended  to  determine  if the person is depressed and to what level. It is brief and simple to  complete,  and  has  good  detection  properties for depression alone and in combination with medical problems. It can be used to grade  the  severity  of someone’s  depression  at  baseline  (first  appointment) and  then  again  at  follow-up  (after treatment has begun).

It can also be used as a self-report (the person completing the responses themselves) or asked within a clinical consultation. Adding together the score for all the responses at the end gives a simple measure of how severe someone’s depression is, the higher the score the more severe. A copy of the PHQ-9 is included as Appendix  1 on page 48.

Further assessment is then required to determine the type and number of symptoms that the person is experiencing, their severity and the effects on their daily life, before discussing the range of possible treatments with them.


Rating scales to recognise and monitor anxiety

We have already explained that anxiety often co-occurs with other mood disorders and with physical health problems.  If  someone  is  experiencing symptoms

of both depression and anxiety NICE (National Institute for Clinical  Excellence)  suggest  that  whichever  is  the most severe and worrying disorder from the patient’s perspective  should  be assessed  and treated  first.

Similarly to the ‘Whooley questions’ for depression, there is a simple two question  screening  tool  for anxiety  called  the  GAD-2.



Over the past two weeks, how often have you been bothered by:

  1. Feeling nervous, anxious or on edge?
  2. Not being able to stop or control worrying?


There  are  four  response options:

  • Not at all (0)
  • Several days (1)
  • More than half  the days (2)
  • Nearly every day (3).


“It is possible that individuals who are coping with anxiety through avoidance behaviour may score quite low on the GAD-2.”

People  scoring  a  combined  score  of  three  or  more are considered  to potentially  have  an anxiety  disorder.

It  is  possible  that  individuals  who  are  coping  with anxiety through  avoidance  behaviour  may  score  quite low on the GAD-2. Therefore, if you suspect an anxiety problem  but the individual  scores  less than  three, a further question: “Do you find yourself avoiding places/activities and does this cause you problems”, should also be asked, and those with  a  positive response  should  be  assessed further.

Following a positive response to the GAD-2 and/or  to  the  third  panic  question,  a longer questionnaire may be useful in clinical practice to assess the presence and severity of someone’s anxiety or to monitor change over time (especially following therapy or when considering  treatment).

In this  situation,  a further five questions  which  can  be combined with the initial questions to make a scale called the GAD-7, may be useful. A score of eight or above indicates an anxiety disorder (the instrument is most sensitive to the detection of generalised anxiety disorder).

A copy of the GAD-7 has been included in appendix 2 on  page 49.


Section 5 Assessing the risk

Assessing the risk of suicide and self-harm

Although  it  is  not  very  likely  to  happen, you may encounter a patient about whom you become very concerned. This may be because the patient seems very depressed and  is  not  receiving  adequate  treatment or because they disclose  suicidal  thoughts or plans.

Many people experiencing depression (probably most people in fact) have transient thoughts of dying or of self-harm or suicide. It doesn’t mean they will attempt to act on them.

It is very important to remember that asking about suicidal  thoughts  or  plans  does  not  put  the  idea into  someone’s  head  or increase  the risk.

Brief risk assessment

—   Have you had thoughts about harming or killing yourself?

—   Have you felt like acting on them?


—   Have you considered actually ending your life?

—   Have you made any plans about how you would do this?

—   How likely is it that you might act on these plans?

People are often relieved to have the chance to talk about how bad they are feeling or their fears of what they  might  do.  But  if people  do have  these  thoughts it is a good idea to ask them the following  questions (stop when they say no).


Talking about suicide

It can be frightening or even embarrassing to ask someone about suicidal thoughts or actions. You may also find it distressing to listen to someone who is in despair. However, if you are able to set aside your own feelings and focus on the needs of the person and stay within the remit of your role, then you will be able to work to identify and support someone who may be considering suicide.

Suicide is associated  with  depression  and  risk  factors such as chronic illness, physical impairment, unrelieved pain,  financial  stress,  loss  and  grief,  social  isolation and  alcoholism.

People who have self-harmed previously are at more risk of taking their life in the future, as are older men and those who  are  socially  isolated  with  chronic physical  illnesses.


Warning signs for suicide

The following may be associated with a risk of suicide:

  • Feeling hopeless  or worthless  in  a persistent
  • Putting affairs in order, giving things away or making changes to
  • Stockpiling medication or any other specific  plans to  harm
  • Previous suicide  or self-harm
  • Goodbyes such as “this is the last time you’ll see me” or “I won’t need any more  appointments.”
  • Preoccupation with death or a lack of concern about personal


How to respond to what the patient tells you

If this assessment suggests that the patient is at serious risk of suicide or harm then you should give them space and  time  to  talk,  as  this  might  be  the  first  time  they have spoken about these feelings. If you are concerned that they are at a crisis point then you should explain to them that you need to make sure they see the GP before they leave the practice, and also offer them information about organisations such as the Samaritans.


Looking after yourself

If  you  have  worked  with  someone  who  is  suicidal, perhaps including being with them whilst you wait for  a  GP to come and assess them, it may have a significant impact on you. For example you may find that it raises emotions in you such as sadness, anger or feelings of helplessness. Remember to take time to give yourself a break in order  to  calm  yourself  and  find  a colleague  to talk to for  a few  minutes  if you feel  it would  be useful in order to help you let go of these feelings.


If a patient  has  a clear  plan  as to  how they may kill themselves and they (or you) feel there is a chance  that  they  may  act soon on their plans, you should speak with a doctor before  the  patient  leaves  the surgery and ask them to see the patient before  they leave.

However, if the patient has only felt like acting on suicidal thoughts or has made less specific plans which they don’t think they will act on at the moment, you should let them know that you will need to discuss this with a doctor as soon as possible and you would like them to see a GP for review in the next day or two.

You need to make sure this appointment is made and agreed with the patient before they leave the surgery if they are not assessed by a doctor straightaway.

You will need to tell the patient that you are discussing your concerns with one of the doctors in  the  surgery. People will nearly always agree to this, but if they don’t and you are concerned that they are at significant risk     of  taking  their  own  life  you  are  ethically  obliged  to inform  someone  else  about  this  and  would  be expected  to  do so even  if this  breaches confidentiality.

“If you have worked with someone who is suicidal, perhaps including being with them whilst you wait for a GP to come and assess them, it may have a significant impact on you.”



Section 6 Management and treatment Mild depression and anxiety disorders

One of the most important factors in determining what treatment is most appropriate is the severity of the depression and anxiety. Patient choice, and past history of what may have been helpful or not are also crucial in deciding treatment options.


Active monitoring

For patients presenting with mild features of depression (i.e. relatively few symptoms and little functional impact), getting a clear picture of their symptoms and any life circumstances or stresses which may be associated is the  correct  thing  to  do,  This  also  helps them  to  feel  understood  and  they  will  be more  likely to  feel  comfortable  returning  for  a further assessment.

