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## Complete Summary

#### GUIDELINE TITLE

Identification of common mental disorders and management of depression
in primary care.

#### BIBLIOGRAPHIC SOURCE(S)

New Zealand Guidelines Group. Identification of common mental disorders
and management of depression in primary care. Wellington (NZ): New
Zealand Guidelines Group; 2008 Jul. 188 p. \[580 references\]

#### GUIDELINE STATUS

This is the current release of the guideline.

### COMPLETE SUMMARY CONTENT

 SCOPE\
 METHODOLOGY - including Rating Scheme and Cost Analysis\
 RECOMMENDATIONS\
 EVIDENCE SUPPORTING THE RECOMMENDATIONS\
 BENEFITS/HARMS OF IMPLEMENTING THE GUIDELINE RECOMMENDATIONS\
 CONTRAINDICATIONS\
 QUALIFYING STATEMENTS\
 IMPLEMENTATION OF THE GUIDELINE\
 INSTITUTE OF MEDICINE (IOM) NATIONAL HEALTHCARE QUALITY REPORT
CATEGORIES\
 IDENTIFYING INFORMATION AND AVAILABILITY\
 DISCLAIMER

### SCOPE

#### DISEASE/CONDITION(S)

Depression, including:

-   Major depression

-   Dysthymia

-   Postnatal depression

**Note**: It is beyond the scope of this guideline to address the
management of dementia.

#### GUIDELINE CATEGORY

Diagnosis\
Management\
Screening\
Treatment

#### CLINICAL SPECIALTY

Family Practice\
Geriatrics\
Internal Medicine\
Obstetrics and Gynecology\
Pediatrics\
Psychiatry\
Psychology

#### INTENDED USERS

Advanced Practice Nurses\
Health Care Providers\
Health Plans\
Managed Care Organizations\
Nurses\
Physician Assistants\
Physicians\
Psychologists/Non-physician Behavioral Health Clinicians\
Public Health Departments\
Social Workers\
Substance Use Disorders Treatment Providers

#### GUIDELINE OBJECTIVE(S)

-   To provide a summary of current New Zealand and overseas evidence
    about the identification of common mental disorders and the
    management of depression among young people and adults in the
    primary care setting

-   To identify evidence-based practice for most people, in most
    circumstances, thus forming the basis for decision-making by the
    health care practitioner in discussion with the person in developing
    an individualised care plan

-   To promote clinical practice that will protect and improve Māori
    mental health as part of New Zealand\'s commitment to the Treaty of
    Waitangi

#### TARGET POPULATION

General population of New Zealand

**Note**: Among young people the focus is largely on adolescents as they
are the most vulnerable.

#### INTERVENTIONS AND PRACTICES CONSIDERED

**[Diagnosis and Screening]{.underline}**

**Young People**

1.  Applying strengths-based and biomedical models (enhancing
    resiliency, minimizing obstacles, social connectedness)

2.  Screening

3.  Psychosocial assessment

    -   HEEADSSS (Home, Education, Employment, Eating, Activities,
        Drugs, Sexuality, Suicide, Safety)

    -   HEARTS (Home, Education, Activities, Relationships, Temper,
        Size)

    -   Biopsychosociocultural model of assessment

4.  Additional assessment tools

    -   Strengths and Difficulties Questionnaire (SDQ)

    -   Short Moods and Feelings Questionnaire (SMFQ)

    -   Reynolds Adolescent Depression Scale (RADS)

    -   Substance Use and Choices Scale (SACS)

    -   CRAFFT (Car, Relax, Alone, Forget, Family/Friends, Trouble) Tool

5.  Clinical features

6.  Diagnosis and referral

**Adults**

1.  Psychosocial assessment

2.  Targeted screening of high-risk groups using verbal 2-3 questioning
    screening tool

3.  Additional assessment tools

    -   Patient Health Questionnaire for Depression (PHQ-9)

    -   Kessler Psychological Distress Scale (K10)

    -   Generalised Anxiety Disorder Assessment Tool (GAD-7)

    -   Alcohol Use Disorders Identification Test (AUDIT)

    -   Case Finding and Help Assessment Tool (CHAT)

4.  Diagnosis and referral

**Women (Antenatal and Postnatal)**

1.  Screening using verbal 2-3 questioning screening tool

2.  Assessment tools

    -   Edinburgh Postnatal Depression Scale \[EPDS\]

    -   Patient Health Questionnaire for Depression \[PHQ-9\]

    -   Hospital Anxiety Depression Scale \[HADS\])

**Older Adults**

1.  Targeted screening of high-risk groups

2.  Assessment tools:

    -   Geriatric Depression Scale

    -   Short Form (GDS-15)

    -   Patient Health Questionnaire for Depression (PHQ-9)

    -   Mini Mental State Examination (MMSE)

**[Management]{.underline}**

**Young People**

1.  Clinical management

    -   Combined risk-management and strengths-based approach

    -   Active support and monitoring

    -   Self-management advice

2.  Specific interventions

    -   Guided self-help

    -   Exercise

    -   Psychological therapies (e.g., cognitive behavioral therapy
        \[CBT\])

    -   Pharmacological therapies

    -   Complementary and alternative medicines \[CAMs\])

**Adults**

1.  Clinical management

    -   Active support and monitoring

    -   Self-management advice

2.  Specific interventions

    -   Guided self-help

    -   Exercise

    -   Psychological therapies (e.g., CBT, interpersonal psychotherapy
        \[IPT\])

    -   Pharmacological therapies (e.g., selective serotonin reuptake
        inhibitors \[SSRIs\], tricyclic antidepressants \[TCAs\])

    -   CAMs

**Women (Antenatal and Postnatal Depression)**

1.  Clinical management

    -   Patient preference and clinical experience

2.  Specific interventions

    -   Guided self-help

    -   Exercise

    -   Psychological therapies (e.g., CBT, IPT)

    -   Pharmacological therapies

    -   CAMs

**Older Adults**

1.  Active support and liaison with other agencies

2.  Specific interventions

    -   Exercise

    -   Psychological therapies (e.g., CBT, behavior therapies (BT),
        reminiscence and life-review therapies, IPT)

    -   Pharmacological therapies (SSRIs)

**General**

1.  Culturally specific models of care

2.  Therapeutic alliances

#### MAJOR OUTCOMES CONSIDERED

-   Quality of life

-   Symptom severity, symptom persistence, and functional impairment

-   Patient satisfaction

-   Effectiveness of psychological therapies

-   Side effects of pharmacological therapy

-   Cost-effectiveness of treatment

### METHODOLOGY

#### METHODS USED TO COLLECT/SELECT EVIDENCE

Hand-searches of Published Literature (Primary Sources)\
Hand-searches of Published Literature (Secondary Sources)\
Searches of Electronic Databases

#### DESCRIPTION OF METHODS USED TO COLLECT/SELECT THE EVIDENCE

**Clinical Questions**

The Guideline Development Team (GDT) developed the following clinical
questions:

1.  What risk factors are associated with depression in
    children/adolescents/adults?

2.  How do children/adolescents/adults with common mental disorders
    present in primary care?

3.  Does routine screening for depression/common mental
    disorders/postnatal depression in children/adolescents/adults in
    primary care lead to improved outcomes?

