A population-based cohort study from the Nordic countries has found that women who take SSRIs during the second half of pregnancy are more than twice as likely to give birth to children with persistent pulmonary hypertension of the newborn (PPHN). However, the absolute risk remains very low. Data were obtained from national registers of births, deaths and dispensed prescriptions. Exclusion criteria were multiple births and a gestational age of less than 33 weeks. More than 1.6 million infants, born between 1996 and 2007, were included in the study.

A cross-sectional, postal survey of GPs has found high levels of burnout. The study revealed high scores for emotional exhaustion and depersonalisation in more than four out of ten respondents, and low scores for perceived personal achievement in a third. Dr Phillip Bland, GP with an interest in mental health reflects upon the findings, 'It is suprising that, in the current study, depersonalisation did not appear to be associated with impaired performance.'

Individual music therapy improves outcomes in depression when combined with standard therapy, a randomised controlled trial from Finland has found. A total of 79 participants (62 women), aged 18 to 50, with an ICD-10 diagnosis of depression were recruited from psychiatric health centres and polyclinics. Thirty three were allocated to the intervention group and 46 received standard care only. The intervention consisted of 20 twice-weekly sessions, each session lasting for one hour. Both the therapist and patient were provided with a keyboard, percussion instrument and acoustic drum. A therapeutic musical relationship was developed by improvising music together.

Life review therapy is an effective intervention for adults aged 55 and older with depressive symptoms, a Dutch pragmatic randomised controlled trial has found. Dr Philip Bland comments ont he study: 'NICE recommends a low-intensity psychosocial intervention for patients with persistent subthreshold symptoms (>2-3 months). Life review therapy would seem to be an attractive option for older patients, but the positive findings of the present study should be treated with caution. First, the participants in this study were recruited by advertisement and may therefore have been more highly motivated and more likely to respond to therapy than patients presenting in a primary care setting. Second, comparison with usual care does not control for non-specific benefits of group participation, so we do not know what proportion, if any, of the response to treatment was due to the specific intervention. Finally, there is a problem of publication bias among trials of psychotherapy for adult depression. GPs are primarily diagnosticians, not therapists. The diagnosis of depression is complex and should incorporate an assessment of cognition as well as the number and severity of symptoms and the degree of functional impairment. Depressed patients have negative, unhelpful thoughts about themselves, their current experiences and the future: Beck’s cognitive triad. I suggest that for older patients we should add a fourth category i.e. negative evaluation of their past life. I find that the use of genograms is an effective way of placing the presenting problem within a historical and family context, and encouraging patients to tell stories about their lives. '

A large cohort study from the UK has reached the surprising conclusion that tricyclics are the safest class of antidepressants in elderly people. The cohort comprised 60,746 primary care patients aged 65 and over (mean age 75) with a new diagnosis of depression recorded between January 1 1996 and December 31 2007. The cohort was followed up until December 31 2008. Comments Dr Phillip Bland,'Perhaps the most striking result from this study is that almost 90% of the patients were given antidepressants. For elderly patients with mild to moderate depression, the risks of antidepressant medication are likely to outweigh the benefits, and a psychosocial intervention may well be preferable.If we are to prescribe, I do not think there is sufficient evidence to justify prescribing very low dose tricyclics (<75mg amitriptyline). Venlafaxine is not a first-line treatment, and this study suggests that we should be wary of prescribing mirtazapine to elderly patients (although NICE concluded that this might be the most cost-effective drug for moderate to severe depression).6 NICE recommends SSRIs, but I think a strong case can be made for considering lofepramine as an alternative in elderly patients: compared with older tricyclics, it causes fewer side effects, is less cardiotoxic and is safer in overdose.'

