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Clinical guidelines

National guide to a preventive health assessment for Aboriginal and Torres Strait Islander people Second edition

Prevention of depression

Author Dr Tim Senior
Expert reviewer Mrs Patricia Delaney

Background

The National Mental Health Plan 2003–08 notes that mental health is an area where ‘diverse views exist and ... terms are used in different ways’.1 The term ‘social and emotional wellbeing’ is often used in Aboriginal and Torres Strait Islander communities when discussing what clinicians might consider to be ‘mental health’, as it implies a holistic, strengths-based approach rather than a medical model.

Social and emotional wellbeing is a key component of the Aboriginal definition of health, includes concepts of connection to country, kin and community and is a view held across the whole lifecycle. However, much of the research in this area is done in settings outside Indigenous communities and is grounded within a more individualistic model of health. As such, inclusion criteria and outcomes are determined by diagnostic categories such as those in the Diagnostic and Statistical Manual of Mental Disorders, 4th edition (DSM-IV) (Table 10.1). In looking at evidence to make recommendations for the prevention of depression and suicide, this chapter recognises there can be tensions between biomedical and Indigenous concepts of mental health and that traditional research evidence may not be suitable in this context, particularly when assessing the suitability of community based interventions.

Table 10.1. DSM-IV criteria for a depressive episode
  • Five (or more) of the following symptoms have been present during the same 2-week period and represent a change from previous functioning; at least one of the symptoms is either depressed mood or loss of interest or pleasure
  • Depressed mood most of the day, nearly every day
  • Markedly diminished interest or pleasure in all, or almost all, activities most of the day, nearly every day
  • Significant weight loss when not dieting or weight gain
  • Insomnia or hypersomnia nearly every day
  • Psychomotor agitation or retardation nearly every day
  • Fatigue or loss of energy nearly every day
  • Feelings of worthlessness or excessive or inappropriate guilt nearly every day
  • Diminished ability to think or concentrate, or indecisiveness, nearly every day
  • Recurrent thoughts of death, recurrent suicidal ideation without a specific plan, or a suicide attempt or a specific plan for committing suicide
  • In addition the episode must interfere with the person’s daily routine or relationships, and not have a cause such as alcohol or other drugs, a physical illness or the death of a loved one
Source: American Psychiatric Association 200013

The extent of depression in Aboriginal and Torres Strait Islander communities is recognised to be a large problem, though it has been difficult to measure accurately. The National Aboriginal and Torres Strait Islander Health Survey (NATSIHS) of 2004–05 contained questions looking at social and emotional wellbeing (rather than depression).2 Age adjusted figures show that Aboriginal and Torres Strait Islander people aged over 18 years are twice as likely as non-Indigenous people to feel high or very high levels of psychological distress. Similarly, hospitalisation rates for ‘mental and behavioural disorders’ are nearly twice as high.

NATSIHS also found high rates of self reported stress for Aboriginal and Torres Strait Islander adults aged over 18 years compared to the general population (Table 10.2).1 These stressors are interrelated, often linked to broader life experiences, and include comorbidity associated with other medical conditions. The high prevalence of these stressors in adults has effects on children. The West Australian Aboriginal Child Health Survey found that 70% of children were living in families that had experienced three or more significant life events in the previous 12 months.3

 Table 10.2. Proportions of stresses reported in the previous 12 months, by Indigenous status, year and stressor type, Australia, 2004–05 and 2006

Indigenous status/year
 IndigenousTotal population
Type of stressor 2004–06 2006
Death of a family member or friend 42 21
Serious illness or disability 28 30
Not able to get a job 17 13
Alcohol or drug related problem 25 8.6
Overcrowding at home 17
Members of a family sent to jail/in jail 19
Witness to violence 14 2.9
Trouble with police 16 3.9
Discrimination/racism 12
Any stressor 77 59
Source: ABS, 20062 ABS, 200729
Notes: 1. Proportions are expressed as percentages
2. The total population for ‘serous illness or disability’ data has been estimated by adding proportions for the two sub-components, so may slightly overstate the true proportion

These figures show the levels of psychological distress and significant life events in Aboriginal and Torres Strait Islander communities around Australia. While there are no data that translate these into specific diagnoses within the community, admissions for a principal diagnosis of ‘mental and behavioural disorders’ were nearly twice as high for Aboriginal and Torres Strait Islander people when compared with non-Indigenous people.1

The situations in which depression risk is greater and the situations in which depression is more likely to be missed are outlined in Table 10.3.