A follow-up assessment of their symptoms and relevant social  situation  within  two weeks of  your  first  meeting is the appropriate  initial  response.

This is termed active monitoring – and it is important because quite a few of those people who experience relatively  mild  symptoms  of  depression  and  anxiety will find that these resolve without treatment. If you have used a scale like the PHQ-9 or GAD-7  alongside the assessment this can help to determine whether someone’s  symptoms  have  improved  if you repeat it  at  their  follow-up appointment.


Health education and simple interventions

If at the follow-up review, someone still has clear symptoms of depression and anxiety, but the features are mild, providing health education about the symptoms and their likely cause and the available types of self-management and treatment may be helpful (termed psycho-education). The benefits of information, advice and education about depression should not be underestimated. Simple explanations about depression can help people to make sense of their distressing symptoms and give hope about recovery. Organisations like Mind produce lots of information aimed at people who are experiencing mental health problems, see Further information on page  44.


Physical activity

Many  people  with  depression  experience  a  loss  of energy and constant feelings of tiredness. Taking some form  of  exercise,  for  example  swimming,  walking, running  or  kickboxing  two  to  three  times  per  week, can  help  relieve  several  of  the  symptoms  associated with depression. Where possible, encourage outdoor exercise as that has  a greater  benefit  than  indoor exercise. Physical activity is  an effective  antidepressant, as when we exercise our bodies release ‘feel good’ chemicals called  endorphins.  Exercise  can  also  give people more energy  and  improve  their  sleep  and appetite. Of course you will need to tailor advice about physical  activity  to  the  physical  health  of  the  person and  recognise  that  a  person  who  is  depressed  will nearly always lack  motivation  and  energy  and  so  will need to  build  up their  activity level slowly.



Depression can affect people’s appetite, so encourage those affected to eat regular, appropriate amounts.

Missing out  valuable  nutrients  can  make  people  feel tired and run down, so it is important to include plenty   of fresh fruit and vegetables. Alcohol can act  as  a depressant so is best avoided,  and  many  recreational drugs  which  bring  about  short  term improvements in mood have been shown to lower mood over time. Obesity is also closely linked to depression, as it can negatively impact on self-esteem, so support with weight-loss  may  also  be appropriate.


Relaxation techniques

Depression is frequently associated with tension, stress and anxiety.  Relaxation  is the natural  answer to  stress.

It is good to make time during the day to relax, whether or not an individual feels under stress. There are many ways to relax – yoga, reading, listening to a relaxation tape, going away for a short holiday – encourage the patient to try to find out what works for them and to regularly give themselves time to wind down. Learning and practising relaxation techniques will help them

(and you!) to cope better with the effects of stress, particularly if they are used regularly and not just when someone is feeling under particular pressure. Relaxation exercises can also be used to help people to prepare for sleep. A simple example of muscular relaxation exercises which you can copy and give to people are given on the right. Often, these exercises may be  adapted  to  assist people to prepare for sleep.


Some simple relaxation exercises

Sit in a well-supported chair or lie on your back. Concentrate on your breathing for a few minutes. Breathe slowly and calmly, and each time you breathe out say words to yourself such as “peace” or “relax”. Then start the muscle exercises, working around the different muscle groups in your body.

Hands – clench one hand tightly for a few seconds as you breathe in. You should feel your forearm muscles tense. Then relax as you breathe out.

Repeat with the other hand.

Arms – bend an elbow and tense all the muscles in the arm for a few seconds as you breathe in. Then relax as you breathe out. Repeat the same with the other arm.

Neck – press your head back as hard as is comfortable  and roll it slowly from side to side. Then relax.


“Encourage the patient to try to find out what works for them and to regularly give themselves time to wind down.”

Face try to frown and lower your eyebrows as hard as you can for a few seconds, then relax. Raise your eyebrows (as if you were startled) as hard as you can, then relax. Clench your jaw for a few seconds, then relax.

Chest – take a deep breath and hold it for a few seconds, then relax and go back to normal breathing.

Stomach tense the stomach muscles as tight as possible, then relax.

Buttocks – squeeze the buttocks together as much as possible, then relax.

Legs – with your legs flat on the floor, bend your feet and toes towards your face as hard as you can, then relax. Then bend them away from your face for a few seconds, then relax.



Some simple sleep techniques

—   Only go to bed when you feel sleepy.

Do not try to get more sleep by going to bed early.

—   Do not read, watch television or eat in bed, unless you  are  sure  from  past  experience that  these activities help  you get to sleep.

—   When  lying  in  bed,  relax  your  muscles.  Taped or written instructions may help you to do this. You may want to listen to a relaxation tape or soothing music.

—   Do not think about getting to sleep or worry about the day’s activities. Try instead to think about  pleasant  events  or places.

—   If you are unable to get to sleep after a while, get up and do something different in a different room and do not return until you feel sleepy.

—   Set your alarm and get up at the same time each morning, regardless of how much you slept during the night.

—   Do not drink coffee or tea before you go to bed as they contain caffeine.

—   A warm bath before going to bed may help you to unwind.

—   Avoid heavy meals and alcoholic drinks late in the evening.

—   Make sure your bed is warm and comfortable.

—   Try  and keep  to a fixed  routine  every night.

Sleep disturbance is a frequent and distressing feature of depression and anxiety disorders. Often simple things can improve sleep.


Social support

When  people  are  experiencing  depression  they  can often feel very  isolated.  They  may  feel  that  they  don’t have  the  energy  to  socialise,  or that  their  mood is  too low  to  mix  with  others.  The problem  is  that  social isolation can fuel depression and  make  it  even  worse. When  they’re  alone,  people  who  are  depressed  may tend to revert to negative thinking, which only increases feelings  of  worthlessness,  shame  and alienation.

You may want to make the following suggestions to patients who are affected in this way.

Turn to trusted friends and family members When depressed, people may retreat from their most important  relationships.  However,  these  relationships may  be  potentially  helpful  in  getting  through  this tough time. Encourage anyone who is depressed to communicate their needs to people they love and trust, but to be selective in who they confide in. Talking  to someone  who  does not  seem sympathetic,  or is  prone to say tactless things,  can  make  someone  who  is depressed  feel worse.


Join an interest group

Joining or continuing to attend a group that shares an interest such as a choir, music group, adult education class, local neighbourhood group or sports team can help a person experiencing depression to feel more positive and to regain an interest in activities and pleasures. It can also allow a person to have something interesting and positive to focus on at a time when everything can seem to be negative and the person tends to focus only on their feelings of depression.


Join a support group

If it seems appropriate, you can discuss with patients whether they would be interested in finding a group of people who  are  also  working  towards  getting  better from  depression.  This  does  not  suit  everyone,  but  can be very effective  for  some.  Being  with  others  in  the same  situation  can  go  a  long  way  in  reducing  one’s sense of isolation, and group members  can  encourage each  other,  give  and  receive  advice  on  how  to  cope, and share experiences. The Depression Alliance has information  about  support  groups  around  the country see Further information on page  44.


