Treatment of Depression Pathway | Right Decisions

Announcements and latest updates

Welcome to the Right Decision Service (RDS) newsletter for August 2024.

Contingency planning for RDS outages

Following the recent RDS outages, Tactuum and the RDS team have been reviewing the learning from these incidents. We are committed to doing all we can to ensure a positive outcome by strengthening the RDS to make it fully robust and clinically resilient for the future.

We would like to invite you to a webinar on 26^th September 3-4 pm on national and local contingency planning for future RDS outages. Tactuum and the RDS team will speak about our business continuity plans and the national contingency arrangements we are putting in place. This will also be a space to share local contingency plans, ideas and existing good practice. We would also like to gather your views on who we should send communications to in the event of future outages.

I have sent a meeting request for this date to all editors – please accept or decline to indicate attendance, and please forward on to relevant contacts. You can also contact Olivia.graham@nhs.scot directly to register your interest in participating.

2.National IV fluid prescribing calculator

This UK CA marked calculator is now live at https://righdecisions.scot.nhs.uk/ivfluids . It has been developed by a multiprofessional steering group of leads in IV fluids management, as part of the wider Modernising Patient Pathways Programme within the Centre for Sustainable Delivery. It aims to address a known cause of clinical error in hospital settings, and we hope it will be especially useful to the new junior doctors who started in August.

Please do spread the word about this new calculator and get in touch with any questions.

New toolkits

The following toolkits are now live;

Gender identity healthcare: adults and young people standards. (https://rightdecisions.scot.nhs.uk/genderidentity ) Note that this toolkit includes self-evaluation forms for each standard. A Scottish Government launch of these standards, together with the toolkit and NES educational resources, is planned for 3^rd September.
Care Inspectorate staffing method framework.
Vascular surgery pathways from the Modernising Patient Pathways Programme within the Centre for Sustainable Healthcare Delivery.

Updated guidance on current and future Medical Device Regulations

We have updated and simplified this guidance within our standard operating procedures. We have clarified the guidance on how to determine whether an RDS tool is a medical device, and have provided an interactive powerpoint slideset to steer you through the process.

Guide to six stages of RDS toolkit development

We have developed a guide to support editors and toolkit leads through the process of scoping, designing, delivering, quality assuring and implementing a new RDS toolkit. We hope this will help in project planning and in building shared understanding of responsibilities throughout the full development process. The guide emphasises that the project does not end with launch of the new toolkit. Implementation, communication and evaluation are ongoing activities throughout the lifetime of the toolkit.

Training sessions for new editors (also serve as refresher sessions for existing editors) will take place on the following dates:

Thursday 5 September 1-2 pm
Wednesday 24 September 4-5 pm
Friday 27 September 12-1 pm

To book a place, please contact Olivia.graham@nhs.scot, providing your name, organisation, job role, and level of experience with RDS editing (none, a little, moderate, extensive.)

7 Evaluation projects

Dr Stephen Biggart from NHS Lothian has kindly shared with us the results of a recent survey of use of the Edinburgh Royal Infirmary of Edinburgh Anaesthesia toolkit. This shows that the majority of consultants are using it weekly or monthly, mainly to access clinical protocols, with a secondary purpose being education and training purposes. They tend to find information by navigating by specialty rather than keyword searching, and had some useful recommendations for future development, such as access to quick reference guidance.

We’d really appreciate you sharing any other local evaluations of RDS in this way – it all helps to build the evidence base for impact.

If you have any questions about the content of this newsletter, please contact his.decisionsupport@nhs.scot If you would prefer not to receive future newsletters, please email Olivia.graham@nhs.scot and ask to be removed from the circulation list.

With kind regards

Right Decision Service team

Healthcare Improvement Scotland

Objectives

Depression as diagnosed by ICD-11 criteria can present as mild, moderate and severe. There are different treatment options (medication and non-medication) appropriate for the different levels of severity.