Table 10.3. Features of comprehensive support services associated with improved outcomes from depression screening
  • An initial visit with a nurse specialist for assessment, education and discussion of patient preferences and goals
  • A follow up visit with a trained nurse specialist and ongoing support for adherence to medication for those prescribed antidepressant medications
  • A visit with a trained therapist for cognitive behavioural therapy
  • A reduced copayment for patients referred for psychotherapy
  • Professional support including the following:
    • staff and clinician training (1 or 2 day workshops)
    • availability of clinician manuals
    • monthly training lectures
    • academic detailing
    • resource materials for clinicians, staff, and patients
  • Institutional financial commitment
Source: O’Connor EA, Whitlock EP, Beil TL, Gaynes BN 20095

Screening for depression

A 2005 Cochrane review concluded that screening or case-finding instruments for depression had little or no impact on the recognition, management or outcome of depression in primary care or hospital settings.4 Evidence of benefit from screening programs for depression has been demonstrated only in settings where there is a substantial degree of supportive infrastructure. Improved outcomes may be achievable where patients identified by the screening program receive intensive support as part of a multifaceted intervention.5 Where these intensive support services are available, sensitivity and specificity that is comparable with other larger screening tools can be achieved by asking the following questions:6

‘Over the past 2 weeks, have you felt down, depressed or hopeless?’

‘Over the past 2 weeks, have you felt little interest or pleasure in doing things?’

These two questions achieve 95% specificity and 66% sensitivity in general populations. These questions have also been tested with Aboriginal people with ischaemic heart disease attending an Aboriginal Medical Service in Darwin.7 In this setting, a ‘Yes’ answer to either question was 100% sensitive and 12.5% specific for depression, meaning that a negative result rules out depression but there are many false positives. It is not clear how applicable this result is in other Aboriginal and Torres Strait Islander communities or people without ischaemic heart disease. Further, there is evidence to suggest that ‘probable depression’ detected with a screening tool may no longer be present 2 weeks later.8 This suggests that repeat screening may be needed.

Although there is no evidence to suggest any harm from screening programs, there are potential harms from treatment. Increased prescription of selective serotonin reuptake inhibitor medications for depression is associated with an increased risk of suicidal ideation and, in older people or those on non-steroidal anti-inflammatory drugs, upper gastrointestinal bleeding.5 A natural desire to use a screening tool across a population to identify and treat depression would need to take the risk of harm into account. Given this evidence, the mainstay of depression should continue to be the use of a careful clinical assessment in the context of an ongoing relationship with the patient, and the judicious use of antidepressants as part of a management plan that includes ongoing support from skilled healthcare professionals aware of the local culture and context.

In a systematic review commissioned by the US Preventive Health Task Force,5 the minimum support needed to demonstrate a beneficial effect from depression screening was availability of a nurse who screened patients, reported the results to the physician and provided a protocol that facilitated referral for behavioural treatment.

Interventions with the greatest beneficial effect are complex. Table 10.4 highlights the features most strongly associated with improved outcomes. Working as part of a team, including Aboriginal and Torres Strait Islander health workers, is considered good practice in Aboriginal and Torres Strait Islander health. The lack of published research evidence in this area should not be considered evidence of lack of effect.

Table 10.4. People at greater risk for depression
  • Exposure to adverse psychosocial events, such as unemployment, divorce or poverty
  • A previous history of depression or suicide attempts
  • A history of physical or sexual abuse
  • A history of substance abuse
  • Presence of other chronic diseases, including chronic pain
  • Multiple presentations to health services may also be an indicator of depression. Factors that make it more likely that depression will be missed include:
    • limited consultation time
    • presentations of mostly physical or atypical symptoms
    • health professional attitudes – eg. the belief that nothing can be done, or that depression is a normal response to stress
    • communication difficulties
Source: National Collaborating Centre for Mental Health and the Royal College of Psychiatrists 20106

Interventions to prevent depression

There is insufficient evidence to recommend behavioural programs to prevent depression. There is weak evidence that psychosocial interventions in the elderly may have a small effect on preventing depression.9 There is some evidence that exercise is mildly beneficial in prevention of depression for children and adolescents.10

There is currently limited evidence that interventions targeting children and adolescents in other settings such as communities, schools and workplaces are effective for children or adolescents in the long term.11 There is weak evidence that social activities for older people can produce statistically significant reductions in symptoms of depression, however the magnitude of effect is unlikely to be clinically significant.9 

There is no evidence to support the use of antidepressants medication for primary prevention of depression in the general population.