Problem solving

Often people’s problems can play a key role in generating  and  maintaining  the  psychological symptoms they present with. Difficulties such as debts, relationship problems or unemployment can provoke low mood – but then a vicious cycle can develop where the person’s anxiety or low mood hinder their dealing with these problems, and they become more discouraged and unconfident about taking  action.

The problem-solving technique is a way of working through problems, and trying to set goals which are achievable and can reduce the burden of the problem. It has defined stages which can be worked through over a number of sessions, as given below.

  • Formulate a problem list – talk about the things that are causing concern and write them
  • Clarification and definition of problem – choose one from the list and using probing questions find out more about
  • Setting achievable goals – talk about how the person would like this problem to change, what is a realistic goal for the
  • Generating solutions – brainstorm as many possible ways of achieving this goal as
  • Choosing and implementing preferred solution – look at all the possible solutions and choose the one that seems to be most Break it down into stages to make it seem manageable.

“The problem–solving technique is a way of working through problems, and trying to set goals which are achievable and can reduce the burden of the problem.”

Some of the nurses and patients involved in the ProCEED trial found this to be a good way of approaching and working on their problems. It can be applied to any of the psycho-social problems which patients may have and which are not necessarily associated with being anxious or depressed. If you are  interested  in  finding  out  more  there  is  a  useful small book telling you how to do this, Problem-solving treatment for anxiety and depression: A practical guide, Oxford  University  Press, 2005.


Moderate and severe depression and anxiety disorders

For moderate and severe depression (and for  more severe anxiety disorders), there are two broad approaches to treatment that  should  be  used  in addition  to  helping  people  address  the  lifestyle factors as outlined previously: antidepressant medications  and  formal  psychological  treatments.

These  two  approaches  appear  to  be  equally  effective and there is some evidence  that  the two together  may be more effective than  either  alone  – it may  be that taking antidepressants  will  lift  someone’s  mood sufficiently for  them  to  then  be able  to  make  effective use of the psychological therapy offered. Many patients prefer  psychological  treatments,  and  dropout  rates appear to be lower than for drug treatment.

The patient’s past experience, and prior response to treatments, together with their current preferences, and  the  availability  of  desired  treatments  are  the key  considerations.

You can play a crucial role in helping someone consider and choose the treatment that will be best for them.

This section summarises the key points about therapies and medication and there is further useful information available  from  Mind,  see Further information on page  44.


Psychological therapies

There are many different types of psychological therapies, which may be suitable for different people depending on the person’s personality and preferences, as well as the nature, severity and duration of their  problem.

It is  important  to  gain  a sense  of  the  patient’s perspective about talking therapies, some helpful areas  to  explore include:

  • Is there a type of treatment that the patient would prefer?
  • Would they prefer short or longer term treatment?
  • How interested are they in   self-exploration?
  • Do they see problems  as related  to  life experiences?
  • Do they want to address problems ‘here and now’ or link to their past?
  • Are they interested in exploring causes, or alleviating symptoms?
  • Are they able to tolerate a degree of emotional distress?


Are they at risk of turning to alcohol, self-harm or abandoning the treatment if they find it hard to cope?

“You can play a crucial role in helping someone consider and choose the treatment that will be best for them.”

It can be helpful to think of psychological therapies as ongoing processes – someone might have a ‘course’ of treatment to deal with a particular crisis or concern, and may come back for further treatment at a later point. One course is not usually going to ‘cure’ a person’s problems, nor is it usually intended to. It can, however, help people to think about their symptoms and their lives, and it can teach them skills or enable them to tackle or manage  some of their  own problems.  It is likely to reduce the risk of further  episodes  of depression, or to help people to deal with these better if  they occur.

We have described a selection of the  most commonly used therapies, but this list is not totally comprehensive and you may have heard of others.


Behavioural activation

This therapy aims to identify the effects of behaviour on current symptoms, mood and problem areas.

It  seeks  to  reduce  symptoms  and  problematic behaviours  through  behavioural  tasks  related  to reducing avoidance, activity scheduling, and enhancing positively reinforced behaviours. The intervention usually consists  of 12  to 20  sessions over  three  to four  months.


Cognitive-analytic therapy (CAT)

CAT was developed by Dr Anthony Ryle, who had previously worked as a GP. This brief therapy was developed in the context  of the UK NHS, with the aim  of providing effective and affordable psychological treatment, but is not  available  in all areas  of the UK. The model gives emphasis on collaborative  work  with the client and focuses on the understanding  of  the patterns of maladaptive behaviours. The aim of  the therapy is to enable the person  to  recognise  these patterns and understand their origins and to learn alternative strategies in order to cope better.  It has features of  both  cognitive  behavioural  and psychoanalytic  therapies.


Cognitive behavioural therapy (CBT)

CBT is a talking treatment which  helps  people  to recognise  problems  and  overcome  emotional difficulties. It is based on the premise that emotional difficulties can arise  from  self-destructive  ways  of feeling, thinking and behaving. This may mean  that people misinterpret situations  or symptoms  in  a negative  manner  (also  termed  negative assumptions).

This can lower the person’s mood and in turn lead to further negative thoughts and a worsening of the situation.

The therapist helps clients to identify connections between their thoughts, how their thoughts affect  them and how they may then behave. CBT aims to help people change some of the ways in which they think, feel and behave, in areas of their lives where there are significant difficulties. It aims to help people to develop practical skills which can then help them to lead a more positive and constructive way of life, which should in turn improve their mood. It may not always address the underlying causes behind a problem, but it may be useful in helping people to develop practical skills to help manage their symptoms. Duration of treatment varies depending on the disorder and its severity but for people with depression it should be in the range of 16  to 20 sessions over three or four months; for people with GAD it should usually consist of 12 to 15 weekly sessions (fewer if the person recovers sooner, more if clinically required), each lasting one hour.


Do it yourself CBT

There is a wide range of books and leaflets on self-help  for depression  (see  Further information on  page  44 for  some  examples).  A further  recent development is using interactive CD-Rom programmes on  the computer, which can be accessed via the GP or other service-providers. Some of these are very high quality and people may prefer them to seeing a therapist, particularly as a first step. See Further information on page 44 for more details. They may become more freely available for self-help  use in the near future,  as the Government is putting funds into such schemes. However, computerised CBT programmes  are  not suitable for someone with severe symptoms and it is recommended that people are assessed  before  using one  of  these programmes.