4.  What is the validity and utility of case-finding tools for
    assessment of depression, anxiety and dysthymia (either alone or
    with other common mental disorders) in children/adolescents/adults
    in primary care?

5.  In children/adolescents/adults managed in primary care for
    depression do the following interventions improve outcomes:

    -   A healthy lifestyle (e.g., complementary and alternative
        medicines, exercise, etc.)

    -   Guided self-help

    -   Psychological therapies

    -   Pharmacological therapies

6.  In children/adolescents/adults managed in primary care for
    depression, which models of liaison/teamwork/service delivery have
    the best outcomes (in general, and specifically for Māori and
    Pacific peoples)?

**Evidence Collation and Appraisal**

To address the clinical questions, New Zealand Guidelines Group (NZGG)
used the Appraisal of Guidelines for Research and Evaluation (AGREE)
instrument to appraise the following international guidelines for the
quality of their methodologies: Agency for Healthcare Research and
Quality (AHRQ) 2002, National Institute for Health and Clinical
Excellence (NICE) 2004, NICE 2005, NICE 2007. They were assessed as
being well-developed and suitable for updating where they addressed one
or more of the clinical questions.

The GDT determined that questions 3 to 5 required an updated search and
systematic review, while questions 1, 2 and 6 could be answered with
reference to the above-mentioned international guidelines, supplemented
by a narrative review of New Zealand literature and literature published
since the guidelines.

The research team determined inclusion criteria for studies pertaining
to questions 3 to 6 and designed literature searches. The full searches
and inclusion criteria for studies are available on the NZGG website
([http://www.nzgg.org.nz](http://www.nzgg.org.nz/)).

Searches of electronic databases were undertaken and studies were
retrieved.

#### NUMBER OF SOURCE DOCUMENTS

Not stated

#### METHODS USED TO ASSESS THE QUALITY AND STRENGTH OF THE EVIDENCE

Weighting According to a Rating Scheme (Scheme Given)

#### RATING SCHEME FOR THE STRENGTH OF THE EVIDENCE

An overall summary level of evidence was assigned to each study, as
follows:

(+) assigned when all or most of validity criteria met

(\~) assigned when some of criteria met and where unmet criteria are not
likely to affect the validity, magnitude/ precision or applicability of
the results markedly

\(x\) assigned when few or none of the criteria met

Intermediate grades (+/\~,\~/x) were assigned when overall study quality
fell between these categories. Studies that met few or none of the
quality criteria were excluded.

#### METHODS USED TO ANALYZE THE EVIDENCE

Systematic Review with Evidence Tables

#### DESCRIPTION OF THE METHODS USED TO ANALYZE THE EVIDENCE

**Study Appraisal**

Studies that met the inclusion criteria for each clinical question were
appraised and graded for quality, using relevant checklists developed by
the Scottish Intercollegiate Guidelines Network (SIGN). These were
modified to incorporate summary levels of evidence for the validity,
magnitude/precision of effect and applicability of each study. An
overall summary level of evidence was assigned to each study (see
\"Rating Scheme for the Strength of the Evidence\" field above).

For every study included in the evidence review, the level of evidence
assigned is listed alongside the citation in the reference list at the
end of the guideline.

**Weighing the Evidence**

Evidence tables (which are available on the New Zealand Guidelines Group
(NZGG) website ([http://www.nzgg.org.nz](http://www.nzgg.org.nz/)) were
prepared for each clinical question and were summarised on considered
judgment forms The Guideline Development Team (GDT) considered the body
of evidence and made recommendations, based on the validity, quantity,
consistency and clinical impact of the whole body of evidence.

#### METHODS USED TO FORMULATE THE RECOMMENDATIONS

Expert Consensus

#### DESCRIPTION OF METHODS USED TO FORMULATE THE RECOMMENDATIONS

The Guideline Development Team (GDT) developed consensus recommendations
following a review and discussion of the evidence as expressed in the
evidence tables and considered judgment forms. Recommendations are
graded based on the level to which they are supported by the evidence.

Grading of the recommendations was based on the quality of the evidence,
which does not equate to the importance of the recommendation. When
there was no evidence to answer a specific question, recommendations
were based on the consensus of the GDT and were classified as \'Good
Practice Points\'.

Two expert subgroups were convened to consider the evidence and draft
recommendations for the specific populations of youth (children and
adolescents) and older adults. The subgroups comprised both GDT members
and external experts. Their recommendations were discussed and finalised
by the full GDT.

New Zealand Guidelines Group (NZGG) drafted the guideline with support
from Guideline Development Team (GDT) members, expert contributors and
Māori perspectives from the NZGG Board of Directors.

#### RATING SCHEME FOR THE STRENGTH OF THE RECOMMENDATIONS

**Grading of Recommendations**

**A** - The recommendation is supported by good evidence (based on a
number of studies that are valid, consistent, applicable and clinically
relevant).

**B** - The recommendation is supported by fair evidence (based on
studies that are valid, but there are some concerns about the volume,
consistency, applicability and clinical relevance of the evidence that
may cause some uncertainty but are not likely to be overturned by other
evidence).

**C** - The recommendation is supported by international expert opinion.

**Good Practice Points (GPP)** - Where no evidence is available, best
practice recommendations are made based on the experience of the
Guideline Development Team, or feedback from consultation within New
Zealand.

#### COST ANALYSIS

The guideline developers reviewed published cost analyses:

-   The literature strongly advocates the use of interdisciplinary
    team-based models of care as a cost-effective way of improving
    primary care outcomes for patients with depression.

-   There is accumulating evidence that shared decision-making increases
    the cost-effectiveness of treatment, strengthens the therapeutic
    alliance and improves patient satisfaction.

-   Cultural competence means that a practitioner has the attitude,
    skills and knowledge to work effectively and respectfully with
    people of other cultural backgrounds. The benefits include improved
    willingness to access services, improved communication, increased
    patient satisfaction and compliance with treatment, improved patient
    outcomes, and improved cost-effectiveness and efficiency in health
    service delivery.

-   An Australian cost-benefit analysis of cognitive behavioural therapy
    (CBT) versus antidepressants found CBT the most cost-effective
    first-line intervention for depression in children and adolescents.

-   Overall, the evidence suggests that psychological therapies and
    antidepressants are of comparable efficacy. Psychological therapies
    are better tolerated, and may have a more sustained effect, though
    the Guideline Development Team (GDT) notes that access to these
    therapies can be difficult due to barriers of cost and
    accessibility.