 A significant minority of depressed patients have unrecognised bipolar disorder, a primary care study from Wales has found. Dr PhilipBland comments on the study: 'There are a number of reasons why bipolar disorder is often not recognised. Patients may perceive hypomania as normal wellbeing, distinction from personality disorder (particularly borderline personality disorder) can be difficult, and comorbid substance misuse may be misdiagnosed as the primary disorder. At the same time, early recognition is important. There are concerns that antidepressant monotherapy may be harmful in bipolar disorder, with a risk of mood destabilisation, rapid cycling and treatment resistance. Therefore, we should raise our awareness of bipolar disorder, particularly among those with early-onset, severe or treatment-resistant depression. However, I would argue against the routine use of screening questionnaires as this is likely to replace the problem of underdiagnosis with that of overdiagnosis.'

Online messaging via an electronic medical record is an effective and efficient way of providing enhanced care for depressed patients, a primary care study from the United States has found. Patients were also more likely to be satisfied with their treatment than those who received standard care.

A systematic review has concluded that patients with mild to moderate anxiety and depression derive only limited short-term benefit from guided self-help interventions in primary care.  Comments Dr Phillip Bland, 'There are good reasons for not prescribing antidepressants to patients with mild-moderate depression of <8 weeks' duration. It is not clear, however, whether we should offer patients a low intensity intervention (CCBT, bibliotherapy or group exercise therapy) or watchful waiting. Guided self-help may be beneficial for a small sub-group of well educated, well motivated patients, but current evidence does not support its widespread adoption.'

Following a coronary heart disease (CHD) event, group CBT reduces the risk of recurrent cardiovascular events by 41%, a randomised controlled trial from Sweden has found. Philip Bland, The Practitioner's reviewer in mental health, writes: 'This study provides some justification for the NICE recommendation that group CBT should be the treatment of choice for CHD patients with moderate depression.^' However, it would appear that long-term therapy (6-12 months) may be necessary in order to improve cardiovascular outcomes, whereas NICE recommends that group CBT should be delivered over a period of six to eight weeks. Screening for depression among patients with CHD is of doubtful value in view of the high number needed to screen, the reluctance of patients to accept treatment, and the lack of evidence to suggest that treatment of depression can reduce cardiovascular mortality. A more fruitful approach may be to facilitate successful adjustment in all patients through the addition of group CBT to cardiac rehabilitation programmes.'

A multiple treatments meta-analysis has found that sertraline is the best tolerated therapy for generalised anxiety disorder (GAD). There were 27 randomised controlled trials which were suitable for inclusion in the analysis. Response was defined as a reduction of 50% or more from the baseline Hamilton anxiety scale (HAM-A) score, remission as a final HAM-A score ≤7 and tolerability as the withdrawal rate due to adverse events. For each outcome measure, drugs were ranked according to the probability of their being the most effective/well tolerated treatment.Nine drugs (duloxetine, escitalopram, fluoxetine, lorazepam, paroxetine, pregabalin, sertraline, tiagabine, and venlafaxine) were compared with one another. Fluoxetine was ranked first for response (probability 62.9%) and remission (60.6%) whereas sertraline was ranked first for tolerability (49.3%). Of those drugs which are licensed in the UK for the treatment of GAD, duloxetine was ranked first for response (probability 2.7%), escitalopram was ranked first for remission (26.7%) and pregabalin was ranked first for tolerability (7.7%). 'These findings need to be treated with caution. All studies were sponsored by drug companies, unpublished studies were not specifically looked for, and publication bias is therefore likely. The absence of tricyclics from the list of drugs included in the analysis does not mean that SSRIs are superior to tricyclics in the treatment of GAD. It simply reflects the fact that most clinical trials of tricylics were carried out before GAD became a recognised diagnosis.'

Antidepressants are a safe and effective treatment for depression in patients with a chronic physical illness, a NICE systematic review and meta-analysis has concluded. There are several reasons for not prescribing antidepressants to patients with chronic conditions who present with mild to moderate depression of recent onset:antidepressants are little better than placebo;the physical illness may increase susceptibility to side effects; there is an increased risk of drug interactions;patients may be reluctant to take them. NICE recommends that they should only be prescribed if low-intensity psychosocial interventions are ineffective, or if there is a previous history of moderate or severe depression, or if the depression complicates the care of the chronic condition. If an antidepressant is to be prescribed, SSRIs are the drug group of first choice as they may be better tolerated and have been shown to improve quality of life. NICE recommends sertraline and citalopram as they are less likely than other SSRIs to interact with other medication and appear to be safe in heart disease.