Counselling  involves  talking  with  someone  who  is trained to listen with empathy and acceptance, allowing people to express their thoughts and feelings  without feeling  judged  or  criticised.  It  is  one  of  the  most common  types of  talking  therapy  available  and  is generally well accepted  by  most  people.  It  has  been shown  to  be  an  effective  treatment  for  mild  to moderate  depression.  Depending  on  the setting, it can vary from a short-term (six to 12 sessions) to a more medium-term treatment. As the number of sessions provided on the NHS is usually limited,  in  this context it is usually indicated for more acute difficulties,    or when someone only wants to try a fairly short course  of  a  ‘talking treatment’.

Counselling can be used to help with adjustment to life events, such as divorce or retirement, or can create an opportunity to think  about ongoing  life  difficulties  with  a view to trying to solve them. If time-limited in nature     it is likely to be most useful  for  more  acute  problems, such as when there is an indication that a  person’s depression is of fairly recent onset (or has recently worsened) in relation  to some   external  circumstance.

Short-term counselling may not be particularly suitable for more severe depression, or addressing problems which may be associated with long-term difficulties going back to childhood. However, it may help people in these positions begin to think about their situation and seek further help if they have found a course of counselling to be helpful.


Group therapy

Group therapy helps people to deal with interpersonal problems and develop self-awareness. There are generally eight to 12 people in the group, who meet together regularly with a therapist, and talk about their concerns.


Interpersonal therapy (IPT)

The person works  with  the  therapist  to  identify  the effects of problematic areas related to interpersonal conflicts, role transitions, grief and loss, and social skills, and their  effects  on  current  symptoms,  feelings  states and  problems.  They  seek  to  reduce  symptoms  by learning to cope with or resolve such problems or conflicts. The intervention usually consists  of 16 to 20 sessions over three or four months.


Mindfulness-based  cognitive therapy

A  group-based  skills  training  programme  using techniques  drawn  from  meditation  and  cognitive therapy designed specifically  to  prevent  depressive relapse or recurrence of depression. Its aim is to enable people to learn to become more aware  of  bodily sensations, and thoughts and feelings associated with depressive relapse. The intervention usually consists of eight weekly two hour sessions  and  four  follow-up sessions in the 12 months after the end of treatment.


Psychodynamic psychotherapy/psychoanalysis This is what many people might initially think of when they consider psychological therapies. This  technique helps people to look at their  past  experiences  and  to think about how these may be affecting their current situation and ability to make choices. This method is probably  the  most  useful  when  someone’s  problems or depression seem to be caused by difficulties  going back to their childhood, their  way  of looking at things,  or the way  they relate  to others.  It can be  helpful when problems are long standing. The process requires a high level of interest in self-exploration and an understanding that painful or difficult past experiences may be returned to and talked about. This means that it can be suitable for people who want to ‘get to the bottom’ of their difficulties and are able to tolerate a  certain  amount  of  emotional  pain.  It  is  usual  for the patient to develop a strong relationship with the therapist and this is one of the ways the therapist works with the patient. As such this process typically takes longer than other kinds of psychological therapies, usually lasting at least six months and often longer.


Relationship counselling and family therapy

This  is  for  couples  who  want  to  sort  out  problems  in their relationship. They attend sessions together and the counsellor  helps  them to express their  difficulties,  listen to each other, to increase  their  understanding  of  each other and find ways of making their  relationship  work better, or possibly to decide that it is time to separate.

If they decide to end the relationship they will hopefully have gained more understanding of why it was not working and what lessons they can learn for the future. Family therapy works in a similar way, with all family members encouraged to attend the sessions.


Accessing talking therapies

The availability of these talking  therapies  varies enormously and it is worth spending a little time trying  to establish what the situation is for you locally. The Improving Access to Psychological Therapies (IAPT) programme  supports  practices  in  implementing National Institute  for  Health  and  Clinical  Excellence (NICE)  guidelines  for  people  experiencing  depression and  anxiety disorders.

Many  doctors’  surgeries  have  counsellors  or psychologists working within the surgery and there are also outside services that people can be referred on to. Despite the implementation of IAPT there are still often long waiting lists, particularly in the NHS, but  also sometimes in the voluntary  sector.  Some  organisations will see people fairly quickly for an initial assessment appointment to see if they are suitable for the therapy offered, and then put them on a further (possibly quite    a lot  longer)  waiting  list  for  treatment if accepted.

What is available varies a great deal from place to place and, unfortunately, there is not always something suitable on offer. What services do exist may not be well publicised and it is worth asking about them in as many  places  as possible.

The cost  of  private  counselling  or  psychotherapy  can vary a  great  deal.  A  fee  of  £50  to  £70  per  session  is quite common but therapy in a group may be cheaper. Sometimes people can pay less if they are  on a low income  or if they are prepared  to see a  student.

See Further information on page 44 for useful organisations to contact for access to talking therapies.



Antidepressants are drugs which work by increasing the activity and levels of certain chemicals called neurotransmitters  in  the brain.

The most common antidepressants work on the neurotransmitters  serotonin  and  noradrenaline.  If effective  this  medication  can  help  to  lift  a  person’s mood and can  also  often  be helpful  for  anxiety symptoms. Sometimes it can improve  a person’s symptoms, so that they  then  feel  better  able  to  take action  to  deal  with  their  depression  and  its  effect  on their life.  This may mean that they are then in a position  to  make good use of a psychological therapy.

There are several different types of antidepressant, including:

  • Selective serotonin  reuptake  inhibitors (SSRIs)
  • Tricyclic antidepressants  (TCAs)
  • Monoamine oxidase  inhibitors  (MAOIs)
  • Mixed or third generation antidepressants – working on more than one

See table on page 37 for further details.


Indications for antidepressants

According to NICE guidelines antidepressants are not recommended for use in mild depression.  However, where mild depression does not respond to other treatments or a person presents with mild  depression but has a past history of more severe illness, then antidepressants may be  considered.  Antidepressants may also be appropriate for persistent ‘sub-threshold’ depression which is termed dysthymia – involving persistent symptoms that only meet a mild depression level, but continue over a couple of years.

Antidepressant treatment should be considered and offered to patients with moderate and severe depression. The trials show a moderate, but by  no means  universal  effectiveness  of  antidepressants (50 to  60 per  cent  improvement  for antidepressant treatment compared to 30 to 40 per cent for placebo treatment). Use of medication and choice of medication should be tailored to the individual patient; based on patient choice, known side effect profiles, previous response to antidepressants, co-morbidity and cost.

Many patients do not take the antidepressants they have  been prescribed  or take  them intermittently.

This may be because of  side-effects, worry about becoming addicted, or because they interpret initial improvement as  indicating  they  no  longer  need  them. The role of the nurse in monitoring the use  of antidepressants if the patient has decided to try them is therefore very important. There is  evidence  that  people will  be more  likely  to  use  antidepressants  if they  are given  clear  information  about  how  these  medications are believed  to  work  and  support  in  taking  the medication.  Giving  an  education  leaflet  is  also potentially beneficial – Mind and other organisations produce patient focused  information  about antidepressants,  see Further information on page  44.