-   Two randomised controlled trials (RCTs) evaluated the use of CBT
    booklets with practice nurse or assistant psychologist support. One
    found no benefit at 3 months in the intervention group compared to
    waiting list controls, while the other reported cost-effective
    clinical benefits to the intervention group compared with usual
    general practitioner (GP) care.

-   An economic analysis calculated that non-directive counselling (home
    listening visits) were likely to be the most cost-effective option
    for treatment of women with mild to moderate depression in the
    postnatal period, but noted considerable uncertainty around this
    finding.

-   Barriers to the adoption of collaborative care models could include
    financial or time costs to anyone involved, including patients and
    their families, and the need for substantial changes to clinical
    practice (e.g., protocols for follow-up or referral between
    services).

-   An Australian study describes a modelling exercise that found that
    with the number of people needing treatment held constant,
    evidence-based care using a stepped care approach was no more
    expensive and was more effective than the traditional model (i.e.,
    allocating resources top-down, according to the needs and demands of
    stakeholder groups). Increased coverage was also possible because
    the additional cases tended to be of disorders that were easier and
    less expensive to treat. The model assumed a sequence of stepped
    care from the less intensive, lower-cost interventions (i.e., GP
    advice plus patient self-management), through to more intensive
    higher-cost interventions (i.e., active GP treatment, involvement of
    allied mental health staff and on to psychiatric and inpatient
    care).

-   There is evidence that multifaceted collaborative care has benefits
    for the treatment of depression in the primary care setting.
    Potential elements of a cost-effective model include a stepped care
    approach, use of telephone care management and the employment of
    care managers (e.g., practice nurses) to work with patients and
    liaise across levels of care.

#### METHOD OF GUIDELINE VALIDATION

External Peer Review\
Internal Peer Review

#### DESCRIPTION OF METHOD OF GUIDELINE VALIDATION

-   A draft of this guideline was circulated to 263 individuals and
    organisations for comment in December 2007 as part of the peer
    review process.

-   The guideline was circulated nationally for feedback. Following
    consideration of the feedback, the guideline was redrafted.
    Significant changes were made to Chapter 7 of the original guideline
    document, following advice from a maternal mental health specialist,
    the New Zealand College of Midwives, the Royal New Zealand Plunket
    Society and general practitioners with an interest in this area.

### RECOMMENDATIONS

#### MAJOR RECOMMENDATIONS

The grades of recommendation (A-C, and Good Practice Points \[GPP\]) are
defined at the end of the \"Major Recommendations\" field.

**[Key Messages]{.underline}**

-   Mental disorders are common in primary care and are a major cause of
    disability

-   All assessment, support and treatment of mental disorders in primary
    care should be culturally appropriate

-   Routine psychosocial assessment is the key to improving the
    recognition of common mental disorders

-   The use of verbal 2--3 question screening tools is recommended as a
    support for clinical assessment, when targeting adults at high risk
    for common mental disorders

-   A high index of suspicion is needed for substance use disorder,
    which is common but often hard to recognise as it is relatively less
    disabling than other mental disorders

-   Most young people and adults with depression can be managed within
    primary care using a \'stepped care\' approach. A good outcome
    depends on partnership between the patient and practitioner and on
    provision of active treatment and support for a sufficient length of
    time

-   Planned treatment for depression should reflect the individual\'s
    values and preferences and the risks and benefits of different
    treatment options

-   Use of self-management strategies for depression should be
    encouraged and supported by practitioners

-   Psychological and pharmacological therapies are equally effective
    for treating adults with moderate depression, on the basis of
    current evidence

-   Brief psychological interventions for depression such as structured
    problem-solving therapy should be available in the primary care
    setting

-   Where antidepressant therapy is planned, selective serotonin
    reuptake inhibitors (SSRIs) are first-line treatment, with few
    exceptions

**[Recognition and Assessment of Common Mental Disorders in Young
People/Rangatahi/Tamariki]{.underline}**

**Recognition of Common Mental Disorders in Young People**

  -----------------------------------------------------------------------
  **Young people/rangatahi/tamariki** are defined in this context as
  individuals up to the age of 18 years and comprise both rangatahi
  (adolescents) and tamariki (young children). However, 18 years is a
  pragmatic cut off point that reflects the cut off age used in most
  research: it does not necessarily represent a developmental threshold.

  -----------------------------------------------------------------------

**C** - A young person with serious suicidal intent, psychotic symptoms
or severe self-neglect should be referred immediately to secondary care
mental health services

**C** - Every interaction with a young person in primary care should be
regarded as an opportunity to assess their psychosocial as well as
physical wellbeing. Both strengths and difficulties should be taken into
account

**C** - Psychosocial wellbeing in adolescents should routinely be
assessed using a standardised format, such as the HEEADSSS acronym
(Home, Education/ Employment, Eating, Activities, Drugs, Sexuality,
Suicide, Safety) (see Table 1 below)

**C** - Adolescents presenting in primary care should routinely be
offered individual time with a practitioner

**C** - Brief tools may be used as optional aids to the practitioner\'s
clinical assessment. Valid brief tools include:

-   The Strengths and Difficulties Questionnaire (SDQ)

-   The Short Moods and Feelings Questionnaire (SMFQ)

-   Reynolds Adolescent Depression Scale (RADS)

-   The Substance Use and Choices Scale (SACS)

-   The CRAFFT acronym (A tool designed specifically for adolescents for
    detecting alcohol and substance abuse, and dependence.)

See \"Appendix D: Assessment Tools for Common Mental Disorders\" in the
original guideline document for links to these tools.

**GPP** - Practitioners involved in the assessment of young people for
mental disorders should endeavour to build a supportive and
collaborative relationship with the young person and their family/whānau

  -----------------------------------------------------------------------
  **Whānau** is a much wider concept than the nuclear family. It
  approximates what non-Māori would generally understand to be an
  extended family. For Māori, whānau provides care, nurturing, identity
  and a sense of belonging and purpose. The goal of health for Māori is
  whānau ora: \'Māori families supported to achieve their maximum health
  and wellbeing\'.