Antidepressants are no more effective than placebo as a treatment for patients with subthreshold depression, a meta-analysis has found. Six double-blind randomised controlled trials met the inclusion criteria. There was a total of 468 participants (234 treated with antidepressants and 234 with placebo). Three studies compared paroxetine with placebo, and fluoxetine, amitriptyline and isocarboxacid were each compared with placebo in individual studies. 'Both NICE and the British Association for Psychopharmacology do not recommend the use of antidepressants for short-duration (<2-3 months) subthreshold depression. The findings of this study strongly support this guidance.'

Patients who have undergone bariatric surgery are at substantially increased risk of suicide, a study from the United States has found. Although the absolute suicide rate (1 in 538) was low, this was much higher than that of the general population. All Pennsylvania residents who underwent bariatric surgery between January 1st 1995 and December 31st 2004 were identified from the comprehensive state records. This data was then matched to mortality data for the period September 1st 1996 to December 28th 2006. Of the 16,683 patients who underwent bariatric surgery, 31 committed suicide during the study period. The suicide rates for men and women were 13.7 and 5.2 per 10,000 person-years respectively. The corresponding age-matched rates for the US population were 2.4 (men) and 0.7 (women) per 10,000 person-years.The true number of suicides is likely to have been significantly higher as a result of the misclassification of suicides as unintentional poisoning. While the official US suicide rate declined by 12% between 1987 and 2006, there was a more than four-fold increase in the number of deaths attributed to unintentional poisoning. 'I would draw two lessons from this study. First, before referring patients for bariatric surgery, we must have a detailed discussion with them regarding both the potential benefits and associated risks of surgery, including the risk that they will ultimately be disappointed with the result. Second, we should ensure that bariatric surgery patients receive adequate support and follow-up, particularly during the second and third postoperative years.'

A single-blind, randomised trial from the USA has found that tai chi significantly improves the health-related quality of life of patients with fibromyalgia. A total of 66 tertiary care patients were randomised to tai chi or a control intervention. Both groups attended two one-hour sessions a week over a period of 12 weeks. The control intervention consisted of 40-minute lectures on various aspects of fibromyalgia followed by 20 minutes of stretching exercises. 'Should we advocate tai chi for our patients with fibromyalgia and/or depression? I am even tempted to suggest that GPs might benefit from tai chi between consultations, although this may disconcert our receptionists! I think the answer is that any form of group exercise is likely to be beneficial, and the choice will probably be determined by what is available locally.'

An observational study from Sardinia has found that rapid discontinuation of antidepressants places patients at increased risk of early relapse.There were 398 patients, 261 women and 137 men, included in the study: 224 had a DSM-IV diagnosis of recurrent major depressive disorder, 75 panic disorder and 99 bipolar disorder. Patients were followed up with regular semistructured interviews and rating scale assessments. 'The association between the speed of discontinuation and time to relapse remained highly significant after adjustment for factors known to be associated with increased risk of relapse, including the number of previous episodes, depression severity and shorter duration of antidepressant treatment.However, not all potential confounders were accounted for. It is possible, for example, that those patients who choose to stop their treatment abruptly are more likely to have personality traits or mood cycling disorders which place them at increased risk of relapse.^'

Passive smoking is associated with psychological distress and the risk of developing severe psychiatric illness, a cross-sectional and longitudinal study has found. A total of 8,155 adults, of whom 2,595 were smokers, with no previous history of admission to psychiatric hospital were recruited from the Scottish Health Survey. 'It is unlikely to be helpful if we suggest to patients that their depression has been caused by their partner's smoking habit. Nevertheless, this study provides a useful reminder that we should consider depression within the context of relationships: depression is often preceded by marital problems, and the effects of the depression on the other partner and his/her reaction to it are likely to have an important influence on the future course of both the depression and the relationship.'