Advice for patients taking antidepressants

  • It often takes two to four weeks before such drugs take
  • The common side-effects are often experienced initially but fade in seven to ten
  • Antidepressants need to be taken regularly, even when patients feel
  • Antidepressants are not addictive but should not be stopped
  • Patients should consult you or the GP before stopping taking the All antidepressants should be withdrawn slowly. The length of time for withdrawal depends on how long the drugs have been taken for.
  • If the patient shows a poor response to antidepressants after four to six weeks, check adherence and consider switching to another type of
  • Patients should be maintained on the same therapeutic dose for four to six months after their symptoms have
  • For patients with three or more episodes in the last five years, or a total of five or more episodes ever, maintenance drug  treatment  for  several  years  or even indefinitely should  be considered,  if medication is  found
  • If the patient is older or physically ill, use medication with fewer  anticholinergic  and cardiovascular side-effects.
  • Monitoring suicide risk is Tricyclics and MAOIS are  contra-indicated  in  people  who  are  a high suicide risk, unless closely supervised by their  GP or a psychiatrist. SSRIs are less dangerous in overdose, but there  is  a small  increased  risk  of suicidal thoughts/behaviours in some people when first  starting  on SSRIs  or with  changes  in dose.

Common  questions  and comments about antidepressants’

This section is designed to help you answer questions that  patient  commonly  ask  about  taking antidepressants:

“I haven’t been taking the medication, as I’m not sure about it.”

Quite a few people who are prescribed antidepressant medication do not take it. This may be because they are concerned  that  it  may  be  addictive,  or  that  they  will have  bad  side-effects. Discuss  the  way  that  the medication works and the  side-effects  with  the  patient and direct them to further sources of information

(see Further information on page 44) if they feel this way. Suggest that if their depression is quite severe, it is usually a good idea to try taking medication  to  treat  it, and  that  if  one  type  of  antidepressant  doesn’t  suit them,  another  might.


“I haven’t been taking the medication regularly – is this a problem?”

Many people do not take their medication regularly, either because their memory is unreliable (this can be a symptom of the depression) or because they only take their antidepressants on ‘bad days’, thinking it will help them to feel better at that time, and that they will avoid a risk of getting dependent or addicted to them if they don’t take them regularly. Unfortunately, this is not a good idea and can mean that the medication doesn’t then work effectively. As most antidepressants work by adjusting the brain chemistry over a period of weeks, they won’t work on a daily basis. Also, taking  medication on and off can cause withdrawal symptoms, which can usually be reduced or avoided by a careful gradual withdrawal at the end of treatment.


“I don’t like the side-effects. Nobody told me I’d feel like this.”

Some people stop taking antidepressants because they dislike  the  side-effects.  Tricyclic  and  SSRI  medications may have  side-effects  which  are  noticeable  in  the  first few  weeks but they tend  to pass after this.  It also takes  a few weeks for the antidepressant  effect  to  begin,  so there may be a time at the beginning when people may  be experiencing the side-effects but getting  little noticeable  benefit  on mood or other  symptoms.

If the side-effects don’t pass and are not tolerable they should see the doctor again.

Patients should always be fully informed most likely side-effects of a drug, all medications are supplied with a leaflet indicating all the side-effects (see the chart on page 44). There are many possible side-effects listed but most people will not suffer many, if any, of them.

Patients can report any side-effects they experience at, a national scheme to help monitor the safety of the medication.


“I feel better – can I stop taking  my medication?”

Many people tend to stop taking prescribed medication before the recommended time period because they feel better. However, if they do this there is about a 50 per cent chance of the return of the depression and

it is usually recommended that people stay on the medication for four to six months after  feeling  fully better to avoid this risk of  a recurrence.  In addition, some  antidepressants  have  unpleasant  side-effects on withdrawal, which can be reduced by a regime of coming  off  the  medication  slowly  with support.


“I have a history of many episodes of depression – how long should I stay on antidepressants?“

For some people who have experienced a number of episodes or continuous depression, it may  be recommended that they remain taking antidepressant medication indefinitely if it helps to manage  their symptoms, or as a preventative measure to stop future recurrences. Some  people  ask  to  do  this  themselves  if they have had previous recurrences of their  depression when  stopping  their  antidepressants.  However,  it  is always worth at least one trial without medication once the symptoms of depression have  subsided,  to see what  is  likely  to  happen  and  whether  they  can  remain  well off  medication.


“I’m  taking  my  medication  but I  don’t  feel  any better.”

Not all people with  depression  respond  to antidepressants. The current guidelines suggest that if someone doesn’t seem to be getting any better on an antidepressant within six weeks, the medication should  be reviewed and probably changed. Other  treatments, such as psychological therapy and appropriate lifestyle interventions should  also be reviewed  at this  point,  and it would  be  appropriate  to  have  an  appointment  with the GP to discuss this. If three  different  types of medication have been  prescribed  and  they  are  not helping  a severe  depression,  the  case should  be discussed  with  a  mental  health specialist.


Up to two weeks First follow-up appointment to check that the patient is OK, is taking the medication as prescribed and dealing with any side-effects.
Two to four weeks Between two and four weeks they should be noticing improvements to their

symptoms. Side-effects should be lessening.

Around six weeks Second follow-up appointment to check adherence and effectiveness of treatment. If it is not being effective, a new treatment should be considered.
Up to six months During  this  time  the  depression  should  have lifted and they should be able to function better than  when  they  were depressed.
After properly well It is usually advisable to keep taking antidepressant  medication  for  at  least  four to six months after feeling well again and to discuss how best to come off the medication with  the  nurse or doctor.


Treatment Timescale

There is a definite timescale associated with antidepressant medication and it can be very helpful for both you and the patient  to  know  what  to expect  when.


Which antidepressant to  suggest

The recommending and  prescribing  of  antidepressants is  likely  to  be carried  out  by  the  GP,  but  it can  be helpful to have an idea of how the different types of antidepressants work in order to be better able  to  discuss  them  with patients.

SSRIs (serotonin selective reuptake inhibitors) Prozac (fluoxetine), Seroxat (paroxetine), citalopram, sertraline

These  are  the  most  commonly  prescribed antidepressants in general practice nowadays and are considered the first  line  treatment  by  NICE.  Most  are taken as one tablet daily and  do not  need to  have  the dose titrated (increased over time as needed) which can increase the likelihood of people continuing to take this medication. They generally have less severe side-effects than the other groups,  but  nausea/indigestion  and agitation can  be  a  problem  for  some  people,  and  can lead  to  withdrawal  problems  although  these  usually wear  off  with time.