  -----------------------------------------------------------------------

**GPP** - Practitioners should discuss the right to confidentiality and
exceptions to confidentiality with the young person

**GPP** - In young children, a standardised format such as the HEARTS
acronym (Home, Education, Activities, Relationships, Temper, Size)
should be used for routine assessment of psychosocial wellbeing (see Box
3.3 of the original guideline document)

**GPP** - Practitioners should be aware of the cultural identity and
health care preferences of young people in their care

  -----------------------------------------------------------------------
  **Table 1: HEEADSSS**
  -----------------------------------------------------------------------
  The HEADSS acronym updated in 2004 to HEEADSSS or HE^2^ADS^3^ is a
  well-known prompt to structure a psychosocial assessment in
  adolescents. It has the advantage of progressing from routine questions
  to more probing ones, giving the practitioner a chance to establish
  rapport before approaching the most difficult areas. However, the order
  of the interview depends on the dictates of common sense and clinical
  instinct and the young person\'s presenting complaint should be
  addressed as a priority.\
  \
  **H**ome: relationships, communication, anyone new?\
  \
  **E**ducation/Employment: ask for actual marks, hours,
  responsibilities\
  \
  **E**ating: body image, weight changes, dieting, exercise\
  \
  **A**ctivities: with peers, with family\
  \
  **D**rugs: tobacco, alcohol, other drugs -- use by friends, family,
  self\
  \
  **S**exuality: sexual identity, relationships, coercion, contraception,
  pregnancy, sexually transmitted infections (STIs)\
  \
  **S**uicide and depression: sadness, boredom, sleep patterns,
  anhedonia\
  \
  **S**afety: injury, seatbelt use, violence, rape, bullying, weapons\
  \
  Issues of ethnic identity may also be critical domains, particularly
  among adolescents/rangatahi from minority cultures.\*

  \*The earlier version, HEADSS, has been adapted for New Zealand.
  -----------------------------------------------------------------------

**Asking about Sexual Identity**

In order to give a young person the opportunity to acknowledge their
sexual identity, the practitioner could say:

-   How do you feel about relationships in general/about your own
    sexuality?

-   Some people are getting involved in sexual relationships. Have you
    had a sexual experience with a guy or girl or both?

Ask for permission to pass relevant information to other health
professionals involved in the young person\'s care. This may save them
the stress of having to explain themselves anew.

**Determining Severity in Young People and When to Refer**

**C** - A young person with serious suicidal intent, psychotic symptoms
or severe self-neglect should be referred immediately to secondary care
mental health services

**C** - A young person with severe depression should be referred
urgently to secondary care mental health services

**GPP** - A young person with suspected bipolar disorder should be
referred urgently to secondary care mental health services

**[Management of Depression in Young
People/Rangatahi/Tamariki]{.underline}**

**Management of Depression in Young People**

**C** - A young person with serious suicidal intent, psychotic symptoms
or severe self-neglect should be referred immediately to secondary care
mental health services

**C** - A young person with severe depression should be referred
urgently to secondary care mental health services

**C** - Practitioners involved in the management of a young person with
depression, should endeavour to build a supportive and collaborative
relationship with the young person and their family/whānau

**C** - A young person with mild or moderate depression should typically
be managed within primary care services

**C** - Practitioners should consider involving support services such as
school guidance counsellors or family services in the management of a
young person with depression

**C** - If a young person with depression does not report substantial
improvement after 6--8 weeks of treatment, he/she should be referred to
secondary care mental health services

**C** - Antidepressant treatment of a young person (\<18 years) should
not be initiated in primary care without consultation with a child and
adolescent psychiatrist

**GPP** - When planning management of a young person with depression,
practitioners should consider symptom severity, symptom persistence,
functional impairment, response to any previous intervention and also
the wider psychosocial context, identifying factors that may impact
positively or negatively on outcome

**GPP** - Initial management in primary care of a young person with mild
to moderate depression should include active listening, problem
identification, advice about simple self-management strategies and
systematic follow-up comprising 2-weekly monitoring (e.g., by
phone/text/email)

**GPP** - A young person being treated for depression in primary care
should be seen for reassessment at 2--4 weeks

**GPP** - A young person who reports improvement with treatment in
primary care should be proactively monitored (by phone, email, text, or
face-to-face) 1--2 monthly until he/she has a satisfactory response to
treatment (remission of symptoms/return to normal function). He/she
should have an action plan to use if symptoms recur (i.e., what to do
and who to contact)

**GPP** - If the young person reports no improvement at 2--4 weeks,
he/she should receive an extended appointment for intensified support. A
simple psychological intervention such as structured problem-solving
therapy should be offered

**GPP** - If the young person reports deterioration in symptoms at 2--4
weeks, either treatment should be intensified or he/she should be
referred to secondary care mental health services, depending on the
severity of symptoms

**GPP** - Counselling for young people in primary care should use a
recognized therapeutic approach which targets depression and related
problems and which focuses on resilience and behavioural support

**GPP** - If another health practitioner delivers psychotherapy to a
young person with depression in primary care, there should be regular
communication about the young person\'s progress

**[Recognition and Assessment of Common Mental Disorders in
Adults/Pakeke]{.underline}**

**Recognition of Common Mental Disorders in Adults**

**C** - An adult with serious suicidal intent, psychotic symptoms or
severe and persistent self-neglect should be referred immediately to
secondary care mental health services

**C** - Targeted screening for common mental disorders is indicated for
adults not well-known to the practitioner and for:

-   People with chronic illness, a history of mental disorder or suicide
    attempt, multiple symptoms or a recent significant loss

-   Other high prevalence groups, such as Māori (especially Māori women)
    and older adults in residential care

-   Women in the antenatal and postnatal period

**B** - Targeted screening for depression and anxiety should include the
use of verbal 2--3 question screening tools (see Table 2 below)

**GPP** - Every interaction with an adult in primary care should be
regarded as an opportunity to assess their psychosocial as well as
physical wellbeing. Both strengths and difficulties should be taken into
account

**GPP** - The practitioner should strive to establish and maintain a
good therapeutic relationship with the patient, as this increases the
likelihood that mental disorders will be identified

**GPP** - Targeted screening for substance abuse should comprise a
verbal 2--3 question screening tool

**GPP** - Targeted screening should be conducted annually

**GPP** - Brief tools are optional aids for use by the primary care
practitioner as an adjunct to clinical assessment. Examples of brief
tools include:

-   The Kessler 10 (K10)

-   The Patient Health Questionnaire for Depression (PHQ-9)

-   The Generalised Anxiety Disorder Scale (GAD-7)

-   The Alcohol Disorder Use Identification Test (AUDIT)

-   The Case-finding and Help Assessment Tool (CHAT)

See \"Appendix D: Assessment Tools for Common Mental Disorders\" in the
original guideline document for links to the above tools.