An observational study from the UK has assessed the relative toxicity of 14 antidepressants. As in previous studies, tricyclics were found to be much more toxic in overdose than SSRIs. 'Venlafaxine and mirtazapine were of intermediate toxicity. When choosing an antidepressant, we need to consider not only toxicity in overdose, but also efficacy, acceptability, teratogenicity and the risk of discontinuation reactions. A recent meta-analysis suggested that sertraline provides the most favourable balance between efficacy and acceptability. According to the present study it possesses the further virtue of having a very low toxicity; case fatality ratio 0.4 (95% CI: 0.2-0.8).'

A cross-sectional study has found an association between depression and lack of vitamin D in older people. Data were provided by the 2005 Health Survey for England, which focussed on the health of older people. This identified a nationally representative sample of community residents aged ≥ 65, of whom 2,070 agreed to participate in this study. 'Recognition and treatment of vitamin D deficiency is important on account of its health consequences: vitamin D deficiency (<10 ng/ml) is associated with osteomalacia and vitamin D insufficiency (<30 ng/ml) is associated with increased mortality, cardiovascular disease, diabetes, some cancers and multiple sclerosis.^'

A nested case-control study has found an association between current use of SSRIs/venlafaxine and cataracts. The cohort comprised residents of Quebec aged ≥ 65 years who had undergone coronary revascularisation between 1995 and 2004. Clinical and prescribing data were captured prospectively by linked databases. 'If confirmed, the 15% increased risk of cataract development is a further potential hazard of SSRI use in elderly patients. Other important risks are upper GI bleeding, hyponatraemia and fragility fracture. The absolute risk of serious bleeding is small but clinically significant in patients > 80,4 elderly patients are more likely to develop SSRI-induced SIADH and the risk of fragility fracture may be doubled in patients > 50.5.'

A longitudinal cohort study from New Zealand has suggested a unidirectional cause and effect relationship between cigarette smoking and depression, in which smoking increases the risk of developing symptoms of depression. The Christchurch Health and Development Study has followed up a group of 1,265 children who were born in 1977. Participants were studied at ages 18, 21 and 25, when 79-81% of the original cohort attended. 'When case finding among patients with chronic conditions, smoking is yet another important risk factor to add to the list of functional impairment, previous depression, physical inactivity, obesity and maladjustment. More controversially, it has been suggested that we should routinely target smoking cessation when treating depressed smokers.'

There are three lessons for GP practice from this paper: when case finding among patients with chronic conditions, physical inactivity and obesity should suggest the possibility of depression; when treating mild to moderate depression in obese patients, referral to a group exercise programme is likely to be a better option than prescribing antidepressants, which may themselves cause further weight gain; when following up our depressed patients, there is a case for monitoring their BMI (and physical activity levels) as well as the PHQ-9.

The authors suggest that the simpler definition is preferable for two reasons. First, it is easier to remember and will reduce the time needed to make an assessment. Second, for patients with a chronic condition, it avoids the difficulty of deciding whether somatic symptoms are caused by depression or by the physical illness itself. Another group of patients for whom this is often a problem are antenatal and postnatal mothers.

The authors recommend that we should routinely ask about sexual abuse in patients who have associated somatic syndromes. Disclosure itself may have a therapeutic benefit and patients may wish to be referred for cognitive therapy.

However, I think some caution is necessary here. The link has not been established by prospective cohort studies, and no trials have yet been carried out to determine whether abuse disclosure is beneficial in patients with FSS. There is a risk that disclosure, if it is not handled sensitively, may exacerbate feelings of shame and guilt.

Of those patients whose depression is recognised, less than half will complete a minimal treatment course (≥2 months' antidepressants or four psychotherapy sessions). Case management is a low-cost intervention which can improve outcomes as a result of better adherence and increased recognition of non-responders.

GPs are primarily diagnosticians, not therapists. Nevertheless, the process of diagnosis itself may have therapeutic value, by helping patients to understand their problems and empowering them to address them. It is thought that GPs who provide more complex psychosocial explanations are more likely to achieve this.