TCAs (Tricyclic antidepressants) Amitriptyline,  lofepramine,  clomipramine, dosulepin

These are an older group of drugs, which used to be the most commonly prescribed for depression, but have now been largely supplanted by SSRIs, certainly for first line treatment. They are more complicated to take, in that the patient has to start on a low dose and then titrate upwards to reach what is generally considered a therapeutic level. Their side-effects tend to be more pronounced than with SSRIs – notably anti-cholinergic side-effects such as a dry mouth, constipation and postural hypotension. These side-effects usually decrease over the first couple of weeks of taking the tablets. Nausea can be helped by taking the medication with food.

They can be fatal in  overdose  and  therefore  pose a definite risk in suicidal patients. They may however be indicated as a second-line treatment for patients where    a first line SSRI has been ineffective. Amitriptyline in particular can be helpful for severe agitated  depression and is also sometimes used in lower doses for the management  of  chronic  pain.


MAOIs (Monoamine Oxidase Inhibitors) Phenelzine, moclobemide, trancylcypromine

These are only ever prescribed as a second or third line medication because MAOIs can affect  the  way  certain foods are digested, causing them to become poisonous. People taking these medications have to avoid matured cheeses, game,  protein  extracts,  alcohol  and  overripe fruits but this is less of a problem with a newer MAOI, moclobemide,  which  is  sometimes  prescribed  for  people  where  other  antidepressants have proved  ineffective.



Antidepressants and their possible side-effects


Venlafaxine,  mirtazapine

(usually second or third line drugs)

These are thought to work  on  a  combination  of receptors in the brain, and so can have side-effects commonly associated with either SSRIs or tricyclic antidepressants. They are usually only prescribed as a second or third line treatment, but can sometimes be very effective. Mirtazapine can  be  quite  sedating  – which may be a desired effect: it can  assist  sleep  if taken  in  the evening.

It can  be difficult  to  predict  which  anti-depressant is likely to be more suitable for a particular patient, although  within  each  group  there  are  some which are usually more likely to be more alerting and some which are more sedating. Patients  may  however  be very individual in their responses, and it is important  to take  their  perspective on the treatment  seriously.

If one antidepressant in a particular group has been ineffective this does not necessarily indicate that other drugs in this class will not help – there is considerable individual variation in response, and it is often worth considering  more  than  a single  SSRI  before trying a move to a different group of antidepressants.


Name and type of medication Possible side-effects
SSRIs (serotonin selective reuptake  inhibitors)

Prozac (fluoxetine), Seroxat, (paroxetine) citalopram, sertraline

Decreased appetite/indigestion, nausea/vomiting,  anxiety/agitation,  insomnia or  sleepiness,  headache,  dry  mouth,  sexual  dysfunction,  tremor, dizziness.

Sexual dysfunction can continue after stopping the drug.


Amitriptyline, lofepramine, clomipramine, dosulepin

Drowsiness, blurred vision, constipation, dry mouth, difficulty urinating, eye sensitivity to light, nausea, weight gain, dizziness when standing up, impaired thinking.

Phenelzine, moclobemide, trancylcypromine

Low blood pressure on standing, dizziness, drowsiness, insomnia, headache, weakness and tiredness, dry mouth.

MAOIs can affect the way certain foods are digested, causing them to become poisonous. Avoid matured cheeses, game, protein extracts, alcohol, overripe fruits.


Venlafaxine,  mirtazapine

(usually second or third line drugs)

These are thought to work on a combination of receptors in the brain, and so can have side-effects commonly associated with either SSRIs or tricyclic  antidepressants.




Section 7 Health care professionals


Working as a team and who to ask for help

Depression and anxiety are common, and using the techniques outlined in this guide can help you to develop the confidence and skills to support patients. However, there will be times where you need support for yourself, or where you feel the patient  needs to  be referred for  more  specialist help.

Mental health professionals work in a range of different roles, and it can be difficult to know who the most appropriate person to go to is. This section  gives  an overview of the key  people involved  in   mental health care.



An advocate is someone who represents their own  or someone else’s interest and speaks on their behalf. There are many forms of advocacy in mental health including advocates for people who have been admitted to hospital under the Mental Health Act, legal advocates and peer advocates.

Approved mental health professional (AMHP) These  are  professionals  who  have  had  additional training to be able to carry out certain functions of the Mental Health Act, such as assessing people who are unwell  and  might  need to  be detained  under  section. In practice these are often social workers but nurses, occupational therapists, psychologists and other professionals  can also  perform  this role.



A person who supports someone who has mental health problems is referred to as a carer, although many carers would not use this term to describe themselves. Carers may or may not be related to the person they are caring for.  Carers may be adults or children, working or unemployed. They may be providing help and support to their parent, partner, son or daughter, neighbour or friend.


Care coordinator

A care coordinator is a named individual who is designated as the main point of contact and support for a person who has a need for ongoing care from secondary care mental health services. The Government’s ‘care programme approach’ for specialist psychiatric services advises that health and social services should designate a person to keep in close contact with a ‘patient’ in the community and to monitor their care.


Care manager

A care manager is responsible for assessing a person’s social care needs and  for  arranging  delivery  of community  care  services  within  available resources.

Care managers work within social services departments and organise community care for many different client groups. When arranging services for people with mental health problems, they often work as part of a community mental health team. Their role is to carry out the local authority’s duties under the NHS and Community Care Act (1990). This is called ‘care management’.


Community mental health nurse (CMHN)

A CMHN, also known as a community psychiatric nurse (CPN), is a registered nurse with specialist training who works in the community. Some are attached to general practice surgeries or community mental health centres, others to mental health units. Most work as part of a community mental health team. The role of a CMHN can be wide and may include:

  • Counselling or anxiety management, or exploring different coping strategies with people with acute short-term
  • Working with people who have had severe mental health problems for many years and require long- term support to enable them to establish a rewarding life in the
  • Administering psychiatric drugs; for example, as


Clinical psychologist

Clinical psychology involves the assessment and treatment of mental health problems using evidence based psychological therapies. Clinical psychologists are not medical doctors and work in a range of health and social care settings, to help individuals manage and alleviate their mental distress. The Government’s IAPT initiative (Increasing Access to Psychological Therapies) has led to a significant increase in the number of clinical psychologists available to deliver psychological therapies to patients in community or primary care settings.


Community mental health team

This is a team of professionals from both health and social care services who work together to provide a coordinated service for people with severe and enduring mental health problems. These patients most often have ‘psychotic’ disorders such as schizophrenia or bipolar disorder, but people with severe and enduring depression and anxiety may sometimes be under their care. The team will usually include one or two psychiatrists, community mental health nurses, a psychologist, occupational therapist and social worker.


Crisis team

This is  a team  of  mental  health  professionals  who may be contacted if someone is acutely unwell, of a severity which would usually merit  a  hospital  admission,  but where it may be appropriate to look after them in the community. This is achieved by  the  crisis  team  visiting them at home regularly, daily  or  more  frequently,  to review  how  they  are  and  to  support  them  in  taking their  medication  if needed.