The Scottish Borders Mental Health Services Integrated Care Pathway (available at mentalhealthpathway_doc_19-2-.pdf (scot.nhs.uk)) describes the different levels of mental health support available in NHS Borders. These range from self help websites, primary care to secondary care support and, where clinically appropriate, admission to the psychiatry unit.

The pathway and algorithm detail non-medication and medication options that should be optimised in the treatment of moderate depression before referral to secondary care.

NHS24 funds the choice and medication website on behalf of NHS Scotland. This website contains helpful drug and disease specific information for mental health conditions, as well as patient information leaflets on each medication listed: https://www.choiceandmedication.org/nhs24

Additional information from the above site is also available, with examples below:

Taking an antidepressant for the first time:
- 1-page summary (https://www.choiceandmedication.org/nhs24/generate/handyfactsheetantidepressantsfirsttimehighlightsuk.pdf)
- 2-page leaflet (https://www.choiceandmedication.org/nhs24/generate/handyfactsheetantidepressantsfirsttimeuk.pdf)
Charts on comparing treatment options and side effects of medicines: handychartdepression.pdf (choiceandmedication.org)
Coming off antidepressants: handyfactsheetstoppingantidepressants.pdf (choiceandmedication.org)

Treatment of Depression Pathway

Psychological and Community Therapy

SPRING Social Prescribing available at: Health in Mind | Social Prescribing in the Scottish Borders (health-in-mind.org.uk)

NHS Borders Wellbeing Hub available at: nhsborders.scot.nhs.uk/patients-and-visitors/our-services/children-young-peoples-services-directory/health-improvement-team/mental-health-and-wellbeing/

RENEW Psychology Primary Care Services available via GP referral through SCI Gateway for moderate depression and anxiety.

Treatment of Depression Algorithm

Prescribing Notes & Choice of Alternative Antidepressant

Prescribing notes:

Trials of antidepressants must last at least 4 weeks (6 weeks in the elderly) at a dose approximately mid way between starting and maximum dose.
If treatment fails the diagnosis should be regularly review.
Doses should be increased/reduced in intervals of at least 1 week
Please check the additional information available in the East Region Formulary

Alternative Antidepressant	Helpful in patient group	Caution in patient group
Sertraline	Recent cardiovascular events/ acts on serotonin only	Risk of hyponatraemia in elderly
Citalopram	Helpful if fluoxetine has been ineffective and only moderate depression / Acts on serotonin only	Risk of Qtc prolongation: avoid if other risk factors for QTc prolongation (cardiovascular disease, other QTc prolonging medications)/ risk of hyponatraemia in elderly
Mirtazapine	Patients with problems sleeping, underweight, lacking appetite, elderly patients / dual action on noradrenalin and serotonin	Obesity/concerned with weight gain, patients who need to be up early
Venlafaxine	Patients who lack motivation and struggle to get up in the mornings/more severe depressive symptoms/ dual action on serotonin and noradrenalin	Hypertension, cardiovascular disease, some elderly patients, significant overdose risk

Prescribing Antidepressants in Pregnancy

Once indication to prescribe has been established, unless other considerations (such as prior response to an alternative SSRI), sertraline is a suitable first line treatment.

If insufficient response to sertraline, high risk patient, symptoms of severe depression – refer to referral pathways for pregnant and postnatal patients.

Information on antidepressants in pregnancy should be provided to the patient:

BUMPs medicine information: https://www.medicinesinpregnancy.org/Medicine--pregnancy/
NHS 24 Choice and Medication website:handyfactsheetperinatalhcdepression.pdf (choiceandmedication.org)

Last reviewed: 01/02/2024

Next review date: 28/02/2026

Author(s): Richardson-Read S.

Version: MH010/03

Author email(s): segdae.richardson-read@nhs.scot.

Approved By: Area Drugs and Therapeutic Committee

Reviewer name(s): Richardson-Read S.