Screening for depression in high-risk patients does not appear to be effective and has diverted attention from the need to provide more effective care to patients with recognised depression

The authors suggest that screening followed by brief CBT interventions might both reduce symptoms and the risk of progression to OCD. OCD itself often goes unrecognised. Patients may be reluctant to disclose their symptoms because of shame or embarrassment, and fears of stigmatisation. NICE therefore recommends that we should use a six-question screening questionnaire for patients who are at increased risk of OCD. Depression, in particular, commonly occurs in association with OCD and I think a case can be made for asking patients to complete the six-question screen at the same time as the PHQ-9.

The fact that an almost identical proportion of patients were given antidepressant treatment despite the large discrepancy between the severity ratings would suggest that the questionnaire scores had only a limited influence on the decision whether or not to prescribe. This may reflect a problem with the PHQ-9 threshold: the authors suggest that if this were raised to ≥ 12 this would correlate better with GPs' diagnostic thresholds.

My current first choice antidepressant is citalopram (moderate efficacy, high acceptability, low suicide risk, intermediate half-life). While I might be tempted to consider switching to sertraline, I am not yet convinced that this would achieve a clinically significant benefit.

The authors suggest that the poor prognosis can be linked to inadequate treatment. It is well recognised that only a small proportion of older patients with depression receive treatment, either because of the attitude of the patient and/or doctor or diagnostic difficulties.

We live in an increasingly violent society. Nearly a third (31%) of GPs in the BMA survey felt violence had increased over the past year whereas only 0.3% felt it had decreased. Although it is important not to stigmatise mental illness, we need to be alert to patient attributes and situations where there is the potential for conflict and take steps to minimise the risk.

If we are to prescribe antidepressants, providing there are no contraindications, low- dose amitriptyline would appear to be the drug of choice. As yet, however, we do not know how effective this is in a primary care setting nor whether benefits are maintained long term.

This trial provides a further reminder that we should regularly review our patients with dementia and seek to withdraw antipsychotic medication at the earliest opportunity.

The National Dementia Strategy is to recommend training for GPs in the recognition of early signs of dementia. This is based on evidence that earlier provision of home support and carer support can reduce admissions to care homes. However, we face the problem that, having made an early diagnosis of dementia, we have no treatment to offer which can alter the progression of the disease. A prescription for walking would be an attractive option, but it is not yet clear whether this can achieve a clinically significant effect.

GPs should be aware that there is increased risk of becoming homeless for those with learning disabilities, and that a significant proportion of the homeless patients they see will have intellectual disability. Health information and advice for the homeless should be provided in an accessible way, potentially supported by appropriate written and visual information.

Perhaps we should abandon screening for depression in CHD patients and replace this with screening for physical inactivity, linked to the provision of local exercise therapy schemes.

Laughter is an effective antidote to stress, promotes a sense of wellbeing, strengthens relationships and may have beneficial effects on immunity and pain tolerance. Lack of a sense of humour may increase vulnerability to depression, and loss of the ability to appreciate humour may contribute to the downward spiral of mood in patients with depression.

This study suggests that we should encourage our depressed patients to stop smoking once they have achieved remission. However, we need to be aware that, by emphasising the role of lifestyle factors in depression, we may unwittingly make patients feel responsible for their illness, adding to their sense of guilt.

This study suggests that we should not only promote exercise as an effective treatment for patients with mild to moderate depression but also as a way of reducing their risk of developing diabetes.

In my opinion, the key question is whether the placebo effect is mainly caused by spontaneous remission or a genuine therapeutic effect. If the former, we should perhaps adopt a policy of watchful waiting, only offering antidepressant treatment if there is no improvement within a specified period of time. If the latter, unless we have access to an effective alternative (such as CBT), we need to consider whether we can justify withholding such a highly effective treatment from our patients.