Graduate mental health worker

Graduate mental health workers work in primary care settings, such as general practices  or  health  centres. Their function  is  to  improve  the  capacity  of  primary care  to  manage  common  mental  health problems.

The duties of graduate mental health workers vary between health trusts but may include:

  • Delivering talking therapies such as cognitive behaviour therapy (CBT).
  • Promoting good mental health in the
  • Providing information and referral to other services, including voluntary  sector


General practitioner (GP)

A GP is the first point of contact with the NHS for most people.  Many  mental  health  problems  are  dealt  with by GPs by themselves or in conjunction with other professionals working within the practice such as a counsellor or graduate mental health worker. If more specialised treatment is needed, the  GP  can  make  a referral to secondary mental health services such as a community mental health team or acute mental health  crisis service.


Occupational therapist

Occupational therapists work in mental health units, day hospitals and the community. They may be employed by a health authority, social services department or voluntary organisation. Their role is to help people with mental health problems to build up the confidence and skills needed for personal, social, domestic, leisure and work activities. They focus on the learning of specific skills and techniques, including arts, crafts, drama, dance, writing, group work (such as anxiety management and assertion training), individual counselling and training activities in daily living.



Psychiatrists are qualified medical doctors who have specialised and taken further training  in  ‘mental illnesses’. In some areas, psychiatrists have close links with GP surgeries; others work in community mental health  centres  or  multidisciplinary teams.


Social worker

Social workers are involved in mental health in a number of ways and work in a variety of settings.

Local authority social services are tending to move away from generalist social workers towards specialist teams, including  specific  mental  health  social  service teams.

However, there are no clear guidelines about the level of social services that people are entitled to expect and there is wide variation between geographical areas in terms of the services provided.

Social workers should be able to offer advice on practical matters such as day care, accommodation and welfare benefits, or can link you with appropriate services. Some may offer counselling.


Section 8

Key messages

Key messages for patients

As a practice nurse you can make a huge difference to the care, treatment and recovery of people with depression and anxiety.

Know  about treatment

Make sure people are clear about the treatments they have been given, how they work, what side-effects there might be, and how they will hopefully help.

If patients don’t know the answers to these points, then encourage them to ask the relevant health professionals and try to become an expert in  their own  care.


Have realistic expectations

People experiencing depression and anxiety are unwell. They  shouldn’t  expect to  be able  to  achieve  all  the things  they  can  do  in  their  lives  normally.  Not  being able  to  do everything  as normal  isn’t a failure.


Getting better

The large majority of people who experience depression will get better, even if they don’t believe it at this time. This is a crucial message and one that is often referred to by patients after they have recovered – the importance of those caring for them emphasising that they would get better. Hope aids recovery.


General wellbeing – looking after themselves People who are feeling depressed and anxious should try to eat healthily and regularly, get regular sleep, and maintain something of a normal routine.

They should see their GP if they are physically ill or not able to eat properly.



It is not a good idea to make any major life changes when feeling depressed, because negative emotions might unfairly influence decisions. However, making some decisions can help recovery by allowing people to feel in control, and it is very important to involve patients in decisions about their treatment.


Confiding  in people

Friends  and  loved  ones  are  very important,  and confiding in them can  help  people  to  feel  understood and cared for. However, confiding  in some people may  be problematic  if  they  respond  in  a  critical  or  unkind way.  It  is  therefore  important  to  identify  friends  who can  be trusted.


Support groups

If people are  feeling  very socially  isolated,  consider interest or support groups or activities like volunteering. There may be specific support available for people with mental health problems to volunteer in your local area.


Physical activity

Physical activity has been shown to be an effective antidepressant. If people  can  take  exercise  outside in nature  it is very likely  to boost mood.


Contact with other voluntary and statutory agencies

Voluntary and statutory agencies can provide further support, and can help with bigger issues, such as Relate for relationship difficulties or the Citizens Advice Bureau for financial difficulties.


Feeling worse

If patients start to feel worse, they should get in touch with you or with their doctor, or give permission for a friend to do this. Ignoring symptoms can cause more problems in the future and can slow recovery.



Key messages for you as a practice nurse

 A range of social, demographic and health related factors can help inform initial risk prediction for depression and anxiety (such as gender, socio- economic indicators, past history, medical problems).

Where you suspect a problem, use brief screening instruments such as the ‘Whooley’ screen for depression  and  the  GAD-2  for anxiety.

For individuals who screen positive, follow-up questioning using more detailed instruments such as the PHQ-9 or the GAD-7 may help to grade the severity of the problem and may be useful for monitoring the effects of treatment.

A past history of a common mental disorder is an important predictor of current problems, as is asking the  patient  what  interventions  or  treatments  may have  helped in the  past.

You can make a big difference as a practice nurse  in advising patients about some of the life-style issues which may be impacting on their depression

and anxiety, such as diet, exercise and physical health issues. Signposting people  to  appropriate  voluntary sector services, such as the Citizens Advice Bureau for financial or housing queries can be very helpful. See Further information for  other  resources  on page 44.

If someone appears moderately or severely depressed the assessment and management of suicide risk is paramount  (see  page 21).

Management and treatment is based on a shared problem assessment and a care plan that accounts for the patient’s preferences. There are a several different treatments for depression and anxiety that seem of equivalent effectiveness. People’s past response to treatments is an important guide to what may work again.

If  you  are  interested  in  developing  more  skills  or working  in  more  detail  with  patients  with  depression we recommend you access some of the resources listed    in Further information on page 44, such as the LMC practice nurse toolkit and RCGP  courses which  are open  to practice nurses to join.


“You can make a big difference as a practice nurse in advising patients about some of the life- style issues which may be impacting on their anxiety or depression, such as diet, exercise and physical health issues.”



Section 9

Further information

This list of organisations and resources is provided to help you to begin to find out more about treatments and services and to explore what support is available in your area.


Alcoholics Anonymous Helpline:  0845  769 7555

AA is a society of people recovering from alcohol abuse.

Anxiety UK

(formerly the National Phobics Society)

T: 0844 477 5774

Information, counselling, helpline and online support for those suffering from anxiety disorders.

British Association for Behavioural

and Cognitive Psychotherapies (BABCP)

T: 0161 705 4304

Can provide details of accredited therapists.


British Association for Counselling and Psychotherapy (BACP)

T: 01455 883 316

For  details  of  local practitioners.

British Psychoanalytic Council (BCP)

BCP is a linking body of psychoanalytical psychotherapist societies. Website includes guidance on finding the right therapist.


Carers UK Helpline:  0808  808 7777

Information and advice on all aspects of caring, including for those with mental health problems.

Citizens’ Advice

The Citizens Advice service helps people resolve their legal, money and other problems by providing free information  and  advice.

Complementary and Natural Healthcare Council

T: 020 3178 2199

Lists officially registered complementary healthcare  practitioners.



Cruse Bereavement Care Helpline:  0844  477 9400

Cruse provides information and support to bereaved people.


