What is Depression?
Diagnosing Depression
The PHQ-9 questionnaire is the screening tool for most depressive disorders, except those covered in other sections of this Handbook (e.g. Bipolar Disorders).
In the initial appointment we aim to risk assess the patients, looking at their individual symptom profile and make a management plan based on whether the patient falls into:
- Less severe depression (PHQ-9 < 16) → Consider guided self-help, CBT and other therapies as first line. Important to focus on non-pharmacological treatments.
- More severe depression (PHQ-9 ≥ 16) → Consider CBT alongside antidepressant medication as a first line for these patients.
See NICE Guidelines for less severe depression for recommendations.
See NICE Guidelines for more severe depression for recommendations.
Penrose Health Action Plan
We aim to keep the number of Mental Health Nurse visits to a maximum of 6 per patient in any given episode. See Schedule of Reviews below for more specific/detailed guidance.
⚠️ Safety netting
If at any time a patient presents:
- with a significant change in risk status; or
- if there is a commencement/change in medication
The visit count resets back to the beginning (i.e. First review)
Secondary and External services may be better placed to help/support patients than we are.
- Secondary services offer psychological treatments (e.g., interpersonal/psychodynamic therapies, CBT)
- External services in the community offer many options for social and psychological help through relationships with the wider service network (e.g. Social Prescriber, Befriender, Care Coordinator, Therapist, Lifestyle Coach, etc.)
We do not provide any form of psychotherapy within our surgeries.
Patient Journey - Determining Schedule of Reviews
Click the toggle to see a schematic of the action plan/treatment policy for all Penrose Health surgeries, or follow the written guidance below.
If patient is low risk and already stable on long-term medication, or does not want to start medication → review in 1 month
If starting/changing medication or with significant concerns about risks then:
- Aged 18-25 → review within 2 weeks.
- Aged over 25 → review in 2-4 weeks.
Signpost/refer to services as appropriate (see Referring Onward below).
- If a patient is actively managed by another mental health provider → liaise with services as required and conclude routine MHN appointments.
- If rejected by secondary services and patient is at high risk → review again in <1-2 weeks.
If patient is already on long-term medication, or does not want to start medication, and:
- is stable/improving → conclude routine MHN appointments.
- has issues ongoing:
- Reconsider medication if appropriate or consider up-titration → review in 1 month
If this is second review after initiation of medication and patient:
- is stable/improving → review in 4-6 weeks.
- has issues ongoing:
- Reconsider medication if appropriate or consider up-titration → review in 2-4 weeks.
If patient is starting/changing medication → go back to First review.
Signpost/refer to services as appropriate (see Referring Onward below).
If patient is already on long-term medication, if this is third review after initiation, or patient does not want to start medication, and:
- is stabilised/improving → conclude routine MHN appointments.
- has issues ongoing:
- Consider discussing patient with other professionals/peers, either within Penrose at weekly supervisory meetings, or at an external service.
- Reconsider medication if appropriate or consider up-titration.
If patient is starting/changing medication → go back to First review.
Signpost/refer to services as appropriate (see Referring Onward below).
If patient remains on medication for a long-term, routine review should occur every 6 months.
If patient needs ongoing MHN input after senior discussion → Reviews may be offered every 2 months, for a maximum of 3 further sessions.
If patient has had the maximum 6 appointments with MHN, but still has low-level needs requiring further check-ins, consider booking in with Mental Health Care Coordinator (MHCC) for follow-up.
Referring/Signposting Onward
Below are some services to which you can signpost/refer patients. More services can be found on the Penrose Portal in Mental Health Services Database.