**GPP** - Practitioners should be aware of the cultural identity and
health care preferences of people in their care

+-----------------------------------------------------------------------+
| **Table 2: Verbal 2-3 Questions Screening Tools for Common            |
| Disorders**                                                           |
+=======================================================================+
| **Screening Questions for Depression**                                |
|                                                                       |
| -   During the past month, have you often been bothered by feeling    |
|     down, depressed or hopeless?                                      |
|                                                                       |
| -   During the past month, have you often been bothered by little     |
|     interest or pleasure in doing things?                             |
|                                                                       |
| If Yes to either question, ask Help question (below)\                 |
| \                                                                     |
| **Screening Question for Anxiety**\                                   |
| \                                                                     |
| During the past month have you been worrying a lot about everyday     |
| problems?\                                                            |
| \                                                                     |
| If Yes, ask Help question (below)\                                    |
| \                                                                     |
| **Screening Questions for Alcohol and Drug Problems**                 |
|                                                                       |
| -   Have you used drugs or drunk more than you meant to in the last   |
|     year?                                                             |
|                                                                       |
| -   Have you felt that you wanted to cut down on your drinking or     |
|     drug use in the past year?                                        |
|                                                                       |
| If Yes to either question, ask Help question (below)\                 |
| \                                                                     |
| **Help Question**\                                                    |
| \                                                                     |
| Is this something with which you would like help?\                    |
| \                                                                     |
| Options: no / yes, but not now / yes\                                 |
| \                                                                     |
| **Further Action**\                                                   |
| \                                                                     |
| A positive response to one of the screening questions detects most    |
| cases of the relevant disorder.\                                      |
| \                                                                     |
| If a person responds positively to a screening question and           |
| identifies that they want help to address the issue, the GDT          |
| recommends that the practitioner proceeds with further clinical       |
| assessment, reschedules a further consultation or refers the person   |
| to their general practitioner/practice nurse team, as appropriate.    |
+-----------------------------------------------------------------------+

**[Determining Severity in Adults and When to Refer]{.underline}**

**Assessing Severity of Depression and When to Refer**

**C** - An adult with serious suicidal intent, psychotic symptoms or
severe and persistent self-neglect should be referred immediately to
secondary care mental health services

**B** - Practitioners should consider the use of a tool such as the
Patient Health Questionnaire for Depression (PHQ-9) for assessment of
the severity of depression

**GPP** - An adult with suspected new-onset bipolar disorder should be
referred urgently to secondary care mental health services

**GPP** - When assessing the severity of depression in an adult and
planning management, practitioners should consider symptom severity,
symptom persistence, functional impairment, response to any previous
intervention and also the wider psychosocial context, identifying
factors that may impact positively or negatively on outcome

**[Management of Depression in Adults/Pakeke]{.underline}**

**Management of Depression in Adults**

**C** - An adult with serious suicidal intent, psychotic symptoms or
severe and persistent self-neglect should be referred immediately to
secondary care mental health services

**C** - First-line treatment for an adult with mild depression is active
support, advice on exercise and self-management, and referral to
psychosocial helping agencies as required (e.g., relationship
counselling)

**B** - First-line treatment for an adult with moderate depression is
either an SSRI or a psychological therapy (e.g., 6--8 sessions of
problem-solving therapy or cognitive behavioural therapy \[CBT\] over
10--12 weeks)

**B** - For an adult presenting initially with severe depression, the
practitioner should consider a combination of antidepressant medication
with a structured psychological intervention (e.g., CBT or interpersonal
psychotherapy \[IPT\], 16--20 sessions)

**C** - An adult starting antidepressant treatment who is considered at
increased risk of suicide or is younger than 30 years should be followed
up at 1 week and monitored 1--2 weekly, preferably face-to-face, until
the risk is no longer considered significant, then at least 2 weekly
until there is clear improvement

**C** - An adult starting antidepressant treatment who is not considered
at increased risk of suicide should be reviewed by the health
practitioner within 1--2 weeks and monitored at least 2 weekly until
there is clear improvement

**C** - If an adult on antidepressant medication has had only a partial
response after 3--4 weeks, consider increasing the dose

**C** - If an adult on antidepressant medication has not responded to
treatment by 4--6 weeks, review the treatment plan and consider either
increasing the dose, changing the antidepressant, or changing or adding
a psychological therapy

**B** - An adult being treated for depression should be actively
monitored and supported (e.g., by phone, text, email or face-to-face) by
an appropriately trained member of the primary care team, informed by
clear treatment protocols

**B** - Practitioners should consider the use of a tool such as the
Patient Health Questionnaire for Depression (PHQ-9) to assist in the
monitoring of treatment response in an adult with depression

**C** - If another health practitioner delivers psychotherapy to an
adult with depression, the primary care team should be in regular
communication about the individual\'s progress

**C** - An adult with depression who is treatment resistant should be
referred urgently to secondary care mental health services while
continuing treatment. Treatment resistance is defined as an
unsatisfactory response after adequate trial of two antidepressants
(with or without psychological therapy)

**B** - An adult with depression who is responding to antidepressant
treatment should normally continue to take the antidepressant for at
least 6 months after remission of an episode of depression in order to
reduce the risk of relapse

**GPP** - When planning the management of an adult with depression, the
practitioner should consider: symptom severity and symptom persistence;
functional impairment; response to any previous intervention; and the
individual\'s wider psychosocial context, identifying factors that may
impact positively or negatively on outcomes

**GPP** - The practitioner should endeavour to build a supportive and
collaborative relationship with an adult with depression and their
family/whānau

**GPP** - A practitioner managing an adult with severe depression in
primary care needs to have easy access to consultation with a
psychiatrist

**GPP** - First-line treatment for an adult with melancholic depression
is a tricyclic antidepressant

**GPP** - If an adult on antidepressant medication has had no or minimal
response after 3--4 weeks, or if side effects are unacceptable, review
the treatment plan and consider changing to a different antidepressant,
or changing to or adding a psychological therapy

**GPP** - If an adult with mild depression does not respond to
supportive treatment (psychosocial support and self-management
strategies) within 2--4 weeks (i.e., ≥50% reduction in symptoms) the
patient and practitioner should review the treatment plan and consider
intensifying, changing or augmenting measures taken to date

**GPP** - The primary care team should include members skilled in
conducting brief psychological interventions for depression

**GPP** - Psychological therapies offered should use a recognised
therapeutic approach which targets depression and related problems and
which focuses on resilience and behavioural support

**[Special Issues: Women with Mental Disorders in the Antenatal and
Postnatal Period]{.underline}**

**Women in the Antenatal and Postnatal Period**

**C** - As part of routine antenatal care, the practitioner should
enquire whether a woman has any history of mental disorder or any family
history of mental illness in the antenatal or postnatal period

**C** - At a pregnant woman\'s first contact with primary care, her
\'booking\' visit and 6-week postnatal check, the practitioner should
consider the use of the verbal 2--3 question screening tool for
depression as part of routine assessment (see Table 2 above)

**C** - A woman with depression in the antenatal or postnatal period
requires full discussion of the risks and benefits of treatment options
and the risks of untreated depression. The uncertain state of the
evidence should be acknowledged

**C** - There should be close collaboration and sharing of information
between the midwife, general practitioner and other practitioners
involved in the care of a woman with antenatal or postnatal depression.
All relevant information should be available to the Lead Maternity Carer

**C** - Nonpharmacological interventions such as enhanced social support
and/or a psychological intervention should be considered before
prescribing medication for antenatal or postnatal depression, especially
for a woman with mild symptoms or in very early pregnancy

**C** - If a woman\'s response to a verbal 2--3 question screening tool
arouses concern about a possible mental disorder (or if other issues do
so) she should normally be referred promptly for further clinical
assessment by her general practitioner/practice nurse team. This should
include a check for suicidal ideation or intent