Recommendations: Depression prevention
Preventive intervention typeWho is at risk?What should be done?How often?Level/strength of evidence
Screening All people aged 15+ years Screening for depression is not routinely recommended unless comprehensive support services are available (see Table 10.3 ) N/A IB5
In the absence of services outlined in Table 10.3, useful support services include those provided by social and emotional wellbeing workers and Aboriginal mental health workers and psychologists with an understanding of the local context (see Resources) GPP12
If comprehensive support services are not available then assess for the presence of risk factors for depression (see Table 10.4) GPP6
People in whom depression risk is greater (see Table 10.4) Take a patient history to assess mood and consider asking:
‘Over the past 2 weeks, have you felt down, depressed or hopeless?’
‘Over the past 2 weeks, have you felt little interest or pleasure in doing things?’
(See Table 10.1 for diagnostic criteria)
Opportunistic 1B6
Behavioural All people aged 15+ years Behavioural interventions are not recommended for prevention of depression N/A ID9–11
Chemoprophylaxis All people aged 15+ years Medications are not recommended for primary prevention of depression N/A GPP
Environmental All people aged 15+ years Community based psychosocial programs are not recommended for prevention of depression N/A IC9,11

References

  1. Thomson N, MacRae A, Burns J, et al. Overview of Australian Indigenous health status. Health Infonet, April 2010 cited 2011 October 10. Available at www.healthinfonet.ecu.edu.au/ health-facts/overviews.
  2. Australian Bureau of Statistics. National Aboriginal and Torres Strait Islander Health Survey,2004–2005, cat. no. 4715. Canberra: ABS, 2006.
  3. Zubrick SR, Silburn SR, Lawrence DM, et al. The Western Australian Aboriginal Child Health Survey: the social and emotional wellbeing of Aboriginal children and young people. Perth: Curtin University of Technology and Telethon Institute for Child Health Research, 2005.
  4. Gilbody S, House AO, Sheldon TA. Screening and case finding instruments for depression. Cochrane Database Syst Rev 2005 Oct 19;Oct 19;(4):CD002792.
  5. O’Connor EA, Whitlock EP, Beil TL, Gaynes BN. Screening for depression in adult patients in primary care settings: a systematic evidence review. Ann Intern Med 2009;151(11):793–803.
  6. National Collaborating Centre for Mental Health and the Royal College of Psychiatrists. Depression: the treatment and management of depression in adults. London: Royal College of Psychiatrists, 2010.
  7. Esler D, Johnston F, Thomas D, Davis B. The validity of a depression screening tool modified for use with Aboriginal and Torres Strait Islander people. Aust N Z J Public Health 2008;32(4):317–21.
  8. Gunn JM, Gilchrist GP, Chondros P, et al. Who is identified when screening for depression is undertaken in general practice? Baseline findings from the Diagnosis, Management and Outcomes of Depression in Primary Care (diamond) longitudinal study. Med J Aust 2008;188(Suppl 12):S119–25.
  9. Forsman AK, Schierenbeck I, Wahlbeck K. Psychosocial interventions for the prevention of depression in older adults: systematic review and meta-analysis. J Aging Health 2011;23(3):387–416.
  10. Larun L, Nordheim LV, Ekeland E, Hagen KB, Heian F. Exercise in prevention and treatment of anxiety and depression among children and young people. Cochrane Database Syst Rev 2006;Jul 19;(3):CD004691.
  11. Merry S, McDowell H, Hetrick S, Bir J, Muller N. Psychological and/or educational interventions for the prevention of depression in children and adolescents. Cochrane Database Syst Rev 2004(1):CD003380.
  12. Purdie N, Dudgeon P, Walker R. Working together: Aboriginal and Torres Strait Islander mental health and wellbeing principles and practice. Canberra: Commonwealth of Australia, 2010. Cited January 2012. Available at www.ichr.uwa.edu.au/ files/user5/Working_Together_book_web.pdf.
  13. American Psychiatric Association. Diagnostic and statistical manual of mental disorders, 4th edn, text revision. Washington: American Psychiatric Association, 2000.
  14. Australian Bureau of Statistics. General Social Survey: Summary Results, Australia, 2006, cat. no. 4159. Canberra: ABS, 2007.
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