Children of mothers with persistent antenatal depression were 34% more likely to have developmental delay

GPs need to be sure that patients in treatment who have, or who have contact with, children are properly counselled about the safe storage of take-home doses of buprenorphine. Given the absence of any fatality in the study, I would welcome debate about the relative safety of inadvertent methadone and buprenorphine overdoses in children.

The findings of this study are consistent with the evidence from randomised controlled trials that exercise may be effective in the short term as a treatment for mild to moderate depression. However, this is a cross-sectional study and cannot therefore indicate the direction of causation. The results may simply reflect the fact that depressed patients are less motivated and exercise less.

This study provides strong evidence to support the recommendation that bereavement visits should occur as soon as possible after a patient has died:the surviving spouse is at most risk during the first few days. Risk assessment tools may help to identify those most at risk; this study suggests that age and gender are relevant.

The use of CBT, either alone or with antidepressant treatment, may not only help patients to change their harmful modes of thought and behaviour, but also help to prevent them teaching them to their children.

Combination therapy with an atypical antipsychotic and metformin may be an attractively simple solution but more data from larger, long-term, preferably primary care-based trials are required to test this approach. In the meantime, we should be closely monitoring weight gain and cardiovascular risk in patients newly started on atypical antipsychotics, bearing in mind that the Framingham risk score underestimates risk in obese patients with the metabolic syndrome.

NICE recommends that GPs should ask two questions to screen for depression at the postnatal check. A recent audit in our practice found that an assessment of mental health was documented in the records of only 31% of our postnatal women, and we have therefore decided to send out the two-question screen with our postnatal check invitations. Although postnatal depression tends to remit spontaneously at 4-6 months, it leads to considerable distress and disruption, and treatment doubles the recovery rate. Screening and treatment is therefore entirely justified.

After controlling for patient prognosis, a significant inverse relationship was found between quality of care and the probability of persistent depression at 18 and 24 months. This suggests that doctors whose practice is concordant with guidelines achieve better outcomes; as an observational study, however, a causal link cannot be established.

There are two possible conclusions. Either the DSM-IV fails to identify a large proportion of elderly patients with depression, or depression is much less common in the elderly than generally believed and is overdiagnosed by GMS-AGECAT.

A prescription of chocolate, hot baths and plenty of sleep is not a panacea for depression. There may, however, be a subgroup of patients whose personality not only makes them vulnerable to depression, but also allows them to alleviate symptoms in this way.

The authors conclude that there is a favourable risk/benefit profile, justifying the cautious use of antidepressants as a first-line treatment option. It is likely, however, that they have underestimated the risk of suicidal behaviour. Youths at risk were excluded from the trials and data were only collected retrospectively as part of adverse event reporting.

The question as to whether identification and treatment of post-MI depression can improve cardiovascular prognosis remains unanswered: an adequately powered trial that incorporates managed care in the intervention arm is required. This trial does, however, provide further evidence for the view that we should not be screening for depression until we have set in place efficient and effective management programmes.

The data suggest that patients on high doses of conventional antipsychotics may be at particularly high risk of CHD mortality, although dose may simply be a marker of illness severity.

One of the fundamental principles of cognitive therapy is that it requires a sound therapeutic alliance. It has even been suggested that the quality of the therapeutic relationship is more important than the specific type of psychotherapy used in determining the clinical outcome. Computers may complement the role of physicians and therapists, but they are no substitute.

Antidepressants may have a role in treating associated major depression, panic disorder or functional somatic syndromes, but more evidence is required before they can be advocated as a specific treatment for hypochondriasis.

The review cites a number of studies that provide evidence that cognitive behaviour therapy (CBT) following successful pharmacotherapy reduces the risk of relapse. Given the paucity of CBT therapists, our patients are unlikely to receive CBT if we do not provide it ourselves.

This study provides support for the view that screening alone cannot improve outcomes for depressed patients and that the focus should be on achieving better organisation and delivery of care.

This study suggests that it is important to take an adequate family history of patients who are at risk of attempting suicide, particularly in men. This may be facilitated by construction of a simple genogram.