**C** - If a possible mental disorder or a history of significant mental
disorder is identified in a woman in the antenatal or postnatal period,
her general practitioner/practice nurse team should be made aware, even
if no referral is made (e.g., referral is declined), provided the woman
consents

**C** - A brief psychological intervention (e.g., 6--8 sessions of
non-directive counselling, interpersonal psychotherapy \[IPT\] or
cognitive behavioural therapy \[CBT\]) should be considered as a
first-line intervention in the management of a woman with mild to
moderate depression in the antenatal or postnatal period

**C** - For a woman with depression in the antenatal or postnatal period
who does not respond to initial treatment, a structured psychological
therapy (e.g.,  CBT or IPT) could be considered, in consultation with
maternal mental health services

**C** - An antidepressant may be considered as first-line treatment for
a woman with moderate to severe depression in the antenatal or postnatal
period, after thorough discussion of the likely benefits and possible
risks of treatment

**C** - A woman with severe depression in the antenatal or postnatal
period should be managed in consultation with maternal mental health
services or other appropriate psychiatric services

**C** - If a woman who is pregnant or planning pregnancy is being
treated with an antidepressant, her treatment preference, previous
history and risk should be reviewed. If appropriate, attempts should be
made to withdraw the antidepressant and substitute an alternative
treatment and/or ensure that the antidepressant with the lowest risk
profile is used

**GPP** - At a pregnant woman\'s first contact with primary care, at her
\'booking\' visit and 6-week postnatal check, the practitioner should
consider the use of verbal 2--3 question screening tools for anxiety and
substance abuse as part of routine assessment

**GPP** - A practitioner should regularly review his/her practice in
relation to antidepressant prescribing during the antenatal or postnatal
period and consider seeking specialist advice when initiating
antidepressant treatment in a woman who is pregnant or breastfeeding

**GPP** - A practitioner should support breastfeeding in a woman with
depression in the postnatal period who opts to take antidepressants,
provided she is well-informed about known risks and benefits

**GPP** - A woman with depression in the postnatal period should be
encouraged to attend a mother and baby support group

  -----------------------------------------------------------------------
  Advice for women\
  \
  It may be helpful to advise women that the \'postpartum blues\' are a
  different entity from depression. The \'blues\', with characteristic
  tearfulness, anxiety and low mood, are relatively common but are
  transient, peaking at 3--5 days after birth and resolving by 10--14
  days.

  -----------------------------------------------------------------------

**[Special Issues: Older Adults/Koroua/Kuia]{.underline}**

**Older Adults**

**C** - Targeted screening for common mental disorders is indicated for
older adults in groups with high prevalence rates including:

-   Older adults in residential care

-   Older adults with a history of mental disorder or suicide attempt

-   Older adults with multiple symptoms

-   Older adults with a recent significant loss

**C** - An older adult presenting with possible cognitive impairment
should be assessed for both dementia and depression

**C** - Where there is a rapid change in cognitive status in an older
adult, medical assessment should exclude delirium

**C** - An older adult with depression should be offered the same range
of psychological therapies as other adults: chronological age should not
be a bar to specific therapies

**C** - SSRIs are suitable as a firstline antidepressant for an older
adult: for a patient also taking other medications, choose one with a
low risk of drug interactions

**C** - An older adult prescribed antidepressants should be carefully
monitored for adverse effects

**C** - Where antidepressants are the treatment of choice, treatment for
an older adult with depression and dementia should be as for other older
adults with depression

**GPP** - Among older adults living in residential care, older adults
with other risk factors or where there is clinical concern, routine
psychosocial assessment should include questions that screen for
depression, anxiety and substance abuse. This assessment should be
conducted annually

**GPP** - Brief tools are optional aids for use by the primary care
practitioner as an adjunct to clinical assessment. Examples of brief
tools for detecting depression among older adults include:

-   The Geriatric Depression Scale (GDS)

-   The Patient Health Questionnaire for Depression (PHQ-9)

**GPP** - Clinical assessment of an older adult for dementia and
depression should include the use of tools to assess cognitive function,
such as the Mini Mental State Examination (MMSE) and/or clock drawing
test, in addition to a tool to assess for depression (such as the GDS or
the PHQ-9)

**GPP** - Assessment of an older adult with depressive symptoms should
include a physical examination, complete blood count and thyroid
function tests. The practitioner should also consider checking
creatinine and B12 and folate levels

**GPP** - An older adult with depression should be offered advice on
simple behavioural measures to increase social, physical and/or
intellectual activity

**GPP** - In an older adult starting treatment with a SSRI consider
checking serum sodium after 1 week and after each dose adjustment,
especially if the patient is at risk of hyponatraemia (e.g., frail, on
diuretics, has renal impairment)

**GPP** - In a frail older adult prescribed antidepressants, treatment
should be initiated at a low dose and increased slowly to optimisation
or until a response is achieved

**[Definitions]{.underline}**:

**Grades of Recommendations**

Grades indicate the strength of the supporting evidence rather than the
importance of the evidence.

**A** - The recommendation is supported by good evidence (based on a
number of studies that are valid, consistent, applicable and clinically
relevant).

**B** - The recommendation is supported by fair evidence (based on
studies that are valid, but there are some concerns about the volume,
consistency, applicability and clinical relevance of the evidence that
may cause some uncertainty but are not likely to be overturned by other
evidence).

**C** - The recommendation is supported by international expert opinion.

**Good Practice Points (GPP)** - Where no evidence is available, best
practice recommendations are made based on the experience of the
Guideline Development Team, or feedback from consultation within New
Zealand.

#### CLINICAL ALGORITHM(S)

The original guideline document contains clinical algorithms for:

-   The management of depression in young people in primary care

-   The management of depression in adults in primary care

-   The management of severe depression in adults in primary care

-   The management of moderate depression in adults in primary care

-   The management of mild depression in adults in primary care

### EVIDENCE SUPPORTING THE RECOMMENDATIONS

#### TYPE OF EVIDENCE SUPPORTING THE RECOMMENDATIONS

The type of supporting evidence is identified and graded for each
recommendation (see \"Major Recommendations\").

### BENEFITS/HARMS OF IMPLEMENTING THE GUIDELINE RECOMMENDATIONS

#### POTENTIAL BENEFITS

Appropriate identification and management of common mental disorders and
depression among young people and adults in the primary care setting.

#### POTENTIAL HARMS

**Selective Serotonin Reuptake Inhibitors (SSRIs)**

-   SSRIs are overall fairly well tolerated, apart from mild nausea,
    occasional diarrhoea and sometimes headache. Gastrointestinal
    effects usually settle within 2 weeks.

-   Sexual problems, such as decreased libido and difficulty achieving
    orgasm, occur in around 40% of people taking SSRIs, and in around
    30% of cases the problem is likely to be drug-related, though
    estimates vary widely.