Depression Alliance T:  0845 123 2320

Information and support groups for people affected by depression.


Depression UK E:


Londonwide  Local Medical Communities

General Practice Nurse Toolkit provides a basic unit on mental health – online and face-to-face training available.



Mind infoline: 0300 123 3393


  • Information: Mind has a wide range of patient information materials, covering diagnosis, treatment and wellbeing topics, available online or information can be provided via the Mind infoline.
  • Local organisations: Mind also has network of over 180 local organisations offering self-help groups, supported housing, crisis helplines, drop-in centres, employment and training schemes, counselling and (Details available through Mind infoline.)
  • Ecominds: 130 projects across England and Wales designed to provide a range of outdoor activities for people with mental health problems. Find out more at


NHS Livewell

Website with tips for healthy living including relaxation techniques, exercise programmes and people  talking about  their experiences.


NICE (National Institute for Clinical Excellence) Clinical guidelines on the management of common mental disorders are available from NICE. These are free to access, and full guidelines as well as summary documents are available on the web.

No Panic T:  0808 808 0545

For people experiencing anxiety disorders, such  as phobias.



This pack was developed following a three year research study  called  ProCEED  (Proactive  care  and  its  evaluation for enduring depression).  Further  details  about  the ProCEED  trial  are  available online.

(Buszewicz M, Griffin M, McMahon E, Beecham J, King M, ‘Randomised controlled trial of structured, proactive nurse-led care for chronic depression in primary care: the ProCEED trial’, BMC Psychiatry 2010,   10:61)


Relate offers relationship advice, support and therapy face-to-face, by phone and via their website.


Royal College of GPs

T: 020 3188 7400

Open to Practice nurses to join and offers training both face-to-face and e-learning.


Royal College of Nursing

Royal College Nursing represents nurses and nursing, promotes excellence in practice and shapes health policies. Mental health resources and support are available  through:

Royal College of Psychiatrists  The Royal College of Psychiatrists is the professional

and educational body for psychiatrists in the United

Kingdom. Their website has a wide range of mental health information.


Samaritans T:  08457  90 90 90


Confidential emotional support 24 hours a day.


Time to Change

Time to Change is England’s biggest ever  attempt

to end the stigma and discrimination that faces people with  mental  health  problems.  It is  a campaign

to change attitudes, and behaviour too.


Timebank gives information about volunteering opportunities.




Self-help books for depression

’The feeling good handbook’ by David D. Burns,

Plume publishers, 1999


’Overcoming depression: A step by step approach to gaining control over depression’ by Paul Gilbert,

Oxford University Press, 2000


’Overcoming depression: A five areas approach’ by

Dr. Christopher Williams, Oxford University Press, 2001


‘Depression: the way out of your prison’ by Dorothy Rowe,   Brunner-Routledge

Online cognitive behavioural therapy and skills training


Beating the Blues Beating  the  Blues  is  a computerised  CBT programme

for depression and anxiety which must be purchased for

use at your practice, although some PCTs are making it available in more centralized venues such as local libraries. In February 2006 NICE recommended Beating the Blues as a treatment option for all patients seen with mild or moderate depression. The self-help treatment programme involves eight sessions which patients complete.


Down your Drink


Fear Fighter

Fear Fighter is a computerised CBT programme for anxiety and panic disorders, phobias, obsessive compulsive disorder, depression and sleep disorders. Free access can only be prescribed by a GP, who can then give log-in details to the patient.


Mood Gym

Mood Gym is a free interactive self-help programme for people with depression, which is available on the internet. It is based on the principles of CBT and Interpersonal Therapy and is designed to be used by people whose problems are troubling but not incapacitating. The site includes information, games, quizzes and skills training.


Living Life to the Full

Living Life to the Full is a free on-line life skills course for people feeling  distressed,  and their  carers, which is  based  on a CBT  approach.  The computerised

programme helps the user to understand why they feel as they do and make changes in thinking, activities, sleep and relationships.



Ultrasis  produce  interactive,  computer based




CBT programmes.




Appendix 1:

PHQ-9 Assessment for depression

This questionnaire  is an important part of providing  you with the best health  care possible.  Your  answers will help    in understanding problems that  you may  have.  Please answer every question to the best of your  ability unless you  are  requested  to  skip a question.

Over the last two weeks, how often have you been bothered by any of the following problems?


1. Little interest or pleasure in doing things 0 Not at all
1 Several days
2 More than half the days
3 Nearly every day
2. Feeling down, depressed or hopeless 0 Not at all
1 Several days
2 More than half the days
3 Nearly every day
3. Trouble falling or staying asleep, or sleeping too much 0 Not at all
   1 Several days
   2 More than half the days
3 Nearly every day
4 Feeling tired or having little energy 0 Not at all
1 Several days
2 More than half the days
3 Nearly every day
5. Poor appetite or overeating 0 Not at all
1 Several days
2 More than half the days
3 Nearly every day
6. Feeling bad about yourself, or that you are a failure, or have let yourself or your family down 0 Not at all
1 Several days
2 More than half the days
3 Nearly every day
7. Trouble concentrating on things, such as reading the 0 Not at all
newspaper or watching television 1 Several days
2 More than half the days
3 Nearly every day
8. Moving or speaking so slowly that other people could have noticed. Or the opposite – being so fidgety or restless that you have been moving around a lot more than usual 0 Not at all
1 Several days
2 More than half the days
3 Nearly every day
9. Thoughts that you would be better off dead, or of hurting yourself in some way 0 Not at all
1 Several days
2 More than half the days
3 Nearly every day
Sum Questions 1-9 Total Score (0-27)


Appendix 2:

GAD-7 assessment for anxiety disorder


The first two questions form the GAD-2



Over the last two weeks, how often have you been bothered by the following problems?

Not at all Several days More than half the days Nearly every day
1. Feeling nervous, anxious or on edge 0 1 2 3
2. Not being able to stop or control worrying 0 1 2 3
3. Worrying too much about different  things 0 1 2 3
4. Trouble relaxing 0 1 2 3
5. Being so restless that it is hard to sit still 0 1 2 3
6. Becoming easily annoyed or irritable 0 1 2 3
7. Feeling afraid as if something awful might happen 0 1 2 3


GAD-7 Anxiety

 Column totals: ___ + ___ + ___ + ___ = Total Score _____

Simply  reading  out  these  questions  or  asking  a patient to complete the GAD-7 will not provide an effective assessment. It will feel cold and clinical and might  damage  your  relationship  with  the patient.

You can use the techniques outlined to help assess for depression, such as open-ended questions, and welcoming body language to help the patient feel at ease and talk with you openly.


For more information about this guide, contact:

Beth Murphy

T: 020 8215 2282



15-19 Broadway London E15 4BQ T:  020  8519 2122

F: 020 8522 1725                                                                                                                          Design:

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