A 34 year old man attends his GP surgery with two months of persistent low mood, poor sleep and an inability to enjoy any of his former interests and hobbies. He had a similar episode two years earlier. There have been no suicidal thoughts so far.

He lives with his partner and works as an IT consultant. Although he enjoys his job less than he used to, he has so far managed to maintain his performance. He makes an effort to go for jogs with his partner, which can boost his mood. He drinks 10 units of alcohol per week, and has no past medical history.

Which of the following is the most appropriate initial management?

Options:
explanation: This vignette describes mild depression as although it fulfils the DSM-V criteria of depression, there seem to be no major functional impairments. Green social prescribing involves using nature-based interventions and activities to connect people to natural environments. Although green social prescribing is proven to work in some cases of mild depression, it should be referred to on a case-to-case basis. In this vignette, the patient mentions that he has already been going on jogs with his partner and admits to making extra efforts to do so. Therefore, prescribing more nature-based interventions may not be the most helpful.
name: Green social prescribing
label: d
answer: no
explanation: This vignette describes mild depression as although it fulfils the DSM-V criteria of depression, there seem to be no major functional impairments. Vagus nerve stimulation is a treatment that implants a device that sends electrical impulses to the vagus nerve, to stimulate the vagal brainstem pathways associated with mood regulation. This treatment is invasive and is only suitable for severe, treatment-resistant depression.
name: Vagus nerve stimulation
label: e
answer: no
explanation: This vignette describes mild depression as although it fulfils the DSM-V criteria of depression, there seem to be no major functional impairments. Although mirtazapine may be prescribed for moderate to severe depression that does not respond to selective serotonin reuptake inhibitors or psychological interventions, it is not indicated at this stage.
name: Start mirtazapine treatment
label: b
answer: no
explanation: This is the correct answer. This vignette describes mild depression as although it fulfils the DSM-V criteria of depression, there seem to be no major functional impairments. Initial treatment may consist of low-intensity psychological interventions such as individual or group-based Cognitive Behavioural Therapy (CBT).
name: Individual or group-based Cognitive Behavioural Therapy
label: a
answer: yes
explanation: This vignette describes mild depression as although it fulfils the DSM-V criteria of depression, there seems to be no major functional impairments. Referral to specialist mental health services is normally needed when there are red flags such as suicidal ideation and thoughts, more severe depression or chronic depressive symptoms, and significant co-existing mental and physical health conditions. In this vignette, there are no red flags, therefore, referral at this stage is not necessary although follow-up should be arranged through primary care.
name: Referral to specialist mental health services
label: c
answer: no

Correct answer: a