-   Some people gain weight and there is also an increased risk of
    bleeding.

-   Fluoxetine has a long half-life, which may cause problems with
    washout periods when switching to other antidepressant drugs, but
    has the advantage of causing less withdrawal symptoms.

-   Increases in anxiety, restlessness or agitation may occur in the
    first few weeks of SSRI treatment. This may be very distressing and
    can be associated with increased suicidality.

-   Patients should be warned that they may experience withdrawal
    symptoms, which are usually mild and self-limiting. Common
    withdrawal symptoms for SSRIs are flu-like symptoms, \'shocklike\'
    sensations, dizziness, excessive dreaming, insomnia and tearfulness.

-   There is some evidence that SSRIs may increase the risk of premature
    labour. Women should be informed of a possible link between SSRIs in
    early pregnancy and the occurrence of birth defects. Late in
    pregnancy, concerns over neonatal toxicity or drug withdrawal
    associated with third trimester exposure to SSRIs (e.g.,
    irritability, respiratory difficulties and feeding problems) may
    prompt some women to lower the dose of SSRIs until after delivery.
    (For more information see \"Safety and Adverse Effects on the
    Infant/Foetus\" in the original guideline document.)

-   If a pregnant woman decides to keep taking antidepressants
    (including SSRIs), she should be advised that the pharmacokinetics
    of many drugs change during pregnancy, especially in the third
    trimester, due to increased fluid volumes.

-   Older patients may be at increased risk of rare but potentially
    serious adverse events associated with SSRIs, such as hyponatraemia
    and weight loss. Moreover, a large observational study published
    recently reports a doubling of fracture risk in people aged 50 years
    and over taking SSRIs.

**Tricyclic Antidepressants (TCAs)**

-   All TCAs cause anticholinergic side effects (such as dry mouth,
    blurred vision, constipation, urinary retention and sweating),
    sedation and postural hypotension. Usual recommendations are to
    start with a low dose and titrate up to the therapeutic serum level
    as quickly as the patient can tolerate this. TCAs can cause
    ventricular arrhythmias in the absence of adequate oxygenation of
    heart muscle (e.g., with ischaemic heart disease) and in overdose.
    Overdose can also cause seizures.

-   Withdrawal of TCAs can cause flu-like symptoms and insomnia. If
    symptoms are severe, the patient may need to resume taking the
    antidepressant and reduce it more slowly.

-   There have been few documented problems arising from the use of TCAs
    in pregnancy, though data are limited, but they are generally
    avoided nowadays due to their adverse effects and risk of fatal
    overdose.

### CONTRAINDICATIONS

#### CONTRAINDICATIONS

-   Doxepin is contraindicated in lactation, due to case reports of
    drowsiness and hypotonia in the breastfed infants of mothers taking
    this drug.

-   Antidepressant medication should not be continued in a confused
    older person unless there is clear clinical evidence of benefit.

### QUALIFYING STATEMENTS

#### QUALIFYING STATEMENTS

-   Evidence-based best practice guidelines are produced to help health
    care practitioners and consumers make decisions about health care in
    specific clinical circumstances. Research has shown that if properly
    developed, communicated and implemented, guidelines can improve
    care. The advice in this guideline is based on evidence from
    epidemiological studies and other research. Where no evidence is
    available, but guidance is needed, recommendations for best practice
    are developed through a systematic consensus process based on the
    experience of the Guideline Development Team.

-   While guidelines represent a statement of best practice based on the
    latest available evidence (at the time of publishing), flexibility
    will be required in local interpretation and they are not intended
    to replace the health practitioner\'s judgment in each individual
    case.

### IMPLEMENTATION OF THE GUIDELINE

#### DESCRIPTION OF IMPLEMENTATION STRATEGY

The New Zealand Guidelines Group (NZGG) has identified four principles
which should characterise implementation.

These are:

1.  Strong visibility of the guideline, given the opportunity that
    evidence-based care represents to improve the lives of people living
    with depression

2.  The use of multifaceted approaches to engage practitioners and
    patients

3.  Recognition that all implementation is ultimately \'local\'; this
    means an emphasis on providing useful tools and processes for
    practitioners, with central agencies as facilitators of change

4.  A commitment to supporting the sector to measure its performance in
    following the guideline\'s recommendations

See chapter 10 of the original guideline document for a detailed
discussion of potential implementation activities, such as improved
access and uptake of patient self-management tools, quality improvement
collaboratives, workforce development, electronic evidence resources,
broad guideline dissemination, and evaluation and performance indicator
development.

#### IMPLEMENTATION TOOLS

Chart Documentation/Checklists/Forms\
Clinical Algorithm\
Patient Resources\
Quick Reference Guides/Physician Guides

For information about
[availability](#identifying-information-and-availability), see the
\"Availability of Companion Documents\" and \"Patient Resources\" fields
below.

### INSTITUTE OF MEDICINE (IOM) NATIONAL HEALTHCARE QUALITY REPORT CATEGORIES

#### IOM CARE NEED

Getting Better\
Living with Illness

#### IOM DOMAIN

Effectiveness\
Patient-centeredness

### IDENTIFYING INFORMATION AND AVAILABILITY

#### BIBLIOGRAPHIC SOURCE(S)

New Zealand Guidelines Group. Identification of common mental disorders
and management of depression in primary care. Wellington (NZ): New
Zealand Guidelines Group; 2008 Jul. 188 p. \[580 references\]

#### ADAPTATION

Not applicable: The guideline was not adapted from another source.

#### DATE RELEASED

2008 Jul

#### GUIDELINE DEVELOPER(S)

New Zealand Guidelines Group - Private Nonprofit Organization

#### SOURCE(S) OF FUNDING

New Zealand Guidelines Group

This guideline was funded by the Ministry of Health and its development
was independently managed by the New Zealand Guidelines Group. Appraisal
of the evidence, formulation and reporting of recommendations are
independent of the Ministry of Health.

#### GUIDELINE COMMITTEE

Guideline Development Team

#### COMPOSITION OF GROUP THAT AUTHORED THE GUIDELINE

*Guideline Development Team Members*: Professor Tony Dowell (*Chair*),
General Practitioner, Island Bay, Wellington, Professor of Primary
Health Care and General Practice, University of Otago, Wellington; Tim
Antric (from August 2007), Project Manager -- National Depression
Campaign, Wellington, Mental Health Foundation of New Zealand, Auckland;
Professor Bruce Arroll; Professor and Head of Department, Department of
General Practice and Primary Health Care, University of Auckland,
Auckland; Dr Clive Bensemann, Psychiatrist, Mental Health Services for
Older Adults, Waitemata; Dr Sunny Collings; Consultant Psychiatrist,
Capital & Coast District Health Board, Wellington, Senior Lecturer in
Social Psychiatry and Population Mental Health, University of Otago,
Wellington; Dr John Cosgriff, General Practitioner, South Auckland, GP
Liaison Mental Health Services, Counties Manukau District Health Board,
South, Auckland; Joanna Davison, Nurse Educator, Bachelor of Nursing
Programme, Whitireia Community Polytechnic, Porirua; Professor Pete
Ellis, Head of Department, Psychological Medicine, University of Otago,
Wellington; Lita Foliaki, Pacific Perspective, Pacific Health Manager,
Waitemata District Health Board, Auckland; Dr Allen Fraser, Consultant
Psychiatrist, Auckland Mind Psychiatric Consultants, Senior Lecturer
(Hon) Department of Psychiatry, University of Auckland, Auckland, Chief
Medical Officer, Waitemata District Health Board, North Shore City,
Chairman, New Zealand National Committee, RANZCP; Karin Keith, Consumer
Perspective, Manager, Wellington Mental Health Consumers Union Inc,
Wellington; Associate Professor Ngaire Kerse, Senior Lecturer, Division
of General Practice and Primary Health Care, University of Auckland,
Auckland; Dr Sally Merry, Senior Lecturer in Child & Adolescent
Psychiatry, The Werry Centre for Child and Adolescent Mental Health,
Department of Psychological Medicine, University of Auckland, Auckland;
Aroha Noema, Māori Perspective, Project Leader, Te Rau Matatini,
Palmerston North; Janet Peters, Registered Psychologist, Tauranga; Carol
Seymour, Nurse Leader Mental Health Services and Ambulatory Services
Auckland District Health Board, Auckland; Claudine Tule, Māori
Perspective Project Manager Māori Health, Funding Division, MidCentral
District Health Board, Palmerston North; Dr Peter Watson, Paediatrician
and Youth Health Specialist, Whirinaki, Counties Manukau District Health
Board Child and Adolescent Mental Health Services, South Auckland;
Rebecca Webster, Consultant Clinical Psychologist, South C ommunity
Mental Health Team, Wellington

#### FINANCIAL DISCLOSURES/CONFLICTS OF INTEREST

Professor Bruce Arroll is on the primary care committee of the Future
Forum, funded by Astra Zeneca UK and has received financial support to
attend the annual conference in Europe for the past four years. Bruce
received financial support from the PHARMAC committee to run three CME
(continuing medical education) sessions.

Dr Sunny Collings has received research funding from the Health Research
Council and the Ministry of Health.

Dr John Cosgriff has received financial support from Jannsen-Cilag for
the Metabolic Symposium Atypical Antipsychotics.

Professor Pete Ellis has received financial support from Eli Lilly for
funding a PhD student for investigator initiated research, ending June
2006. Pete Ellis has a beneficial interest with shares in CSL Limited,
GlaxoSmithKline, Pfizer and Roche.

Dr Allen Fraser has received financial support from Sanofi Synthelabo to
attend the annual bipolar disorder meeting, 2001--2006, and the
International Society for Bipolar Disorders Pittsburgh 2003.

Dr Mark Huthwaite has received financial support from Eli Lilly,
Lundbeck, Jansen Cilag, Astra-Zeneca and Pfizer to conduct clinical drug
trials and to attend and present at conferences and meetings.

#### ENDORSER(S)

College of Nurses Aotearoa NZ - Academic Institution\
Mental Health Foundation of New Zealand - Medical Specialty Society\
New Zealand Association of Counsellors - Professional Association\
New Zealand College of Clinical Psychologists - Professional
Association\
New Zealand College of Mental Health Nurses, Inc. - Professional
Association\
Paediatric Society of New Zealand - Medical Specialty Society\
Royal Australian and New Zealand College of Psychiatrists - Professional
Association\
Royal New Zealand College of General Practitioners - Medical Specialty
Society

#### GUIDELINE STATUS

This is the current release of the guideline.

#### GUIDELINE AVAILABILITY

Electronic copies: Available in Portable Document Format (PDF) from the
[New Zealand Guidelines Group Web
site](http://www.nzgg.org.nz/guidelines/dsp_guideline_popup.cfm?guidelineCatID=8&guidelineID=152).

Print copies: Available from the New Zealand Guidelines Group Inc.,
Level 10, 40 Mercer Street, PO Box 10 665, The Terrace, Wellington, New
Zealand; Tel: 64 4 471 4180; Fax: 64 4 471 4185; e-mail:
<info@nzgg.org.nz>.

#### AVAILABILITY OF COMPANION DOCUMENTS

The following is available:

-   Identification of common mental disorders and management of
    depression in primary care: guideline summary. Wellington (NZ): New
    Zealand Guidelines Group (NZGG); 2008 Jul. 12 p.

Available in Portable Document Format (PDF) from the [New Zealand
Guidelines Group Web
site](http://www.nzgg.org.nz/guidelines/0152/NZG92_Summary_web.pdf).

Additionally, an assessment of suicide risk tool can be found in
Appendix C in the [original guideline
document](http://www.nzgg.org.nz/guidelines/dsp_guideline_popup.cfm?guidelineCatID=8&guidelineID=152).

#### PATIENT RESOURCES

The following is available:

-   New Zealand Guidelines Group (NZGG). Depression. There is a way
    through it. Information for you, and your family, whanau, friends,
    and support networks. Wellington (NZ): New Zealand Guidelines Group
    (NZGG); 2006. 16 p. Electronic copies: Available in Portable
    Document Format (PDF) from the [New Zealand Guidelines Group Web
    site](http://www.nzgg.org.nz/guidelines/dsp_guideline_popup.cfm?guidelineID=152&guideline_popup_mode=consumer).

Please note: This patient information is intended to provide health
professionals with information to share with their patients to help them
better understand their health and their diagnosed disorders. By
providing access to this patient information, it is not the intention of
NGC to provide specific medical advice for particular patients. Rather
we urge patients and their representatives to review this material and
then to consult with a licensed health professional for evaluation of
treatment options suitable for them as well as for diagnosis and answers
to their personal medical questions. This patient information has been
derived and prepared from a guideline for health care professionals
included on NGC by the authors or publishers of that original guideline.
The patient information is not reviewed by NGC to establish whether or
not it accurately reflects the original guideline\'s content.

#### NGC STATUS

This NGC summary was completed by ECRI on December 10, 2008. The
information was verified by the guideline developer on January 4, 2009.

#### COPYRIGHT STATEMENT

The copyright owner of this publication is the Ministry of Health, which
is part of the New Zealand Crown. Content may be reproduced in any
number of copies and in any format or medium provided that it is not
changed, sold, used to promote or endorse any product or service, used
in any inappropriate or misleading context, and a copyright
acknowledgement to the New Zealand Ministry of Health is included.

### DISCLAIMER

#### NGC DISCLAIMER

The National Guideline Clearinghouse™ (NGC) does not develop, produce,
approve, or endorse the guidelines represented on this site.

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Guidelines represented on the NGC Web site are submitted by guideline
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<http://www.guideline.gov/about/inclusion.aspx> .

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